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86664 tn?1291561395

Reduced dose

Hello Everyone, long time no see.  I'm 24 weeks into tx, cleared at 9 weeks.  Been deathly sick, mostly bedridden, lost 30 lbs (am looking quite skeletal), hemoglobin down to 9.1 so I reduced interferon to 135 instead of 180 and riba to 800 instead of 1000 about 10 days ago.  Also, took Alinia for first 6 months but stopped it.  For anyone taking Alinia, it really messes with your intestinal bacteria so be sure to load up on various probiotics upon completion.  Tomorrow I'll post a recipe to replenish the hundreds of different types of flora found in the gut.

Am feeling better with the reduced dose but now starting to worry about chances of SVR decreasing.  Will see specialist soon to discuss procrit although original doctor thinks it's a nasty drug.

My question for the old timers here is have many people who reduced dose greatly reduced chances of attaining SVR?   Thanks!

Best regards,

Kittyface
17 Responses
Avatar universal
It is very well documented that dose reduction is not a good thing. That said, having dropped 30 lbs., your actual dose/kg may very well be the same as when you started..Can you post your weight at start of tx and current weight? (I know, I'm not supposed to ask a woman this question(g)..
pro
Avatar universal
Glad to hear your feeling better with the reduced meds but if you can go back to the 180 peg and push for the Procrit from the doc. 9.1 is low and am sure it is hard to do anything but lay in bed. I am a 1b and was UND at week 8, 12, and continued to stay UND through out the rest of treatment but I had reduced only the riba at week 20 because of the sx’s until week 44 and then went back to the 1200mg a day. I still remained UND at week 48 and 53 and am waiting on the 6 well 5 1/2 month PCR. It can be and has been done but would suggest pushing hard for the Procrit and at least go back to full does of the peg for the remaining 24 weeks. At to the Flora the first 8 weeks of riba should have taken care of that and then to add alinia to it? What were/are the sx’s of alinia? I didn't add any supps and took my meds straight up. Anyway glad your feeling better or at least as much as you can at this point.

jasper
Avatar universal
Hi KittyFace
How ya been. Sorry to hear about the sides.

Below is what ML Shiffman has to say about dose reducing. Seems reducing after UND has minimal impact on SVR rates
http://tinyurl.com/5sbws6

It is difficult for many patients to tolerate even the standard duration of peginterferon alfa and ribavirin therapy. Many studies have suggested that at least 20% of patients have adverse events that are severe enough to require either a reduction in the dose of peginterferon alfa and/or ribavirin, a temporary treatment interruption, or a permanent discontinuation of treatment.[22,23] Staying on full doses of these medications for another 24 weeks is often more than many patients can tolerate.

One strategy to enable patients to remain on treatment longer is to reduce the doses of ribavirin and/or peginterferon alfa by small increments. This will frequently ease the adverse events of these medications and enable patients to remain on treatment longer. Several studies have now demonstrated that mild reductions in the doses of either peginterferon alfa and/or ribavirin will not adversely affect the chance of achieving SVR, especially if this strategy is employed after the patient achieves undetectable HCV RNA

By contrast, interrupting treatment for more than 7 days because of adverse events leads to breakthrough and relapse.
Therefore, it is the recommendation of this author to reduce ribavirin stepwise by 200 mg every 2-4 weeks until adverse events either resolve or are tolerable.

Peginterferon alfa-2a can be reduced from 180 to 135 μg/week and peginterferon alfa-2b from 1.5 to 1.0 μg/kg/week. Neither peginterferon alfa nor ribavirin dosing should be interrupted unless the adverse event is particularly severe and there is a concern for patient safety.

Whenever the doses of peginterferon alfa and ribavirin are modified or temporarily interrupted, HCV RNA testing should be performed again to ensure
that breakthrough has not occurred.

Anemia is a common adverse event during peginterferon alfa and ribavirin treatment.
A randomized, placebo-controlled trial demonstrated that epoetin alfa can correct anemia in this setting.
However, a more recent randomized study demonstrated that the routine use of epoetin alfa initiated in all patients at the start of therapy did not improve virologic response, relapse, or SVR.

Although the dose of ribavirin was reduced in 40% of patients in the control group compared with only 10% in patients taking epoetin alfa, the percentage of patients who received more than 80% of the cumulative ribavirin dose was comparable in the 2 groups.

This is because the ribavirin dose was reduced in only 200-mg increments every 2-4 weeks, and most dose modifications were performed after patients had achieved undetectable HCV RNA.

Up to 25% of patients enrolled in large, registration trials required that the doses of one or both of these agents be modified during treatment.
This figure is likely to be higher in less controlled settings.

Several years ago, it was felt that any dose reduction could potentially impair the ability to achieve SVR.
However, it is now recognized that small reductions in the dose of peginterferon alfa and/or ribavirin, particularly after patients achieve undetectable HCV RNA,are less likely to impact SVR as long as dosing is not interrupted.

Hope this Helps
CS


Avatar universal
So good to hear from you. Been thinking of you. I started Alinia 7/7, first shot 8/9. So far so good, sx not too bad (nasty rash but it's better) Your weight loss is surly a concern. 30lb is a lot. Do post your recipe. I haven't been as diligent with my pro/prebiotics as I should. Up to this point I have experienced few sx from the Alinia. What was going on to cause you to drop it?  Really is good to hear from you again. jerry
Avatar universal
Hey again, I wasn't sure I could find this but did.---Study Demonstrates Safety of Erythropoiesis-stimulating Agents to Manage Ribavirin-related Anemia in Hepatitis C Patients
Last updated:01August2008

By Liz Highleyman hivandhepatitis.com


erythropoiesis-stimulating agents (ESAs)

Red Blood Cells
Hemolytic anemia is a common treatment-limiting side effect of ribavirin used in combination with pegylated interferon for chronic hepatitis C. But an adequate dose of ribavirin helps prevent HCV relapse after completion of therapy, leading physicians to use erythropoiesis-stimulating agents (ESAs) such as Procrit to increase red blood cell production.

In November 2006, the U.S. Food and Drug Administration (FDA) issued a warning regarding an increased risk for serious cardiovascular complications associated in patients receiving ESAs More recently, the agency warned that these drugs were associated with more rapid tumor growth and increased risk of death in people with certain types of cancer.

Noting that clinical data in other patient populations has demonstrate increased rates of cardiovascular events, thrombosis (clotting), malignancy, and death among ESA recipients, Canadian researchers sought to determine whether these complications were also increased in hepatitis C patients using ESAs to manage ribavirin-induced anemia during hepatitis C treatment.

As reported in the July 15, 2008 issue of Clinical Infectious Diseases, the investigators identified all recipients of combination interferon/ribavirin therapy at the Ottawa Hospital Viral Hepatitis Clinic between October 2003 and October 2006. During this period, patients initiated 174 total courses of anti-HCV therapy. Predictors of ESA use were assessed using regression analysis, and adverse events during and after treatment were evaluated.

Results

Predictors of ESA use included older age, lower body weight, lower baseline hemoglobin level, and infection with HCV genotypes 1 or 4.

88% of ESA recipients achieved targeted hemoglobin levels of > 110 g/L.

The sustained virological response (SVR) rate was higher in ESA recipients compared with non-recipients (54% vs 45%, respectively), but the difference did not reach statistical significance.

In the period following HCV treatment, no patients experienced myocardial infarction, deep vein thrombosis, or pulmonary embolism.

The frequencies of stroke and cancer events were low overall.

Rates of adverse events appeared to be similar in the 2 groups.

Based on these findings, the study authors concluded that "ESA use is not associated with increased risk of cardiovascular events, malignancy, thrombosis, or death in HCV-infected patients during receipt of HCV therapy or in the period after completion."

"Given the inherent differences in patient populations, practitioners should exercise caution when extrapolating the results of studies of other diseases to HCV infection," they added. "Our efficacy and safety analysis suggests against the withholding of ESAs in the management of anemia induced by HCV treatment."

Department of Internal Medicine and Division of Infectious Diseases, Ottawa Health Research Institute Methods Centre, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Damos, Hamilton, Ontario, Canada.

7/29/08

Reference
CT Costiniuk, F Camacho, and CL Cooper. Erythropoiesis-stimulating agent use for anemia induced by interferon-ribavirin treatment in patients with hepatitis c virus infection is not associated with increased rates of cardiovascular disease, thrombosis, malignancy, or death. Clinical Infectious Diseases 47(2): 198-202. July 15, 2008. (Abstract)

179856 tn?1333550962
I just don't understand why a doctor wouldn't give someone with your weight loss and hemo level procrit to begin with.  Why chance letting the virus back in with a reduction at all?  Why force you to live with a '9'?

I remember full well what it feels like however I refused to reduce (I was on WAY too much but I was paranoid because i was a 1a and also a 1b and somehow got confused and thought that meant I needed more meds) but the doctor did give me epogen and I lasted from week 3 to 72 that way.

Nobody knows how YOUR body will continue to learn how to boost it's own immune system (this is why we stay on treatment AFTER we are UND) with a reduction. It could be just fine - you have to hold on to that hope.

Have CBCs as often as you can and if your hemo doesn't go up that much find a doctor who WILL give you the epogen.  Cautionary tale to everyone - if you dont HAVE to dose reduce just don't!

When is your next PCR? I would hope that this doctor is really monitoring you and what is going on because it sounds like you need it and God forbid IF (big IF) you did become positive again you wouldn't want to stay on the meds in this shape any longer than you have to.

All the best to you! Good luck!
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