| Archived
Questions and Responses |
 |
| Management
of Side Effects |
|
| |
In
a patient on Peg/Copeg (interferon/ribavirin) with neutropenia,
what is the recommended absolute neutrophil count (ANC) target
range when treating with Neupogen (filgrastim)? At what ANC
value do you initiate filgrastim therapy, and what is the suggested
dosage? |
 |
|
| Laboratory
Assessment |
|
| |
A
patient diagnosed with hepatitis C in 1981. He was treated in
2,000 with interferon threes times weekly and daily ribavirin
with excellent results. Readings as of 8-23-04 are less than
10 IU/mL. What should the liver enzyme readings be? |
|
| |
An
anesthetist had a screening test that revealed anti-HCV antibodies
by enzyme-linked immunosorbent assay (ELISA), positive EIA test,
negative HCV RNA PCR, and normal liver enzymes. There were no
symptoms. What is the protocol for management and what type
of lifestyle should this person follow? |
|
| |
I
see many patients with hepatitis C. I wonder why my lab provides
results which include a RIBA. This test seems unnecessary. |
|
| |
I
have a patient with a serology test showing reactivity for hepatitis
C antibody (57.47; cutoff rate, 1.00). What measure should I
adopt? |
|
| Treatment
of HCV |
|
| |
What
are the criteria for the treatment of hepatitis C with
interferon and ribavirin? |
|
| |
A
49-year-old man with HCV, genotype 1, with a high viral load
also has cryoglobulinemia and a history of vasculitic rash.
He had a 9-month course of peginterferon with ribavirin in 2001,
discontinued due to complications of drug abuse. A second course
of treatment this year was stopped when he did not achieve SVR.
He did not have the rash during the periods he was on treatment,
but has now had a recurrence while off treatment. Is there any
role for maintenance with peginterferon in this setting? |
|
| |
What
is the rate of recurrence for a 40-year-old female patient whose
viral load has dropped from 457,000 mL to less than detectable
during the first 3 months of interferon/ribavirin therapy? She
cannot tolerate side effects. |
|
| |
What
is your recommendation for hepatitis B vaccination in chronic
HCV patients who are hep-B-core-antibody positive, but hep-B-surface-antigen/antibody
negative? |
|
| |
How
should a dentist approach treatment of a patient with hepatitis
C who needs a complete denture? |
|
| |
Are
there any other therapies for hepatitis C besides interferon? |
|
| |
Is
a viral load of 10,700,000 considered high in a patient with
genotype 1a hepatitis C, and if so, what are the implications
for treatment or development of complications? The patient has
recently contracted the virus and does not know whether to attempt
treatment. |
|
| |
A
32-year-old woman was diagnosed 2 years earlier with idiopathic
thrombocytopenic purpura (ITP) and HCV infection. The ITP is
in remission, and the patient continues to take Prezolon, 10
mg per day. Her liver chemistry is normal and HCV PCR is positive;
she has 35,000 c/ml. Do you think the HCV infection played a
role in the ITP? |
|
| |
I
have a patient who has had hepatitis C for 2½ years.
She was sent to a GI specialist, who started interferon therapy.
She had a very bad reaction to it. As of August 2004, her PCR
had substantially increased in less than a year. She has an
appointment to see her GI specialist. Her liver enzymes are
slightly elevated. Should I be concerned with the doubling of
the PCR? |
|
|
After
6 months of IFN injection with hepatitis C virus (HCV) negativity
on polymerase chain reaction test, what is the risk of the virus
becoming reactive once again? |
|
| |
Your
patient develops anemia after 4 weeks of treatment with ribavirin
and pegylated interferon (PEG-IFN). At what point do you treat
the anemia? Currently, his hemoglobin has dropped from 14.3
to 11.3, with significant fatigue. Do you need other labs? Do
you give epoetin alfa? |
|
| |
A
36-year-old woman with HCV genotype 3 was treated with the standard
dosage of PEG-IFN and ribavirin for 24 weeks. Her biopsy showed
some fibrosis and much fat. Her body mass index is 25. She had
an excellent response, with normalization of liver tests and
hepatitis RNA negativity at 3 and 6 months. However, she relapsed
at 3 months post-treatment and her HCV RNA turned positive.
What do you recommend—retreatment with the same dosage
and duration, or retreatment with same dosage but for a longer
duration? |
|
| |
What
do you recommend for hepatitis C patients who have failed treatment
with PEG-IFN and ribavirin? Do you have any experience with
treating these patients with the so-called consensus interferon
(Infergen), and if so, at what dosing regimen? |
|
| |
What
are the guidelines for treating a pregnant hepatitis C patient
who has a moderate viral load--for instance, the best drug combination,
the risk of transmission during delivery, and recommendations
about breast-feeding? |
|
| |
I
have a 47-year-old male patient who has been an HCV carrier
for 20 years. Post-transfusion, he is asymptomatic and has normal
liver function tests. His physical examination is normal. Is
he a candidate for interferon therapy? |
|
| |
Does
interferon cure hepatitis C or does it just help to induce remission? |
|
| |
Please
explain why a well patient with HCV and normal liver tests should
be treated? |
|
| |
Once
a patient has been successfully treated for HCV (and has a negative
HCV RNA PCR six months after treatment is stopped), how should
I monitor this
patient going forward? |
|
| |
I
do not know why "stopping rules" do not apply to patients
with genotype 2 or 3 HCV treated with Pegylated Interferon and
Ribavirin. It seems as if we could save a lot of money by stopping
therapy after 12 weeks if the HCV RNA PCR
is not reducing by 2 logs. |
|
| Retreatment |
|
| |
I
have a 42-year-old patient weighing 62 kg, and he has been an
HCV carrier for 20 years, post-transfusion. He has genotype
1, RNA titer by PCR of 1,624,520 IU/mL, and normal liver function
tests. I prescribed him a combination therapy of Peg-Intron
100 µg, with 800 mg ribavirin. The RNA test result after
12 weeks of therapy was negative, and the decision was made
to continue for 48 weeks. The test result after 6 months of
the completion of 48 weeks shows a positive viral load of 1,829,400
IU/mL. Is there any benefit to retreating using a product from
a different manufacturer, or should he wait for another treatment
to be discovered? |
|
| |
I
have patient who 41-year-old man, weigh 60 kg, and have never
had alcohol. He has HCV (from blood transfusion in 1984) genotype
1, with a viral load of 1,561,927 IU/mL. The liver biopsy
report read microscopy reveals liver tissue with preserved
lobular architecture. The portal areas are widened by moderate
fibrosis and moderate numbers of mainly lymphocytic inflammatory
cells. Bridging with piecemeal necrosis was noted. The hepatocytes
are swollen with focal hepatic cell necrosis. He has been
treated with Peg-Intron, 120 mg once a week, along with ribavirin
800 mg daily. At week 12, the PCR RNA test showed HCV was
negative (not detected). He continued treatment for 48 weeks.
After 6 months of completion of therapy, the PCR test shows
positive HCV with viral load of 1,718,720 IU/mL. liver function
tests were normal before, during, and after treatment. What
is your advice? Should he wait for new treatments, repeat
the treatment using Pegasys, or do nothing? |
|
| Screening
for Liver Cancer |
|
| |
What
is the cause of focal lesions in hepatitis C and cirrhosis patients?
What are the focal lesions? What are the methods of management? |
|
| |
I
am a gastroenterologist, many of my colleagues ask me how often
a patient with HCV should be screened for hepatoma. Since I
work in a HMO, costs are a concern. How often should patients
be screened and is there any evidence this is really cost effective? |
|
| |
Are
there any data showing the benefit of hepatoma screening in
the setting of HCV infection? |
|
| Transmission
of HCV |
|
| |
A
doctor, from our hospital, pricked his finger while with a patient
infected with HCV. What can he do now to protect himself? |
|
| |
Can
HCV be transmitted to a doctor who has naked eye contact with
blood droplets from and HCV-positive patient during surgery? |
|
| |
I
am a dentist who works out (sports jujitsu and grappling similar
to wrestling) with a man just diagnosed with hepatitis C. Is
sweat transmission a concern? Should I be tested? |
|
| Liver
Biopsy |
|
|
| |
What is the standard of care when determining
duration of time between liver biopsies in patients with chronic
active hepatitis C, serotype 1a, in the evaluation of cellular
degradation for purposes of staging and grading? |
|
| |
A woman, age 44, was recently diagnosed
with HCV, genotype 1a, with a viral load of 176,000. She shows
no symptoms at this point. She has a history of sickle-thalassemia
and has received many blood transfusions. She is currently being
treated with hydroxyurea and maintains a hemoglobin of 8.5 to
9.9. Considering that interferon and ribavirin will lower hemoglobin,
is treatment for her advisable? Can you tell me about viramidine? |
|
| |
Should
a liver biopsy be obtained for all newly diagnosed hepatitis
C patients? |
|
| Special
Groups |
|
|
What are the criteria for the treatment of
HCV-related decompensated cirrhosis? |
|
|
I was accidentally pricked while performing
an abdominal tap on an HCV-positive patient. Should I start
treatment with ribavirin/interferon prophylactically? If not,
when? |
|
|
We have a 40-year-old, co-infected HIV/HCV,
Hispanic man with well-suppressed HIV (<50 copies/mL for
over 6 years), CD4 >800 on Combivir (lamivudine/zidovudine
combination) and efavirenz. We treated his HCV 1a (stage 2 grade
2) infection with 48 weeks of peginterferon alfa-2a/ribavirin.
He had an HCV viral load of <50 since week 12 of treatment
and throughout his therapy. Six months after completion of therapy,
his HCV viral load is positive at 1 million. What can we offer
him next? |
|
|
A 39-year-old, 222-lb, co-infected man started
peginterferon alfa-2a with ribavirin last week. He experienced
bloody diarrhea twice. His last platelet count before therapy
was 166. Could this be related to therapy? |
|
| |
How
do you manage a patient with HCV who is on hemodialysis? |
|
| |
What
are the current consensus recommendations for the treatment
of hepatitis C virus (HCV)-infected patients with persistently
normal alanine aminotransferase (PNALT) levels? |
|
| |
HCV
was detected in a 7-year-old child? Please give your opinion. |
|
| |
A
biopsy diagnosed a patient's liver to be in stage 4 from hepatitis
C and alcohol consumption. Approximately how long does this
patient have to live, and is his disease at the stage for a
liver transplant? |
|
| Management
of Psychiatric Disorders in HCV |
|
| |
Is
there any recommendation regarding the length of time that is
efficacious for the use of antidepressants after completion
of a course of interferon? |
|
| Miscellaneous |
|
| |
What
is the life expectancy of a 45-year-old woman with hepatitis
C and recently diagnosed gestational diabetes and stage 1 liver
cancer? She is 7 months into her second pregnancy. |
|
| |
What
effect will a vitamin B12 injection have on a patient
in her fourteenth week of therapy? The patient achieved undetectable
viral load in her eighth week and has viral genotype 1a. She
is currently on Neulasta and Procrit for hematological side
effects. |
|
| |
This
patient has persistent right upper-quadrant pain. She had her
gallbladder removed 18 months ago and still has the pain. Her
liver enzymes are elevated. She has had CT scans and a magnetic
resonance cholangiopancreatography (MRCP), which were normal.
Any suggestions? |
|
| |
Once
a patient is known to have hepatitis C, is it necessary to order
more tests to rule out other hepatic diseases before beginning
treatment? |
|
| |
A
man with a history of head and neck cancer (in remission) was
diagnosed with idiopathic thrombocytopenic purpura (platelets
70,000) and then contracted hepatitis C after surgery. Can such
a patient be treated with interferon? |
|
| |
I
have had good experience with the use of DDB (biphenyl dimethyl
bicarboxylate)15 mg tds plus amantadine 100 mg bid in treating
Egyptian HCV patients (mostly type 4). They have had SVR of
about 30% and stabilization of the condition chemically and
pathologically in 90% of patients. What is your comment? |
|
| |
A
54-year-old female health care worker that works in a wound/ostomy
clinic had a liver biopsy. She had genotype 1 HCV, mild fibrosis,
and an HCV viral load of 13,000,860. She had two treatments
with mild silver protein IV 400 ppm. The last treatment was
5 months ago. The side effects were so bad that she thought
she would lose her life and had to stop treatment. She did not
know how she contracted HCV; she did not use drugs or have blood
transfusions. She has a child and had breast biopsy, neuroma
surgery, and arthroplasty. She was lethargic and had laboratory
tests that showed an HCV RNA of 12 million IU/ML. Her GI physician
told her she had 10 years left to live. After reading about
peginterferon/ribavirin treatment, the side effects sound the
same as those she had, with projectile vomiting, headaches,
a feeling of broken bones for days to weeks, nausea, rigors.
Are there any treatments with fewer side effects? Another important
question is: Is there a way to accurately pinpoint when one
contracted the virus? |
|
| |
I
am a cardiologist. My mother contracted acute hepatitis C following
a surgery. She subsequently recovered fully. Twice, her hepatitis
C titers were negative. Now, she again shows 6,000, but has
a normal AST and ALT and is totally asymptomatic. She is not
willing to have a biopsy. Do we need to initiate aggressive
treatment, or can we wait considering the very low titers, normal
liver function, and absence of any symptoms? |
|
| |
After
being diagnosed with hepatitis C (2b), I was placed on pegylated
interferon and ribavirin therapy. Unfortunately, I had to discontinue
treatment after 11 weeks because of side effects. My doctor
tested my level 6 months later, and there was no virus detected.
For over 2 years, my liver enzymes have been normal. I also
have rheumatoid arthritis (RA). Since treatment for hepatitis
C, my RA has been out of control. I am currently taking indomethacin
and increasing doses of prednisone. My rheumatologist does not
want to try anything else because of my past liver problems.
Would medications that suppress the immune system cause the
hepatitis C to surface again? Do you know if this situation
has come up before and how it was managed? |
|
| The
Team Approach to Hepatitis C Management |
|
| |
What
is the economic impact of not treating an HCV patient, as patients
in my country cannot afford pegylated interferon treatment? |
