hemolytic anemia

[benefitsdonna]

hello, 6 wks into treatment, procrit 2 weeks, hemoglobin still low @ 8.3, riba reduction to 400 beginning yesterday.  talking transfusion monday.

thoughts please.  genotype 2, on pegasys and riba

[ahmedgnz]

From studies I've read done by John Hopkins (see http://www.hivandhepatitis.com/hep_c/news/2011/0111_2010_a.html)
there's a silver lining to early-onset hemolytic anemia during Pegasys/Ribavirin treatment.
At least in patients with the less responsive Genotypes 1a and b it seemed to indicate a better chance of sustained viral response (that is of remaining virus free six months after treatment) after protocol completion. The study also found that reduction in Ribavirin dose did not negatively affect SVR either as previously thought, and that the use of Procrit (which often takes a bit to jumpstart red blood cell creation) allowed hemolytic anemia patients to weather the rough patch and complete treatment effectively. I'm in the same boat, too. So I would say, hold on to the gunwale and ride it through!

[Idyllic]

I am not sure if bordering on cirrhosis, being Geno 2a & 2b and having to stop treatment the first time at week three qualifies you as "difficult to treat" or not. This is from the VA web site. It is dated 2006:

Rules For Adjusting Therapy According To CBC Changes:

If you scroll through the link at each Hgb level one of the suggestions at each juncture (even at the first level, "Hgb 10-11 g/dL"): is
♦ Candidates for Recombinant Erythropoietin Criteria for Use for Hepatitis C Treatment-Related Anemia.

It is actually a PDF file called, "Recombinant Erythropoietin Criteria for Use for Hepatitis C Treatment Related Anemia."

http://tinyurl.com/8plgh3b

There is a section that says:
Although evidence to determine the best indications for erythropoietin are unavailable, use of erythropoietin may be considered prior to dose reduction in the following situations:
1. Documented evidence of cirrhosis
2. Post liver transplantation
3. HIV co-infection

I figure it may be a tad dated as well since the goals of therapy are
1. Resolution of severe anemia with target Hgb 12g/dL
2. Maintain target Ribavirin dose (80% of original dose)
☞ This would put you at 800
3. Reduce need for transfusion &/or hospitalization
4. Increase energy, activity & overall quality of life
5. Enhance treatment adherence

____________________
Lastly, The Clinical Care Options web site has a small study and an article titled, "Treating HCV-infected Patients at High Risk of Anemia."

http://www.clinicaloptions.com/Hepatitis/Treatment%20Updates/Ribavirin%20Analogues/Modules/easlsatsym_benhamou/Pages/Page%205.aspx

It does not address SVR per se. Rather, it merely points out, "These studies suggest that addition of epoetin alfa to maintain ribavirin dose could be an option, particularly for patients with progressive fibrosis, who are difficult to treat.

These data may give hope to many patients who have experienced treatment failure as a result of suboptimal ribavirin dosing."

To me the operative words are "suboptimal ribavirin dosing"

Finally, the real question is what it asks in the conclusion, " Should epoetin alfa be used as preemptive therapy or as curative therapy?"

And to that I say I agree 100% with Can-do's post that mentions Melissa Palmer:

Side effects are seen in almost 80 percent of people treating with peginterferon and ribavirin. As patients we need to recognize these symptoms early on in order to avoid discontinuation or a dose reduction in therapy. Compliance to HCV treatment is an important factor for achieving SVR.
_______________

I do not know how long you are going to treat but I really hope the Procrit kicks in and raises your Hgb to where you are able to take your prescribed dose of Ribavirin. Who knows, initially it might help administering Procrit every five days - or something along that line.

I hope you can find a groove with your dose and frequency of Procrit and avoid transfusions. The other reason is that (to me) it gets harder and harder to rebound every time Hgb plunges. The first time my Hgb dropped to 8.1 was in week 13 or so. I was basically OK because I did not know my Hgb was that low. There is no way I could handle a drop like that at week 37.

Feel better and hang in there!!

[benefitsdonna]

thank you all for your support.  other than the anemia and a little nausea, side effects have not been too bad...other than i am grouchy, but i gguess who wouldn't be.  we go through alot with this disease.  it has taught me alot, and i look at life entirely differently today than i did 7 years ago.

I would like to say congrats to all of us fighting this thing and hoping we beat this beast!

[benefitsdonna]

Can-do  you are absolutely correct.  i cannot quit, so i have to do everything i can to stay on.  I have to say they are watching me very closely and am in pretty much daily contact with dr.  i believe they are doing a good job in seeing me thru.  while i am quite reluctant to have a blood transfusion since i know it is a temporary fix, i willl do it in order to take more riba.  they will test again at week 8.  I am happy i was able to complete my 6th injection!  wasn't that lucky last time.  i guess with the temporary dose reduction, if i am still undetectable at week 8 that will be a good sign.  I am not quitting....no matter what.

[can-do-man]

Being you have both 2a and 2b and your right at being cirrhotic, plus this is your third try at treatment.... Your doctor needs to do everything possible to see you succeed, time is running out....... Wishing you the best

[goater]

The procrit took about two full weeks to begin raising my Hgb.  With your 2nd dose only 3 days ago maybe you are just now starting to turn the corner and will stabilize soon.  Wow, you're a tough one.  I'd have trouble raising my head off the couch with those numbers.

A transfusion sounds appropriate with an 8.3 and would provide almost immediate relief to you.  I would hesitate reducing Riba any futher if possible and other options are available.   After you stabilize maybe your doc will consider raising Procrit from 40,000 to 60,000/wk for maintenance.

Excepting other cardiac issues, your heart rate is likely high to compensate for the decreased Hgb in circulation due to the hemolytic anemia.   If the HR remained low the body wouldn't be adequately oxygenated.  

Hope you feel better soon, marty

[can-do-man]

Its always been my understanding that dose reducing under just SOC is not a great ideal....
-------------------------------------------

Side effects are seen in almost 80 percent of people treating with peginterferon and ribavirin. As patients we need to recognize these symptoms early on in order to avoid discontinuation or a dose reduction in therapy. Compliance to HCV treatment is an important factor for achieving SVR.




What we know is 100% compliance with the peginterferon and ribavirin regime always produces better results than 80 or 90% compliance.
From : Melissa Palmer, MDClinical Professor of MedicineDepartment of Hepatology

[benefitsdonna]

i was on 5 riba/pay until hgb started to drop.  then 4.  2nd shot of procrit, on wed., but heartrate is up to 85-95 bpm....blood pressure low as well.  talking to dr. monday.  i am very hesitate about blood transf. but i do not want to stop or reduce treatment.  am seeing a very very slight difference in the way i feel, but still very weak.  worried about the pulse rate.

[jules2551]

"From what I have always heard the priority is reduce ribavirin 1st, Procrit 2nd and transfusion last. But it is up to the doctor and his experience. "
*************
Maybe it's time to change protocol since I have seen less than stellar results in riba reduction.  Maybe they should try Procrit lst, transfusion 2nd, and then if all else fails reduce Riba.  (JMHO)

She's only in wk 6 but UND @ wk 4.  Riba has been reduced yesterday down to 400mg.  What was the original dosage amount?  

[HectorSF]

Are you undetectable?
From what I have always heard the priority is reduce ribavirin 1st, Procrit 2nd and transfusion last. But it is up to the doctor and his experience.

Has the Procrit helped at all?

Of course it will take time for the reduced dosage of ribavirin to take effect.


Hang in there! I hope that can get back up soon!
Hector

[benefitsdonna]

btw, i am undet. at week four.