injections

[mumovsix]

when treatment starts where are you injected and can you do it yourself

[DH Bill]

I started in my belly area but I got a big red spot each time I injected which can be normal so I started in my thigh. Like you say we guys don't always have a lot of fat there like our bellys so I have to be careful but I didn't like a red belly big is bad enough ha ha.
Bill

[willing]

Hi Bob - researchers analyzing why tx does/doesn't work group the reasons into a 4 classes: tx factors (inadequate dose/duration, mono vs peg, adherence), host/disease factors (weight, age, race, stage of fibrosis, hiv coinfection) and viral factors (the genomic sequence of the strain you're infected with, the virus' actual Gs, As, Us and Cs). One of HCV's tricks for survival is the ability to shut-down the "intruder-alert" mechanisms kicked off by IFN - it's the equivalent of wrapping the alarm in a blanket before breaking into a store -it still goes off but no one hears it (<a href="http://mustafa.ingentaselect.com/vl=10264471/cl=23/nw=1/fm=docpdf/rpsv/cw/mal/08828245/v15n1/s9/p95">see</a>.
How successful your particular strain is in evading interferon has a lot to do with the likelihood of successful tx - and  the success of the early predictors studies suggests this can be measured pretty early on.

Also, for those interested in extended tx, I'd forgotten DITTO hcv included a 72 week arm. Here's their <a href="http://www.abstractsonline.com/viewer/viewAbstract.asp?CKey={6837D9F9-800E-4CA5-AD71-B6A8693DB0E6}&MKey={201E3AB1-B366-4CFC-879B-196DF41D3A21}&AKey={704CF973-D8A8-4909-A16B-9F7D9FB76BC7}&SKey={B95B7700-4CCE-45A4-8AB0-70F91E33D429}">abstract</a>. Their result weigh in on the side of the Buti and Teravic studies : slow responders can expect a smallish incremental improvement from 72 weeks. It's looking more like the Berg study didn't show any benefit because they lumped everyone together : if your're a rapid responder, or a flat or null responder extented tx won't help. If you're a slow responder it helps a little (40%->46% in DITTO's case). The Teravic <a href="http://www.abstractsonline.com/viewer/viewAbstract.asp?CKey={99753635-F7E5-49BB-BB9A-63350891B720}&MKey={201E3AB1-B366-4CFC-879B-196DF41D3A21}&AKey={704CF973-D8A8-4909-A16B-9F7D9FB76BC7}&SKey={B95B7700-4CCE-45A4-8AB0-70F91E33D429}">study</a> used a different definition of "slow response": still detectable at week 4. When their SVR data comes in (they might have some to present at the conference) the extended-tx picture will be a little clearer. My bet is they'll be in agreement with the DITTO results. This should be good news for those committed to longer tx..

[ral]

Hi willing

"we can will the virus out of our body whereas in fact the outcome is primarily determined by factors (primarily the actual sequence of our virus) over which we have zero control and which are apparent early on".


Willing when you say sequence, do you mean response time?

Thanks

Bob

[willing]

since the aasld conference  started yesterday the press embargo has been lifted and the conference <a href="http://www.abstractsonline.com/viewer/browseOptions.asp?MKey=%7B201E3AB1%2DB366%2D4CFC%2D879B%2D196DF41D3A21%7D&AKey=%7B704CF973%2DD8A8%2D4909%2DA16B%2D9F7D9FB76BC7%7D">abstacts</a> will now start appearing in the advocacy press. It's worth reading the abstracts directly since  you get a little more information. On the other hand the news article sometimes has the benefit of quotes made by the presenters. Here's Avidan Neumann's <a href="http://www.abstractsonline.com/viewer/viewAbstract.asp?CKey={96AB3686-2C23-497C-AD8A-DE9119E5C337}&MKey={201E3AB1-B366-4CFC-879B-196DF41D3A21}&AKey={704CF973-D8A8-4909-A16B-9F7D9FB76BC7}&SKey={D0015512-E667-480F-A367-EF109BA6BF10}">abstract</a>. He's been tinkering with early viral predictors for about 3 years now and the two composite ones he's presenting this year are the best ones yet (but can you imagine the calculation questions  on this forum??)

Personally, I'm a big believer in early predictors. I think that as tx grinds on and on and on we tend to make the mistake  of thinking that as long we grit our teeth hard enough and push on we can will the virus out of our body whereas in fact the outcome is primarily determined by factors (primarily the actual sequence of our virus) over which we have zero control and which are apparent  early on. The massive effort of long tx of  makes relapse all the harder. The insurance companies will of course try to profit, but the flip side is that as the anti-fibrotic benefits of ifn become better quantified it may be easier to get coverage regardless of viral eradication.

[ral]

Ak

Great article, thanks. This was a very interesting comment especially considering what I am going thru right now

"Rapid viral responders were prospectively defined as patients whose HCV RNA declined by at least 99% during the first month of treatment. The study found that in this sub-group, even the most difficult-to-treat genotype 1 patients could achieve 83% SVR. A relatively high SVR rate (71%) was obtained even for the rapid responding patients treated with ribavirin for only the first 6 weeks instead of the standard regimen of ribavirin during the whole peginterferon treatment of 48 weeks. These SVR rates are similar to that achieved by genotype 2/3 patients (88%), who traditionally have been easier to treat".

Thanks Again

AK

[AK - Hepper]

You're welcome...I wouldn't mind getting off this ribavirin myself!
I found that at the fox news website, search word hepatitis c, there was another article today concerning how the body fights off hepc, they found something they think will help in the search for a vaccine.

[new-sojourn]

I might of been part of that study.  I was just F54 w/all the lab work going to several different sites.  My doc was really insistant on testing @2wks, I went in on 18d since I live over a mt range & had to arrange things-b/anyway, I had cl'd (2b) and all doc said was that if it (tx)was going to work, it would have worked by then and it had worked.  Good job.  Finish tx, see ya in 2mo.  So that's what I did.  So it was very easy to finish, since I already had the prize.

[britgirl]

Interesting article, thanks.

[BethUK]

There is a lady who comes here who only managed 17 weeks on the treatment and is SVR

[MajNeni]

Hi, AK,
When you're sitting, then the side of the thigh has the muscle pretty close to the surface, even in people w/extra "flesh".  Pears, like myself.  So I can easily stab myself in a very tender area there...
I'll have to try to hold a little pressure on the shot-site after shots; lately I'm covered with 1/8" purple spots where I've been (peg+procrit+neupogen = 5 shots/week).  Time to play "Connect the dots" again, as I used to with the Pegasys hockey pucks... but they were much more impressive.
Well, I'm just so glad it's not bathingsuit season anymore!  All you poor people in that hot old South... with all that eye-straining sunshine... we don't have to deal with all those problems up here!  Just send us your frozen vegies and fruits, and we'll get by...
Maj Neni

[ral]

Let me finish computer?

Anyway getting of Riba sooner would not be a bad thing or hurt my feelings.

Bob

[MajNeni]

Ak, this sounds terrific.  Here comes my cynical side, though:  I would still want the decision to treat/stop be between the patient and the doctor.  I would not want HMO's and insurance schemes to define 4 weeks as the stop/go benchmark...

About injection locations:  I started on the tops of my thighs, tried the abdomen (staying at least 1-2" away from the navel, of course) and was immediately convinced it is much less painful doing them on the belly.  However, I'm lucky enough to need Procrit and Neupogen shots, too, so I have to use my thighs as well... The nurse told me the pain-sensitive nerves are concentrated on top of the thigh in a fairly straight line, roughly from the edge of your pelvis straight down to the center of your kneecap.  If you go a good inch left or right of that line, you're more likely to avoid hitting a painful spot.

To clarify LVD's comment, as you're going in at an angle (~45) with the shot, make sure the beveled hole of the needle is facing up.  You can see where that is by squeezing out a TINY drop of medicine before you inject.  This squirts the medicine in sideways, and it is easier to absorb (~less painful).  Some people chill the injection site with an icecube prior to injecting.

[ral]

I agree on the insurance issue totaly. The whole system in away is set up to keep them in business thank FOD when  we get ill and they are there. You don't hear of to many insuance companies going belly up. I have a group plan for me and my employees and the major companies tried to pull out of the Colorado western slope. So far they have been made to stay by legislature..


Bob

[AK - Hepper]

I can just see all the insurance cos. drooling on that report right now.
Maj, they told me the thigh injection was better on the side of the thigh, but that didn't matter to me anyway, most guys don't have a lot of extra flab to work with in that area. I do, however, have plenty to spare in the belly region, so that's where I do my shots. I'm an apple, not a pear ;-)

[ral]

Interesting. Maybe they will find out we don't have to suffer so long. But then again it has brought us all together in a unique way so who knows? Getting of the Ri

[lackalustre]

another tip of mine that helped and hurt less with injections:
   instead of pushing/pressing the needle in just tap it in lightly with your index finger on the syringe top. (not the plunger) doesnt hurt much at all.

[AK - Hepper]

Boston, USA, October 24 /PRNewswire/ -- - Study of Patients' viral kinetics yields valuable information for treating physicians

The results of the largest viral kinetics study ever undertaken in hepatitis C (HCV) patients has found that the sustained virological response (SVR) to treatment with peginterferon alfa-2a (40KD)/ribavirin (PEGASYS(r)/ COPEGUS(r)) can now be predicted as early as week 1 or week 4 - by monitoring the pattern of how a patient's viral load declines. At the moment, patients have to undergo 12 weeks of treatment before finding out if it is likely to be successful.

The DITTO-HCV (Dynamically Individualized Treatment of Hepatitis C Infection and Correlates of Viral/Host Dynamics) study, an investigator initiated European Commission project, also found that although early individualization of treatment according to viral kinetics could work in principle when more treatment options are available, it was not possible to improve SVR rates more than the standard regimen of 24 or 48 weeks of PEGASYS(r)/ COPEGUS(r) with the treatment modifications that were tested.

The overall SVR for genotype 1 was 58% for standard treatment (peginterferon alfa-2a 180 mcg weekly plus 1000 - 1200 mg ribavirin daily for 48 weeks) versus 49% for individualized treatment. In genotype 2/3, the SVR was 87% for standard treatment versus 90% for individualized treatment.

"We discovered that one group of patients that we classified as 'rapid viral responders' have the best chance of a sustained virological response with the standard treatment," said Professor Stefan Zeuzem, Director of the Department of Internal Medicine at the University Hospital in Homburg, Germany and DITTO-HCV study investigator. "However, individualized treatment according to early viral kinetics did not improve on the sustained virological response that we can already achieve, since none of the treatment modifications improved the outcome of the patients that do not have a rapid viral response."

The conclusion of the study is therefore that the concept of individualization according to viral kinetics should be retested when better alternatives exist for those patients not rapidly responding to the peginterferon alfa-2a/ribavirin treatment.

Rapid viral responders have most promising results

Rapid viral responders were prospectively defined as patients whose HCV RNA declined by at least 99% during the first month of treatment. The study found that in this sub-group, even the most difficult-to-treat genotype 1 patients could achieve 83% SVR. A relatively high SVR rate (71%) was obtained even for the rapid responding patients treated with ribavirin for only the first 6 weeks instead of the standard regimen of ribavirin during the whole peginterferon treatment of 48 weeks. These SVR rates are similar to that achieved by genotype 2/3 patients (88%), who traditionally have been easier to treat.

"It is therefore critical for these rapid responding patients to be identified," said Professor Zeuzem.

New predictive criteria could move the 12 week stopping rule down to under a month

The DITTO-HCV study retrospectively identified two new criteria to classify rapid viral responders and predict the likely treatment outcome. For the DITTO-1st week criterion viral levels are measured at baseline and two times in the first week of treatment; while the DITTO-2nd slope criterion uses three measurements of viral levels between the second and fourth week of treatment.

"Both of these new criteria predicted who was and who was not likely to respond to treatment more accurately than the existing 12-week stopping rule. We had obtained 100% negative predictive value (NPV) and 90% positive predictive value (PPV) with these criteria," said Professor Avidan Neumann, from the Bar-Ilan University, Israel, and the DITTO-HCV study coordinator.

Using these criteria for stopping treatment in patients predicted early on not to respond will make treatment more cost-effective, even considering the added cost of the extra measurements of viral load.

"This is good news for patients and physicians. Using these new criteria, we will be able to very early, identify more of those patients who will ultimately not achieve an SVR so we can advise them to stop taking their medication, thus improving their quality of life," said Professor Neumann.

"We now know that tailoring treatment according to viral kinetics cannot improve SVR rates with the treatment choices we have at the moment. However, by measuring viral levels earlier in treatment, a test physicians are already familiar with, we can likely move the stopping rule currently defined at week 12 down to week 4 or even week 1 and avoid having patients who will not achieve an SVR being treated unnecessarily. These novel prediction algorithms will hopefully be confirmed soon by other clinical trials and their feasibility in clinical practice will be assessed, thus allowing us to optimise the treatment of hepatitis C patients," concluded Professor Neumann.

[Space Coast]

In the stomach and leg! Yes you do the injections yourself! And oh is it so much fun! #31 tomorrow!

[LvdByGod]

YOU GO TO THE DR. AND HE INSTRUCTS YOU ON HOW TO DO IT. MOST OF US INJECT IN THE THIGH OR STOMACH PER INSTRUCTIONS ON THE PEGYSYS. IF YOU ASK ME I CAN'T EVEN FEEL IT IN MY STOMACH. BUT, I OF COURSE HAVE PLENTY OF FAT THERE. THIS IS THE ONLY BENIFIT TO BEING FAT! ;) ALSO GO IN AT AN ANGLE WITH THE SHARPEST PART OF THE NEEDLE HEADING DOWN. IT SLIDES RIGHT IN AND THE NEEDLES ARE VERY TINY. AND YES WE DO IT OURSELVES OR HAVE ONE OF OUR LOVED ONES DO IT TO US. IF YOU HAVE SOMEONE ELSE DO IT TO YOU BE VERY CAREFUL OF NEEDLE STICKS AND HAVE THEM COME TO THE APT. WITH YOU TO LEARN HOW. I'M AFRAID TO HAVE MY HUSBAND DO IT BECAUSE I DON'T WANT HIM TO ACCIDENTLY POKE HIMSELF AND THEN GET HCV. bUT, IT'S REALLY NICE TO BE IN CONTROL OF IT YOURSELF ANYWAY AND YOU REALLY CANT FEEL IT IN YOUR STOMACH.  I AM THE BIGGIST PHOBIA OF SHOTS PERSON I KNOW. THE FIRST SHOT MAKES YOU ANXIOUS BUT WHEN YOU REALIZE IT DIDNT HURT AT ALL THEN THE NEXT ONE IS A BREEZE. I GO IN REALLY SLOWLY AND JUST PRESS A LITTLE AT A TIME AND I DONT FEEL IT AT ALL. MY DR. SAID TO "JAB" IT IN FAST AND THAT FREAKED ME OUT SO I LET HIM DO MY FIRST SHOT, BECAUSE HE WAS IMPATIENT WITH MY FEAR AND ANXIOTY. BUT I DID IT MY WAY THE SECOUND SHOT AND IT WAS ABSOLUTLY PAINLESS IN MY STOMACH. I AM AFRAID TO GO IN THE THIGH, NOT ENOUGH FAT THERE.HOPEFULLY I CAN KEEP DOING IT IN MY STOMACH.  GOD BLESS TO YOU, YOU ARE IN GOOD COMPANY. KEEP IN TOUCH, SANDI