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Anemia and dose reduction
Well, definItely have anemia and boy is it a kicker! I went to the doctor yesterday and had an interesting conversation. Although I also had my blood drawn yesterday, I won't get that back until Monday. My Hmg from last week was 9.4 and I certainly expect this week's to be lower as I did not reduce my ribavarin until Thursday. The NP originally told me to reduce to 800 but I went ahead and reduced to 600 because that seemed to be the protocol set out by the Incivek site and info I've gleaned from here. Interestingly enough the 600 is what the doctor told me Friday. So a good call on my part. He also told me that he will probably want to transfuse me either next week or the week after depending on how much lower my Hmg goes. He mentioned procrit as well ( which I would kind of like to avoid because of extremely high cholesterol and family history of stroke). I am not thrilled about a transfusion but I do recognize that it is a quick fix.
So here is what else he told me. He said that once my ribavarin has been reduced, that basically it cannot be increased again. In other words, if we reduce to 400 then the highest we can go is 600. But now that we have reduced to 600, we cannot increase it to 800 or 1000 again. I know that I have read on here about doses being reduced and reinstated. What is the thinking on that?
Also, any suggestions for dealing with this anemia until I find out my levels on Monday? Is there anything I would need to watch for if I would need to go to the local hospital? I am resting a lot. Last night was the first time I had a fever (100.4) - down to 99.2 this morning.
As always any input is greatly appreciated.
Susan
So here is what else he told me. He said that once my ribavarin has been reduced, that basically it cannot be increased again. In other words, if we reduce to 400 then the highest we can go is 600. But now that we have reduced to 600, we cannot increase it to 800 or 1000 again. I know that I have read on here about doses being reduced and reinstated. What is the thinking on that?
Also, any suggestions for dealing with this anemia until I find out my levels on Monday? Is there anything I would need to watch for if I would need to go to the local hospital? I am resting a lot. Last night was the first time I had a fever (100.4) - down to 99.2 this morning.
As always any input is greatly appreciated.
Susan
I'm sorry your hgb has gotten this low, I know how bad that feels! I remember almost passing out in a Walmart, also having chest pressure and shortness of breath with exertion, scary for me. I looked and looked but cannot find the information about Ribavirin dose reduction. I know I have seen it somewhere!
In the phase III clinical trials, no rescue drugs were used and anemia was treated by reducing the Ribavirin dose to 600 mg when hgb went below 10. When hgb returns to 10 or above (I think) the dose can be increased again. This was my experience in the ADVANCE trial. After 3 wks at the reduced dosage my hgb returned to above 11, and I was increased to 1000 mg, but not to the 1200 mg I'd started at. Later I again dropped into the 9's, and was again reduced for another 4 wks. After that I stayed on 1000mg for the remainder of the 24 wks.
SVR for almost 3 years now!! Hang in there, you can do it! Cheering you on...
In the phase III clinical trials, no rescue drugs were used and anemia was treated by reducing the Ribavirin dose to 600 mg when hgb went below 10. When hgb returns to 10 or above (I think) the dose can be increased again. This was my experience in the ADVANCE trial. After 3 wks at the reduced dosage my hgb returned to above 11, and I was increased to 1000 mg, but not to the 1200 mg I'd started at. Later I again dropped into the 9's, and was again reduced for another 4 wks. After that I stayed on 1000mg for the remainder of the 24 wks.
SVR for almost 3 years now!! Hang in there, you can do it! Cheering you on...
From the Incivek Website:
http://www.incivek.com/hcp/anemia
In patients treated with INCIVEK combination treatment, 32% underwent a ribavirin dose modification (reduction, interruption, or discontinuation) due to anemia vs 12% treated with pegIFN-RBV alone
Evaluation and management of patients with anemia
Evaluate
Hematology evaluations are recommended at baseline and weeks 2, 4, 8, and 12, or as clinically appropriate
Manage
Ribavirin dose reductions should be used (refer to the Prescribing Information for ribavirin for its dose reduction guidelines)
If ribavirin dose reductions are inadequate, discontinuation of INCIVEK should be considered
If ribavirin is permanently discontinued for the management of anemia, INCIVEK must also be permanently discontinued
The dose of INCIVEK must not be reduced and INCIVEK must not be restarted if discontinued.
And:
The updated AASLD guidelines refer clinicians to the drugs’ labeling, or detailed package insert, for information on managing side effects, although the guidelines authors do provide their own guidance on managing anemia. Anemia is a common side effect from ribavirin and the HCV protease inhibitors. During hepatitis C treatment, if anemia develops, people are either treated with a red blood cell growth factor, such as Procrit (erythropoietin), or given a lower dose of ribavirin. The authors noted that cure rates were similar no matter which strategy was used to manage anemia. Since growth factors are costly and add side effects, AASLD recommends reducing the ribavirin dose to manage anemia while maintaining full-dose Incivek or Victrelis.
http://www.hepmag.com/articles/incivek_victrelis_aasld_2501_21290.shtml
So, am not sure where I got the 600 figure. I read so much stuff that day. This is some of the info I sent to my doctor. I'm quite happy to leave it at 600. I am going to call tomorrow about my bloodwork from Friday and I will ask about what research he is basing the 'no increase' statement.
Still feeling pretty awful. A friend came by and took me to the grocery store. I rode in a little electric cart at the store and an hour of being out just wiped me out!
http://www.incivek.com/hcp/anemia
In patients treated with INCIVEK combination treatment, 32% underwent a ribavirin dose modification (reduction, interruption, or discontinuation) due to anemia vs 12% treated with pegIFN-RBV alone
Evaluation and management of patients with anemia
Evaluate
Hematology evaluations are recommended at baseline and weeks 2, 4, 8, and 12, or as clinically appropriate
Manage
Ribavirin dose reductions should be used (refer to the Prescribing Information for ribavirin for its dose reduction guidelines)
If ribavirin dose reductions are inadequate, discontinuation of INCIVEK should be considered
If ribavirin is permanently discontinued for the management of anemia, INCIVEK must also be permanently discontinued
The dose of INCIVEK must not be reduced and INCIVEK must not be restarted if discontinued.
And:
The updated AASLD guidelines refer clinicians to the drugs’ labeling, or detailed package insert, for information on managing side effects, although the guidelines authors do provide their own guidance on managing anemia. Anemia is a common side effect from ribavirin and the HCV protease inhibitors. During hepatitis C treatment, if anemia develops, people are either treated with a red blood cell growth factor, such as Procrit (erythropoietin), or given a lower dose of ribavirin. The authors noted that cure rates were similar no matter which strategy was used to manage anemia. Since growth factors are costly and add side effects, AASLD recommends reducing the ribavirin dose to manage anemia while maintaining full-dose Incivek or Victrelis.
http://www.hepmag.com/articles/incivek_victrelis_aasld_2501_21290.shtml
So, am not sure where I got the 600 figure. I read so much stuff that day. This is some of the info I sent to my doctor. I'm quite happy to leave it at 600. I am going to call tomorrow about my bloodwork from Friday and I will ask about what research he is basing the 'no increase' statement.
Still feeling pretty awful. A friend came by and took me to the grocery store. I rode in a little electric cart at the store and an hour of being out just wiped me out!
Hi Susan: Bummer about feeling so exhausted today. Staying hydrated may help you feel a little better. I agree with Bean. I have never heard that riba can't be increased after a decrease. Don't know what a transfusion costs, but Procrit/Epogen is probably a least costly alternative. Plus, I read the Hgb threshold for a transfusion is ~7 while the Hgb threshold for Procrit/Epogen intervention is ~10. If you are so exhausted, you may want to consider starting Procrit/Epogen instead of waiting for a transfusion. That said, blood clots caused by Procrit/Epogen are a valid concern. Best, Sentinel.
I feel for you. the 9s is the pits. Been there for 3 months myself. I have never heard that you cannot increase the riba once the hgb increases.
I am curious - you said you gleaned from the Incevik website that protocol was to reduce riba to 600. I could not find that on the Incevik site. Do you have a link to that? All I read was to use the ribavirn guidelines.
I am curious - you said you gleaned from the Incevik website that protocol was to reduce riba to 600. I could not find that on the Incevik site. Do you have a link to that? All I read was to use the ribavirn guidelines.
Thanks, mo.....I may ask to see his research.
Can barely lift head up today...
Can barely lift head up today...
My HGB has stayed 9.2 most of tx. A month ago they reduced Riba from 1000 to 800 and she said when hgb goes up I will con,t with 1000 Riba again. She wants to keep me at the highest dose possible. HGB has not gone back up yet, blood work again on monday. I have never heard that you can not raise it back up.
Mo
Mo
lots of us have raised riba back up....and at 9 hgb your not too bad....some have even had to stop riba for a short time...do blood work every week...maybe twice a week...fevers are common..take it easy...do you have help at home? keep up with the incivek...your symptoms may not be that bad or they may be awful...in either case do everything you can to stay with tx...my symptoms were so tough but i took as much drugs as possible to beat the virus...good luck....billy
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