Some clarification if someone knows or doctor has explained

[willbb]

It is a known fact that HCV therapy(specifically INF. can reduce neutrophil counts (neutropenia) in patients quite often.
However it seems clear from the thousands that have been involved in the studies below that there seems to be" little" if "none" at all correlation between low neuts(ANC) and increased incidence of infection.
The labeling on INF. is to reduce it if there is incidence of  neutropenia ,however I can fully understand doctors not wanting to do that ,especially early ,and not jeopardize possible treatment success,however I fail to fully grasp why some doctors are very quick to prescribe  another fairly powerful drug like Neupogen (which I don"t believe is FDA approved for HCV therapy) that often can have  side effects of it"s own(we have often heard of deep bone pain,amongst some other ones listed) when the studies below show  such results.

I know my own Hepa says he rarely prescribes Neup   unless the ANC was extremely low combined with the patient having other health factors,specifically diabetes (which may increase chance of infection )

Possibly I have missed something ,on why some doctors are often  prescibe this   and if any one"s doctor has explained why they are quick to add this to the soup I would appreciate the info. Possibly it is the diabetes??
Thanks

Will

119 patients in this study: No incidence of infection because of low neuts

http://clinicaltrialsfeeds.org/clinical-trials/show/NCT00895947

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In this study 4243 patients:

http://www.medscape.com/viewarticle/493202_4

Two recent reports indicate that there is no association between neutropenia in this population and the development of bacterial infections.[35,36] In the largest study report, featuring preliminary data from a still ongoing multicentre trial, there were only 30 of 4243 patients (0.7%) who developed severe infections during anti-viral therapy.[36] When examined closer, the mean ANC nadir in this group was no different than that of the entire treated study population. There was also no difference in the percentage of patients who had ANC < 750/mm3, or was there any association between the ANC nadir and the development of infection. These data suggest that further meticulous studies are required to determine the criteria for dose reduction and to define the use of G-CSF for PEG-IFN-induced neutropenia.

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In this study 2876 patients:

http://www.ncbi.nlm.nih.gov/pubmed/20830784?dopt=Abstract#

Bacterial infections during treatment with peginterferon alfa and ribavirin are not associated with neutropenia. Older patients and patients with poorly controlled diabetes mellitus have a greater risk of developing infections during HCV treatment.

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In this study 319 patients:

http://www.ncbi.nlm.nih.gov/pubmed/18458815

During the treatment with pegylated interferons and ribavirin, we did not find a correlation between neutropenia and infections. This result provides a support for the notion that current guidelines for pegylated interferons dose reduction in the treatment of chronic hepatitis C for hematologic toxicity could be overly strict.

[willbb]

I guess the bottom line is no doctor wants  their patient to pass away from runaway infection and no patient needs that added worry.even if it is an extremely rare event if ever(actually in the approx. 8000 that were studied this never happened that I saw )

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Meant to say : (actually in the approx.8000 that were studied it never happened that there was a runaway infection..).

not that  any had passed away   Passing away in a study is never that great for end result   :0)

[willbb]

Thank H for passing along Terrault"s take on this. It would seem to me after what I have heard from these three different experienced Hepa"s  and what I have read from all the various studies and some that others have passed along here...the bottom line is  Filgrastim (neupogen) very well may be over prescribed in the HCV treatment regime.

I guess the bottom line is no doctor wants  their patient to pass away from runaway infection and no patient needs that added worry.even if it is an extremely rare event if ever(actually in the approx. 8000 that were studied this never happened that I saw )

In my own study there was no rescue for Neuts allowed and my ANC got to 540 and I asked "what now" ? they said if it get down to around <400 he would start me on an antibiotic( I don"t remember which one)

I asked him if that was not dangerous and he said "no" in 15 years of treating  he only had one patient that had a runaway infection and that person did not even have neutropenia and it would have happened to them probably regardless.

I guess the bottom line is anyone that has no underlying health issues or complications  that an experinced doctor would be worried about infection  then the automatic start of another powerful drug introduced should at the very least be questioned,,especially as Dave mentioned  "there seems to be a number of not so experinced doctors" taking on this treatment therapy.
Thx.
Will

desrt..I wonder what a decent # of neuts is? I read what you passed along and couldn"t seem to figure that out .thx.

[desrt]

Cipro is good stuff. I used it effectively while on tx myself. It also appears to remain effective (especially if administered IV) even in the presence of neutropenia.

http://www.faqs.org/abstracts/Health-care-industry/Intravenous-ciprofloxacin-for-infections-in-cancer-patients.html

"Thirty patients had neutropenia, an abnormally low number of a type of white blood cell, the neutrophil. Ciprofloxacin was effective in 78 percent of patients.."

However, it appears to be most effective in the presence of a decent # of neutrophils.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC89547/

"Neutrophils accumulate ciprofloxacin and other fluoroquinolones, a process that enhances the killing of intracellular pathogens and could facilitate the delivery of these agents to infection sites by migrating neutrophils."

[spectda]

"Bottom line -
So if a doctor wants to prevent bacterial infections in a patient during treatment they should prescribe an antibiotic, not Neupogen. "

I wasn't clear from that video (which I think was made in 2007) if she meant that neupogen should never be used no matter how low the ANC. My impression was that she was saying that neupogen is overused, not that it should never be used. I didn't find the place on the video where she was totally black and white on her position about it's use. I didn't see where she included non-cirrhotics at all in her talk.

It seems to me that since that time experienced hepatogoligists who really know what they are doing as a result of research about the correlation between low ANC and infection have changed there threshold for using neupogen, but I don't think they never use it. Unfortunately many people are treated by doctors who don't fully know what they are doing or are as she suggested covering there a$$ by using neupogen too freely.

"So the point that both Dr, Terrault and Will's hepatologist is making is there is NO correlation between neutropenia and the incidents of infections in patients during treatment."
I believe she said the word "little" correlation, not "no" correlation in the video.

I am not cirrhotic, my WBCs and ANCs were normal prior to treatment, my ANC went to 280 at week 6 and I developed a bacterial infection in my ear and throat and was put on antibiotics and neupogen. I read about one person on this forum (can't remember who it was) whose ANC went to 0 and was hospitalized with bacterial pneumonia and put on intravenous antibiotics and neupogen. Although it seems obvious that neupogen is overused, I am not sure that it should never be used.

Prophylactic antibiotics in the high risk group seems to be more then subject of her comments which makes sense since the whole talk is about the importance of treating cirrhotics and and handling their complications.

Maybe you could ask her position on the rest of the treating population and neupogen, is there ever an appropriately low ANC threshold where she would advise using neupogen?  I can't imagine she is suggesting using prophylactic antibiotics in the whole treating population.  

-Dave

[jules2551]

So I have a question....is the Neuprogen a common drug they use for non-cirrhotics when their ANC drops below 500?  I just read a study where 87% of GT 1b's were administered this drug and reduced INF.  "Studies show that the drug Neuprogen was well tolerated"......what does "well tolerated" mean

Happy New Year to All!

Jules

[HectorSF]

Howdy...

The point being that patients who are prone to cytopenias and infections (ie cirrhotics in doctor Terrrault's presentation) show no benefit by adding Neupogen to protect against infections.

Now that the antivirals are on the market we know that cytopenias are much more common in all patients (not just cirrhotics) treating with antivirals and peg-inf and riba.

So the point that both Dr, Terrault and Will's hepatologist is making is there is NO correlation between neutropenia and the incidents of infections in patients during treatment.

As I said before my own treatment experience as someone with compensated cirrhosis (so prone to cytopenias and infections) was to take Cipro to prevent bacterial infections while on treatment. An as a cirrhotic infections are always a concern since they can be life-threatening, the patient should have most current flu vaccine to prevent the most common viral infection as well.

Bottom line -
So if a doctor wants to prevent bacterial infections in a patient during treatment they should prescribe an antibiotic, not Neupogen.

Happy New Year!!!
I hope you are feeling better.
Hector