Dear Prof. Alavian,

I suggest to involve ITPA SNPs assessment especially in this group of patients. As you know variants of ITPA gene are protective against anemia and as a result patients with these genotypes of ITPA can tolerate ribavirin in more extent. what is your idea to use ribavirin according to ITPA genotypes? Thank you.

Dear Heidar,

Thanks for your comment. Is any published or unpublished data regarding ITPA in thalasemi with HCV infection or not?

No. There is no publication regarding ITPA SNPs in thalassemia patients with HCV infection. Previously we had excluded these patients from our ITPA project because of anemia independent of ribavirin in thalassemia but I think we can have a different insight to this issue and we can assess these SNPs when we prescribe ribavirin in thalassemia patients.

Dear Prof. Alavian

I recommend Ribavirin in thallassemic patients , and Im sure using Peg without Riba isnt very effective , as you know, the rate of relaps is high, although adding Riba increases the rate of anemia and Iron overload , we can manage theses complications with shortening of blood transfusion interval and iron chalator agents properly. according to our experience, thalassemic patients can tolerate Ribavirin although careful monitoring is essential. cardiac consultation before and during treatment should not been forgotten.

Heidar,

a very important question since HCV infection is so frequent in thalassemic patients. The problem is relatively simple, in my opinion. It depends on the HCV genotype and on the fibrosis stage of the liver. I presume you are referring to HCV genotype 1 infection. If this is the case, fibrosis stage should be assessed by clinical parameters, elastography (Fibroscan) and, possibly, liver biopsy. If bridging fibrosis or advanced fibrosis is present, there is no indication to delay treatment, and Peg+Riba(+/- Telaprevir) should be considered. I no advanced fibrosis is present, I would further expect future treatments.

Dear Dr. Brillanti,

Beside liver fibrosis, IL28B SNPs and core 70 substitution (especially in HCV-1b) are strong predictors of treatment response and can be utilized for decision making.

Yours,

Heidar

For sure. But at last, you have to prevent progression of liver disease. I completely agree that IL28B and HCV core region variations are important predictors of response, but if you have advanced fibrosis you probably should try treatment, independently of pre-treatment variables. Response should be assessed early while on-treatment, and decision to follow.

Regards

Heidar,

here are two recent publications that have described use of ribavirin in thalassemia patients:1: Tabatabaei SV, Alavian SM, Keshvari M, Behnava B, Miri SM, Karimi Elizee P, Zamani F, Amini Kafiabad S, Gharehbaghian A, Hajibeigy B, Lankarani KB. Low dose ribavirin for treatment of hepatitis C virus infected thalassemia major patients; new indications for combination therapy. Hepat Mon. 2012 Jun;12(6):372-81. 2: Paschos P, Vlachaki E, Pasvanti C, Sinakos E, Kalpaka A, Klonizakis P, Perifanis V. Safety and efficacy of combination therapy with pegylated interferon alpha-2a and ribavirin in treating patients with chronic hepatitis C and beta-thalassaemia major: a Greek single-center experience. Acta Haematol. 2011;126(4):231-3.

Dear Prof. Alavian,

We ave trated one patient with talasaemia with RBV the patient was in need of blood transfusions, however he expirenced SVR. I do not belive that ITPA SNp´s helps you a lot, because you can not do anything about it. I belive adding RBV is essential!

Dear Dr. Maieron,

Since there is no evidence around impact of ITPA SNPs on ribavirin induced anemia in thalassemia patients, we can't ignore it and I believe we should assess its possible role on treatment related anemia in this group of patients.

Best

Dear Dr Maieron,

Thanks for your response. I agree with you. I think the exaggeration of anemia and need more to blood transfusion is a real event with using ribavirin in therapy of HCV in thaasemia, but it can increase the rat of SVR.

It makes a big difference if you are considering the major or the minor form. I personally use ribavirin for HCV infected patients with the minor (heterozygotic) form

Prof. Alavian,

I also recommend Ribavirin in thalassemic patients with close follow up, because I believe that Peg + Riba is more effective. I have reviewed these publications about this importante issue:

1. Safety and efficacy of combination therapy with pegylated interferon alpha-2a and ribavirin in treating patients with chronic hepatitis C and beta-thalassaemia major: a Greek single-center experience.

Paschos P, Vlachaki E, Pasvanti C, Sinakos E, Kalpaka A, Klonizakis P, Perifanis V.

Acta Haematol. 2011;126(4):231-3. doi: 10.1159/000330516

2. Safety and efficacy of pegylated interferon alpha-2a and ribavirin for the treatment of hepatitis C in patients with thalassemia.

Harmatz P, Jonas MM, Kwiatkowski JL, Wright EC, Fischer R, Vichinsky E, Giardina PJ, Neufeld EJ, Porter J, Olivieri N; Thalassemia Clinical Research Network.

Haematologica. 2008 Aug;93(8):1247-51. doi: 10.3324/haematol.12352

Regards

Dear all,

attached please find our experince with RBV induced anemia

Sorry,

this was also on G6DH deficient patients

Thanks. It was interesting for use to predict the probability of anemia after using ribavirin in classic therapy of HCV infection.

I use SOC therapy in thalassemia cases. I begun to use this treatment on my patients about five years ago. I think it is more difficult to treat microcythaemic patients than thalassemic because of the poor response of the first to the erythropoietin treatment. However you need a good haematologist because this therapy, i think, is a team game.

Good luck

Caterina Furlan

I agree with Caterina we should treat the HCV patients especially the thalassemia in a team.