Aa
Labs - Requesting input please
So here are my labs from Pre-Treatment through the 24th of February. Needless to say, I am a bit anemic I have asked what they plan to do at this point. I'd like to see a 200 mg ribavarin dose reduction before I have to get on the procrit (which was mentioned). I am asking for input from anyone who would like to weigh in on this. I'd like to have my proverbial ducks in a row before I go for my shot on Friday. I am looking very pale, cannot get warm, hear whooshing sounds in my ears, have a constant bleeding (not gushing, just bleeding) nose and generally feel like crud. Interestingly enough, I felt great on Saturday and Sunday and feel like I have tanked since then.
Labs from the past couple of weeks
Before tx (Nov 2011)
Vl 4.2mil
AST 35
ALT 43
WBC 5.0
RBC 4.35
Hmg 15.5
Platelet 229
1/24/2012
AST 33
ALT 33
WBC 3.5
RBC 4.51
Hmg 15
Platelet 148
1/30/2012
AST 38
ALT 40
WBC 2.9
RBC 3.97
Hmg 13.2
Platelet 111
2/10/2012
AST 46
ALT 54
WBC 2.0
RBC 3.34
Hmg 11.0
Platelet 123
Viral Load Undetected 2/10/2012
2/17/2012
AST 33
ALT 46
WBC 3.0
RBC 3.15
Hmg 10.4
Platelet 125
2/24/1012
AST 34
ALT 48
WBC 2.5
RBC 2.83
Hmg 9.5
Platelet 145
Labs from the past couple of weeks
Before tx (Nov 2011)
Vl 4.2mil
AST 35
ALT 43
WBC 5.0
RBC 4.35
Hmg 15.5
Platelet 229
1/24/2012
AST 33
ALT 33
WBC 3.5
RBC 4.51
Hmg 15
Platelet 148
1/30/2012
AST 38
ALT 40
WBC 2.9
RBC 3.97
Hmg 13.2
Platelet 111
2/10/2012
AST 46
ALT 54
WBC 2.0
RBC 3.34
Hmg 11.0
Platelet 123
Viral Load Undetected 2/10/2012
2/17/2012
AST 33
ALT 46
WBC 3.0
RBC 3.15
Hmg 10.4
Platelet 125
2/24/1012
AST 34
ALT 48
WBC 2.5
RBC 2.83
Hmg 9.5
Platelet 145
mykids & Looking Forward:
The Riba dosing reduction question may have slightly different implications without the addition of the DAA's( in other words now in the cases of treating G2 & 3)
Below is from 2010 when there only was INF/Riba therapy being practised
Best to you...
Will.
http://www.mjhid.org/article/view/5582/html_30
Summarizing, erythropoietic agents appear to be effective in increasing haemoglobin level, allowing maintenance of the RBV dose and improving the quality of life for the period of time they are used. However, their effects on early and sustained viral response remain uncertain, as do the duration of treatment, optimal dose, and reference level of haemoglobin. Identifying patients with pre-existing anaemia and those at high risk of developing anaemia during anti-HCV treatment facilitates the individualisation of PEG-IFN/RBV therapy with lower RBV dosing or earlier growth factor support.
Possible indications for therapy with rHuEPO include a fall in haemoglobin level by > 4 g/dL, haemoglobin levels of 11 g/dL and not the return to pre-treatment levels [60]. The first evidence of a response to rHuEPO administration is an increase in the reticulocyte counts within ten days. If no response occurs in 6-8 weeks despite an appropriate increase in the dose, therapy with erythropoietic growth factors should be discontinued.60 If the rate of increase of haemoglobin content with erythropoietic agents therapy is > 1 g/dL over two weeks, rHuEPO dose should be decreased because of association with increased risk of thromboembolic phenomena. Once an adequate haemoglobin level (between 10-12 g/dL) is achieved, RBV dose can be increased to the optimum level. Once started, adjunct rHuEPO therapy may be required until the end of treatment.
Disadvantages of these agents are that they adds another parenteral drug to the patient’s treatment regimen, thereby increasing the costs, inconvenience and potential side-effects. The rHuEPO agents are costly, but when compared with standard care, their use has recently been shown to be cost-effective in managing HCV, by increasing therapeutic compliance, improving the quality of life and avoiding the complications of chronic liver disease [61].
The Riba dosing reduction question may have slightly different implications without the addition of the DAA's( in other words now in the cases of treating G2 & 3)
Below is from 2010 when there only was INF/Riba therapy being practised
Best to you...
Will.
http://www.mjhid.org/article/view/5582/html_30
Summarizing, erythropoietic agents appear to be effective in increasing haemoglobin level, allowing maintenance of the RBV dose and improving the quality of life for the period of time they are used. However, their effects on early and sustained viral response remain uncertain, as do the duration of treatment, optimal dose, and reference level of haemoglobin. Identifying patients with pre-existing anaemia and those at high risk of developing anaemia during anti-HCV treatment facilitates the individualisation of PEG-IFN/RBV therapy with lower RBV dosing or earlier growth factor support.
Possible indications for therapy with rHuEPO include a fall in haemoglobin level by > 4 g/dL, haemoglobin levels of 11 g/dL and not the return to pre-treatment levels [60]. The first evidence of a response to rHuEPO administration is an increase in the reticulocyte counts within ten days. If no response occurs in 6-8 weeks despite an appropriate increase in the dose, therapy with erythropoietic growth factors should be discontinued.60 If the rate of increase of haemoglobin content with erythropoietic agents therapy is > 1 g/dL over two weeks, rHuEPO dose should be decreased because of association with increased risk of thromboembolic phenomena. Once an adequate haemoglobin level (between 10-12 g/dL) is achieved, RBV dose can be increased to the optimum level. Once started, adjunct rHuEPO therapy may be required until the end of treatment.
Disadvantages of these agents are that they adds another parenteral drug to the patient’s treatment regimen, thereby increasing the costs, inconvenience and potential side-effects. The rHuEPO agents are costly, but when compared with standard care, their use has recently been shown to be cost-effective in managing HCV, by increasing therapeutic compliance, improving the quality of life and avoiding the complications of chronic liver disease [61].
I am not sure. If you access the article, I believe it is just referencing treatment with Incivek or Victrelis. As I have never done SOC I really wouldn't know. Either willbb or hrsepwrguy (is that right? brainfog here) would be best equipped to answer that question.... or pooh or OH.
Here is the information from AASLD:
The updated AASLD guidelines refer clinicians to the drugs’ labeling, or detailed package insert, for information on managing side effects, although the guidelines authors do provide their own guidance on managing anemia. Anemia is a common side effect from ribavirin and the HCV protease inhibitors. During hepatitis C treatment, if anemia develops, people are either treated with a red blood cell growth factor, such as Procrit (erythropoietin), or given a lower dose of ribavirin. The authors noted that cure rates were similar no matter which strategy was used to manage anemia. Since growth factors are costly and add side effects, AASLD recommends reducing the ribavirin dose to manage anemia while maintaining full-dose Incivek or Victrelis.
http://www.hepmag.com/articles/incivek_victrelis_aasld_2501_21290.shtml
(there REALLY needs to be an edit function on these posts!)
The updated AASLD guidelines refer clinicians to the drugs’ labeling, or detailed package insert, for information on managing side effects, although the guidelines authors do provide their own guidance on managing anemia. Anemia is a common side effect from ribavirin and the HCV protease inhibitors. During hepatitis C treatment, if anemia develops, people are either treated with a red blood cell growth factor, such as Procrit (erythropoietin), or given a lower dose of ribavirin. The authors noted that cure rates were similar no matter which strategy was used to manage anemia. Since growth factors are costly and add side effects, AASLD recommends reducing the ribavirin dose to manage anemia while maintaining full-dose Incivek or Victrelis.
http://www.hepmag.com/articles/incivek_victrelis_aasld_2501_21290.shtml
(there REALLY needs to be an edit function on these posts!)
Im ready to die my hair (what I have left) and call myself snow white. Very pale here also. Look like I live in a cave. LOL
Oh, and what bothered me is if it were 9.5 last Friday, goodness knows what it is today. I just felt like I tanked yesterday all of a sudden.
Armed with this information and also the article found here: http://www.hepmag.com/articles/incivek_victrelis_aasld_2501_21290.shtml
I called my doctor this afternoon, and as of now, my riba has been reduced by 200 mg. I will see him on Friday. I was going to take this up with him last week at my appointment, but he left before I got my shot. I believe he had the Procrit in mind already, according to the NP. I sent four emails in quick succession this afternoon with information from the AASLD and the Incivek site.
I wish I had known I could reduce this morning! I started to do it on my own, but am trying to be the compliant (albeit informed) patient.
Thanks for the input.
Signed:
The ghost (which is what I look like - pale enough to be mistaken for English!)
I called my doctor this afternoon, and as of now, my riba has been reduced by 200 mg. I will see him on Friday. I was going to take this up with him last week at my appointment, but he left before I got my shot. I believe he had the Procrit in mind already, according to the NP. I sent four emails in quick succession this afternoon with information from the AASLD and the Incivek site.
I wish I had known I could reduce this morning! I started to do it on my own, but am trying to be the compliant (albeit informed) patient.
Thanks for the input.
Signed:
The ghost (which is what I look like - pale enough to be mistaken for English!)
I also refused procrit because I had five weeks left. Spoke with pharmacist at speciality pharmacy and as with all drugs procrit does have side effects. The biggest one from what she said was high blood pressure along with a laundry list of others. If I had not been so close to the end I would have done it for sure! Reduced riba from 1000 to 800 and as I just posted holdling my own at 9.5 and not feeling that bad at all. I dont think I will be running the gasparilla road race on sunday but can do the stairs without fainting. Three more weeks!!!!!!!! :)
Hi Lookingforward, I agree with Willbb. I also had HGB drop to 7.4 and reduced Riba and started Procrit, I eventually had to stop the Riba altogether for more than two weeks. I am now 8 weeks post Tx and I am still undetec. with regards to Procrit: I don't understand why so many people are hesitant to use it. It doesn't have any sides and can make a difference by keeping you on Riba. Best of luck to you - It will all be worth it if you clear this virus!! - Fred
You have anemia (<!0 ) and the porper protocol is to "slightly" reduce Riba by 200 mg. increments until HGB stabilizes (especially after one is UND.).
Since the 10th of this month (just about 3 weeks ago) when your HGB was at 11 and had been steadily dropping is when your doctor should have had a definite plan in place to deal with anemia and conversed with you about it and then initiated that plan on the 17th when you became anemic.
If your doctor has not addressed this with you and has no plan in place,possibly a referal to a knowledgeable doctor that understands the situation better would be warrranted..
Good luck...
Will.
Since the 10th of this month (just about 3 weeks ago) when your HGB was at 11 and had been steadily dropping is when your doctor should have had a definite plan in place to deal with anemia and conversed with you about it and then initiated that plan on the 17th when you became anemic.
If your doctor has not addressed this with you and has no plan in place,possibly a referal to a knowledgeable doctor that understands the situation better would be warrranted..
Good luck...
Will.
MY DR did not reduce my till I was 8.6 and he started me on procrit. Personally I thought he was a little slow to make the changes. Some DOCs make changes a lot sooner.
Many have had to do Riba reductions due to anemia, so hopefully they can que in with their personal experience.
Considering your Hgb is already below 9.5, I agree with your thoughts on the Riba reduction of 200 mg. I'd call your trt doctor today/tomorrow to discuss this rather than waiting until Friday, since this is protocol for trt with Inc. Your platelets look good, wbc (ANC?) are ok for now. But the anemia needs to be addressed quickly with a possible combination of Riba reduction and addition of Procrit. Discuss with the doc asap. Good luck
And Congrats on the UND!!
And Congrats on the UND!!
My husband's doctor reduced Riba to 800 when his Hgb hit 11.2, and plans to keep it that way as it doesn't impact SVR once you're UND, as I understand it. He has managed to avoid anemia, and as a matter of fact, now that he ended INC, his numbers shot back up. My two cents would be to ask for an immediate Riba reduction to see how that impacts your numbers, unless there's a good reason to keep it at the same level. I'm sorry :(
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