Low Neutrophils

[Diana66]

Since I started tx with a base of 1.64 I have been flaoting around the 0.56-0.7-0.88-1.05 for the last 14 weeks

Today all of a sudden I bottomed to 0.3. This is on an already reduced Interferon dose of 135. I am waiting to hear from the doctor now of what the plan is but would this sudden drop be just from the Interferon or is it possible to have other reason as well

2 weeks after the Incivek: Hemoglobin at 10.1, Platelets at 58 so only the Neutrophils are the problem

Any ideas, suggestions?

[flcyclist]

The ANC can bounce around a bit and can vary depending on when the cbc was done.  For example, if you do the interferon shot on Friday, I'd expect your ANC to be the lowest a day or two after, then slowly climb up as Friday approaches.  Then the cycle continues each week.  If you do the cbc on Thurs or Friday before the Inf shot, I'd expect your ANC to be its highest during the week.  

Do you have the option of using Neupogen?  If not, and you doctor insists, you might have no option but to further reduce the Inf dose.  I never liked dose reductions, but you need to do what is needed to get through trt.  Good luck.  

[Diana66]

yea, that is what I thought as well but I have done my injection last Thu evening and i had the cbc today (Thu) in the morning. So should have been the highest....

I think they might have Neupogen available, waiting to hear from them later today

Is it any other reason for the neutrophils to drop (eg. low level viral or bacterial infection)?

[Advocate1955]

I don't think you need to worry about low level virus causing your Neuts to drop.  After all, your Neuts were fine before you treated your Hep C, right?  To my understanding, and I'm not a doctor, the drop in Neuts is due to the effects of treatment drugs.  Sometimes we just need the Neupogen to help rebuild.  I would suggest asking for Neupogen and trying to rebuild (so you don't get sick or get infections that might compromise finishing treatment).
Advocate1955

[willbb]

You may want to go over this thread if you have some time.(below).

Good luck..

Will


http://www.medhelp.org/posts/Hepatitis-C/Some-clarification-if-someone-knows-or-doctor-has-explained/show/1656098?personal_page_id=1837989

[Diana66]

My neutrophils were reduced even before tx. I started with a base of 1.64 (minimum should be 1.9) and that was a good month. Had drops to 0.9 even the few months before tx. Presumably low values were from lymphoma

How long is taking for Neupogen to rebuild
I have been told to hold on doing my Interferon injection last night, we are waiting for an answer from the doc today

[Idyllic]

I would think you would see some type of increase in ANC a few days after the Neupogen. Frequent (routine) CBCs might be necessary in the beginning. Here is a good thread thread that answered a lot of my questions when I started Neupogen (the posts are the same people who posted in this thread)

flcyclist's post is interesting since he was able to have CBCs within days
http://www.medhelp.org/posts/Hepatitis-C/Timing-of-neuprogen/show/1786950

Oh sorry I just noticed you addressed this to Advocate. Hope this is OK
http://www.medhelp.org/posts/Hepatitis-C/Timing-of-neuprogen/show/1786950

[flcyclist]

"How long is taking for Neupogen to rebuild?"
It boosted the ANC very quickly for me.  Since I never had a cbc prior to 2 days after the neupogen shot, I'll have to say 2 days, but I'd suspect quicker than that.  Although patients may respond differently, I believe this to be most common response.   I've heard some report that their ANC stayed elevated after one neupogen shot, while mine went through the weekly crash after the interferon injection, so weekly for me.  

I'd suggest to read through the thread that Idyllic posted above for more detail.  I was referred to a Hematologist to monitor the cbc's, so I was fortunate to request these reports prior to each neup injection.  Hope that helps.

[jules2551]

The first time I had to take a Neup shot my numbers shot up to pre-tx numbers and lasted about 4 weeks.  Then we had to start doing Neup shots about every other week and now I have to do them basically every week.  I am on week 35 and today my ANC was .43.  

So I have to agree with flcyclist that the Neup rebuilds quickly, within 1-2 days, then the effectiveness wears off throughout the week.  Then it's time for an INF shot and the ANC tanks again.  One helluva balancing act!  :)

[Diana66]

Ok, so the advice is to give the dose a miss this week, retest neutrophils in couple of days and restart  Interferon at 90 when Neutrophis >0.5

It seems that this is ok to do since I finished Telaprevir

[flcyclist]

Curious if the doc discussed neupogen as well.  Sounds like a good plan otherwise.  

[jules2551]

I would never suggest skipping an INF shot. You really need to talk to your Dr about Neupogen and see if its available to you. Which I hope it is.

[can-do-man]

I agree with jules, ok after telaprevir skipping shots. I don't recall any talk of reducing or stopping the interferon at any time. The Riba, reducing yes.......... Maybe it's out there but I don't remember it.

[Idyllic]

Wow I know you have other issues but I wonder about missing an Interferon dose as well. I remember once I asked a question about the half life of Interferon and Riba dosing and the long short of it is that Riba gives the Interferon Ooomph. Though it varies for everyone ANC hikes up pretty fast after the Neupogen.

Since from what I gather, in this respect you are not in dangerous territory with the Peg. Since Neupogen does kick in relatively rapidly it seems like keeping you on Interferon and administering the Neupogen and making dose adjustment decisions based on the labs right after that.

[jules2551]

Haven't you already reduced your INF to 135? I would carefully reconsider reducing anymore and especially skipping any doses.

[Diana66]

Interferon is reduced to 135 since week 8

The newer theory is that even for people with cirrhosis (which I do not have) is ok to reduce Interferon to 90 once they are UND

Usually I am due for the shot on Thu night. Specialist did ot recommend neupogen, even though they do have stuff available
I have been told to not do the shot and repeat test on Mon. If all good, do it ( which will make it 4 days late basically)

If neutrophils still low on Mon, then we will look to options. This would have been week 19.
Nobody will give me neupogen in the weekend so I do not have much choice right now

Specialist is really good and if he made the statement that a skip or a delay right now after Telaprevir and UND, he must base this statement on something

Well should see on Mon, midday what results I have on blood counts. Not that I really want to change my shot to Mon, but what can I do?

[Advocate1955]

Isn't the ribs NOT supposed to be taken alone? Diana, I would really try not to reduce and try to insist on Neup. I agree w everyone, a couple of days to rebuild, but you will probably remain on weekly CBCs.

[can-do-man]

"The newer theory is that even for people with cirrhosis (which I do not have) is ok to reduce Interferon to 90 once they are UND"

I take it you have not seen the video about the current CUPIC study? It's becoming quite clear even dose reducing the Riba is not a good ideal for cirrhotics

[jules2551]

I have to speak up and say i dont agree with sny kind of reductions. That is your choice. A friend of mine is tracking dose reductions and 17 have relapsed. Whether it be Riba or Inf doesnt matter. The main point is go as long as you can without reductions. That is the whole point eith tx. Dont reduce anymore and get Nuep

[flcyclist]

Since I was a Geno 1a and only on Inf/Riba (48 wks), I was very reluctant to do any dose reductions.  My gastro doc agreed, so neupogen allowed me to continue from wk 8 until eot with any dose reductions.  I agree with the others, that this would concern me, especially being cirrhotic.  You want to give yourself the best chance possible.  

However, based on the dose modifications guidelines for Pegasys, it states that for an ANC < 750 to reduce to 135 mcg and for ANC < 500 to discontinue treatment until ANC values return to more than 1000 cells/mm
and Reinstitute at 90 mcg and monitor ANC.   I'm fortunate that my doctor didn't following this prescribing information and prescribed neupogen instead, otherwise who knows what the outcome would have been.  There are different theories on which is the best approach.  I wish you the best outcome.  

[flcyclist]

http://www.gene.com/download/pdf/pegasys_prescribing.pdf

Tabe 3, pg 5.

[Dee1956]

I hope your numbers are back up on Monday so you can take your shot. or hopefully on Monday they will give you Neupogen.
Since you are already on a reduced dose I would worry about skipping a week.
Saying that your doctor knows your entire story/history so he/she knows what is best for you

I hope the best for you.  My ANC dropped below the 500 several times during my first tx and nothing was done about it.  At the time I did not know anything about it.  It stayed low for a long time after tx, still they did nothing.  I was on INF, RIBA and a polymerase inhibitor (trial drug)

Good luck
Dee

[Idyllic]

I can imagine how frustrating this must be right now. I really hope the timing of all this works out and your ANC rebounds enough for you to continue treatment.

I am not sure what you can do since you are right. It is the weekend and on most of the guidelines it does indicate to discontinue PegIFN until resolution when ANC < 0.50.

It's as flcyclist said in his post as well as in this chart
http://www.medhelp.org/user_photos/show/368377?personal_page_id=1282072
________________
The table as well as others are:
http://www.hepatitis.va.gov/provider/guidelines/2012HCV-tables.asp


Hang in there!

[Diana66]

Unfortunately it is not my choice. There is not much I can do, someone needs to prescribe the neupogen and at the moment they don't :(

So 17 have relapsed with dose reduction. Out of how many?

Jules, I do not have a choice here unfortunately

[can-do-man]

Lets not forget them "guidelines" were made when it was just SOC, and we had a 38% cure rate for geno 1's and that would have been less if it wasn't for the "good" doctors who paid no attention to those...