Multiple Procrit injections at once or spread out through week?

[GrandOak]

For those doing more than 40,000 U of Procrit, which requires multiple injections because 40,000 U is the largest single vial dosage, do you inject them all in one sitting or spread them out over the week?

I'm on 100,000 U right now (yes 3 injections at once makes me feel like a pincushion or a watercan that's been shot with buckshot) and we looking at splitting that up to 50,000 U two time per week to even the level at which it is present in my system.  Yea, it means yet another injection per week, but hey it'd only be a maximum of 2 per sitting.

Has anyone else done this, or know of anything which indicates that a steadier level throughout the week is better than a single weekly boost at one time?

[jmjm530]

Yes, no need for iron supplementation there.

[GrandOak]

Actually those other iron tests were run too.

Ferritin 693 (20-400)
Iron 119 (40-150)
UIBC (Unstaturated) 256
Iron Binding 375 (245-400)
Iron % Staturation 32 (20-55)

So all look good and should allow Procrit to properly work.

[NYgirl]

When I was doing 80,000 Epogen I did 40k one day and 40k 3/4 days later.  when my hemo started to rise I switched to every 5 days and then the doc dropped me now back to once a week.

I wouldn't do it all at the same time though...and I tried not to do it on shot night (just because I am wierd and kept thinking of drugs mixing and all sort of INVALID wierd things I convinced myself that wouldn't help me LOL).

[sfbaygirl]

Yep, you may be lucky you didn't know about ANC. If it ever gets too low and your dr. wants to give you a white cell booster, don't take Neulasta! It is time released and lasts longer than Neupogen. I am in bed one week out of 3 in agony with Neulasta. NOT FUN. Going to try Neupogen in 2 weeks...hopefully the sx are not so bad.

Those commerials about Neulasta with the smiling people asking,"Are you ready for Chemo?" They have NO CLUE! or they wouldn't be smiling! LOL

[DougV]

Okay my tests list it as Granulocytes (%) and (ABS).  Any clue as to where you find or calculate % bands?

Dang I'm learning something new.  Hmmm, could be a good thing I didn't know of this one while on tx. <grin>

Doug

[sfbaygirl]

My test isn't Quest, but Absolute Neutrefil Count is located under WBC%. Also I have noticed some people's labs don't count it as a .8, but rather an 800.

[jmjm530]

On my quest lab CBC, ANC is denoted as "NEUTROPHILS, ABSOLUTE). Here is one ANC calculator: http://www.curehodgkins.com/hodgkins_resources/anc_calculator.html

[jmjm530]

Statistically, you're probably OK, but the serum Iron test you mention is different from the iron stores panel which consists of two additional tests:  Serum Ferritin and Transferrin Saturation (TSAT).

If your doctor hasn't already, I can't see any harm ordering these tests given your high dose of both riba and Procrit. As I mentioned earlier, almost the entire high-dose ribavirin study group was on supplemental iron presumably because of low iron stores. Don't at all mean to be intrusive with your treatment, but from experience I've found that even the best doctors sometimes don't order the iron stores test because statitically you should have enough iron stores to last an average treatment. On the other hand, we all don't fit into the statistical model.

-- Jim

[DougV]

I see it is a calculate value but how the heck is it calculated?  I looked but the calculations I found still don't match my lab work, in this case standard CBC although I do love all the lines that say either;

Slide Reviewed - Consistent with instrument results
Results Verified - Consistent with recent patient results.

Now don't statements like that on lab work give you that warm fuzzy feeling. <grin>

Doug

[GoofyDad]

I'm another who did the 5 day procrit rotation for 60,000 weekly. It was an easy way to get the stuff in me. Never got me above hgb 10 though -- and my doc didn't want to go more.

I learned not to double whammy Neupogen with the Procrit. Maybe psycological (sp), but it seemed to bother me. So when they fell on the say day, I just shifted one to another day. In fact, 6 mos off tx and I still have 3 Neups to go till I'm caught up ;-)

[jmjm530]

I couldn't find "bands" either until I realized that ANC was already computed right in front of me, just using different words. Maybe you should take the lazy way out and call the lab, not that they will necessarily know what you're talking about. Good luck!

[mikesimon]

You've got a great doctor. Good luck to you. Mike

[DougV]

Mr. Grandoak,

Ooops, sorry about the menopausal question.  And just for the record, if all your wife says is you have PMS she's much kinder then mine.

Stage 4 answers a lot.  Certainly explains why you and your doctor are willing to take some risks.  I did the same at 3/3 and had told my doc that at the get go.  Which is why my HGB hovered at 7.0 except post trans and post tx.  Which both are kind of cool in a weird way.  You can literally see the counts go up.  First tiny pink lines chriscross that nice Casper complextioin.  Then the skin turns pink, and finally I got my first tan.  Killed my budding movie career though, I figured I was gonna be a star in vampire and ghost films.  I mean look at the cost savings on makeup artists.  Oh well.

Drops I experienced were also about the same.  16.9 down to 11.8 at 30 days down, 10.4 next time, weekly labs after that and to the end of treatment.  Procrit, 20,000 a week later, 2 weeks later 7.8 procrit 40.000, made it two more weeks and one unit packed RBC bumped me all the way up to 8.8 and dang that felt good.  One monnth later 6.8 and back to hosp for another unit of packed RBC again.  Then immediately to hemo doc.  60,000 Procrit.  HGB 8.6 post trans.  Fell to 7.2 over the next four weeks and then the miracle, up to 7.4, stabalized rest of tx at around 7.8 up and down 0.2 or so but no more.  WBC stayed between 1.8 and 2.4 the entire time.  Never had so much as a sneeze though.  Also I was real lucky, even with HGB at 7.8 I never had shortness of breath and my O2 content remained consistently in normal ranges.  Now I would get tired running up a couple flights of steps, but heck I smoked and would get tired going up those two flights anyway.  I did make it, as a matter of pride, a practice to run up the one flight of steps I needed to get to my lab.  I absolutely refused to take the elevator.  Goofy I know, but that was my benchmark I was okay.  BP and pulse remained dead steady at 110/70 pulse 72.  Give or take a small amount that is what it has been my entire life.  That too gave me a perverse pleasure.

FWIW as I've heard the Neupogen shot is no fun my doc let me slide to 1.8 and it was like things finally bottomed out there.  As I did not get sick we let it ride.  Helped I'm sure that I'm retired and my son is 17 and not prone to illness.  Exposure to disease was reduced.  Gotta admit always scared me when I had to go to the hospital and doctors offices.  (Psst, I'll let you in on a little secret, sick people go there.)

Assume your failure to move faster towards undetectable was due to lowering RIBA, cranking back up hopefully with get that undetectable soon.

My compliments to your doc.  He obviously realizes the importance of this to you and is willing to let you determine what is acceptable risk.  My doc did the same and unless somebody shoots him, or me, I wouldn't switch for all the supermodels in the world.  (Now I'm lying through my teeth 'cause after the worlds supermodels were through with me I think I'd be happy to die.)

Looks like yall got bases covered, only things would be B12 and B6, wouldn't hurt to have those checked, along with O2 for grins.  (O2 isn't that great as it really only measures O2 in the existing cells and can be normal as long as a few cells float by, but if you end up with a lot of immature cells that are incapable of carrying O2 it's an easy way to tell.  

I assume your doc is also considering potential of future TP, if he can get this sucker beat if and when you ever needed a TP you'd be miles ahead of us.

If I don't clear on my next round I may move back up to MN just for your doc.  I lived in Winnegago for a year.  We loved it and my wife hated to give up that house.  She cried when she first saw it but I saw the potential.  I spent 20,000 grand fixing it up with me doing all the labor.  House sold for three times what I paid for it in 3 days.  First time I've ever had a realtor aplogize for not charging more.  With a doc like you've got it would be worth the move.  (I might have to have terrorist hit that ethenol plant though, on the rare days the wind changed..........)

Other then I'd split the shots and the few test suggested above, my only other advice would be relax and enjoy the ride.  With this doc's attitude and yours I'd happily bet money on the outcome.  Just be prepared for transfusion if you hit 7.0 or below, but considering all you've been through that ought to be a walk in the park.  I plan on starting my next round in Jan., I think I'm going to see if it is possible to donate a few units for storage, just not sure what shelf life of packed RBC is.

Stupid though, wouldn't hurt to wonder by a BP chair in a phamacy and keep a close eye on BP, just in case ya know.  Besides I've always like those chairs and as a kid could never pass up the chance to sit in one, okay okay, I still never pass up the chance.

Relax, go with the flow, and think of the story you'll have to tell your great grandkids.

Doug

[sfbaygirl]

You said your doc let your white count go to 1.8. Do you mean ANC? My WBC doesn't go above 2 and my ANC goes down to .4, but my dr. makes me get Neulasta when it goes below 1.0,  so I was wondering about the 1.8. Maybe your labs use a different value?

BTW Thanks for the dinner invite! Sounds like you cook up a storm, if I can make it I will be sure to see what the menu is for the night!

[GrandOak]

The change being made to my Procrit regiment is instead of 100,000 U at one sitting, to spread it out to 50,000 in a couple of sittings through the week.

As indicated in my question the objective is to maintain a more steady level of the med in my body rather than a single boost which tapers off over the week until the next boost.

This sounds much similar to what Beagle Bailey, nygirl, and goofydad have done during their tx and I'm hoping to achive a similar result which hopefully will kick my Hgb up another notch or two and lessen the chance of long-term sx's from the med.  From what goofydad experienced, I now know to not place to high an expectation on the Hgb boost, which is one thing I was wondering about.  The other is how effective it will be keep Hgb at levels it currently has reached with the existing dosage being split into injections spread out over several days?

Like Jim, I too found multi-ml was too much for a single injection.

[GrandOak]

Jim,

That's why we did additional labs last Thursday after Tuesday's showed Hgb continuing to drop.  Results were Iron mid-range norm and new red cell count mid-range normal.

Doug,

My ANC it 700 and 600 before I was prescribed the Neupogen regiment.  Throughout most of tx ANC has hovered around 1000 - 1100.

[DougV]

Jim,

I did read the full post on six months post relapse.  I think the biggest kick out of it was when Bill57 claimed he has degrees in both biology and chemisty, yet he can't spell, write well, punctuate, and has no clue of scientific method.  If that guy has degrees in anything I might as well go shoot my son now as no telling how far education will fall before he graduates High School and he's a senior.

Anyway last post I saw from him dated the 20th of August.  Hopefully the powers to be on that site quietly evicted him.

Doug

[jmjm530]

Yeah, I was going to chime in on the thread, but when someone posted like the definition of SVR from half a dozen sources, I figured talking to Bill would be like talking to a rock.

[DougV]

Just checked my labs.

These are labcorp, perhaps Quest reports differently?

Reference numbers for White Cell Count for my age and sex:

4.3-10.8 X10^3/CM  Pre-tx mine generally run just a tiny bit on the high side, 12 or so, during tx generally stayed in low 2 range with occasional dips to 1.8.  My GI wouldn't even consider Neupogen until 2.0.

Doug

[jmjm530]

My WBC was also below "2" for much of treatment. I think what SF was suggesting is that ANC (absolute Neutrophils), a WBC fraction, is usually what determines Neupogen intervention. In fact, my hepatologist was never concerned about WBC as long as my ANC was within limits.

Some doctors intervene with Neupogen when ANC hits 1000 but many let it fall to 500 or even lower before prescribing Neupogen. My med team doesn't get concerned until ANC remains close to 200-300.

ANC has a tendency to bounce around a lot. One week my ANC was 320, and a couple of weeks later it was over 1000. This was without Neupogen intervention. In fact, recent studies suggest that interferon-induced low WBC does not correlate with higher infection rates for those treating for HCV. My thinking is that many doctors are still working off older data which suggested WBC did correlate with higher infection rates.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16082419&dopt=Abstract

--Jim

[sfbaygirl]

Yes, I was referring to the ANC numbers. My doc doesn't care if my WBC is 1.4, but if my ANC is .8, he says he will take me off tx if I don't do the shot. GRRRR Maybe I need to space my appts. with him...

I haven't heard of anyone getting infections from low ANC around here, have you? I tend to believe that study, as I have had lots of opportunities to get sick and have not, when my WBC is low.

[jmjm530]

Not sure if this ground has been covered, but with all the Procrit you're taking, have you had your iron stores checked?

Adequate iron stores are needed for hemoglobin production and Procrit over a period of time can deplete them. The two iron store tests are Serum Ferritin and Transferrin Saturation (TSAT). These are different and usually have to be ordered separatly from the basic serum iron test that is somewhat routine.

In general, if Ferritin is below 100 or TSAT below 20%, you probably need supplemental iron for the Procrit to work. This sounds counter-intuitive to what we learn regarding iron supplementation, but what we learn assumes normal iron stores. In fact, in the Swedish High Dose Ribavirin study, all of the participants eventually ended up on Procrit and I believe all or at least most required supplemental iron.

I do think spreading your dose out over the week might be a good idea but haven't heard or read anything to that effect. I should also add that my NP did tell me at one point during treatment that there is a point of diminishing returns regarding adding Procrit and also suggested that compromised kidney function (from the interferon) could also inhibit hemoglobin production or Procrit efficacy -- not sure which, but I assume your doctor is monitoring your kidney function tests carefully in light of all the Procrit.

All the best in your fight to get those red cells up !

-- Jim

[GrandOak]

Thx for the info, some good ideas there, both new and some I'd forgotten about.

Actually I have a pretty good doc.  Here's his basic credentials:

Director of the Division of Gastroenterology, and Director of the Liver Transplantation Program at the University of Minnesota Medical Center in Minneapolis. Dr. Lake is a past president of the American Society of Transplantation. He is the Chair of the Liver and Intestinal Committee of the United Network for Organ Sharing. He is an Associate Editor for the American Journal of Transplantation. He is on the editorial boards of Liver Transplantation and Surgery and Transplantation Proceedings. He is a co-author of the textbook, Comprehensive Clinical Hepatology. Dr. Lake has published more than 200 scientific papers and book chapters on topics ranging from hepatitis C in liver transplant recipients to changes in quality of life after liver transplantation among adults.

As for the rest:

1A
Stage 4
Base VL 72 mil
wk 8:   2.4 mil
wk 12:  1.8 mil
wk 24:  2.9

CBC        8/29      8/31
WBC:       2.5       2.4
RBC:       2.67      2.76
Hgb:       9.3       10.0
HCT:       27.5      28.8
ANC:       1.9       1.4
Platelets: 52        64  

Iron normal, new RBC production detected.

36 wks on tx

treatment duration? base 48 wks, Now possibly 99 wks

How long on tx and at what rate did they drop?

13.5 base to 9.8 in 4 wks.

What is your RIBA dose?

ID doc cut from 1200 to 600 at wk 3

Switched to Dr. Lake wk 8

wk 10 Epoetin-Alpha 40,000
wk 14 RBN 800 mg
wk 18 Epoetin-Alpha 60,000
wk 19  RBN 1000 mg
wk 21 RBN 1200 mg
wk 24 Epoetin-Alpha 80,000
wk 27 Neupogen
wk 27 RBN 1400 mg
wk 31 Epoetin-Alpha 100,000
wk 31 Neupogen

new 12 wk for 2 log drop from 72 mil began wk 27 if achieved tx 72 wks from wk 27

Pre or Post menopausal? Pre-male, but wife claims still Riba-PMSing

Ulcers or any other internal bleeding issues? Only as pre-teen

Any heart issues whatsoever?  No

Are you having symptoms of anemia?  Yes

Have you had O2 levels checked?  No

How often are you getting labs? Bi-weekly, unless doing a Neupogen regiment

Follow-up initial every 4 wks, now 6 wks after wk 27

[Mister beagle bailey]

I did 60,000 units every 5 days of procrit.  I would spread it out to allow it to work better,  Let me know how you make out.  Will be thinking of you.

Beagle :)