Aa
Dose reduction
i got a call today from my DR telling me that my HGB has dropped to 8.7. I have been on Procrit for 2 months (40,000 units). 3 weeks ago, they increased my dose to 80,000 units. well it doesn't seem to be doing anything. so now they want me to reduce my Riba to 600 mg/day and INF to 135 mcg. i'm currently at week 16 of TX. i feel the normal symptoms of low HGB, and it has gotten worse in the past 2 weeks. they want me to continue with the 2 doses of Procrit, but i don't think it's doing much for me. at what HGB level is a transfusion required? other than dose reduction, is there any other option?
i asked if i could cut a Riba pill in half and do the 300mg at night, and she said i could. i get weekly CBC's and i do think they are on top of my situation. so right now the dose is 900mg/day of Riba, and 135mcg of INF/day.
this is what i was afraid of. it sux.
i was UND at 12 weeks and i want to stay that way.
i asked if i could cut a Riba pill in half and do the 300mg at night, and she said i could. i get weekly CBC's and i do think they are on top of my situation. so right now the dose is 900mg/day of Riba, and 135mcg of INF/day.
this is what i was afraid of. it sux.
i was UND at 12 weeks and i want to stay that way.
i didn't mention that they reduced the INF to 135U, from 180U. she seems to think that it might be the reason. either way i feel so much better. i actually have some color. was startin to look like Casper the Unfriendly ghost. Booooooooooooooooo
I'm with Dave on this, I find it odd that your nurse thinks it's the INF when your HGB goes up after a riba reduction. B12 deficiency makes some sense if your HGB is low - my doc put me on B12 and folic acid when my hgb dropped. So it's good they're testing for B12...though my doc didn't bother, just put me on it assuming low hgb meant a need for B12. No matter..testing won't hurt at all.
Back on full dose this weekend would be great....and glad that you're feeling better!
Trish
Back on full dose this weekend would be great....and glad that you're feeling better!
Trish
it seems strange that your nurse thinks the fin is causing the anemia since you went up a point since you reduced your rbi.
Regardless, I am glad to hear that you are feeling better. Besides the increase in HGB, your body will compensate to some extent after being anemic for a while. I hope you are able to maintain the hgb with an increase in rbi.
Good luck,
Dave
Regardless, I am glad to hear that you are feeling better. Besides the increase in HGB, your body will compensate to some extent after being anemic for a while. I hope you are able to maintain the hgb with an increase in rbi.
Good luck,
Dave
Glad to hear your hgb went up. It's amazing what a difference one point makes!!!
Hang in there, Unc!
Hang in there, Unc!
it's been one and a half weeks on the dose reduction and my HGB is up to 9.8 and i feel so much better. my NP thinks it's from the INF, and not the riba, that's causing my anemia. i hope to be at full dose this weekend. anemia is not fun. i'm diggin this low dose of riba tho. i hate the riba. they also feel i might have a B12 deficiency, so my next blood work will include a test for it.
18 weeks down and almost half way there....woooohooo
18 weeks down and almost half way there....woooohooo
Wow, I'm really sorry you're having to go through this. I can't imagine what it must feel like for you to have HGB that low. I'm sorry the Procrit doesn't seem to be doing its job. I think you started right before me if I recall. I had to cut back to every two weeks because it was working too well. And the damn stuff hurts going in so I'm sorry you're having to deal with that annoyance without it really even doing what it's supposed to do.
Best of luck to you. Really. I thought I was going to jump ship when mine was 9.7. I can't imagine what the 8's feel like.
June
Best of luck to you. Really. I thought I was going to jump ship when mine was 9.7. I can't imagine what the 8's feel like.
June
thank you to all for the great answers and support.
I decided to go with 600 Riba for a couple of days and then bump it to 900 until the HGB improves. I hope it does, cuz this doesn't feel to good.
sidenote: i am taking the Procrit on Sunday and Wednesday, as I was told it doesn't go with the INF very well.
I decided to go with 600 Riba for a couple of days and then bump it to 900 until the HGB improves. I hope it does, cuz this doesn't feel to good.
sidenote: i am taking the Procrit on Sunday and Wednesday, as I was told it doesn't go with the INF very well.
That's what *she* said. Short and concise - that's me! At least it keeps me from missing the 11:00 News.
I admire how concise you are, I wish I could think that way. Instead it takes me 12 paragraphs of rambling and 4 posts to express myself. :)
When it looked like procrit wasn't working for me my doc put me on 1 gram of folic acid daily. At one point I did dose reduce riba - and the hgb rebound was very quick. Going on a foggy memory - the hgb interference that riba causes happens as it's metabilized. Once metabolized, it has a long halflife. Thus, a brief dose reduction can boost hgb values, without severely impacting your riba's anti-viral assault.
Good luck.
Good luck.
My HGB dropped to 7.5 and platelets dropped to 31, that's when I reduced dose and went in for the blood transfusion. (At that point Procrit was not an option for me) After the transfusion my HGB went up to 9.7 and platelets to 35.
Did your Dr. say reduction would be temporary until HGB went back up?
I know you must be feeling like cr@p right now, for me it felt like my body was encased in cement and my head was in the clouds.
Hang in there and don't give up! -Rhonda
Did your Dr. say reduction would be temporary until HGB went back up?
I know you must be feeling like cr@p right now, for me it felt like my body was encased in cement and my head was in the clouds.
Hang in there and don't give up! -Rhonda
I don't mean to suggest that temporary riba reduction is preferable in general. I'm referring only to you and your situation and for right now, as your hgb is at 8.7 and you're already on 80,000 of Procrit. Not too many options left at that point as you're getting close to transfusion level. Transfusion is okay if you end up needing one but goal is to stay away from that also if you can. Quite a balancing act between all the various bits, isn't it. I personally resisted riba reductions as much as possible but sometimes there is little choice. Hang in there.
Trish
Trish
Good that this is occurring after Week 12. Good that they've increased your procrit. Are they having you take it 80,000 at once or two doses a week at 40,000? A one-week dose reduction of ribavirin after Week 12 has no impact so for this week, breathe easy. The impact of dose reductions beyond that are based on the length and amount of dose reduction. You've got some room yet with the aim being to get back to normal as soon as possible. I got hit with a riba dose reduction at Week 13 so I understand the concern. I was back to regular dose the next week when the one week allowed my levels to come up just enough and we started Procrit at that point. I never did have another riba dose reduction after that one week. INF another matter but had nothing to do with the riba reduction so won't go there.
I would ask for an iron panel asap, I echo Dave on that. Procrit is less effective when iron levels are low. My docs had me on Folic acid and B12 with the procrit - can't hurt, might help and might want to talk to your doc about that.
I would ask for weekly CBC's the next while if you aren't getting them already. Once dose reductions became a reality, I started weekly CBC's at Week 13 - 15 as I was always skirting the edges with either hgb or white counts and the weekly CBC's continued until the end of treatment which ended up being Week 34 for me - due to white counts, not hgb.
Overall, try not to panic. 8.7hgb is getting really low and one week dose reduction is not going to hurt you at Week 16 so you can breathe easy - maybe literally breathe a little easier, if you can bring that count up some with a temporary riba reduction along with increase in procrit.
Please keep us posted how it's going and good luck with this.
Trish
I would ask for an iron panel asap, I echo Dave on that. Procrit is less effective when iron levels are low. My docs had me on Folic acid and B12 with the procrit - can't hurt, might help and might want to talk to your doc about that.
I would ask for weekly CBC's the next while if you aren't getting them already. Once dose reductions became a reality, I started weekly CBC's at Week 13 - 15 as I was always skirting the edges with either hgb or white counts and the weekly CBC's continued until the end of treatment which ended up being Week 34 for me - due to white counts, not hgb.
Overall, try not to panic. 8.7hgb is getting really low and one week dose reduction is not going to hurt you at Week 16 so you can breathe easy - maybe literally breathe a little easier, if you can bring that count up some with a temporary riba reduction along with increase in procrit.
Please keep us posted how it's going and good luck with this.
Trish
Although I would guess you feel like hell, you are still most likely in the safe zone. of course only the right doctor can determine that for you. I thought all this information might be helpful to you if it keeps going south.
Best to you,
Dave
Best to you,
Dave
http://www.wadsworth.org/labcert/blood_tissue/redblood.htm
"The American Society of Anesthesiologists Task Force on Blood Component Therapy recommendations1 based on hemoglobin concentration are:
Hemoglobin > 10 g/dL -- transfusion is rarely indicated.
Hemoglobin 6-10 g/dL -- indications for transfusion should be based on the patient's risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors.
Hemoglobin < 6 g/dL -- transfusion is almost always indicated."
"The American Society of Anesthesiologists Task Force on Blood Component Therapy recommendations1 based on hemoglobin concentration are:
Hemoglobin > 10 g/dL -- transfusion is rarely indicated.
Hemoglobin 6-10 g/dL -- indications for transfusion should be based on the patient's risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors.
Hemoglobin < 6 g/dL -- transfusion is almost always indicated."
My hgb was in the high 7s and low 8s for many months during treatment. I finally had to stop treatment early at 43 weeks because my hgb went to 7.0 while taking 40,000 units of procrit every 4-5 days.
My trial required tx to stop if hgb went below 7.5 and transfusions were not permitted if I wanted to continue treating. I never transfused, even when it went to 7.0 You should be carefully monitored by your doctor at this point and you should probably be having CBCs often to insure that you are safe. For me activity became almost non-existent.
Although most guidelines I have read say that transfusions for healthy people who are not elderly or have heart disease is 7.0 or below, the risk for heart attack and stroke is truly elevated when in the 7s. Many people have survived even lower hgb then the 7's, but then the risk starts going through the roof.
http://www.venturafamilymed.org/Documents/Heme%20and%20Chemo%20Guidelines/Hematology/rbc%20transfusion.pdf
"There is no absolute level of hemoglobin for which transfusion is reflexly indicated. In healthy persons a shift to anaerobic metabolism occurs at hemoglobin levels of 7.5g/dl or lower. Gradual development of anemia leads to a number of compensatory adjustments that maximizes tissue oxygen delivery. These include decreased oxygen affinity of hemoglobin due to increased 2,3-diphosphoglycerate, increased cardiac output and decreased plasma pH. Patients with co-morbid problems such as CHF, coronary artery disease, peripheral vascular disease and ischemic cerebral vascular disease may have symptoms of poor tissue oxygen delivery with hemoglobins as high as 10 that may be improved by blood transfusion. As with any guideline, risks and benefits must be weighed for each individual patient using one’s experience and clinical judgment."
My trial required tx to stop if hgb went below 7.5 and transfusions were not permitted if I wanted to continue treating. I never transfused, even when it went to 7.0 You should be carefully monitored by your doctor at this point and you should probably be having CBCs often to insure that you are safe. For me activity became almost non-existent.
Although most guidelines I have read say that transfusions for healthy people who are not elderly or have heart disease is 7.0 or below, the risk for heart attack and stroke is truly elevated when in the 7s. Many people have survived even lower hgb then the 7's, but then the risk starts going through the roof.
http://www.venturafamilymed.org/Documents/Heme%20and%20Chemo%20Guidelines/Hematology/rbc%20transfusion.pdf
"There is no absolute level of hemoglobin for which transfusion is reflexly indicated. In healthy persons a shift to anaerobic metabolism occurs at hemoglobin levels of 7.5g/dl or lower. Gradual development of anemia leads to a number of compensatory adjustments that maximizes tissue oxygen delivery. These include decreased oxygen affinity of hemoglobin due to increased 2,3-diphosphoglycerate, increased cardiac output and decreased plasma pH. Patients with co-morbid problems such as CHF, coronary artery disease, peripheral vascular disease and ischemic cerebral vascular disease may have symptoms of poor tissue oxygen delivery with hemoglobins as high as 10 that may be improved by blood transfusion. As with any guideline, risks and benefits must be weighed for each individual patient using one’s experience and clinical judgment."
I feel for you my friend. You can't take more procrit then you already are, you have to dose reduce at least for now. Has your doctor ordered an iron panel for you? Although it is not good to take iron if not needed when one has hcv or is treating, it can prevent the procrit from working if it is low. I had mine checked during tx and it was normal.
Here is the information from the manufacturer of procrit:
http://www.procrit.com/
"Prior to and regularly during PROCRIT® therapy, monitor iron status; transferrin saturation should be ≥ 20% and ferritin should be ≥ 100 ng/mL. During therapy, absolute or functional iron deficiency may develop and all patients will eventually require supplemental iron to adequately support erythropoiesis stimulated by PROCRIT®."
Here is the information from the manufacturer of procrit:
http://www.procrit.com/
"Prior to and regularly during PROCRIT® therapy, monitor iron status; transferrin saturation should be ≥ 20% and ferritin should be ≥ 100 ng/mL. During therapy, absolute or functional iron deficiency may develop and all patients will eventually require supplemental iron to adequately support erythropoiesis stimulated by PROCRIT®."
I hope that extra procrit kicks in for you soon... sorry to hear you're dealing with this. My husband was a 'slow' responder to procrit too, and he had to be transfused twice before the 80,000 IUs weekly started to work; for him it took about a month dosing twice a week before it started to impact the anemia. Being that you are undetected, the lowered dose should have minimal impact on your SVR odds but should certainly work quickly to give your hgb a lift.
As far as 'when' transfusion is indicated, there is some variance. My understanding is that most hepas will consider transfusing tx patients once hgb dips to 8.0 or lower, but it's not a hard-and-fast guideline and does vary from doctor to doctor as well as from patient to patient. My husband was transfused the first time at hgb of 7.3, but when his cardiologist heard about it, he flipped on the hepas, and drew a new guideline to transfuse if hgb remained below 10.0 for more than 2 weeks. Hope that helps some; hang in there! ~eureka
As far as 'when' transfusion is indicated, there is some variance. My understanding is that most hepas will consider transfusing tx patients once hgb dips to 8.0 or lower, but it's not a hard-and-fast guideline and does vary from doctor to doctor as well as from patient to patient. My husband was transfused the first time at hgb of 7.3, but when his cardiologist heard about it, he flipped on the hepas, and drew a new guideline to transfuse if hgb remained below 10.0 for more than 2 weeks. Hope that helps some; hang in there! ~eureka
Sorry to hear you are having such a hard time. My hgb fell very low to early on in treatment and I was dosed reduced. I, like you, was already UND. Try not to worry over something you have no control over. I believe from what I have read if you are tanking that low it is a sign your body metabolizing the drug well and you are receiving enough the eliminate the virus. I was dosed reduced throughout much of my treatment.
I am unsure as to when transfusions would begin.
I just posted my 12 week post which was UND! Stay positive!
I am unsure as to when transfusions would begin.
I just posted my 12 week post which was UND! Stay positive!
I think you will be fine reducing the Riba since your are Und. It is so built up in your system by now that is will keep doing it's job with lower dose. best of luck
That truly suxx, Unc, having to reduce, but you are getting into that danger zone - even the the hefty Procrit dose. One good thing is that you are already UND and hopefully your dose reduction will be short-lived. Are your WBC's or platelets runing low to act on a INF reduction too?
Spectda (Dave) if I remember right, has been experiencing the ultra low blood counts too, so perhaps he will chime in here with some personal experiences.
Every dr. has their guidelines for blood tranfusions on yx, mine wouldn't let it get lower than low 8's. You must be feeling pretty crummy by now - even when I was in the mid-to upper 8's, I felt as bad as I looked.
Hang tight and hope your labs improve soon! Pam
Spectda (Dave) if I remember right, has been experiencing the ultra low blood counts too, so perhaps he will chime in here with some personal experiences.
Every dr. has their guidelines for blood tranfusions on yx, mine wouldn't let it get lower than low 8's. You must be feeling pretty crummy by now - even when I was in the mid-to upper 8's, I felt as bad as I looked.
Hang tight and hope your labs improve soon! Pam
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