facial jaundice

Question

I  am 42 weeks into 48 wks of triple treatment with incivek.  I am now developing a little jaundice and swelling across my cheeks on both sides.  My liver enzymes have been up and down, but have remained elevated through treatment.  Any ideas? I've never had jaundice before.

pooh55811 · Accepted Answer

I listed some causes of jaundice below, but I am sure you are aware of most or all of them. 

I recall that you are at Stage 3 or 4 fibrosis level. You have been on Tx for 42 weeks. Have you had a recent bilirubin test? If I was you I would call my Hepatologist ASAP and let him/her know that you are developing jaundice.  That way he/she can order the appropriate tests to determine the cause and institute appropriate interventions ASAP. 

Here are a few causes of jaundice, most of which you probably already know:

Jaundice causes

Jaundice is a yellow color in the skin, mucus membranes, or eyes. The yellow color comes from bilirubin, a byproduct of old red blood cells. Jaundice is a sign of other diseases.

Common causes of jaundice in older children and adults include:

    Viral infection of the liver (hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E)
    Parasite infection of the liver
    Gallstones
    Cancer of the pancreas

Other causes of jaundice include:

    Cancer of the pancreas
    Disorders present since birth that makes it hard for the body to breakdown bilirubin (such as Gilbert syndrome, Dubin-Johnson syndrome, Rotor syndrome, or Crigler-Najjar syndrome)
    Eating poisonous mushrooms or other poisons
    Immune disorder that mistakenly attacks healthy liver tissue (autoimmune hepatitis)
    Liver damage caused by reduced oxygen or blood flow to the liver
    The body destroys too many blood cells and the liver cannot handle them (hemolytic anemia)
    Use of certain drugs, including an overdose of acetaminophen

Gallbladder and bile duct disorders that can cause jaundice include:

    Blocked or narrowed bile ducts (by infection, tumor, stricture, or gallstones)
    Primary biliary cirrhosis
    Bile build up in the gallbladder because of pressure in the belly area during pregnancy (jaundice of pregnancy)

http://www.nlm.nih.gov/medlineplus/ency/article/007491.htm

dontworry_behappy1 · Answer

I really think you should contact your doctor right away. Swelling of the face and jaundice sounds like something to not wait about.  I'm sure others will have more to say but I would get right on it if this was happening to me.

garrygee · Answer

I had labs done this past Wed.  I should have results by Monday and will call my doctor.  They don't routinely do a bilirubin.  It sounds like I need one.  Thanks to all. 

Garry

garrygee · Answer

They do monthly bilirubin, after I rechecked.  It was as high as 0.9 shortly after I started treatment, but has been 0.6-0.7 since then.  I will get a new one on Mon. as I get all my results faxed to me when they are done.  I will still contact my doc on Mon.  I can't see calling him on the weekend when I don't feel any different.  My normal is pretty bad right now, but it's still what it was the last time I saw him.  Thanks again.  Garry

garrygee · Answer

I got my labs back a little early.  Bilirubin 0.6.  RBC:  3.76 with macrocytosis 1+ and polychromasia 1+.  last month only macrocytosis 1+.  Hgb: 12.7, but my normal, pre-treatment was 17.2.  It sounds like my continued anemia won't allow my bone marrow to keep up with production demand.  Will speak to my doctor on Mon.

Thanks,  Garry

HectorSF · Answer

Bilirubin is a product of the breakdown of hemoglobin, which is the protein inside red blood cells. If bilirubin cannot leave the body, it accumulates and discolors other tissues. The yellow discoloration of the skin, sclera (whites of the eye) and deeper tissues like the mucus membrane of the mouth.

The normal total level of bilirubin in blood serum is usually between 0.2 mg/dL and 1.2 mg/dL depending on the lab. When it rises to 3 mg/dL or higher, the person's skin and the whites of the eyes become noticeably yellow. Bile in the skin many times will become itchy.

Gary, your lab results show all NORMAL bilirubin levels.0.9, 0.6, 0.7.

When your doctor see you he/she can easily diagnose jaundice.

FYI: You DON"T have anemia. "Hgb: 12.7". 
Anemia is defined as a Hbg of <10.0  
While lower then normal,a Hgb of 12.7 is a very good level of red blood cells to have when treating with interferon based treatment.

Do you have a hematocrit level?

Good luck on Monday!
Hector

garrygee · Answer

Thanks for your input Hector.  Actually a hgb is a lab number and normal is defined as whatever that lab determines is normal for their facility.  Wikipedia says normal for males is above 13.0.
I am 67 years old and have a history of COPD.  My normal has been higher.  Additionally, my Hct is below normal by my labs standard, my MCV, MCH and RDW are all high.  My RBC count is low and is noted to have microcytosis 1+ and polymorphosis 1+.
I am looking forward to talking to my doctor.  My tests may not warrant it but my face is yellow.  That part's for sure.
Thanks again for your input.  Garry

HectorSF · Answer

You are correct Gary about the normal range of Hgb. I guess I didn't explain it very well. I wasn't saying your Hgb was normal (as your bilirubin levels were all within normal range) It is typical for Hemoglobin levels to go lower then normal during hepatitis C treatment when using interferon based treatments such as triple therapy with Incivek. But anemia during treatment of Hepatitis C is when Hgb is less than 10g/dL.
-----------------------------------------------------------------------------------------------------
Gastroenterology and Hepatology

"Mechanism of Anemia in Patients Receiving Triple Combination Therapy

The PI (Protease Inhibitor) registration trials used modified World Health Organization guidelines to define toxicity grades for anemia based on hemoglobin levels: Grade 0 anemia was defined as a hemoglobin level of 11 g/dL or above; grade 1 anemia was defined as a hemoglobin level between 9.5 g/dL and 11 g/dL; grade 2 anemia was defined as a hemoglobin level of 8.0—9.5 g/dL; grade 3 anemia was defined as a hemoglobin level of 6.5—8.0 g/dL; and grade 4 anemia was defined as a hemoglobin level below 6.5 g/dL.2–5 

The package insert for RBV (ribavirin) states that dose reduction is appropriate if hemoglobin levels fall below 10 g/dL; if hemoglobin levels fall below 8.5 g/dL, discontinuation of RBV is recommended. These were also the guidelines used in the PI registration trials to manage anemia."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533206/

INCIVEK TM (telaprevir) Film Coated Tablets, for oral use
Initial U.S. Approval: 2011

-----------------------WARNINGS AND PRECAUTIONS----------------------
"Anemia: Monitor hemoglobin prior to and at regular intervals during 
INCIVEK combination treatment. Follow dose modifications for 
ribavirin; discontinue INCIVEK if required.

"Anemia has been reported with peginterferon alfa and ribavirin therapy. The addition of INCIVEK to peginterferon alfa and ribavirin is associated with an 
additional decrease in hemoglobin concentrations. A decrease in hemoglobin levels occurred during the first 4 weeks of treatment, with lowest values reached at the end of INCIVEK dosing. Hemoglobin values gradually returned to levels observed with peginterferon alfa and ribavirin after INCIVEK dosing was completed. Hemoglobin values less than or equal to 10 g per dL were observed in 36% of subjects who received INCIVEK combination treatment compared to 17% of subjects who received peginterferon alfa and ribavirin. 

In clinical trials, the median time to onset of hemoglobin less than or equal to 10 g per dL was faster among subjects treated with INCIVEK combination treatment compared to those who received peginterferon alfa and ribavirin: 56 days (range 8-365 days) versus 63 days (range 13-341 days), respectively. Hemoglobin values less than 8.5 g per dL were observed in 14% of subjects who received INCIVEK combination treatment compared to 5% of subjects receiving peginterferon alfa and ribavirin. "

http://pi.vrtx.com/files/uspi_telaprevir.pdf

Ribavirin Dose Modification Guidelines
Hemoglobin <10 g/dL in patients with no cardiac disease
1 x 200 mg tablet A.M. 
2 x 200 mg tablets P.M.

Hemoglobin <8.5 g/dL in patients with no cardiac disease
Discontinue

http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021511s023lbl.pdf
---------------------------------------------------------------------------------------------
Hematocrit is sometimes known as "red blood cell count." The hematocrit is the percentage of red blood cells in the total contents of your blood.

* The hematocrit is directly related to the hemoglobin level. 
* Low hematocrits can develop during treatment with interferon and ribavirin.
Often, lowering the dosage of ribavirin will help bring the hematocrit back up.

So low Hct is typical for anyone going through hepatitis C treatment just as low RBC and Hemoglobin is. 

If you are concerned about these lab values ask your doctor if there is anything to worry about.

Best of luck on your doctors visit.
Hector

garrygee · Answer

Thanks for all your research.  Garry

facial jaundice

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Over 9 million RNC's quantitative viral load of Hep C

Hepatitis C : Questions

Starting treatment in shortly for hep c.

Antibody test came back positive, waiting on RNA result.

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