Hepatitis Researcher or Anyone one else with a good idea

[St. George]

How would someone taper off Infergen at the end if they were taking 15 mcg daily the entire treatment?  Would they taper off a few months leading up to the end of their 48 week treatment or might they finish up the entire 48 weeks at full dosage(15 mcg) and then have a 1-2 month extension which would be used to taper down?  Any thoughts anyone?

[jmjm530]

Just want to clarify that "foreign doctor/foreign journal" remark, before someone take it the wrong way. What I meant was that this concept is obviously well known in this country by some leading treatment doctors such as M.Shiffman which answers the question St. George asked -- why don't our doctors know? Well, they must know. At least Shiffman does and his collegues do.

[jmjm530]

While you were posting I was just muddling through the full-text of that very article. Apparently the trick was googling "gradual withdrawal" instead of "taper".
Full text avail here: http://www3.interscience.wiley.com/cgi-bin/fulltext/106594360/PDFSTART

The study is indeed interesting from a number of points of view. Of minor but not insignificant interest is that this 1996 study was without ribavirin or pegalayted interferon and the tapered group treated 48 week total compared to the non-tapered group which only treated 24 weeks.

But of more interest to me, is really St. George's reaction "  Holy ****!!!!  Why don't our doctors know about this study.

Dr. Mitchell Shiffman, author, is not an obscure foreign doctor writing for obscure journals. He's a major player on cutting edge treatments and has numerous papers out on treatment, re-treatment protocols, including his tutorials on the Clinical Care Options Web site.

Because of this, like St. George, the question has to be asked why isn't Shiffman or others touting tapering now? Previously, I had thought because it hadn't been studied but obviously it has, which begs the question has Shiffman or others furthered these studies with current meds? If I was treating now, I'd probably be motivated to zip off an email to Shiffman (hint to ST. George :) )and ask what work has been (or hasn't been) done since and what's his current position on tapering. He may have some data at hand. Data that I was looking for when my EOT came about and data I never found. Certainly an interesting topic that now seems even more interesting.

-- Jim

[St. George]

The above study stated they tapered very slowly at the rate of one dosage cut per month, so how does that relate to the info you gave earlier about the weekly reduction of 16,8,4...?  Would slow cuts every month be more advantageous?

[St. George]

Holy ****!!!!  Why don't our doctors know about this study.  This taperin down ould change so many lives due to the resulting SVR's.  This info needs to be in the hands of every gastro doc in the U.S.

[Hepatitis Researcher]

If you do all the heavy lifting and want to shift it to another crew, you better transfer the burden gradually - the other party needs to come into function slowly.

Tapering IFN has indeed been compared to abrupt stopping:


Hepatology. 1996 Jul;24(1):21-6.

Improved sustained response following treatment of chronic hepatitis C by gradual
reduction in the interferon dose.

Shiffman ML, Hofmann CM, Luketic VA, Sanyal AJ, Contos MJ, Mills AS.

Hepatology Section, Medical College of Virginia, Richmond, Va 23298, USA.

Interferon (IFN) treatment of chronic hepatitis C virus (HCV) is associated with
a high rate of relapse. IFN is thought to exert its effect against HCV via direct
viral inhibition and immune stimulation. We have hypothesized that relapse
following termination of therapy results from the sudden withdrawal of this
immune modulatory effect and that gradual reduction in the IFN dose may decrease
the incidence of relapse. One hundred six patients with chronic HCV were enrolled
into this 24-month controlled, randomized prospective trial. All were treated
with 5 mU of interferon-alpha-2b three times a week for 6 months. Patients who
achieved biochemical response were randomized to either stop or taper IFN
gradually at monthly intervals as follows; 3 mu, 2 mU, 1 mU, and 0.5 mU (all
three times a week). 0.5 mU twice weekly and then once weekly. Liver histology
was assessed by Knodell index and HCV RNA was measured by a quantitative
polymerase chain reaction (PCR) assay. Of the 92 patients who completed the
initial 6 months of IFN treatment, 47 (51%) achieved biochemical response.
Twenty-one of these patients were randomized to stop IFN treatment and 25 to
taper (1 drop-out). At randomization patients were well matched with respect to
age, sex, race, serum alanine transaminase (ALT), and liver histology.
Biochemical relapse was observed in 19 of 21 (91%) patients who stopped IFN
treatment compared with only 60% who tapered IFN (P= .04).

Virological relapse
occurred in 90% of patients who stopped and only 48% of persons who tapered IFN
therapy.

At completion of the 24-month study patients who achieved long-term
sustained biochemical response had a significantly lower mean Knodell score (3.5
vs. 6.5) and a significantly greater number were HCV RNA negative in serum (85%
vs. 18%) compared with relapsers.

We conclude that gradual reduction in IFN dose
is associated with a  SIGNIFICANT HIGHER RATE OF SUSTAINED RESPONSE and clearance
of HCV RNA from serum compared with abruptly stopping treatment. This in turn is
associated with a significant improvement in hepatic histology supporting the
premise that response to IFN therapy can prevent progression to cirrhosis.

[jmjm530]

As a companion thought to my last post -- if tapering was important to guard against relapse -- and given the natural taper of Peg (2-3 weeks) -- wouldn't we then expect to see more relapses after week 4 as opposed to more relapses before week 4? What we do find is that around 90 per cent of relapses occur by week 4.