acute stage treatment protocol?

[BLESSEDHEPPER]

A couple of weeks ago, I posted about my low base viral load of 899. Since then I have been researching 24 week treatment studies for 1a's. The evidence shows that 1a's who are rapid responders can obtain SVR with 24 weeks. However, my question is: Is there a treatment duration that is preferred for acute stage 1a's whom obtain RVR by week 3?

MY STATS:
female  29 years old
1a

PRE TX:
VL= 899
ALT = 16
no biopsy ever done

[BLESSEDHEPPER]

Then Jesus said, "Come to me, all of you who are weary and carry heavy burdens, and I will give you rest (Matthew 11:28). Isn

[NYgirl]

You haven't started treating yet?  I think regardless of the low viral low is when you start...the basic tenants of all the studies still apply.  How fast you respond. UND at week 4 or 12 or 24?

You could start treating and stay at 200 for 18 weeks - and regardless of the LOW viral load...need to treat LONGER.

That is what happened to me, I stayed at 400 from until somewhere between week 12 - 24 and so even though my VL was very low I had to treat LONGER.

Not fair but.......

I wouldn't judge by any other things except the real data we do have and that for me includes Berg and Sanchez studies.

I hope that helps.

[jmjm530]

If you're truly acute, my understanding is that 24 weeks is standard treatment, possibly even without ribavirin. Ordinarily, I would double-check my memory with online sources but my computer is operating at a snail's pace today so keep this in mind.

I would also hope that as an acute, you're being treated and therefore receiving advice by a liver specialist (hepatologist) -- as opposed to a GP or GI -- who can better address the special treatment concerns of someone in the acute stage.

All the best,

-- Jim

[BLESSEDHEPPER]

I am in week 17 of 48. My half way point is approaching, along with a visit with my doc. At the beginning of treatment, it seemed as if I would be "down for the count" for about one day, and then my body would rebound. 17 weeks in I have noticed that my body isnt "bouncing back" as quickly. Makes me wonder about the long term effects this process will have on my body. Alot of people decide not to treat in acute stage, but I am SOOO glad I did. Just was curious as to the doctors who do treat acute stage 1a's, how long they reccomend tx?  Mt dr. is a great dr. but he does not specialize in hep. he's gastro. Nurses are nice but kind of sceptical of me when I called in anxiously for my 4 week pcr, saying it would be unlikely that I was UND by week 4. Then she reviewed results and said YES i was UND. It seems to me that they are not up to speed about all the studies that have been done..

[BLESSEDHEPPER]

I am getting studies together to fax over to the dr. Is there any links that will lead me to a specialist saying that 24 weeks is enough for acute 1a's?? I have looked and looked.

Also if someone's VL is less then 600,000, does this mean they are also acute? Or just have a low viral load?? From what I understand, acute is when someone is 6 months post infection or less??/

THANKS EVERYONE FOR YOUR TIME AND INPUT..

[jmjm530]

If you're seeing a hepatologist (liver specialist) then they should be aware of studies on tx protocols for acute cases. If you're not seeing a specialist, then the studies will only be of marginally help -- possibly counter productive -- because many individual factors may come into play, including how accurate/specific was your diagnosis of "acute" versus chronic hepatitis. Only a liver specialist with the benefit of your complete records can reliably help you with that decision.

In any event, here's one paper I found, and I'm sure you can find many more by simply googling "treating acute hepatitis c" But again, how this applies to your INDIVIDUAL case should be determined by a liver specialist who has experience with acute patients.

http://www.medscape.com/viewarticle/503764_2

"...The largest uncontrolled study which employed induction dosing with standard IFN alpha 2b indicated 95% of treated patients achieved a sustained virological response with only 6 months of therapy.[12] It is unlikely that the newer forms of IFN, namely PEG-IFN alpha in combination with ribavirin are going to be much more successful!"

###

[NYgirl]

"Also if someone's VL is less then 600,000, does this mean they are also acute? Or just have a low viral load??"

I had a very low viral load under 600,000 when I started treatment but I was definitely NOT in acute phase.  

Baseline viral load has NOTHING to do with acute or chronic.

NOTHING.

If you know you were JUST infected it's one thing but you can't use a low viral load to tell if that is so.

Believe it or not - sometimes it turns out that people with a very low VL to start have a MUCH harder time to get to SVR. That is contrary to what they tell us but if you look at the patients who start out very low.....a lot of us who have had to extend started out that way.

[aiuta]

I was treated as an acute case.  My initial VL was 140, but, at week 17 post-infection, I could easily have become a chronic case with a very low VL; they exist (as NYgirl said).  In simple terms, this VL meant that were 140 mutations of the the HCV virus that outwitted my natural immune system and T-cell response, and I needed an Interferon boost/bomb to get rid of them.  Because they already outsmarted my body, these last virions can be the hardest to eradicate.  The fact that you had a RVR at week 3 is VERY important.  Your age is also to your advantage.  Good luck to you.  All my best, Aiuta

[NYgirl]

You just put that so perfectly I am going to copy and paste that somewhere.  I've never read it so perfectly explainned and I never could have done it (I just ramble ramble and try).

Thanks Auita - I think my mother might finally be able to understand what I was trying to explain to her!

There might only be a few left but they are the hardest stupid ones to kill of them ALL!  I was EVR with a 3 log drop by week 4 and thought I had it MADE in the SHADE...but from week 4 to 24 I just could NOT kill of those stubborn ones!

I couldn't explain to her no matter how hard I tried what that meant but now thanks to you I think I can!

Debby

[jmjm530]

"..These last virions can be the hardest to eradicate"
-----------------
I'll give poetic license, but not sure this has been medically substantiated. In fact, it appears in many cases that non-detectible shortly follows a very low viral load while under treatment. As to low pre-tx viral load being a positive factor with SVR -- we know there have been exceptions here in the discussion group, but large studies have shown that your chances of SVR are better with a low pre-treatment viral load, not more difficult as may have been suggested, if it was suggested, not exactly sure.

All the best,

-- Jim

[aiuta]

Deb, Thank you very much for your note.  It put a HUGE smile on my face, esp. as, after I wrote mine, my RibaRaged-racing mind was thinking of all the other things I should have said better or differently.  I'm about to walk out the door to work and you got my day going in a much better direction knowing I've already been useful to a fellow human being.  Have a great day.  You are SO almost there!!! All my best, Aiuta

[BLESSEDHEPPER]

again my Dr. is a GI. He didnt order a BX b4 TX.. He said there was no need, cuz my ALT was at 16.
QUESTION:
Can you tell if your acute with a BX?
Should I have gotten a BX done?
Is it to late?

[jmjm530]

My understanding is that dx acute cases is part medical, part circumstantial. Acute cases are generally not biopsied because little or no liver damage is assumed. On the other hand, you can have little or no liver damage and not be acute, therefore I doubt if biopsy would have any definitive diagnostic value.

All the best,

-- Jim

[NYgirl]

I just don't remember - why does the doctor think you are acute...did you have a needlestick or something recently that you are sure caused this?

Sorry my brain is just so SLOW in these last weeks of treatment...(not that I was ever that 'fast' before :)

[aiuta]

You make a good point about those "last virions."  Frankly, I don't know the "right" answer.  When I called a hepatologist in Europe to report that my VL had gone down (pre-tx)from 3,143,000 to 3,500 (4 logs in 6 weeks), though, the response was "good luck in getting rid of those last guys; they can be very hard to get rid of."  At the time, I thought, "Gee, thanks for being excited for me," but now I understand.  It IS interesting to note, that, while I went down 4 logs in 6 weeks during the earlier part of the acute phase, I only went down 1 log in the last 6 weeks of the acute phase (VL's 3500, 4140 and 140).  It has led some Dr's to wonder if there was a plateau and movement toward chronicity in me.  Of coures, in the end, whatever I say is only my OPINION.  Hope you are well.  All my best, Aiuta

[jmjm530]

My comment was directed toward getting rid of the "last guys" on the treatment drugs, not by getting rid of them with an unaided immune system. I have no doubt that getting rid of "the last guys" may be more difficult without the drugs, although am really not up on this.

As to the plateau you experienced pre-tx, don't know if this has to do with being chronic (versus acute) or just the natural progression of an acute infection. This would be something you might want to run bu a hepatologist (or two) who has larger caseloads and therefore presumably more experience treating acute cases. You mentioned you are coming to NY soon and might want to set up a consult with Dr. Douglas Dieterich at NY's MT Sinai hospital. If this might work, I'd probably email him first with my stats and specific questions in advance. Another excellent clinician in the NE is Dr. Afdhal in Boston. Again, you might want to email him first to see if he can be of some help in putting your concerns into a clinical perspective.

All the best,

-- Jim

[jmjm530]

There's also Dr. Ira Jacobsen in NY but from accounts here he doesn't take insurance. I believe I read he charges around $600 for the initial consultation. Most of these guys are booked up months in advance HOWEVER if you make a compelling case to see them earlier, you often can get to see them in a matter of weeks. In your case, the compelling reason is that you need to make a critical treatment decision by such and such a date and therefore need an appointment prior.

-- Jim

[aiuta]

Thanks so much for your feedback and for the Dr.'s names.  I greatly appreciate both.  Unfortunately, I am already back on the West Coast, but I WILL save the names for when I move back to the East Coast next fall.  

As you know, there's not a lot of data on acute hep C, but some exists.  After consulting several hepatologists here and in Europe, I found that, in order to not treat, most Dr's wanted their patients to have spontaneously cleared by weeks 12-16 post-infection.  My Dr. said he was not comfortable treating me as an acute beyond the 20th week post-infection.  Some more aggressive Docs would begin tx right away and others, after the spike in LFT's/VL (occurred in me at week 6 post-infection), but it depends on the age, gender, overall health of the patient, and the opinion, philosophy and style of the doctor.  

In Europe they made a big deal of 40% of young women (<30) spontaneously clearing, but my doctor in the US wouldn't acknowledge more than 15-20%.  Gender is definitely an issue in acute stage clearance though.  I don't know how they'd pull it off, but a study of the immune and T cells responses of those who DO spontaneously clear, could be helpful, especially the women.  Why is it that more females spontaneously clear than males?  What's the difference?  If they figure out what works in the small percentage who do clear, couldn't that help them decide how to better treat the rest of us who don't?  Just a non-M.D. (probably overly idealistic) pipedream.  

THANKS AGAIN for the doctors' names and for your help, Jim.  I greatly appreciate your thoughts, experience and concern and I highly respect your opinion.

Most sincerely,

Aiuta