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WBC Count Low; Told To Skip 2 Interferon Shots.
I don't have the numbers but the Doc's office help called me the morning after my latest CBC and I was told to skip 2 shots. She said the number had to have been below 2. I don't have insurance and can't afford special drugs or blood transfusions. Any opinions on this? How will this compromise my tx? I'm on week 18 of Peginterferon, Ribaviron & Victrelis. I thought I was doing pretty well, just mainly short of breath.
I personally think that a reduced interferon dose for a week or two would have been a better approach, rather than skipping two doses. It really depends on your current absolute neutrophil count (ANC) and the experience of your treating doctor. Most experienced hepatologists wouldn't consider dose reductions or administering neupogen for an ANC over 0.5. Some less experienced docs get excited when they see the ANC go below 1.0.
As Mike pointed out above, there isn't a relationship between risk of infection and low ANC for HCV patients. However, there IS for cancer patients and this is where many of the treating doctors get overly concerned for fear of infection.
My ANC was very low (< 0.5) throughout my 48 week tx. My doc didn't want to do any dose reductions so I was administered neupogen 2x weekly. Even with that, on some weeks my ANC level was so low it didn't even register. However, I never had any infections throughout tx. Maybe I just got lucky??? This is a discussion you should have with your doctor. You should also keep all your lab results and keep them in a file for future reference. Good luck to you.
As Mike pointed out above, there isn't a relationship between risk of infection and low ANC for HCV patients. However, there IS for cancer patients and this is where many of the treating doctors get overly concerned for fear of infection.
My ANC was very low (< 0.5) throughout my 48 week tx. My doc didn't want to do any dose reductions so I was administered neupogen 2x weekly. Even with that, on some weeks my ANC level was so low it didn't even register. However, I never had any infections throughout tx. Maybe I just got lucky??? This is a discussion you should have with your doctor. You should also keep all your lab results and keep them in a file for future reference. Good luck to you.
"I believe that my last VL test was at 8 weeks and I was detectable but down to "9". These tests are the most expensive part of my tx at $500+ each so we agreed to minimize them and I will get one at 24 wks and 36 wks and 6 months after completing 48 wks of tx"
I dont know your full story but the thing that alarms me are your VL check intervals. If Im not mistaken, the proper protocol for VL blood drawls are at week 4, 12, 24, and 48. I was under the impression based on studies that these protocols were the standard in being able to identify early and rapid virological responders. I dont quite understand why you had an 8 week VL check instead of a 12 week check. I mean its fine to have as many VL checks as you want so long as you still have them on the standard weeks. Because I wasn't UND until week 5 I was clinically classified as an EVR....versus had I been UND a week earlier I would have been an RVR.
Its important to know when you became UND because it can help predict your chances of SVR. Its also important to know when and if you have a viral breakthrough. Like I said, I dont know your full story but from what you wrote it seems that you were still DET at week 8 and because of the cost you will not have another VL check until week 24. So my understanding is that you have missed the 12 week test as you are on week 18 now. Its important to follow the guidelines for proper classification in the unfortunate event that you have to re-treat.
Virological Responses During Therapy and Definitions
Virological Response Definition Clinical Utility
Rapid virological response (RVR) HCV RNA negative at treatment week 4 by a sensitive PCRbased quantitative assay May allow shortening of course for genotypes 2&3 and possibly genotype 1 with low viral load
Early virological response (EVR) 2 log reduction in HCV RNA level compared to baseline HCV RNA level (partial EVR) or HCV RNA negative at treatment week 12 (complete EVR) Predicts lack of SVR
End-of-treatment response (ETR) HCV RNA negative by a sensitive test at the end of 24 or 48 weeks of treatment Sustained virological response (SVR) HCV RNA negative 24 weeks after cessation of treatment Best predictor of a long-term response to treatment Breakthrough Reappearance of HCV RNA in serum while still on therapy Relapse Reappearance of HCV RNA in serum after therapy is discontinued
Nonresponder Failure to clear HCV RNA from serum after 24 weeks of therapy Null responder Failure to decrease HCV RNA by 2 logs after 24 week of therapy Partial responder Two log decrease in HCV RNA but still HCV RNA positive at week 24
http://www.aasld.org/practiceguidelines/documents/hepatitis%20c%20update.pdf
"I was told to skip 2 shots."
What about a dose reduction? Why skip altogether and not reduce the interferon? If you have room to reduce Id speak with my doc about reducing the dose rather than skipping it. And skipping 2 doses? If the CBC is relatively inexpensive than why skip 2 if you dont even know if your WBC have improved? Ask your doc for a CBC after the first week of missing or reduction to see if it improved. Presuming that you need 2 weeks interferon free to improve your WBC may jeopardize your TX. Just my opinion.
I dont know your full story but the thing that alarms me are your VL check intervals. If Im not mistaken, the proper protocol for VL blood drawls are at week 4, 12, 24, and 48. I was under the impression based on studies that these protocols were the standard in being able to identify early and rapid virological responders. I dont quite understand why you had an 8 week VL check instead of a 12 week check. I mean its fine to have as many VL checks as you want so long as you still have them on the standard weeks. Because I wasn't UND until week 5 I was clinically classified as an EVR....versus had I been UND a week earlier I would have been an RVR.
Its important to know when you became UND because it can help predict your chances of SVR. Its also important to know when and if you have a viral breakthrough. Like I said, I dont know your full story but from what you wrote it seems that you were still DET at week 8 and because of the cost you will not have another VL check until week 24. So my understanding is that you have missed the 12 week test as you are on week 18 now. Its important to follow the guidelines for proper classification in the unfortunate event that you have to re-treat.
Virological Responses During Therapy and Definitions
Virological Response Definition Clinical Utility
Rapid virological response (RVR) HCV RNA negative at treatment week 4 by a sensitive PCRbased quantitative assay May allow shortening of course for genotypes 2&3 and possibly genotype 1 with low viral load
Early virological response (EVR) 2 log reduction in HCV RNA level compared to baseline HCV RNA level (partial EVR) or HCV RNA negative at treatment week 12 (complete EVR) Predicts lack of SVR
End-of-treatment response (ETR) HCV RNA negative by a sensitive test at the end of 24 or 48 weeks of treatment Sustained virological response (SVR) HCV RNA negative 24 weeks after cessation of treatment Best predictor of a long-term response to treatment Breakthrough Reappearance of HCV RNA in serum while still on therapy Relapse Reappearance of HCV RNA in serum after therapy is discontinued
Nonresponder Failure to clear HCV RNA from serum after 24 weeks of therapy Null responder Failure to decrease HCV RNA by 2 logs after 24 week of therapy Partial responder Two log decrease in HCV RNA but still HCV RNA positive at week 24
http://www.aasld.org/practiceguidelines/documents/hepatitis%20c%20update.pdf
"I was told to skip 2 shots."
What about a dose reduction? Why skip altogether and not reduce the interferon? If you have room to reduce Id speak with my doc about reducing the dose rather than skipping it. And skipping 2 doses? If the CBC is relatively inexpensive than why skip 2 if you dont even know if your WBC have improved? Ask your doc for a CBC after the first week of missing or reduction to see if it improved. Presuming that you need 2 weeks interferon free to improve your WBC may jeopardize your TX. Just my opinion.
If I were you I'd get another doc. The order sounds odd but just the fact that he/she had the 'office girl' call with this message (no opportunity to question) would be enough for me. Good Luck
To my above post I will add an event in my treatment: I was plagued with neutropenia throughout treatment and my doc was fine with it "as long as it stays above 500". It hovered between 550 and 650 most of the time. I eventually went on Nupogen the last 2 months but prior to that I get a call from another one of the gastro docs in his group (weekend coverage detail) and she's near panic telling me my labs just got back, my ANC is 550 and I need to cut back on my ribavirin (now this is a board certified gastroenterologist believe it or not) . Well, I ignored that (it's the economy stupid) and the next week my regular doc concurred with my call...but as they're all in the club, did his best to CYA her incompetence.
he started me on Nupogen ("or we'll have to cut back on your Peg") when my proceeding labs came back:
1- ANC 462*
2- ALC 1085
3- WBC 1.9
It was all about the ANC as my WBC total had dropped lower before and not a word about it. Lymphocytes dropped from pre-treatment but were still within normal limits. Read studies stating that with HCV 300 should be OK and that it doesn't get dangerous till about 100. Nupogen worked for me with one shot every 10 days (155#, 59 yrs, stage 3, peg-180/d, rib 1000/d).
Good Luck
1- ANC 462*
2- ALC 1085
3- WBC 1.9
It was all about the ANC as my WBC total had dropped lower before and not a word about it. Lymphocytes dropped from pre-treatment but were still within normal limits. Read studies stating that with HCV 300 should be OK and that it doesn't get dangerous till about 100. Nupogen worked for me with one shot every 10 days (155#, 59 yrs, stage 3, peg-180/d, rib 1000/d).
Good Luck
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