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A case study: Hepatitis C treatment and severe anemia

A case study: Hepatitis C treatment and severe anemia. Colina Yim RN(EC), MN Nurse Practitioner CAHN 2013. Objective. To illustrate the change of best practices in managing hepatitis C treatment related anemia. Mr. Number 1. 55 year old man first seen 2009 HCV G1, VL 1.30 x10E6 IU/ mL

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A case study: Hepatitis C treatment and severe anemia

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  1. A case study: Hepatitis C treatment and severe anemia ColinaYim RN(EC), MN Nurse Practitioner CAHN 2013

  2. Objective • To illustrate the change of best practices in managing hepatitis C treatment related anemia

  3. Mr. Number 1 55 year old man first seen 2009 HCV G1, VL 1.30 x10E6 IU/mL Cryoglobulins 2%: leg numbness, leg rash Stopped alcohol age 53 No co-morbidities Liver biopsy: A3 F3-4 Treated 2008 PegIFNα2a 180mcg/ RBV 1200 mg/day HCVRNA negative at wk 12 Stopped after 29 wks: anemia, neutropenia Relapsed !

  4. Mr. Number 1 2009 Treatment # 2 PegIFNα2a 180mcg/wk + RBV 1200 mg/day What to do ? Treat again ?

  5. Treatment # 2

  6. Treatment # 2 Unfortunately Relapsed post treatment

  7. Mr. Number 1 Now May 2011 Cryos rebound from negative on treatment to 7% Skin lesions return Urinalysis now +ve for protein and blood Develops small ascites No varices What to do now ?

  8. Mr. Number 1 May 2011 Treatment # 3 – SAP Boceprevir PegIFNα2b 150mcg/wk + RBV 1200mg/day Plan to add Boceprevir after 4 wks lead-in

  9. Treatment # 3

  10. Treatment # 3 • Erythropoietin 40,000 IU/wk • Blood transfusion q4w • No RBV dose reduction

  11. Treatment # 3 SVR • Erythropoietin 40,000 IU/wk • Blood transfusion q week • Platelets transfusion • Treatment stopped at 24 wks

  12. How should his anemia be best managed now ?

  13. Anemia Study: EPO vs Ribavirin Dose-Reduction 687 pts received boceprevir/ pegIFN/RBV 500 randomized at time of onset of anemia (Hgb < 10 g/dL) to RBV dose reduction (200-400mg) or Erythropoietin (40,000 IU/wk) Poordad et al. EASL 2012 Abstract 1419.

  14. Timing of RBV Dose Reduction Does Not Impact SVR SVR % Poordad F, et al. AASLD 2012. Abstract 154.

  15. Degree of RBV Dose Reduction Does Not Impact SVR SVR % Number of RBV dose reduction steps* * step= 200 mg RBV/day decrease for > 3 days Poordad F, et al. AASLD 2012. Abstract 154.

  16. Lower SVR Rate if < 50% RBV Received SVR % % of total RBV dose received Poordad F, et al. AASLD 2012. Abstract 154.

  17. SVR Rates with RBV Dose Reduction or Erythropoietin in Cirrhotics P=0.59 SVR % n = 438 n = 48 ** Cirrhotics more likely to receive secondary intervention than non cirrhotics Lawitz E et al. AASLD 2012. Abstract 50.

  18. Telaprevir Clinical Trials Pooled Data: RBV Dose Reduction Does Not Impact SVR SVR % Sulkowskiet al. EASL 2011. Abstract .

  19. Take Home Messages • Close monitoring for anemia • RBV dose reduction is the first strategy for managing anemia • Can reduce dose aggressively i.e. to 600 mg • Maintain > 50 % of total RBV dose • Can dose reduce cirrhotics • Cirrhotics may need secondary intervention

  20. Higher SVR Rates if RBV Dose Reduced when HCV RNA was Undetectable SVR % HCV RNA Poordad F, et al. AASLD 2012. Abstract 154.

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