Aa
Riba Dose
I'm geno 3a not taking weight based Riba. I believe my doctor knows best but everyone is constantly saying I need to take 1200mg instead of my current 800mg. I have no side effects and if I am experiencing any they must be slight because I don't notice. I took my fourth shot last night and feel fine. I called my Doctors office and my nurse is out because of surgery and I can't talk directly to the Dr. I have to take my viral load test next week before my fifth shot to see if I'm UND (fingers crossed) I asked the nurse why I wasn't on weight based Riba and she said I didn't need to be for my genotype. Then I asked her of course why? She replied, "Why would you want to use a large gun to kill a small bird"? Witty and amusing and maybe she's right but that wasn't the answer I was looking for.
I then proceeded to ask her why don't they just give me the 1200mg so while I may be sicker I might have a better chance of not relapsing. She asked the doctor who said 800mg, "That is the FDA approved dosage" and that was his final answer. That doesn't really make sense to me. I have to wait and see what this week four test says but this is starting to get annoying. I'm not sick, but I'd rather feel bad now then have to do this all over again.
I've heard so many studies and information and opinions on this matter to the point where I don't know what to believe any more. I can't get a straight answer out of anyone. Some studies show that people that take 800mg actually have a better SVR rate than those that take 1200mg. Other people seem to think that that 1200mg is the way to go I'm just confused.
I then proceeded to ask her why don't they just give me the 1200mg so while I may be sicker I might have a better chance of not relapsing. She asked the doctor who said 800mg, "That is the FDA approved dosage" and that was his final answer. That doesn't really make sense to me. I have to wait and see what this week four test says but this is starting to get annoying. I'm not sick, but I'd rather feel bad now then have to do this all over again.
I've heard so many studies and information and opinions on this matter to the point where I don't know what to believe any more. I can't get a straight answer out of anyone. Some studies show that people that take 800mg actually have a better SVR rate than those that take 1200mg. Other people seem to think that that 1200mg is the way to go I'm just confused.
Jim,
JT's complete lack of symptoms might very well change past week 4. That is when the anemia set in for me. Other than that I totally agree with you on watching hemoglobin levels as a crude meter for riba absorption.
Portann,
Not being a doctor I am not in the position of recommending anything of course. But I liked what my nurse said when I started tx: "We know the enemy is strong, so we use all the ammunition we have." I actually persuaded my doc to increase my interferon dose when I gained weight halfway through tx, and I even took some extra riba pills I laid my hands on during my last months of tx. I wanted to do all I could my first try, to try to avoid the risk of having to go another round.
So if it was Comeagain, and not JT, I would say: "Use all the ammunition you can lay your hands on. The enemy is strong." UND is not the same as SVR.
JT's complete lack of symptoms might very well change past week 4. That is when the anemia set in for me. Other than that I totally agree with you on watching hemoglobin levels as a crude meter for riba absorption.
Portann,
Not being a doctor I am not in the position of recommending anything of course. But I liked what my nurse said when I started tx: "We know the enemy is strong, so we use all the ammunition we have." I actually persuaded my doc to increase my interferon dose when I gained weight halfway through tx, and I even took some extra riba pills I laid my hands on during my last months of tx. I wanted to do all I could my first try, to try to avoid the risk of having to go another round.
So if it was Comeagain, and not JT, I would say: "Use all the ammunition you can lay your hands on. The enemy is strong." UND is not the same as SVR.
If JT RVR's this week (week 4), do you still recommend that he increase his dose?
BTW, he is only 26 and in superb health.
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If he RVRs, increasing the dose becomes less important, although personally I would especially if his lack of symptons continues -- but without a crystal ball, I think both Zazza, others and myself want to give him the best chance of becoming RVR. By the time he gets back the results of his week 4 test, he will probably already be at week 6 of treatment. Increasing riba at that point, would then be an altogether different story and possibly outcome.
BTW, he is only 26 and in superb health.
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If he RVRs, increasing the dose becomes less important, although personally I would especially if his lack of symptons continues -- but without a crystal ball, I think both Zazza, others and myself want to give him the best chance of becoming RVR. By the time he gets back the results of his week 4 test, he will probably already be at week 6 of treatment. Increasing riba at that point, would then be an altogether different story and possibly outcome.
If JT RVR's this week (week 4), do you still recommend that he increase his dose?
BTW, he is only 26 and in superb health.
BTW, he is only 26 and in superb health.
should have read in part:
That's why I suggested he compare his pre-treatment to current HEMOGLOBIN levels which are a crude...
That's why I suggested he compare his pre-treatment to current HEMOGLOBIN levels which are a crude...
Given his weight, by some weight-based schemes, he is borderline 1400 mg/day per WIN-R study. http://www.natap.org/2008/EASL/EASL_08.htm
Also, not sure if he understands the concept that his almost complete lack of symptons very well may (but not necessarily) correlate to sub-optimal riba dosing. That's why I suggested he compare his pre-treatment to current ribavirin levels which are a crude -- but at least some sort -- of barometer based on studies suggesting the more anemic the patient, the better the riba absorption resulting in better RVR and SVR rates.
Also, not sure if he understands the concept that his almost complete lack of symptons very well may (but not necessarily) correlate to sub-optimal riba dosing. That's why I suggested he compare his pre-treatment to current ribavirin levels which are a crude -- but at least some sort -- of barometer based on studies suggesting the more anemic the patient, the better the riba absorption resulting in better RVR and SVR rates.
12 x 94.5 = 1134
So according to the German SOC, you would do fine with 1200 mg ribavirin. That would give you 12.7 mg per kilo.
So according to the German SOC, you would do fine with 1200 mg ribavirin. That would give you 12.7 mg per kilo.
208 lbs = 94.5 kg
800 mg ribavirin / 94.5 kg = 8.46 mg ribavirin per kilo
I have a chart from the ACCELERATE study here, which shows the SVR rate for geno 2s and 3s according to their ribavirin dosage.
less than 8.4 mg/kg - 67% SVR
8.4 to less than 9.9 mg/kg - 76% SVR
9.9 to less than 11.5 mg/kg - 80% SVR
equal to or greater than 11.5 mg/kg - 87% SVR
Remember this is combining geno 2s and 3s, which probably ups the SVR rate somewhat for the 3s.
According to this, with 8.46 mg/kg you would have a 76% SVR rate. Is that good enough for you when you could have 87%?
In Germany SOC is now 12 mg/kg ribavirin for geno 3s.
Comeagain, my ex, a geno 3, weighed 200 lbs when he started his first tx and got 800 mg riba. He was UND by week 12 (the only PCR he got during tx), but relapsed post tx. Second tx he got 1200 mg, weight based, ribavirin. This time he was detectable but not quantifiable at week 4 with a sensitivity of 15 IU/ml. He did 48 weeks since he was a relapser. Wonder if 24 weeks had done it for him if he had gotten weight based the first time? Now he has had to do 72 weeks altogether. So much for "Why would you want to use a large gun to kill a small bird?" Because the bird might get away, and in a large man the bird might not be so small after all.
800 mg ribavirin / 94.5 kg = 8.46 mg ribavirin per kilo
I have a chart from the ACCELERATE study here, which shows the SVR rate for geno 2s and 3s according to their ribavirin dosage.
less than 8.4 mg/kg - 67% SVR
8.4 to less than 9.9 mg/kg - 76% SVR
9.9 to less than 11.5 mg/kg - 80% SVR
equal to or greater than 11.5 mg/kg - 87% SVR
Remember this is combining geno 2s and 3s, which probably ups the SVR rate somewhat for the 3s.
According to this, with 8.46 mg/kg you would have a 76% SVR rate. Is that good enough for you when you could have 87%?
In Germany SOC is now 12 mg/kg ribavirin for geno 3s.
Comeagain, my ex, a geno 3, weighed 200 lbs when he started his first tx and got 800 mg riba. He was UND by week 12 (the only PCR he got during tx), but relapsed post tx. Second tx he got 1200 mg, weight based, ribavirin. This time he was detectable but not quantifiable at week 4 with a sensitivity of 15 IU/ml. He did 48 weeks since he was a relapser. Wonder if 24 weeks had done it for him if he had gotten weight based the first time? Now he has had to do 72 weeks altogether. So much for "Why would you want to use a large gun to kill a small bird?" Because the bird might get away, and in a large man the bird might not be so small after all.
I can't take any more Riba my doctor won't give it to me because he's giving me the "FDA approved dose". There is a lot of different opinions on this matter I guess my best bet is to try and catch the Dr on Thursday (I found out his hours) and talk to him. My Viral Load test will apparently tell me exactly what's going on so I will take that with what the Dr says and figure out what to do in the mean time!
For everyone that asked I'm 6'2 and weigh about 208.
Thanks everyone for your answers and support!
For everyone that asked I'm 6'2 and weigh about 208.
Thanks everyone for your answers and support!
Your last post was perfectly stated. I agree and your explanation, I agree, is the right way to look at it, given the lack of direct evidence.
JT - you're not experiencing sides....why not take more riba? That way you know you've done everything you could. It would REALLY suck if you didn't get RVR simply because you took the minimum amount and could of popped two extra "nasties" per day.
JT - you're not experiencing sides....why not take more riba? That way you know you've done everything you could. It would REALLY suck if you didn't get RVR simply because you took the minimum amount and could of popped two extra "nasties" per day.
To much riba can cause thyroid malfunctions. Loads of other after tx, problems.
Riba should be weight based, I did 1200 two times previous tx, relapsed both times.
Pre dosing riba for week pre inteferon, is ok, because otherwise you will always be a week behind, that is why they say take riba for a week after, if you do not then you will have to take it for a week after.
As long as you are not below 600, most drug companies or GIs will NOT even prescribe 600, it is ineffective.
I would ask your GI /Hepatologist, is he weight basing you? Advocate for your self, if I see something of interest on here, I go in search, of the right answer. Dr Dietrich is the only Doctor on here right now.
I am quite sure he would not even treat you via interent.
Some good info on here, some questions to ask,
Good luck Deb
Riba should be weight based, I did 1200 two times previous tx, relapsed both times.
Pre dosing riba for week pre inteferon, is ok, because otherwise you will always be a week behind, that is why they say take riba for a week after, if you do not then you will have to take it for a week after.
As long as you are not below 600, most drug companies or GIs will NOT even prescribe 600, it is ineffective.
I would ask your GI /Hepatologist, is he weight basing you? Advocate for your self, if I see something of interest on here, I go in search, of the right answer. Dr Dietrich is the only Doctor on here right now.
I am quite sure he would not even treat you via interent.
Some good info on here, some questions to ask,
Good luck Deb
im on 1200 a day..weigh in at 200 and im not fat...just big boned...it hard to lose bone mass ..so im stuck at 200
I suffered through 24 weeks (Gen.2) of 1200mg Riba. If I find out I could have been taking 800, be watching the news for my 15 minutes of fame.
"Although 12 weeks of treatment was inferior to 24 weeks of treatment, a higher ribavirin concentration was associated with a significantly increased SVR," the investigators concluded.
"This indicates that a treatment regiment with ribavirin dose based on plasma concentration at week 4 could significantly improve treatment outcome," they added. "We propose this to be examined in a prospective randomized trial."
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just pulled this from the link in my previous thread. while the study does not directly address flat versus weight-based dosing, it does add to the body of evidence suggesting that serum ribavirin levels are important both for RVR and SVR. Since there is no way in this country for the average patient to measure serum ribavirin levels, all we can use our cruder barometers such as the rate of hemoglobin drop. But going into treatment, at least for me, it suggests the importance of proper riba dosing for all genotypes. As Welling suggests above, there many individual factors to take into consideration, but where I come out, is to err toward weight-based especially if one can tolerate it.
"This indicates that a treatment regiment with ribavirin dose based on plasma concentration at week 4 could significantly improve treatment outcome," they added. "We propose this to be examined in a prospective randomized trial."
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just pulled this from the link in my previous thread. while the study does not directly address flat versus weight-based dosing, it does add to the body of evidence suggesting that serum ribavirin levels are important both for RVR and SVR. Since there is no way in this country for the average patient to measure serum ribavirin levels, all we can use our cruder barometers such as the rate of hemoglobin drop. But going into treatment, at least for me, it suggests the importance of proper riba dosing for all genotypes. As Welling suggests above, there many individual factors to take into consideration, but where I come out, is to err toward weight-based especially if one can tolerate it.
this is an old story in hcv studies : subtler effects are hidden in broad averages. If you are concerned, it's worth getting a copy of
"Optimal dose of peginterferon and ribavirin for treatment of chronic hepatitis C."
http://www.ncbi.nlm.nih.gov/pubmed/18637069
and following the references therein. This is a current summary of available data on rbv/peg dosing. Your Dr's comments go back to peg clinical trials (Hadziyannis'04) that showed no benefit to dosages greater than 800mg or duration longer than 24w for g2-3s
"Notably, RBV dose did not have an impact on outcome of treatment in patients with genotype 2 or 3, nor did duration of treatment when comparing 24 with 48 weeks."
Dr. Dietrich's comments on the other hand are supported by more recent data confirming an effect for higher dosage among g2-3 patients with higher weight:
"This trial demonstrated for the first time the efficacy and safety of a 1400 mg/day dose of RBV, that was received by patients with weight >105–125 kg [10]. Fifty-one patients weighing ≥125 kg, who entered the study as protocol exceptions and received either 800 mg/day (FD) or 1400 mg/day (WBD), further illustrated the point. SVR occurred in 17%vs 50% (P = 0.096) of these patients, respectively; interestingly, in genotype 2 and 3 patients SVR rates were 38%vs 50%, respectively. "
This is not a case of one study showing X and the other Y; the differences simply reflect the reality of patient sampling across many factors (sex, age, VL, genotype, weight, stage, etc.) that affect outcome. It might be worth getting a copy of Jacobson'09, reading through it, and discussing the more recent data with your Dr.
"Optimal dose of peginterferon and ribavirin for treatment of chronic hepatitis C."
http://www.ncbi.nlm.nih.gov/pubmed/18637069
and following the references therein. This is a current summary of available data on rbv/peg dosing. Your Dr's comments go back to peg clinical trials (Hadziyannis'04) that showed no benefit to dosages greater than 800mg or duration longer than 24w for g2-3s
"Notably, RBV dose did not have an impact on outcome of treatment in patients with genotype 2 or 3, nor did duration of treatment when comparing 24 with 48 weeks."
Dr. Dietrich's comments on the other hand are supported by more recent data confirming an effect for higher dosage among g2-3 patients with higher weight:
"This trial demonstrated for the first time the efficacy and safety of a 1400 mg/day dose of RBV, that was received by patients with weight >105–125 kg [10]. Fifty-one patients weighing ≥125 kg, who entered the study as protocol exceptions and received either 800 mg/day (FD) or 1400 mg/day (WBD), further illustrated the point. SVR occurred in 17%vs 50% (P = 0.096) of these patients, respectively; interestingly, in genotype 2 and 3 patients SVR rates were 38%vs 50%, respectively. "
This is not a case of one study showing X and the other Y; the differences simply reflect the reality of patient sampling across many factors (sex, age, VL, genotype, weight, stage, etc.) that affect outcome. It might be worth getting a copy of Jacobson'09, reading through it, and discussing the more recent data with your Dr.
"standard" dosing for genotype two and three is 800 mg a day. That said, the number of the shorter course studies have used weight base ribavirin and produced very good SVR numbers. (see link below)/ and while some people may enter treatment seeking a shorter course, or some may end up with a shorter course because they have to drop out. Something to keep in mind.
The other thing we know is that ribavirin concentrations are both important and individual for RVR. Combining both concepts, one can make a reasonable argument for weight-based ribavirin for geno 2 and 3 if one wants to pursue a somewhat aggressive treatment approach.
in your case, you have had very little side effects. This could have no meaning or it could mean your serum ribavirin levels are not high enough. One crude barometer of serum riba levels would be how much are hemoglobin is dropped from pretreatment. If the drop was minimal, I personally would go on weight-based.
as to Dr. Dietrich, I think you have to take some of his answers in a general context. We know for fact, both from patients here, as well as his published work, that he is a very aggressive treater who was one of the first to endorse double dosing of Peg for example. In fact recently, he unofficially endorsed the concept of free dosing ribavirin. So I was giving a general answer, and I certainly am by no means putting words in his mouth, I doubt very much he would have a problem if one of his geno 3 patients wanted to wait based ribavirin, specially if they're having little or no side effects.
http://www.hivandhepatitis.com/2008icr/easl/docs/050608_a.html
The other thing we know is that ribavirin concentrations are both important and individual for RVR. Combining both concepts, one can make a reasonable argument for weight-based ribavirin for geno 2 and 3 if one wants to pursue a somewhat aggressive treatment approach.
in your case, you have had very little side effects. This could have no meaning or it could mean your serum ribavirin levels are not high enough. One crude barometer of serum riba levels would be how much are hemoglobin is dropped from pretreatment. If the drop was minimal, I personally would go on weight-based.
as to Dr. Dietrich, I think you have to take some of his answers in a general context. We know for fact, both from patients here, as well as his published work, that he is a very aggressive treater who was one of the first to endorse double dosing of Peg for example. In fact recently, he unofficially endorsed the concept of free dosing ribavirin. So I was giving a general answer, and I certainly am by no means putting words in his mouth, I doubt very much he would have a problem if one of his geno 3 patients wanted to wait based ribavirin, specially if they're having little or no side effects.
http://www.hivandhepatitis.com/2008icr/easl/docs/050608_a.html
Geno 3's are more elusive than geno 2's in terms of SVR. Higher relapse rate. Newest protocols are suggesting weight based riba. As was the case with my doctor who did not believe in extending tx past 48 wks for geno 1's who do not achieve UND by 12 wks he reconsidered his position after the latest data was presented at the AASLD conference 2008. No new data was reported at that conference regarding extension but my doctor was behind the curve and after much diligence on my part he is now in line with current tx protocols. Many GI's (and some Hepa's which my doc is) are not up to current standards. In my opinion, you should be on a weight based dose of riba keeping in mind too that you are a geno 3. I'm taking 1000 mg per day and weigh 115 lbs. I am a geno 1, but my weight would allow for 800 mg. That is just not enough.
Trinity
Trinity
Here is what Dr. Dieterich, our forum medical expert and a leading hepatologist, said to GraniteKonig about this issue in December 2008:
http://www.medhelp.org/posts/show/660758
Are you OVERWEIGHT?
http://www.medhelp.org/posts/show/660758
Are you OVERWEIGHT?
Hiya JT!
From a fellow 3A who is now SVR...If you are 160 lbs or less, weight-based dosing is important...Riba will rip you apart if you are smaller. I was told 800 mg is the therapeutic dose unless you are severely overweight or unusually large. I know the 800 mg range covers from 160+ lbs to at least 300 lbs...After that, I'm not sure...3A is one of the most responsive genotypes to Peg/riba txing, whereas the type 1 geno (most common) is the most stubborn, and requires higher and longer dosing. With riba, more is not always better and I do understand your anxiety...Usually, by week 6, if you haven't had any massive drops in your blood values, you will probably be one of the fortunate who can breeze through this. More than likely, you are RVR (a rapid responder) at this point...By the way, 3A has an 80+% chance of SVR (sustained viral response after treatment- which means you've killed the dragon...Just in case you didn't know)...I lend you my Hep C dragon slaying sword and utter a Howard Dean Girlie war cry in your honor! YYYEEEAAAGGGHHH!!!! (By the way, dragon hide makes good boots...LOL) Good luck on your labs! ~Melinda
From a fellow 3A who is now SVR...If you are 160 lbs or less, weight-based dosing is important...Riba will rip you apart if you are smaller. I was told 800 mg is the therapeutic dose unless you are severely overweight or unusually large. I know the 800 mg range covers from 160+ lbs to at least 300 lbs...After that, I'm not sure...3A is one of the most responsive genotypes to Peg/riba txing, whereas the type 1 geno (most common) is the most stubborn, and requires higher and longer dosing. With riba, more is not always better and I do understand your anxiety...Usually, by week 6, if you haven't had any massive drops in your blood values, you will probably be one of the fortunate who can breeze through this. More than likely, you are RVR (a rapid responder) at this point...By the way, 3A has an 80+% chance of SVR (sustained viral response after treatment- which means you've killed the dragon...Just in case you didn't know)...I lend you my Hep C dragon slaying sword and utter a Howard Dean Girlie war cry in your honor! YYYEEEAAAGGGHHH!!!! (By the way, dragon hide makes good boots...LOL) Good luck on your labs! ~Melinda
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