42 year male, case of Hepatitis C (genotype 3) with very high viral load, was treated with Sofosbuvir 400 mg OD with Ribavirin 800 mg, tolerated well with rapid viral response rate. After 12 wks of therapy, he has started c/o severe weakness, and his baseline blood parameters showed Hb of 5.6 gm/dl amd TC of 5000/cmm with normal DLC. Other parameters are normal. Now, whether to stop Ribavirin or simply reduce the dose? Is there any role of Erythropoitein? If yes, at what dose?
ribavirin has to be withdrawn and substituted with pangenotypic antivirals like daclatasvir or other antivirals like ledipasvir or simepravir as there is chance of reinduction of hemolytic anaemia . Ideally ribavirin to be given at adequate dose ranging from 800-1200mg usually, by reducing dose lead reduced efficacy. Erythropoietin cant reduce hemolysis neither well tried in hemolytic anemia, so should not be prescribed.
Below is a paper using computational models to describe a dose-dependent relationship between ribavirin accumulation and erythrocyte destruction. You may find it useful.
http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1001072
You can try reducing the dose rapidly with 4oo mg== 200 mg dayli is also a possibility= Blood transfusion is the treatment in emergensy
Z Krastev
Dear Dr Barman, actually, the best treatment for HCV infection with genotype 3 is SOF+DCV (RIBA is not mandatory) for 24 weeks. RIBA was used at the total dose of 10-15mg/kg b/d when associated to the therapy with IFN. The use of RIBA can induce a risk of anemia (dose dependent) since this drug has a direct toxic effect against RBC. This implies a monitoring of blood cell count at least after the first month of therapy and later on (it depends on the value of RBC). In your situation you can stop RIBA and add DCV for at least 3 more months.
Patient has already completed 4 months course of RBV and SOF, I have treated him with 2 units of PRBC and erythropoietin 4000 IU S/C stat. I have reduced the doses of RBV to 400 mg. His HCV RNA load after 4 wks and 12 wks are undetectable. Now, whether I should go with SOF and reduced dose of RBV or changed to SOF plus DCV for next two months?
A fall in hemoglobin is almost universal with ribavirin but often not significant due to decreased RBC survival. Treatment as suggested reduce dose and then stop altogether
I agree with all of the comments that the best option is to use a regimen treatment free of ribavirin and nowadays is possible and the efficacy is good specially if the patient has not associated cirrhosis
Anemia is very common with Ribavirin. Studies have shown that a 3gm drop in hemoglobin is associated with a good bloood level of Ribavirin. Ribavirin dose is usually 1000mg if weight < 75Kg and 1200mg if >75Kg. Since your patient was only getting 800mg daily and since genotype 3 has turned out to be difficult to treat and we're seeing quite a few relapses, I would switch to Sof+Dac x 3 months. Procrit even when dosed at 10,000 u/week takes about 2 to 3 weeks to start to worrk if tthe patient has adequate iron stores. Otherwise Procrit won't work.
I bet that this anemia is hardly to treat by current way. It's due to all chemical drugs suppress yang qi. I attached yang qi explanation and its functions. Plus all chemicals let liver accumulate toxins. Once toxin accumulated, liver function going down, plus liver is always invade spleen functions. In Chinese medicine, spleen transform and transport nutrients.
On the other hand, drugs also add the kidneys' burden and lower down its function. In Chinese medicine, kidney controls bone marrow that help to make the blood. The blood, making organs be injured. How can you let the patient make blood?
In 2008, Japan government adopted the scientists' recommendation that all western medicine schools should add Chinese medicine courses. I do expect that US also can do so. Otherwise, in the near future, only the health care burden can pull US off the world leading position. It's due to it eats up too much funding that can be used in many education and high tech researches meaningful items.
https://universaltcm.com/yang-qi-functions-relationship-health/
In the treatment with Ribavrin is relatively common the presence of anemic dependent of the dose and duration of the treatment and is completely reversible stoping its administration in few days or just 1-2 weeks
Kindly look at the attached link.
https://www.ncbi.nlm.nih.gov/pubmed/17168855
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