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CASE 2

CASE 2 . 48 yo man IVDU in past….last used 27 yrs ago Stable social situation Currently receiving social assistance with provincial drug coverage No comorbid disease. CASE 2 . Hepatitis C disease parameters Secondary workup negative…no co-infections HCVRNA 3.65 x 10E7 iu /ml

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CASE 2

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  1. CASE 2 • 48 yo man • IVDU in past….last used 27 yrs ago • Stable social situation • Currently receiving social assistance with provincial drug coverage • No comorbid disease

  2. CASE 2 Hepatitis C disease parameters • Secondary workup negative…no co-infections • HCVRNA 3.65 x 10E7 iu/ml • genotype 1a

  3. CASE 2 Hepatitis C disease parameters • AST>ALT • Platelets 71 • INR 1.5 • Bilirubin 38 mmol/l

  4. CASE 2 Hepatitis C disease parameters • Clinically…no previous ascites/edema, encephalopathy or GI bleeds • Imaging…coarse liver/14cm spleen/no free fluid/no varices seen • OGD…no varices

  5. CASE 2 Under what circumstances would you not treat a cirrhotic patient for Hepatitis C? • Ascites…previous vs current • Encephalopathy • Portal Hypertension without previous bleed/with previous bleed • Are there biochemical exclusionary criteria for treatment

  6. CASE 2 Treatment initiated with Peg INF/1400mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 • Severe nausea/intolerable…RBV decreased to 1200mg/day

  7. CASE 2 Peg INF/1200mg RBV (90kg) Week 4-8 • Increasing abdominal girth/soas responsive to a slow diuresis with furosemide and salt restriction • No encephalopathy • SBP prophylaxis initiated

  8. CASE 2 Peg INF/1200mg RBV (90kg) Week 4-8 • Increase in bilirubin from 40 to 75 then stabilized • Inr increased from 1.5 to 1.7 then stabilized • Plts decreased from 80 to 40 then stabilized • Renal function stable throughout with creatinine at 55 mmole/l

  9. CASE 2 Peg INF/1200mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1

  10. CASE 2 Peg INF/1200mg RBV (90kg) Week 8 • Stable clinically with 1.5 kg of weight loss weekly and tolerating therapy day-day relatively well • Warned of concerns re: stalling of HCVRNA but decision to continue therapy made

  11. CASE 2 Peg INF/1200mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1 Week 12 HCVRNA…5.40 x 10E1 WHAT WOULD YOU DO TODAY?

  12. CASE 2 Peg INF/1200mg RBV (90kg) Week 12 • Boceprevir access arranged and therapy initiated at 800mg Q8H

  13. CASE 2 Peg INF/1200mg RBV/Boceprevir 800mg Q8H (90kg) Week 12-16 • Adherent with all meds and Boceprevir addition tolerated well • Erythropoietin initiated at week 15

  14. CASE 2 Peg INF/1200mg RBV/Boceprevir 800 mg Q8H (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1 Week 12 HCVRNA...5.40x10E1 Week 16 (week 8)….undetectable

  15. CASE 2 Questions: • Do you think the dose reduction of RBV by 200mg stalled the progress of therapy? • How long will you treat…is response guided therapy appropriate for this naïve patient? • If week 16 (week 8 of triple therapy) was still detectable would you have continued with therapy?

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