2, hepatitis C, genotype 3, current treatment, interferon alpha
patient do have complaint about shortness of breath, may be side effect from treatment
The goal of treatment is to eradicate HCV RNA, which is predicted by the achievement of a sustained virologic response (SVR) as defined by the absence of HCV RNA by polymerase chain reaction six months after stopping treatment.
PATIENTS FOR WHOM THERAPY IS WIDELY ACCEPTED — Therapy is generally accepted for patients with all of the following characteristics:
- At least 18 years of age
- HCV RNA detectable in the serum
- Liver biopsy with chronic hepatitis and significant fibrosis (bridging fibrosis or higher)
- Compensated liver disease
- Total serum bilirubin <1.5 g/dL (25.7 micromol/L)
- INR <1.5
- Albumin >3.4 g/dL (34 g/L)
- Platelet count >75,000 cells/mm3 (75,000 x 10(6)/L)
- No evidence of hepatic encephalopathy or ascites
- Acceptable hematological and biochemical indices
- Hemoglobin >13 g/dL for men and >12 g/dL for women
- Neutrophil count >1500 cells/mm3 (1500 x 10(6)/L)
- Creatinine <1.5 mg/dL (133 micromol/L)
- Willing to be treated and to conform to treatment requirements
- No contraindications to treatment
In addition, the 2012 UK consensus guidelines recommend treatment with peginterferon, ribavirin, and a protease inhibitor (telaprevir or boceprevir) for most patients with genotype 1, including patients who are treatment naïve or who have failed prior therapy with peginterferon and ribavirin. The guidelines note that because of drug interactions, treatment of patients with HIV needs to be considered on a case-by-case basis. In addition, the guidelines do not currently recommend treatment in patients with decompensated liver disease, hepatitis B co-infection, or active cancer, or in patients who have undergone organ transplantation due to limited data.
PATIENTS IN WHOM THERAPY IS CONTRAINDICATED — Antiviral therapy with peginterferon and ribavirin for chronic HCV infection is contraindicated in patients who have one or more of the following:
- Major, uncontrolled depressive illness
- A kidney, heart, or lung transplant
- Autoimmune hepatitis or other conditions known to be exacerbated by interferon or ribavirin
- Untreated thyroid disease
- Severe concurrent disease such as severe hypertension, heart failure, significant coronary artery disease, poorly controlled diabetes, obstructive pulmonary disease
- Known hypersensitivity to drugs used to treat HCV
Therapy is also contraindicated in patients who are:
- Less than two years of age
- Pregnant, contemplating pregnancy (including men), or unwilling to assure contraception; ribavirin is pregnancy category X due to significant teratogenic and embryocidal effects, and interferon is pregnancy category C
INFLUENCE OF SIDE EFFECTS AND DRUG INTERACTION ON PATIENT SELECTION — Interferon monotherapy and combination therapy with ribavirinand telaprevir or boceprevir (for patients with genotype 1) are associated with several adverse effects. In some patients, treatment is contraindicated due to the risk of side effects, whereas in others, treatment should be undertaken with extreme caution. Conditions that may be complicated or worsened by side effects of treatment include significant anemia or leukopenia, pregnancy, severe depression or other psychiatric conditions, cardiac disease, poorly controlled diabetes, seizure disorders, and autoimmune or potentially immune-mediated diseases. In addition, treatment efficacy may be reduced with advancing age (particularly in those older than 60 years) because of an increased frequency of side effects requiring dose reduction.
Drug interactions are also an important consideration in patients with genotype 1 who are being considered for treatment with a telaprevir or boceprevir and should be taken into account prior to starting therapy (table 1 and table 2). (See "Treatment regimens for chronic hepatitis C virus genotype 1", section on 'Drug interactions with protease inhibitors' and "Treatment of hepatitis C virus infection in the HIV-infected patient", section on 'Potential drug interactions'.
Recurrence after liver transplantation — Recurrence of HCV occurs in more than 95 percent of patients after liver transplantation. Disease progression in this setting is more rapid, and complications are more frequent than in immunocompetent patients with HCV infection [14]. Disease progression correlates with HCV RNA levels at the time of transplantation, the age of the organ donor, and the degree of immunosuppression in the post-transplant period.
MONITORING VIRAL LOAD DURING THERAPY
An early virologic response (EVR) is defined as at least a 2 log10 reduction in HCV RNA or HCV RNA negativity by week 12. A patient with a "complete EVR" has attained complete viral suppression by week 12; a patient with a "partial EVR" has achieved greater than a 2 log10 decline in viremia but continues to have detectable HCV RNA. An SVR is unlikely in patients who lack an EVR, and it is generally recommended that treatment be stopped in patients who fail to achieve an EVR.
We suggest that patients have their viral loads checked at baseline and at weeks 4, 12, and 24 of therapy to assess for a treatment response and to make decisions about continuing treatment or possibly altering the duration of treatment. Patients with an end of treatment response (negative HCV RNA at the completion of treatment) should also have a viral load checked 24 weeks after therapy is completed to assess for an SVR. An SVR is associated with a 99 percent chance of being HCV RNA negative during long-term follow-up
CHOICE OF PEGINTERFERON
meta-analyses suggest a slight advantage for peginterferon alfa-2a
We suggest treatment with peginterferon alfa-2a in patients with chronic HCV genotype 2, 3, or 4 rather than treatment with peginterferon alfa-2b.
DOSES OF PEGINTERFERON AND RIBAVIRIN — There are two peginterferon preparations used in the treatment of HCV (peginterferon alfa-2a and peginterferon alfa-2b). The doses of peginterferon differ for the two preparations:
- For peginterferon alfa-2a, the dose is 180 micrograms subcutaneously per week
- For peginterferon alfa-2b, the dose is 1.5 microgram/kg subcutaneously per week
Depending on the genotype being treated, ribavirin dosing may or may not be weight-based. Ribavirin is given in divided daily doses (typically twice per day). For genotypes 2 and 3, ribavirin dosing is not weight-based. Patients instead receive a standard dose of 800 mg (typically 400 mg twice daily).
For genotype 4, ribavirin is weight-based:
- For patients receiving peginterferon alfa-2a, the ribavirin dose is 1000 mg for patients who weigh 75 kg or less, or 1200 mg for those who weigh more than 75 kg.
- For patients receiving peginterferon alfa-2b, the ribavirin dose is 800 mg for patients weighing <65 kg, 1000 mg for 65 to 85 kg, 1200 mg for >85 to 105 kg, and 1400 mg for >105 kg
Treatment-naive patients — Patients with genotype 2, 3, or 4 should receive dual therapy with peginterferon and ribavirin. Protease inhibitors are not used in the treatment of patients with genotype 2, 3, or 4.
Genotype 2 or 3 — Patients with genotype 2 or 3 should receive treatment with peginterferon and ribavirin. Ribavirin is not weight-based for the treatment of genotypes 2 or 3. All patients receive 800 mg in daily divided doses (typically 400 mg twice daily). Treatment with peginterferon plus ribavirin should be administered for 24 weeks in patients with genotype 2 or 3. These patients generally have a better response to peginterferon and ribavirin than those with genotype 1 or 4.
Genotype 4 — Patients with genotype 4 should received treatment with peginterferon and weight-based ribavirin. Treatment with peginterferon plus weight-based ribavirin should be planned for 48 weeks
Relapsers and nonresponders
Prior treatment with standard interferon monotherapy — In patients who relapse after an initial response to interferon monotherapy, we recommend combination therapy with peginterferon plus weight-based ribavirin.
Prior treatment with peginterferon and ribavirin — The treatment of patients who are nonresponders to peginterferon and ribavirin is unsettled. For those who failed treatment with a full course of peginterferon alfa-2a or alfa-2b plus ribavirin, we generally do not suggest retreatment with peginterferon and ribavirin.
SUMMARY AND RECOMMENDATIONS — The decision to treat a patient with chronic hepatitis C virus (HCV) infection is based upon several factors, including the natural history of the disease, the stage of fibrosis, and the efficacy and adverse effects related to therapy. In general, patients being considered for treatment should have histologic and virologic evidence of chronic HCV infection.
Genotype 2 or 3: For patients with genotype 2 or 3 who are candidates for therapy, we recommend treatment with peginterferon and ribavirin (not weight-based) rather than treating with standard interferon and ribavirin or peginterferon monotherapy. Treatment with peginterferon plus ribavirin should be administered for 24 weeks in patients with genotype 2 or 3.
Genotype 4: For patients with genotype 4 who are candidates for therapy, we recommend treatment with peginterferon and weight-based ribavirinrather than treating with standard interferon and ribavirin or peginterferon monotherapy. Treatment with peginterferon plus weight-based ribavirin should be planned for 48 weeks
For patients with chronic hepatitis C genotype 2, 3, or 4, we suggest treatment with peginterferon alfa-2a rather than peginterferon alfa-2b
We suggest that patients have their viral loads checked at baseline and at weeks 4, 12, and 24 of therapy to assess for a treatment response and to make decisions about continuing treatment or possibly altering the duration of treatment. Patients should also have a viral load checked 24 weeks after therapy is completed to assess for an SVR.
assessment and plan
viral gastritis
celiac disease, no family history
gallbladder dysfunction, likely, because gallbladder pain more often happen during the night
reflux, patient hasn't heartburn for a while, unlikely
so plan is endoscopy to r/o gastritis, ultrasound to r/o gallbladder pathology, if ultrasound is normal, may need to do HIDA scan to estimate function of gallbladder
right now, prescribe Zofran (ondansetron) to treat patient's symptoms
4, 87 year old female with recent low gi bleeding due to diverticulitis come to office for follow up.
during her stay in hospital, she had colonoscopy finding extensive diverticulitis, active bleeding, hepatic flexure limited segment colitis and small benign polyps. she has past history of A Fib, and was on Coumadine. currently, she has no complaint of diarrhea, no bleeding, no abdominal pain, weight loss, recent Hb 9.2, physical exam show no abdominal tenderness. Since last bleeding, her coumadine has been on hold.
Assessment,
although colonoscopy found colitis, but patient show no symptoms, so right now we are not going to give any treatment for that
about her small polyps, biopsy show benign, so would recommend her come back in 1 year to repeat colonoscopy.
patient has history of A Fib and low GI bleeding, if restart coumadine, there is 67% possibility of rebleeding, but compare to the risk and consequence of stroke, we still suggest patient restart coumadine and have a close monitor with patient's symptoms.
5, 50s female with past history of cured Hep C come to the office because her recent ultrasound show abnormal change. She retired 1 year ago, her hep c pcr keep negative for more than 6 months after she completed treatment. no abdominal pain, no nausea, vomiting, no low extremities edema, social drink about 1-2 glass of wine/month, she once a while take walking as exercise, recent there is no new medication. she has gained several pounds since retirement, diet is mostly chicken, fish. recent liver function test is within normal range, cholesterol level is about 200. ultrasound show increased parenchymal echogenicity, suggest fatty liver, and 5mm gallbladder polyps. most gallbladder polyps are not true polyps, especially when size is 5mm or less, which is normal finding. However, true polyps are associated with malignancy.
recommend for patient, follow up with U/S in 6 months, if gallbladder polyps is not growing, can watch on that by doing U/S annually.
keep on low cholesterol diet and aerobic exercise.
recommend for patient, follow up with U/S in 6 months, if gallbladder polyps is not growing, can watch on that by doing U/S annually.
keep on low cholesterol diet and aerobic exercise.
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