ALT vs. Viral Load

[reluctant]

Greetings to the info heroes of this forum...getting clear info from a doctor is often difficult. I am finishing week 5 and the news seems to be good. To recap: I am genotype 2, have probably had the virus for 19 years, biopsy revealed stage 1-2, I was never sick or had overt symptoms from the virus. My viral load was 2 million and my ALT count fluctuated between 200-250.

After week 1 of Tx my ALT was 118, after week 2 it was 61. A few days ago my bloowork revealed my ALT was 30. The doctor says this shows evidence that I was "responding to treatment" and claimed there would be no reason to test my viral load until after treatment was over at week 24. Are ALT enzyme levels sufficient evidence to make this claim? Should I demand a viral load test at some given week? Isn't it viral load that determines if someone has in fact "cleared" the virus?

I don't want to be pushy with the doctor; he has been quite kind and supportive. His point is that regardless of viral load levels, we would continue to week 24 anyway. I guess I am looking for more reassurance that this is working.

Thanks again for your advice.

Tim

[mikesimon]

Yes, viral load testing is the only definitive test to determine whether you are clear of the virus. That being said, I think you can find great comfort in your rapidly decreasing ALT. Furthermore,  as a genotype 2 your chance of viral eradication (SVR) is very good at around 80 - 85 per cent. Add to that the short treatment length and I think you are okay to wait if your doctor is unwilling to order a PCR. If I were you Id push for one at 12 weeks and then, of course after treatment. But I do think the ALT reflects that the tx is working at least insofar as ongoing liver inflamation and/or damage is concerned and I think you can probably assume that your viral load is decreasing as well. I know the stress and the need for reassurance and if your doctor is as supportive as you say I would think that if you make your anxiety known to him he'll order labs if only to give you peace of mind. But, bottom line, I think you're doing great. Good luck. Mike

[PhilaGuy]

Hi Tim:  My situation is simiar to yours in terms of genotype, length of infection, etc.  Today I do shot 17/24 (woo hoo, getting closer!).

I think every doc is different, and everyone's situation is different (not necessarily right or wrong).  I get some flack in here sometimes because my doctor didn't have me get a biopsy, but becasue of my situation and his experience he thought it was the right thing to do, and much of the literature I've read backs him up.

At week 4, my ALT and AST returned to normal and I was undetectable.  He checks my viral load everytime I get my blood counts done (every month now) and they've been undetectable since shot #4.

Anyway, part of the reason I didn't get a biopsy was that I was genotype 2b (one of the most responsive to treatment) and, most importantly, I was determined to treat.  If your liver function is improving and you're determined to go all 24 weeks, I would imagine checking your viral load may not be necessary until the end.

Some folks feel it's important to know where one stands at any given moment, but while it may satisfy your curiosity,it may not have a completely necessary medical rationale behind it.  However, it seems that most docs check viral load at at least 12 weeks into treatment, and getting it done then would probably egg you on to complete treatment.  If you develop some problems that brings ending treatment into the equasion, you may want to know your viral load - if you have become undetectable, that knowledge will help inform your decision about whether to continue or not.

Just my two cents.  Best of luck to you!

[PhilaGuy]

Yeah, what Mike said!  :-)

[Amerabrit]

Sounds as though you are in great shape, best of luck to you!

[jonihs]

If you are taking Pegasys/Copegus, my P.A. told me that Roche states in it's info to physicians that for 2's and 3's, PCR is not necessary until week 20. However she very hurridly tols me she would not put me through the stress of not knowing, because we don't need extra stress on tx. So she did 4 week, 12 week, and my then at the end of tx. another 1. I don't think I'd have been sane if I had had to wait 20 weeks, let alone 24.  Joni

[TnHepGuy_]

Current protocol is to viral load test all people on tx, regardless of genotype, at week #12. ALT may be a good 'indicator' of a positive response to tx, but it is absolutely no substitute to learning if you have serum clearance. Why is knowing that at week #12 important for geno 2's? Most geno 2's will clear more quickly than other genotypes. Many are clear by week #4, as a matter of fact. Let's say, for example, that there is a genotype 2 patient who responds, but more slowly than usual, and doesn't fully clear by week #12. In that case, both the patient and the doctor would benefit from learning that information to better make a decision on if there is reason to extend tx beyond the standard 24 weeks. That kind of information cannot be gleaned from ALT testing.

If I were in your shoes, I'd push for a PCR test as soon as you can - anywhere from now until week #12 - to learn if you are clear, near clear or still have a ways to go. The information you get will help you make decisions for the rest of your tx - and potentially put your mind at ease.



TnHepGuy

[MichaelT]

You are having an excellent biologic response to treatment. You would not have this if the viral load wasn't being well suppressed.

At least 4 PCRs should be done: 1) pre-tx, 2) 12 weeks, 3) a really sensitive one at end of tx, and 4) 6 months post tx.

[new-sojourn]

For heaven sakes, insist on a test.  I cl'ed a transfused infection of 35yrs in 18 days!  My doc wanted to test @ 2wks b/I couldn't get in to the city until day 18.  that was nearly 2 1/2 yrs ago.  It certainly made tx go by w/o a problem.  I could relax and concentrate on healing my liver not killing the virus.

There is no set time on when to have the tests.  Obviously.  My specailist routinely checks his 2's @2wks b/c he says, if its gonna work, it already has by 2wks.  Go figure.  B/why wait?  Avoid all the depression and uncertainty and the AD's and the Monday morning quarterbacking.  You'll know that you won the war and are just mopping up the stragglers and proping up the liver.

[couchpotato]

I am also genotype 2 but because of that my doctor said no viral load testing was needed. I was going to treat it anyway because of the high success rate so he didn't think it was necessary. I have also never had a PCR test and have only seen him once since starting tx and I am finished on Sept. 3 (Sept.9 counting the riba). My ALT levels have been unchanged since starting tx at 40 (304 before tx) and last ALT was 24. (150 before). Must be working right?

Can anyone tell me when the right time is for a PCR test after finishing? I can't get in to see him till October 5 (a whole month post TX) but my very young inexperienced GP can see me Sept. 20. Who should I try and see?? And do the tests take a week or so to come back? Probably just nerves acting up that's making me anxious ot do the test, maybe it's better to wait awhile??? Ummmm??  Thanks.

Couch

[TnHepGuy_]

Generally, a test is given at the end of tx, at 3 months, 6 months and 1 year post. Given that you are at the end of your treatment, I'd ask for a qualitative test. This is a more sensitive test than the quantitative (i.e. - viral load test) and will tell you one of two things - no, I don't have the virus replicating in my blood stream or yes, I do. It doesn't measure the quantity of virus, though. That type of testing would only come into play if you ended up testing postive on the qualitative.

If you want to learn sooner - have your GP order the test.

Generally it takes from 3-10 days to get results. It all depends on what lab is doing the testing. And how good your doc's office is about getting back to patients with results.


TnHepGuy