Hemaglobin

[Prepycp]

I am in week 10 and my Hemaglobin dropped to 8.4. At what level do they recommend a transfusion? I am almost always tired and can't walk up more than 5 steps without stopping.

[Dee1956]

Great post!  Very informative

[Resilient_Mimi]

I have had a shot called Procrit that built my hemoglobin back up, after one shot a week for 3 weeks this brought my #'s back up enough to continue.

[Idyllic]

In an 18 July post you indicated your Hgb was 9.3 and you had been on Procrit two weeks and you stopped taking 400 Riba at night for a couple of days. You mentioned you are UND since week 4 (Congrats on the by the way!!).  Did your doctor increase your Riba back to the 1000?

I think you should discuss altering your Procit dose to once every five days rather than once a week &/or ask about increasing your Procrit dose to 60,000 units (assuming it is currently 40,000)

In the Procrit Dosing it says:
"Use the lowest PROCRIT dose sufficient to reduce the need for red blood cell (RBC) transfusions [see Warnings and Precautions (5.1)]."

Ideally you are are taking Procrit to avoid a transfusion. It looks like your doctor is implementing the standard intervention for haemoglobin when it drops below 10 g/dL but now he needs to individualize (or tweak) your dose.

You still have a chance for your haemoglobin to rebound if you call your doctor and ask about these things tomorrow. Why wait until you feel worse and your HGb drops lower and then assume your doctor is going to opt of a transfusion. He could possibly adjust your Ribavarin again. It may be out of your comfort zone to have to initiate the subject but your doctor will only know you are struggling unless you tell him.

I ended up having to administer Procrit once every five days when my Hgb dropped to 8.1. The minute I knew the Procrit was on the way I increased my Riba back up to 1000 so that is the reason it took a few weeks longer for my Hgb to reach a functionally comfortable level.

http://dailymed.nlm.nih.gov/dailymed/mobile-simple/lookup.cfm?setid=0c721ba4-ae19-417f-aae1-221ed1a0866a
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This article is on the Clinical care Options Web Site in a Module titled
Managing Adverse Effects With Boceprevir- or Telaprevir-Based Therapy
(I removed the Boceprevir info)

In telaprevir clinical trials, erythropoietin use was prohibited and anemia was managed through RBV dose reductions. In a pooled analysis of patients from the ADVANCE and ILLUMINATE trials, 12% of patients (44 of 361) who had hemoglobin reductions to < 10 g/dL required blood transfusion vs 5% of those from the control arms (5 of 92).[60]

In the same pooled analysis of treatment-naive patients in ADVANCE and ILLUMINATE, RBV dose modifications (reductions or interruptions) were not associated with lower rates of SVR in patients who were treated with a telaprevir-based regimen.[60] Anemia appeared to have no association with SVR rates. By contrast, anemia as well as RBV dose reduction was associated with lower SVR rates in patients treated with pegIFN/RBV only (Figure 14).

Figure 14. ADVANCE/ILLUMINATE: SVR by anemia and ribavirin dose reduction.[60]
http://www.medhelp.org/user_photos/show/287176?personal_page_id=1282072

Panel Recommendations
• Modest RBV dose reduction (200-mg increments) is a good approach for managing anemia in boceprevir- or telaprevir-treated patients, as it does not appear to affect response. Some clinicians may choose to use erythropoietin, particularly for severe or symptomatic anemia. However, use of erythropoietin for HCV anemia is off label, and care should be taken to not allow the hemoglobin to exceed 12 g/dL.

• Use of erythropoietin may be necessary to avoid discontinuation of boceprevir or telaprevir. Transfusion may be required for patients and can be effective, particularly for cirrhotics. Once boceprevir or telaprevir has been stopped, it should not be restarted. Best clinical judgment should be used. Boceprevir and telaprevir must not be dose reduced.

1. The proper protocol is to reduce ribavirin to 600 mg when hemoglobin is less than <10 g/dl. (* One 200 mg tablet in the morning and two 200 mg tablets in the evening).

2. Discontinue Ribavirin Tablets if: <8.5 g/dL.

Once Ribavirin tablets  have been withheld due to either a laboratory abnormality or clinical manifestation, an attempt may be made to restart Ribavirin tablets at 600 mg daily and further increase the dose to 800 mg daily. However, it is not recommended that Ribavirin tablets be increased to the original assigned dose (1000 mg to 1200 mg).

"In the same pooled analysis of treatment-naive patients in ADVANCE and ILLUMINATE, RBV dose modifications (reductions or interruptions) were not associated with lower rates of SVR in patients who were treated with a telaprevir-based regimen. Anemia appeared to have no association with SVR rates."


The CCO info is in another post about this topic:
http://www.medhelp.org/posts/Hepatitis-C/risks-with-procrit/show/1644480
and this link:
http://www.clinicaloptions.com/Hepatitis/Treatment%20Updates/HCV%20New%20Agents/Module/Practical_Guide/Pages/Page%206.aspx