Aa
is it normal for doc to lower dose of interferon?
I just went for my 4wk visit. my platelets are fine but my white count is lowering (don't have numbers) and doc said if they keep going down he might lower the dose of my interf shot.
why? isnt a lower white count normal with tx? I feel like lowering dose is like taking a step backward; I just want to move forward! (btw: with my low brain cell count - I did not think to ask him why while I was there) plus i feel better about the info i rec'v from all of you who are living this.
PS: lightheadedness getting used to, nausea is settling down quite a bit. This damn itching and my hands getting numb are the worst! oh well....so i scratch...
why? isnt a lower white count normal with tx? I feel like lowering dose is like taking a step backward; I just want to move forward! (btw: with my low brain cell count - I did not think to ask him why while I was there) plus i feel better about the info i rec'v from all of you who are living this.
PS: lightheadedness getting used to, nausea is settling down quite a bit. This damn itching and my hands getting numb are the worst! oh well....so i scratch...
As of week 24, my WBC's where 1.6.. My Nuetrophils where down to 630 or so.. Dr told me not to worry, that they will fluctuate..
Califia, you got me hiding in my house with the Ionic breeze going, and throwing out all my fruit..LOL!
Califia, you got me hiding in my house with the Ionic breeze going, and throwing out all my fruit..LOL!
Laika asked this question on 3/10 and there was a lengthy and useful discussion. Maybe bring it up via Google?
In general most hepatologists let the counts drop lower than your average oncologist would; liver patients on the combo seem not be as threatened by infection as cancer patients are. A WBC of 1.5 or below and/or an ANC of <500 might make you a candidate for Neupogen. So that's pretty low indeed, and if you're in that range you need to be avoiding raw fruits and vegetables, large crowds of people, ungloved gardening, and so on.
Dose reduction of interferon should be avoided but may not necessarily hurt your SVR odds. Latest research presented at the EASLD showed that total ribavirin intake over the course of therapy was actually more important than the total amount of interferon.
I
In general most hepatologists let the counts drop lower than your average oncologist would; liver patients on the combo seem not be as threatened by infection as cancer patients are. A WBC of 1.5 or below and/or an ANC of <500 might make you a candidate for Neupogen. So that's pretty low indeed, and if you're in that range you need to be avoiding raw fruits and vegetables, large crowds of people, ungloved gardening, and so on.
Dose reduction of interferon should be avoided but may not necessarily hurt your SVR odds. Latest research presented at the EASLD showed that total ribavirin intake over the course of therapy was actually more important than the total amount of interferon.
I
i'm gonna try the archives for that thread u mentioned on 3/10. if not there i'll try and google
thanks!
thanks!
i am determined to go forward....
as always thank you muchly for all the info.
peace out
<3michelle
as always thank you muchly for all the info.
peace out
<3michelle
Whoa...thanks for reminding me Califia, I checked my "archives" and found this info I'd saved from TriHepGuy & (I believe)you. So Chellski, here's what a couple of great minds have to say as of 2 months ago:
THG: The general intervention vs. dose reduction protocol (bearing in mind this can vary greatly from doctor-to-doctor) seems to be:
- put a patient on Neupogen when their WBC is in the 1.5 or below range and/or when their ANC (Absolute Neutrophil Count) is in the 750 or below range.
- put a patient on Procrit when the Hg is around 10.
- and the level of greatest concern regarding platelets is anything near or below 20,000.
In regards to clearance and SVR, there is never any advantage in lowering dosage of either interferon or ribavirin - only the potential for disadvantage. I would make sure to ask your doctor at which blood level results for the above tests that he will intervene with Neupogen and Procrit. And tell him that your preference is to have him act pro-actively (i.e. - before the levels creep too low) with the goal of maintaining dosage level throughout tx. The only reason to lower dosage is if there is a continuing problem AFTER attempting Neupogen or Procrit. Otherwise they are playing it overly cautious or are out-of-step with what is now standard Hep C tx protocol. Your goal is to be on this once, giving it the best shot available. And that 'best shot' includes Neupogen and Procrit, should they ever be needed.
Here are a couple of papers related to low WBC/ANC (a/k/a - neutropenia):
(this is a PDF file) - Neutropenia during combination therapy of interferon alfa and ribavirin for chronic
hepatitis C
(from the paper):
"In conclusion, neutropenia is frequent during treatment of hepatitis C with interferon and ribavirin, but it is not commonly associated with infections. These results suggest that patients with constitutional neutropenia probably can be treated safely and may not require dose modification. These findings support a revision of current criteria for exclusion and dose modification based on white blood cell counts in the treatment of hepatitis C. These modifications would expand the proportion of patients who could receive interferon-based therapy for hepatitis C."
Threshold for neutropenia in the adjustment of interferon treatment in HCV infection
(from the paper):
"Based on these preliminary data, it can be concluded that the onset of neutropenia during combination therapy with interferon and ribavirin is not associated with subsequent infection, even in patients with post-hepatitis C cirrhosis. However, changing the dose of interferon affects the likelihood of achieving a sustained virologic response."
Califia (I think): As for this WBC issue, a few points of clarification:
Neutropenia, which is defined as an absolute neutrophil count of <1000/mm, is a side effect of interferon, not ribavirin. Hepatologists tend not to be overly concerned about low WBC counts, as there is little evidence of infections developing amongst hepatitis patients on treatment, unlike cancer patients doing chemotherapy. If you should need medication for this, however, you would be assigned Neupogen.
Now, as for Procrit: (two early signs of Hepatologists tend to prescribe Procrit when the patient complains of breathlessness or dizziness anemia) at Hgb levels which other doctors might consider normal, i.e. around 11. But keep in mind that Hemoglobin is always looked at in relationship to Hematocrit. If your Hgb is a bit low, but the Hematocrit is in the middle of normal range, you're probably not in need of medication. Your physical symptoms are the proper determinants here.
The lab reports should indicate the normal ranges, as they vary slightly from lab to lab. Just know that both your WBC's and your platelets have to drop very, very low levels before anyone will get excited. I know someone with 36,000 platelets who is being kept on tx. (Normal is roughly 140-400, measured in thousands.) The danger zone is reached when platelets drop below 20,000 per microliter.
Hope this helps! And good luck tomorrow.
white blood cells 3.3 (3.8--10.8 thous/mcl), platelets 120 (140--400 thous/mcl) and absolute neutrophils 1172 (1500--7800 cells/mcl).
Chellski: My experience has been a little like yours & the others too. My wbc's & absolute neutrophils go down and then seem to stabilize. Meanwhile, my dr mutters that if they go any lower, may have to put me on Neupogen. It may just continue to be muttering, as they may not get low enough to require anything special. And apparently, it may not be a disaster if your interferon is lowered. But as TriHepGuy said, "there is never any advantage, just the potential for disadvantage".
So... there are some things to think about.
Laika
THG: The general intervention vs. dose reduction protocol (bearing in mind this can vary greatly from doctor-to-doctor) seems to be:
- put a patient on Neupogen when their WBC is in the 1.5 or below range and/or when their ANC (Absolute Neutrophil Count) is in the 750 or below range.
- put a patient on Procrit when the Hg is around 10.
- and the level of greatest concern regarding platelets is anything near or below 20,000.
In regards to clearance and SVR, there is never any advantage in lowering dosage of either interferon or ribavirin - only the potential for disadvantage. I would make sure to ask your doctor at which blood level results for the above tests that he will intervene with Neupogen and Procrit. And tell him that your preference is to have him act pro-actively (i.e. - before the levels creep too low) with the goal of maintaining dosage level throughout tx. The only reason to lower dosage is if there is a continuing problem AFTER attempting Neupogen or Procrit. Otherwise they are playing it overly cautious or are out-of-step with what is now standard Hep C tx protocol. Your goal is to be on this once, giving it the best shot available. And that 'best shot' includes Neupogen and Procrit, should they ever be needed.
Here are a couple of papers related to low WBC/ANC (a/k/a - neutropenia):
(this is a PDF file) - Neutropenia during combination therapy of interferon alfa and ribavirin for chronic
hepatitis C
(from the paper):
"In conclusion, neutropenia is frequent during treatment of hepatitis C with interferon and ribavirin, but it is not commonly associated with infections. These results suggest that patients with constitutional neutropenia probably can be treated safely and may not require dose modification. These findings support a revision of current criteria for exclusion and dose modification based on white blood cell counts in the treatment of hepatitis C. These modifications would expand the proportion of patients who could receive interferon-based therapy for hepatitis C."
Threshold for neutropenia in the adjustment of interferon treatment in HCV infection
(from the paper):
"Based on these preliminary data, it can be concluded that the onset of neutropenia during combination therapy with interferon and ribavirin is not associated with subsequent infection, even in patients with post-hepatitis C cirrhosis. However, changing the dose of interferon affects the likelihood of achieving a sustained virologic response."
Califia (I think): As for this WBC issue, a few points of clarification:
Neutropenia, which is defined as an absolute neutrophil count of <1000/mm, is a side effect of interferon, not ribavirin. Hepatologists tend not to be overly concerned about low WBC counts, as there is little evidence of infections developing amongst hepatitis patients on treatment, unlike cancer patients doing chemotherapy. If you should need medication for this, however, you would be assigned Neupogen.
Now, as for Procrit: (two early signs of Hepatologists tend to prescribe Procrit when the patient complains of breathlessness or dizziness anemia) at Hgb levels which other doctors might consider normal, i.e. around 11. But keep in mind that Hemoglobin is always looked at in relationship to Hematocrit. If your Hgb is a bit low, but the Hematocrit is in the middle of normal range, you're probably not in need of medication. Your physical symptoms are the proper determinants here.
The lab reports should indicate the normal ranges, as they vary slightly from lab to lab. Just know that both your WBC's and your platelets have to drop very, very low levels before anyone will get excited. I know someone with 36,000 platelets who is being kept on tx. (Normal is roughly 140-400, measured in thousands.) The danger zone is reached when platelets drop below 20,000 per microliter.
Hope this helps! And good luck tomorrow.
white blood cells 3.3 (3.8--10.8 thous/mcl), platelets 120 (140--400 thous/mcl) and absolute neutrophils 1172 (1500--7800 cells/mcl).
Chellski: My experience has been a little like yours & the others too. My wbc's & absolute neutrophils go down and then seem to stabilize. Meanwhile, my dr mutters that if they go any lower, may have to put me on Neupogen. It may just continue to be muttering, as they may not get low enough to require anything special. And apparently, it may not be a disaster if your interferon is lowered. But as TriHepGuy said, "there is never any advantage, just the potential for disadvantage".
So... there are some things to think about.
Laika
this happened to me at about the same point you are. and then 2 more times after, they never lowered my dose, and watched my wbc which did come back up.
There is a med called Neupogen which you can take to boost white cell counts. Lowering your interferon dose may keep you from achieving the goal for which you are undergoing this treatment: stopping the hepC virus.
You need to get with your dr and let him know that, should your white cell counts get too low, you will require Neupogen instead of lowering your interferon dose. Most of us on treatment have lowered white cell counts...how low is the issue. Someone will come by with that info I'm sure...I forget what the number is when you need to bring on the Neupogen. Cuteus knows this stuff. Meantime get a copy of your lab work...you're going to need to get squared away on this. You don't want to "wait & see" and end up with a lowered dose.
Laika
You need to get with your dr and let him know that, should your white cell counts get too low, you will require Neupogen instead of lowering your interferon dose. Most of us on treatment have lowered white cell counts...how low is the issue. Someone will come by with that info I'm sure...I forget what the number is when you need to bring on the Neupogen. Cuteus knows this stuff. Meantime get a copy of your lab work...you're going to need to get squared away on this. You don't want to "wait & see" and end up with a lowered dose.
Laika
I had this happen a few times when my white cell count was getting nead 'dangerously' low. What would happen is I would have another blood test the follwoign week and if they hadn't imroved the next step was to lower my dosage. EWach time thay improved so I never actually had to get my dose lowered. Hope this is your scenario as well!
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