Pegasus Reduction

[Revalation]

What do you guys know about reduction of Pegasus during treatment.
Does it impact SVR rates?
My doctor plans to reduce because of  my very low neutrophil count.

Reva

[Revalation]

Fortunately, the reduced dose will not arrive in time for this 7th week of
treatment. I will be taking what I have which is not reduced.
When I get the numbers next week that will determined if I take the
8th week which I already have and then switch to the lower dose temporarily.

You must not have been as firm and threatening as I was.
They sent me Neupogen that is pre-filled again.

I explained that this treatment is difficult. I told them I knew the Speciality Pharmacy was a business, but  I still planned  for their support during my treatment.

I suggested  they should be trained about the difficulty  of Hep C treatment. That being the case they should not try to reduce their cost at patient expense.

Actuallly, I think you get a more accurated dose whe you push out from a pre-filled rather than filling from a vial into a giant syringe,

To make a long story short I once again have Neupoen Prefilled.
Didn't get the Pegasys I was support  to get. I'll get that nexr week

Reve

[BoceprevirGal]

That sounds like a good idea, Reva. I would try to pressure your Doctor into NOT your meds, until you are Und, definitely. I am glad you hare armed with education, and support : )

[Revalation]

I am taking Neupogen.
A few years ago I took Neupoen and my neutrophils skyrocketed.
I also got some really serious heart pounding.
The doctor then gave a half dose of Neupogen and it did what as needed.

From then on I have been taking the half dose. I would like to have
my next shot be a generous half. Then we'll see what happens.

This time around I'm not sure what's going on. Fortunately, the lower
dose Pegasys will not arrive until next week. That means I won't be reducing this week.

When I see how the numbers go. I might just take that final 8th week dose, and then change over to the reduced Pegasys if the doctor thinks I have to.

Reva

[orphanedhawk]

My first dose reduction was from 180 to 135. When I went ballistic in my doctor's office and refused to go on anti-depressents, he lowered my dosage to 90.
He explained that it probably wouldn't affect my viral load because of my small stature. I was und from week 4.

However, he made a point of saying, there was a chance of the virus showing back up. That he hep C is good at hiding out and he's seen it do this on more than one occasion.  

There is no way I would reduce before being UND.
I agree with Hector, insist on the pharmacy sending you the pre-filled syringes.

How low is your anc ? I used neupogen once it got below .5
Yes, talk to your doctor, express your concerns, be proactive.

Good luck.

[Naya888]

I had the same problem with neutrophils and low Hemoglobin.I insisted to start Procrit and everything went up incl neutrophils..There is also specific med called neupogen just for neutrophils. Check if your insurance cover these ,all these meds come from specialty pharmacy

[flcyclist]

"At first I was sent pre-filled syringes, then they started sending vials with dull "horse" needles."
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The same thing happened to me.  The first box (4) were the preloaded syinges, the next month was the vial with a larger bore needle and larger volume.  I called the specialty pharmacy and requested to have the preloaded syringes for the remainder of tx. and that's what they did.  

Will makes a very good point.  I believe there is much carryover from the low ANC/wbc counts associated with cancer tx, since these patients are at a higher risk of infection.  Since it is protocol for these patients, I believe many doctors base prescribing neupogen or dose reductions on the same theory.  As pointed out, there isn't a direct correlation between low ANC and infection with HCV patients.  Are the doctors CYA??  

I was going to a hematologist at a cancer trt center, so he was very conservative, using 1,000 as the threshold for neup.  There was no convincing him otherwise, so I tried to behave, but the last few months decided to compromise on do 1x per week.   Many experienced hepatologists use 500 or lower as the tx theshold for neup.  I never experienced more than a minor achy feeling from the neup and was hard to isolate from the other sides during tx.  Good luck with your discussion with the doc.  I certainly understand your reluctance to dose reduce at this point.

[willbb]

There was no sub-analysis done in any of the studies (either with Incivek or Victrelis ) on SVR rates as it pertains to Peg reductions.
It is never ideal to have to reduce any of the medications,however sometimes done given prescribing protocols explained above.

Also, it has been looked at very carefully in studies that for the most part HCV patients with lowered ANC levels,because of Interferon , had  "significantly"  no more problems with bacterial infection than patients with normal ANC levels.

There was a discussion not long ago here with studies included(below)  you may be in having a look at.

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

[Revalation]

I think I need to talk to the doctor before the Pegasys reduction.
I know my Neutrophil count was extremely low. I was taking Neupogen
and it was working. However, my neut count dips as soon as I take the next Pegasys Injection.

At first I was sent pre-filled syringes, then they started sending vials with dull "horse" needles. For all I know I may have given slightly less than what I should have been taking. In the past my low Neutrophil count has been
controled with Neupogen. I was taking only 1/2 doses because a whole
dose makes my neuts. sky rocket and my heart race.

My concern is my VL was less than 43 at 1 1/2 weeks and remained the same at 4 weeks. They are suggesting a reduction even before I'm technically undetected. I not sure but with all the added patients I think the doctor is being a lot more conservative this time around. My original VL
was 3,000,000 so it came down real fast. (in less than 2 weeks)
This is the second time treatinf gor me. Use Neupogen before, but had to end at 12 weeks. My Neutrophil count is low even when not on treatment.

I think the nurse has far too many patients now and I think my care has
become a little loose. I'm going down to the office and ask to speak with the
doctor before changing the Pegasys dose

Reva.





Reva

[flcyclist]

Hi Riva,
I don't recall reading any studies related to the reduction of interferon and SVR rates.  As Hector mentioned it above, it would also depend on many factors.  Also, what week of tx are you in and what week did you have your first und?  And how low is your ANC currently?

Is neupogen an option to bring up the ANC?  My ANC dropped at week 8 of tx (Inf/Riba) and stayed down throughout 48 week tx.  My doc didn't want to dose reduce, so went with 2x per week neupogen, then once per week the final few months.  My ANC was consistantly low (<300) and would quickly rebound after the neup.  It allowed my to go through tx without any reductions.   Would it have been better to dose reduce rather than use a rescue drug???  As OH said, it's a bit of a crapshoot.

[HectorSF]

"The absolute neutrophil count (ANC) is the measure of the number of infection-fighting white blood cells in your blood.

What does it mean to have a low ANC or an ANC lower than 500?

The normal neutrophil count is 2,500-6,000.  When you have 1,000 or fewer neutrophils, your risk of infection is increased. When  your ANC is lower than 500, you are at risk for getting a serious infection. This condition
is called “neutropenia.”  If you are neutropenic and develop a fever or signs of infection, contact your doctor immediately.You may be given antibiotics to fight the infection."

Here is the standard protocol. Individual doctors may modify it according to their own experience.
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PEGASYS
HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use PEGASYS safely and effectively.

http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/103964s5204lbl.pdf

Adult Patients

When dose modification of PEGASYS is required for adverse reactions (clinical and/or laboratory), initial dose  reduction to 135 mcg (which is 0.75 mL for the vials or adjustment to the corresponding graduation mark for
the prefilled syringes) is recommended. Dose modification to 135 mcg per week can also be achieved by using  a 135 mcg/0.5 mL strength disposable autoinjector. Dose reduction to 90 mcg (which is 0.5 mL for the vials or  adjustment to the corresponding graduation mark for the prefilled syringes) may be needed if the adverse  reaction persists or recurs. Following improvement of the adverse reaction, re-escalation of the dose may be considered.

PEGASYS Hematological Dose Modification Guidelines

ANC <750 cells/mm   Reduce to 135 mcg

ANC <500 cells/mm   Discontinue treatment until ANC values return to more than 1000 cells/mm. Reinstitute at 90 mcg and monitor ANC.
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Does it impact SVR rates?
I would think it depends on a number of factors...if triple therapy, when and how long and how much it is reduced. Other may have better info on this.

Hector

[ninjamonkey]

I've been worried about the same thing I was told last week if my wbc and neutrophil count didn't come up or went down further they would pull my shot all together, no reduction no rescue drugs offered. I wish there was a straight forward answer I don't have one, and unless I missed it no one else does either I think for me though I don't want to stop any of the Meds until I am sure I'm svr. Maybe someone else will comment and give us advise.

[LookingForward12]

Can only speak from experience....to a degree. My Pegasys was lowered from 180 to 135 mg, in part due to the rash debacle. It has been lowered for three weeks now. I have six weeks of treatment left. The doctor is going to increase the dose back to 180 this week and see how I react. Although my rash was largely a severe reaction to the Incivek, he wanted to give my body a chance to clear the majority of the rash.  We could not rule out the role that the ribavirin and the interferon may have played in my allergic reaction to treatment.
As a side note, the rash is not entirely resolved. The place on my right arm that we suspected might be an injection site reaction, continues to grow in size - every time I  have a shot, although i am taking those in the belly now. From the size of a quarter, it is now the size of a Krispy Kreme donut, red, raised a bit, hot to the touch, itchy, and scaly. I'm off to see the dermatologist again tomorrow.

[orphanedhawk]

Treatment is a crap shoot.
There's a chance of reduction affecting your clearing the virus.
On the other hand we had a member who's pegasys was reduced from week 2 by half, and he still was und at week 4.

Why does your doctor want to reduce your dosage and how far along on tx are you?