WBC still low

[Bill200]

My WBC still continues in the low range.  Going to start taking two shots of G-CSF per week now.

The odd thing was I'm well into treatment (over 5 months) and my WBC held up for a while even through the Incivek.  I'm now about 6 weeks post-Incivek and it has dropped to 0.7.  No infections or any symptoms of anything.

Any suggestions such as foods to eat, exercise as to how I might get it back up?  I feel pretty much fine.  The INF doesn't even both me that much.  RBC is fine.

[goater]

Bill, I just finished 48 weeks (w/Victrelis) and during most of that I was taking Neupogen.  The jury is still out on the benefits of this drug when it is used to prevent infection from interferon induced neutropenia.  That said, my rational for tolerating this unpleasant drug was to avoid dose reducing and increasing my odds of an SVR.  My GI's goal was not risking infection in a cirrhotic patient.  I did not have to dose reduce but did end up starting Neupogen at week 12 and by week 21 was taking it x3 weekly.  By protocol I would have had to stop treatment without growth factor drugs.

Generally, when my WBC was .9 then my ANC was in the mid .3's.  Neupogen was very fast acting for me but with a short half life I'd be back where I started within a couple days.  However, everyone is different.

Have you asked your doc if you can return to full interferon if you can stabilize?

In my experience the first Neupogen dose after the interferon had more bone discomfort and body ache.  The remaining doses that week I hardly paid attention to.  Best wishes, marty

  

  

[Idyllic]

Wow I read the post where you asked abut reduced Interferon and I did not realize you were already on a reduced dose.

It sounds as if you are being being closely monitored with labs and your doctor is trying to tweak the doses of all your meds. Plus, there is an article (dated 2009) in the HCVAdvocate and it mentions a few of the types of bacterial infections associated with Interfeon related Neutropenia during treatment for Hepatitis C:

Infections occurring among the 119 patients treated with interferon and ribavirin.

Infection, n.

Sinusitis, 5.
Pharyngitis, 4.
Gingivitis, 1.
Otitis media, 2.
Bronchitis, 2 .
Pneumonia, 1
Urinary Tract Infection, 4
Prostatitis, 1
Cellulitis, 2

Since these type of infections can be treated with an antibiotic is it possible to have an antibiotic on hand such as Cipro? You may not ever have to use it but perhaps it could allay your concern about your ability to fight infection and your blood counts until you find a dosing routine that works.

I don't know if this is practical I just remember that some cirrhotic people on here bypassed Neupogen altogether and had a standing order of Cipro on hand.

Here is the link:
http://www.hcvadvocate.org/hepatitis/hepC/Neutropenia.html

[frijole]

Not much to add here as the advice is excellent.  You ask what you can do outside the G-CSF (is that Neupogen) to help.  I think the answer is, not much.  It is the interferon that reduces the absolute neutrophils and it will continue to do that, with or without the Incevik.  

Idyllic... in answer to your question:
"I don't know if there is a linear relationship between ANC & WBC or what but I do not know how to interpret intervention based on WBC"

Neutophils are one of the kinds of white blood cells.  The others are lymphocytes,monocytes, eos, and basos .  Each type of WBC has a different function. Neutrophils are on the front line, so to speak.  Normally neutophils are about 40-70% of the total WBC count.

According to Wikepedia, "Neutrophil granulocytes are the most abundant type of white blood cells in mammals and form an essential part of the innate immune system. ..."

The unit of measurement for the WBC is K/uL.  So if WBC is 4, if you add the count of each - the absolute neutophils, lymphocytes, monocytes and others - they will equal the total WBC.  In Bill's case if ANC was .4 and WBC is .8 then  half of his WBC are neutrophils which is in the 40% to 70% range, but low in the terms of absolute.  The range for absolute number of neutrophils is 2.0 - 8.0)

Confusing to be sure.  It is a mystery to me why we don't get the broad range of infections like cancer patients do, but it is a fact that we don't.  
However, my hepatologist said you had to keep a much closer tab on the ANC and WBC when a patient is cirrhotic because the risk of infection is greater.


frijole (bean)

[orphanedhawk]

I was referring to half dosages of neupogen. You really don't want to go lower than half dose on the interferon.

Good luck.

[Bill200]

Thanks for the replies.  My ANC was 0,4 last week.  Don't know what it was this week but WBC went from 0.8 to 0.7.  Started out on 1 shot a week for the past few weeks going to do two this week.  The Neup didn't bother me much last week (3rd shot) but definitely felt it the first two times (headache and achy bones).  Nothing that a little Tylenol didn't take the edge off of.

I took a shot a few hours ago and starting to feel jittery/edgy like INF when it first starts kicking in.  Funny thing is the day after INF I feel pretty good.  Go figure.  Might go take a Tylenol now to ward off the SX from Neup.

I'm on half-dose INF now so don't want to lower that.  I read that that's basically the minimum effective dose (about 1 mcg per kg).

[orphanedhawk]

Although there's some information out there that claims some food can help increase wbc, I don't know of any that work.
Low wbc are a side effect of interferon tx. Once you stop tx, your wbc will rise.
Most hepatologists go by the anc, not wbc.

Most of our hepatologists will wait until our anc is 0.5 before prescribing neupogen.
It's actually somewhat questionable as to whether it is even needed for hep C patients. The drug is an off label. Within the cancer community it helps raise wbc levels and ward off infections. I can't find the research but I read some provided to me by mikesimon that claims those with interferon induced neupogenia ( low wbc) do not get these infections.

If you are going to do neupogen, be sure to take calcium and vitamin D. That stuff is hard on your bones. And if you experience intense side effects don't hesitate to ask your doctor to reduce your dosage.

My labs were the same with the full dose as it was with half, but I found I could tolerate half the dose much better.
You should do the neupogen about 24 hours prior to your interferon shot.

Do you know why they are recommending you begin with a twice weekly shot? It sounds excessive to me but I don't know your medical history.

[Idyllic]

Whoa ~ I should reload my screen before I post.

Flcyclist says all this much better than I do. The one thing I learned from both his old posts as well as OHs is how tricky the timing can be with Neupogen. I knew out the outset to be vigilant about the timing of my labs and the Neupogen dose. Even though this was only weeks ago I see I saved myself some time and discomfort since I knew what to ask and what to look for when I started this med.

[Idyllic]

Glad the Interferon isn't bothering you that much - still, it is the Interferon that causes your ANC to drop. Other than decreasing the amount of Interferon that is the only other thing I have heard that would increase ANC at this stage of treatment. Be glad you don't have to reduce your Interferon though :)

I don't know if there is a linear relationship between ANC & WBC or what but I do not know how to interpret intervention based on WBC. Or what it means when your WBC is that low.


Could you possibly mean your ANC is .7 by any chance? I know there is a relationship between WBC & ANC but it is usually when ANC drops to .5 that intervention is often considered.


I thought you were cirrhotic though? If so there may be additional factors to consider.  In case you mean ANC and yours is.7 ~ then it seems like you could keep an eye on it for a few more days. Your ANC will boost almost immediately after administration. The second dose is sometimes needed a few days later since it varies on how long your ANC will remain at an acceptable level. As I said though everyone's circumstances are different so I will let the others who know more than me chime in.

In my case I am glad I held off a little since I find the side effects of Neupogen uncomfortable. I was afraid I would need two doses a week as well but seem to be doing OK with 300 mcg once a week.

[flcyclist]

Bill, many experienced hepatologists use the ANC threadhold of 0.5 before administering neupogen.  You might have other issues going on which led to your doctors decision to begin earlier at 0.7.  Some doctors use 1.0 for the threshold for fear of risk of infection, but there are many published references to dispute this risk for HCV patients.  For cancer patients? yes.

My ANC was often 0.3 or below and I was taking two neupogen shots per week.  In your case I wonder if only one shot might be sufficient if your doctor insists on you going this route.  In my experience my ANC was at its lowest a few days after the interferon shot, then very quickly rebounded after the neup shot.   The only was to tell is to do a cbc just before the neupogen shot to see if its required.  Hopefully they will allow this and watch is closely.  Some people respond quickly and the ANC shoots well over 1.0 and don't need another boost for a few weeks.  

There is nothing that I'm aware of to boost your ANC other than neupogen or an interferon dose reduction.    It sounds like you are doing very well, so don't worry too much about this blip in your wbc's.   Good luck.