Your "Great" labs might mean the opposite of what you think they do.

[jmjm530]

Always killed me when people here report that my doctor said "my labs look 'great"" or that "my hemoglobin is great" -- when in fact an association between anemia and riba absorption has been known for some time. Now, we have the logical association between anemia/riba absorption and SVR. Bottom line IMO  is that having little or no anemia should at least signal a discussion with your doc about increasing your riba dose, regardless if it's weight based. Espeically if your viral decline isn't what it should be. Also note Procrit's role in keeping people on tx with their anemia. Thanks to "CoWriter" for bringing this particular presentation to my attention.
------------------

Oral Presentations
http://www.kenes.com/easl2009/Orals/276.htm

Session Title: Parallel Session 15: HEPATITIS C VIRUS NATURAL HISTORY AND THERAPY
Presentation Date: Apr 25, 2009

HEMOGLOBIN DECLINE IS ASSOCIATED WITH SVR AMONG HCV GENOTYPE 1-INFECTED PERSONS TREATED WITH PEGINTERFERON (PEG)/RIBAVIRIN (RBV): ANALYSIS FROM THE IDEAL STUDY

M. Sulkowski1, M. Shiffman2, N. Afdhal3, R. Reddy4, J. McCone5, W. Lee6, S. Herrine7, S. Harrison8, W. Deng9, C. Brass9, K. Koury9, S. Noviello9, J. Albrecht9, J. McHutchison10
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Virginia Commonwealth University Medical Centeru, Richmond, VA, 3Beth Israel Deaconess Liver Center, Boston, MA, 4University of Pennsylvania Health System, Philadelphia, PA, 5McCone Endoscopy Center, Alexandria, VA, 6Clinical Center for Liver Diseases, Dallas, TX, 7Thomas Jefferson University, Philadelphia, PA, 8Brooke Army Medical Center, Fort Sam Houston, TX, 9Schering-Plough Research Institute, Kenilworth, NJ, 10Duke Clinical Research Institute, Durham, NC, USA

Background and aims:
Peginterferon (Peg)/ribavirin (RBV) causes significant hemoglobin (Hb) decline leading to side effects and RBV reduction in ~30% of patients (pts). The effect of Hb loss on sustained viral response (SVR) is unknown.

Methods:
3070 HCV genotype-infected pts were treated for 48 weeks with Peg2b 1.5 or 1.0mcg/kg/wk + RBV 800-1400mg/day, or Peg2a 180mcg/wk + RBV 1000-1200mg/day. Anemia was defined as Hb 3 g/dL, 43.7% (984/2250); ≤3 g/dL, 29.9% (231/773) (P8 weeks):
Anemia/no EPO, 59.3% (162/273);
Anemia/EPO, 55.0% (116/211); P=0.33.
Among anemic pts, EPO was associated with less early (< 0.001).

Conclusions:
Among HCV genotype 1-infected pts treated with Peg/RBV, the magnitude of Hb decline is strongly associated with the likelihood of SVR.
The effect of EPO varied by time to anemia;
no benefit was observed for pts who became anemic after treatment week 8.
These data suggest that Hb decline may be a pharmacodynamic marker of treatment effectiveness and that the primary effect of EPO was to prevent treatment discontinuation in pts with early anemia.

[portann]

Okay, I don't mind if you freak me out! :)

I started tx at 15 and at eight weeks was 12, which is not officially anemic. So? Say it straight, I can take it....

I'm taking (was taking!) 17.8 mg per kilo of riba, so could I have really taken more, given that I am, after all, an elderly lady?

In hindsight, should I have stopped tx at eight weeks, calculated that SOC wouldn't do it for me and waited for the PI's?

My 'true' anemia didn't hit for another month, which is past the study's significant point.

[jmjm530]

Interesting you mention creatine, because Lindahl and CO used a pharmakinetic formula for initial riba dosing (as opposed to weight based dosing) involving kidney function markers such as creatine in their 2005 small landmark pilot study on high dose ribavirin. From what I've been told the formula used underestimated the amount of riba needed and therefore it had to be bumped up based on HPLC testing. But the concept does hold and therefore people with impaired kidney function (dialysis patients for example) can do quite well on treatment with much lower doses of ribavirin although I'm unaware of any exacting formulas in this regard other than anemia, unless of course HPLC testing is available in trial setting.

[HCA]

Another useful marker is creatinine.Patients with anemia and rising creatinine are retaining ribavirin and can tolerate dose reduction without prejudicing SVR.
People are gradually learning that ribavirin plays no part in in viral suppression but a major part in preventing relapse (and break-through).High levels of ribavirin are necessary at the point that viral suppression takes place in order to compromise the design of a  successful variant .
A drop in Hgb is indeed a good sign.

[jdwithhcv]

Marcia makes a good point.

hgb < 13.2 indicates anemia

hgb < 10 is the criterion for procrit (epogen)

Many people become anemic on tx, however most doctors will not prescribe (nor insurance companies approve payment for) procrit untli hgb drops below 10.  As hgb levels rise, many doctors will discontinue procrit because it carries a risk of blood clots.

[jmjm530]

Marcia: Not being below 10 doesn't mean one does not have anemia.
----------------------

To quote from the paper, "the magnitude of Hb decline is strongly associated with the likelihood of SVR. "

So, it's not the absolute number per say, or even the technical definition of "anemia", but how much of a decline from pre-tx baseline that is the main thing. Makes sense since many of us start at much different pre-tx hemoglobin levels.

[Marcia2202]

I think that there sometime is a misinterpretation of anemia on the board. Not being below 10 doesn't mean one does not have anemia.

I have sometimes myself stated that my blood work is looking good, meaning that it looks good for being on treatment, meaning that I didn't need Procrit, yet. An Hgb of 10.5 is low, anything under 12 is considered low.

Even though I was anemic all the way through tx, I still did not clear at 4 weeks.

Marcia