Aa
Medication reduction already
I just started treatment and had to go into lab yesterday to get blood redrawn due to a bilirubin spike after one week. Common according to my doc but he wanted to make sure. Sure enough the RBC is starting to go low. He had to reduce my dosage due to low RBC (3.45), hgb 10.3, hct 30.3, RDW 14.5%. Bilirubin went retest came down to 1.9. It's getting better since it went up to 4 after one week of tx. I'm on triple tx and started with 1200 mg daily riba, but doc cancelled my evening dose yesterday so only took 600 mg yesterday. Today he has me on 300 mg (1/2 pill) until I get my 200 mg pills in the mail which he'll have me take 2 per day. I'm only on day 16. My viral load was:
12/5/2011 344933
7/13/2012 371829
7/30/2012 259914 (start of tx)
9/5/2012 284 (one week on tx)
He's hoping I was undetected end of week 2 which was Wed. I won't get the results for one week so we don't know for sure. I guess the reduction in riba is okay if I was undetected. If not, not sure what that means, but the doc said he couldn't take the chance of my blood getting too low.
Platelets are good so far at 229.
I just thought I'd give my results as I just started and am already disappointed on having to reduced meds, but understand the blood issue can get out of control quickly and he didn't want that. This is my second time on tx but first time was in 2005 and only the interferon/riba. I had to do procrit a lot last tx so I have had low RBC & WBC before. So far my WBC is okay. I was a responder but relapsed. Hoping for the best.
thanks to all for your support and advice.
12/5/2011 344933
7/13/2012 371829
7/30/2012 259914 (start of tx)
9/5/2012 284 (one week on tx)
He's hoping I was undetected end of week 2 which was Wed. I won't get the results for one week so we don't know for sure. I guess the reduction in riba is okay if I was undetected. If not, not sure what that means, but the doc said he couldn't take the chance of my blood getting too low.
Platelets are good so far at 229.
I just thought I'd give my results as I just started and am already disappointed on having to reduced meds, but understand the blood issue can get out of control quickly and he didn't want that. This is my second time on tx but first time was in 2005 and only the interferon/riba. I had to do procrit a lot last tx so I have had low RBC & WBC before. So far my WBC is okay. I was a responder but relapsed. Hoping for the best.
thanks to all for your support and advice.
"Does anybody know why, when the hemoglobin drops, the docs don't just put folks on the new iron supplements "
----------------------------------------------------
When we are on treatment (Interferon, Ribavirin, and a Protease Inhibitor) we do not become anemic because we are deficient in iron (Iron Deficiency Anemia). Instead we become anemic because the drugs are causing Hemolytic Anemia.
"Causes of Anemia Associated with HCV Therapy"
"Anemia that develops in a patient receiving HCV therapy often has multiple potential contributing factors, including ribavirin (Rebetol, Copegus), interferon or peginterferon, underlying liver disease caused by HCV infection, and co-morbid conditions, such as HIV infection or chronic renal failure[1]. The anemia associated with ribavirin most often occurs as a dose-dependent hemolytic anemia, typically developing within the first 4 weeks of therapy. With use of higher doses of ribavirin (1000-1200 mg/d), hemoglobin levels frequently decline by 2-3 g/dL, as seen in this case. In addition to causing hemolysis, ribavirin can also down-regulate the number of erythropoietin receptors. Interferon can also contribute to the development of anemia by suppressing bone marrow production of erythrocytes, but this process is generally slower and may account for the continued decline in hemoglobin concentration during the second and third months of treatment, as seen in this case. Finally, patients developing anemia during HCV therapy often have inappropriately poor serum erythropoietin responses, probably related to their underlying liver disease. Because of the mixed nature of HCV treatment-associated anemia, it often is not possible to pinpoint one particular drug as the primary cause of the anemia. "
----------------------------------------------------
When we are on treatment (Interferon, Ribavirin, and a Protease Inhibitor) we do not become anemic because we are deficient in iron (Iron Deficiency Anemia). Instead we become anemic because the drugs are causing Hemolytic Anemia.
"Causes of Anemia Associated with HCV Therapy"
"Anemia that develops in a patient receiving HCV therapy often has multiple potential contributing factors, including ribavirin (Rebetol, Copegus), interferon or peginterferon, underlying liver disease caused by HCV infection, and co-morbid conditions, such as HIV infection or chronic renal failure[1]. The anemia associated with ribavirin most often occurs as a dose-dependent hemolytic anemia, typically developing within the first 4 weeks of therapy. With use of higher doses of ribavirin (1000-1200 mg/d), hemoglobin levels frequently decline by 2-3 g/dL, as seen in this case. In addition to causing hemolysis, ribavirin can also down-regulate the number of erythropoietin receptors. Interferon can also contribute to the development of anemia by suppressing bone marrow production of erythrocytes, but this process is generally slower and may account for the continued decline in hemoglobin concentration during the second and third months of treatment, as seen in this case. Finally, patients developing anemia during HCV therapy often have inappropriately poor serum erythropoietin responses, probably related to their underlying liver disease. Because of the mixed nature of HCV treatment-associated anemia, it often is not possible to pinpoint one particular drug as the primary cause of the anemia. "
Does anybody know why, when the hemoglobin drops, the docs don't just put folks on the new iron supplements like 21/7 by VitaMed which do not have the terrible side effects that most iron supplements do? I know that with us, it's dangerous for iron to build up in us but I asked a doctor and was told it takes a LONG time for that to happen and it doesn't hurt anyone to take the iron supplement for 12 or 24 weeks. The buildup doesn't happen that quickly and once we stop the treatment and stop the iron supplements it goes back to normal.
In two of the clinical trials they had arms that contained no Riba, just Incivek and Interferon. The arms without Riba had significantly lower SVR rates.
Reducing Riba may be the initial step when the Hgb drops below 10, but I don't think I have ever heard of going from 1200 mg to 400 mg in one fell swoop at day 15. And most people on the forum who had Hgb drops reduced Riba some and used Procrit. Many also had transfusions.
I don't know if you have ever had anemia before. I had hemolytic anemia when I had systemic vasculitis. My Hgb was 9. I was short of breath, severely fatigued, white as a sheet, light headed. I could walk only a few steps at a time and then I had to rest. I also had a faster heart rate. I had episodes where I felt like I would pass out and collapse and had to lie down immediately, even when I was driving, I had to pull over and rest. (I only drove to the doctor's office.) I was so tired I did not want anyone to come over or to call me. It was a major effort to keep my eyes open or to talk.
Last fall when my hemoglobin started to drop, I was severely fatigued, short of breath, could feel every heartbeat (and the heart rate was about 110 all of the time), had runs of fast heart beats of 180 per minute which lasted several minutes, felt like I would pass out, was light headed, had reeling dizzy spells, had to hang onto the walls when I walked, felt weak. I am only telling you this to let you know that anemia causes these symptoms. Last fall I tried to compensate some by walking slowly and not much, using elevators, getting up very slowly, resting as needed, hanging onto walls, not overdoing, keeping hydrated.
Some of the symptoms may not be due to anemia. Or at least, the other drugs are compounding the symptoms. I was no longer anemic yet I was still extremely fatigued, light headed at times, felt like I would faint or collapse if I did not sit or lie down right away, felt weak, had no energy. Those things were at least partially caused just by ingesting the drugs, even when I was not anemic.
Here is the data from the studies each containing an arm without Ribavirin:
"Ribavirin: A Critical Component in HCV Treatment"
"Early studies of protease inhibitors include studies in which RBV was not coadministered largely because RBV is known to caused hemolytic anemia and gastrointestinal problems. However, when RBV was excluded from these regimens, SVR rates dropped and resistance arose (Figure 1).[8-20] "
"For example, in the phase II PROVE 2 study, treatment-naive patients chronically infected with genotype 1 HCV were randomly assigned to one of 4 treatment arms:
1. T12PR24
2. T12PR12
3. T12P12
4. Standard pegIFN/RBV for 48 weeks[8]
Comparing the T12PR12 and T12P12 arms that were identical apart from the inclusion or exclusion of RBV, SVR rates were 60% in the arm with RBV and 36% in the arm without RBV. Rates of virologic breakthrough were 1% and 24%, respectively. Similarly, in PROVE 3, which was conducted in patients who had failed previous pegIFN/RBV treatment, SVR rates were 2 times lower for patients not receiving RBV in their telaprevir-based regimen: 24% in the T24P24 arm vs 53% in the T24PR48 arm (Capsule Summary).[9] Similarly, relapse rates were 53% and 13%, respectively. Finally, in the SPRINT-1 study of boceprevir for genotype 1, treatment-naive patients, those receiving low-dose RBV achieved an SVR rate of only 36% vs 50% with standard weight-based RBV dosing, each combined with boceprevir and pegIFN (Capsule Summary).[10] Thus, RBV remains a critical component of these new antiviral regimens."
http://www.clinicaloptions.com/Hepatitis/Annual%20Updates/2011%20Annual%20Update/Modules/DAA%20Naive/Pages/Page%204.aspx
Reducing Riba may be the initial step when the Hgb drops below 10, but I don't think I have ever heard of going from 1200 mg to 400 mg in one fell swoop at day 15. And most people on the forum who had Hgb drops reduced Riba some and used Procrit. Many also had transfusions.
I don't know if you have ever had anemia before. I had hemolytic anemia when I had systemic vasculitis. My Hgb was 9. I was short of breath, severely fatigued, white as a sheet, light headed. I could walk only a few steps at a time and then I had to rest. I also had a faster heart rate. I had episodes where I felt like I would pass out and collapse and had to lie down immediately, even when I was driving, I had to pull over and rest. (I only drove to the doctor's office.) I was so tired I did not want anyone to come over or to call me. It was a major effort to keep my eyes open or to talk.
Last fall when my hemoglobin started to drop, I was severely fatigued, short of breath, could feel every heartbeat (and the heart rate was about 110 all of the time), had runs of fast heart beats of 180 per minute which lasted several minutes, felt like I would pass out, was light headed, had reeling dizzy spells, had to hang onto the walls when I walked, felt weak. I am only telling you this to let you know that anemia causes these symptoms. Last fall I tried to compensate some by walking slowly and not much, using elevators, getting up very slowly, resting as needed, hanging onto walls, not overdoing, keeping hydrated.
Some of the symptoms may not be due to anemia. Or at least, the other drugs are compounding the symptoms. I was no longer anemic yet I was still extremely fatigued, light headed at times, felt like I would faint or collapse if I did not sit or lie down right away, felt weak, had no energy. Those things were at least partially caused just by ingesting the drugs, even when I was not anemic.
Here is the data from the studies each containing an arm without Ribavirin:
"Ribavirin: A Critical Component in HCV Treatment"
"Early studies of protease inhibitors include studies in which RBV was not coadministered largely because RBV is known to caused hemolytic anemia and gastrointestinal problems. However, when RBV was excluded from these regimens, SVR rates dropped and resistance arose (Figure 1).[8-20] "
"For example, in the phase II PROVE 2 study, treatment-naive patients chronically infected with genotype 1 HCV were randomly assigned to one of 4 treatment arms:
1. T12PR24
2. T12PR12
3. T12P12
4. Standard pegIFN/RBV for 48 weeks[8]
Comparing the T12PR12 and T12P12 arms that were identical apart from the inclusion or exclusion of RBV, SVR rates were 60% in the arm with RBV and 36% in the arm without RBV. Rates of virologic breakthrough were 1% and 24%, respectively. Similarly, in PROVE 3, which was conducted in patients who had failed previous pegIFN/RBV treatment, SVR rates were 2 times lower for patients not receiving RBV in their telaprevir-based regimen: 24% in the T24P24 arm vs 53% in the T24PR48 arm (Capsule Summary).[9] Similarly, relapse rates were 53% and 13%, respectively. Finally, in the SPRINT-1 study of boceprevir for genotype 1, treatment-naive patients, those receiving low-dose RBV achieved an SVR rate of only 36% vs 50% with standard weight-based RBV dosing, each combined with boceprevir and pegIFN (Capsule Summary).[10] Thus, RBV remains a critical component of these new antiviral regimens."
http://www.clinicaloptions.com/Hepatitis/Annual%20Updates/2011%20Annual%20Update/Modules/DAA%20Naive/Pages/Page%204.aspx
Oops, I got confused by the Sacramento Pharmacy reference. I see you're in So Cal.
Who you really should see for a consult is Dr. Gish, a very renown wonderful hepatologist there at UCSD. He's one of the best in the nation.
http://www.healthgrades.com/physician/dr-robert-gish-y9dtj/address
Who you really should see for a consult is Dr. Gish, a very renown wonderful hepatologist there at UCSD. He's one of the best in the nation.
http://www.healthgrades.com/physician/dr-robert-gish-y9dtj/address
I find it hard to understand why your doctor would not use procrit unless you have some other medical issues going on.
The reason we suggest hepatologists is as liver specialists they have more training specific to liver disease.
If you are in the Sacramento area you could see one of the hepatologists who do outreach from CPMC. My hepatologist who I adore works in Sac though I'm not sure which days.
You could see him for a consult and continue with your current doctor if you choose.
http://www.sutterpacific.org/locations/outreach/1315alhambra.html
If you want to talk to me more about him, send me a pm. I have his email.
Coincidentally, I began seeing him when my GI wanted to pull me off treatment. One of the members here recommended him. I was able to continue without missing one shot.
The reason we suggest hepatologists is as liver specialists they have more training specific to liver disease.
If you are in the Sacramento area you could see one of the hepatologists who do outreach from CPMC. My hepatologist who I adore works in Sac though I'm not sure which days.
You could see him for a consult and continue with your current doctor if you choose.
http://www.sutterpacific.org/locations/outreach/1315alhambra.html
If you want to talk to me more about him, send me a pm. I have his email.
Coincidentally, I began seeing him when my GI wanted to pull me off treatment. One of the members here recommended him. I was able to continue without missing one shot.
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