Hello Boba,

It's normal for both ALT and Viral load to fluctuate during the acute phase. It looks roughly like this:



About 25% of patients clear the virus and you can see the comparison here where one patient clears the virus and the other patient does not:




Dual genotypes probably occur ~ 10% of the time but are less often reported. Over time, whatever genotype reproduces fastest will become the dominant one, so in your case, it looks like the GT2 more or less beat the GT1a in the cloning stakes.

Epclusa works on both GT1a and GT2 (and all the other genotypes) so your cure rate is not better/worse because of this.

Early treatment tends to be more effective than later treatment as there has not been time for cirrhosis to develop and we know this makes treatment harder. It's probably only a 2% chance (1 in 50) that you won't clear on 12 weeks of Epclusa. While it's nice to see undetected on treatment if your ALT/AST are good, then things are going well. Once you finish the pills they wash out in a week, giving the virus 11 weeks to grow back (if still present) which is why we wait until SVR12 - 12 weeks after the pills finish - to declare cure (it's 99.7% certain you will remain negative indefinitely if negative at SVR12).

I forgot to add.
My alt and ast did fluctuate during last year after infection, after dropping from 2000 to 100 initially. Then every other week it was sometimes 300, sometimes 100.

Right before treatment alt was 120, ast 65.

Hi,
I was diagnosed last summer with hepatitis c in acute phase. My alt and ast were above 2000 in spring. I had some other symptoms. It was all diagnosed by chance.
First, doctors treated me for toxic hepatitis because all viruses were negative but I was in window period.
It turns out I was infected trough medical procedure.
So after hcv diagnosis and hcv rna 40.000 in july doctors said to wait if I can fight it myself.

I returned in october for genotype and viral load. While waiting for results I did another test privately. because in my country it is not that expensive. So these were results:
3.oct- genotype 1a, and 2. viral load 22 milion
24.october- genotype 2, viral load 1.5 milion

So, that was 6 months after infection, because I know date of infection.

I bought generic epclusa and now I am in 8th week. I have 4 weeks to go. I havent tested by myself yet. Doctor said to come and get tested after end of treatment in february. I started sofosbuvir and velpatasvir exactly 8 months after getting infected.

So, my question to Dr. James and anyone with experience is do you know anything about treating hcv immediately after acute phase. And why did my viral load jump like that? In one laboratory they didn't find genotype 1. Is it possible that I fought 1a myself or was it just low on second test so they didnt detect it?

I was in agony after I got infected and after it all settled I found out to have 2 genotypes, that was another shock.
Are my chances lower because of 2 genotypes? or are my chances good because it was caught so early.


Thanks in advance and sorry for maybe confused post. My case is I am sure interesting to you.
Boba

nitro wrote: if i could i would slap the SHIT out of the person who turned me down for treatment when i WAS payin over $300 a month heath care..(canceled)

Hey. I completely understand you friend.

DrJames wrote: Hello Penn,

There is quiet a strong association between autoimmunity and Hepatitis C. The immune-related extrahepatic manifestations include:

• Mixed cryoglobulinemia
• Cryoglobulinemic vasculitis
• B-cell non-Hodgkin’s lymphoma.
• Sicca syndrome
• Arthralgia/myalgia
• Polyarthritis/fibromyalgia
• Autoantibody production (i.e. cryoglobulins, rheumatoid factor, and antinuclear, anticardiolipin, antithyroid and anti-smooth muscle antibodies)
• Polyarteritis nodosa
• Monoclonal gammopathies
• Immune thrombocytopenia
• Glomerulonephritis and renal insufficiency

This article speaks to your questions rmdopen.bmj.com/content/1/1/e000008 with the answer "we just don't know".

This article says "use DMARDs with caution in HCV" www.eurjrheumatol.org/sayilar/211/buyuk/194-9.pdf

This article suggests slightly lower SVR rates in patients with autoimmunity bmjopengastro.bmj.com/content/5/1/e000203

There is a tiny 3 case series here bmcgastroenterol.biomedcentral.com/artic...86/s12876-018-0826-7 showing a transient fall in autoantibodies during treatment

But in terms of a study that said something like "patients with HCV and autoimmunity have reduced autoimmunity on and after HCV treatment" - as far as I know nobody has done a large trial to answer that one way or another.

It sounds like you are weighing up treatment options?

Hey. Thank you very much. This information helped me a lot. I thought I would create a topic. Good luck!

Hello Penn,

There is quiet a strong association between autoimmunity and Hepatitis C. The immune-related extrahepatic manifestations include:

• Mixed cryoglobulinemia
• Cryoglobulinemic vasculitis
• B-cell non-Hodgkin’s lymphoma.
• Sicca syndrome
• Arthralgia/myalgia
• Polyarthritis/fibromyalgia
• Autoantibody production (i.e. cryoglobulins, rheumatoid factor, and antinuclear, anticardiolipin, antithyroid and anti-smooth muscle antibodies)
• Polyarteritis nodosa
• Monoclonal gammopathies
• Immune thrombocytopenia
• Glomerulonephritis and renal insufficiency

This article speaks to your questions rmdopen.bmj.com/content/1/1/e000008 with the answer "we just don't know".

This article says "use DMARDs with caution in HCV" www.eurjrheumatol.org/sayilar/211/buyuk/194-9.pdf

This article suggests slightly lower SVR rates in patients with autoimmunity bmjopengastro.bmj.com/content/5/1/e000203

There is a tiny 3 case series here bmcgastroenterol.biomedcentral.com/artic...86/s12876-018-0826-7 showing a transient fall in autoantibodies during treatment

But in terms of a study that said something like "patients with HCV and autoimmunity have reduced autoimmunity on and after HCV treatment" - as far as I know nobody has done a large trial to answer that one way or another.

It sounds like you are weighing up treatment options?

Has anyone treated with DAAs who also has an autoimmune condition like rheumatoid arthritis or lupus or another one?
What was the outcome? Any flares of autoimmune during DAA treatment?
Can Dr Freeman also comment on his experience with this?

Hi RockHard,

You are right that it can be overwhelming but you are really working through this to get the best option for you.

I took Ribavirin for 24 weeks so I thought I'd share my experience. My G1 Hep C was particularly difficult to treat . Initially I had 12 weeks of Sofosbuvir/Ledipasvir followed by 12 weeks of Sofosbuvir/Daclatasvir. A few weeks after the end of treatment I relapsed. Only a very very small percentage of people relapse and the treatment options have increased over the last few years.

Pretty much straight away I went onto 24 weeks of the Viekira Pak with Ribavirin. Even though I could have probably stopped the Ribavirin earlier I wanted to make sure that I hit the virus with everything. In comparison to the minimal side effects that I experienced with the first treatment I did have a few more with the Ribavirin. More headaches, disrupted sleep, tiredness, dry hair, dry skin and general blah. However the long term effects of having the virus were mixed in there somewhere so it was hard to separate them. I don't think I had the Riba Rage - no-one has mentioned it anyway.

For me it was unpleasant but manageable and I kept my eye on the end goal. I know that everyone is different and that you have had side effects with the Epclusa however my unscientific advice would be to take the Riba, even halfway through, for the extra SAS troops it puts into the fight and for your own peace of mind.

I am coming up to my two year anniversary of being Hep C free and it is the gift that keeps giving.

I really wish you well. Let us know how you are travelling.

Coral

Thanks for your words RSF, really appreciate it.

I'm not sure about Riba yet because of side effects. As you said anticipation is worse than reality so the best thing to do right now is calm down and wait next week for my results.

Thanks for the book recommendation, I will definitely check it out.

Just one more thing, I don't want to sound negative on my treatment outcome. I think this new medicine are a great scientific breakthrough. It just the access to all this information and different opinions is a bit overwhelming sometimes. I really trust my GP, he was recommended to me by a HepC organisation so i have not doubt he knows what he's doing.
Anyways, as you mentioned I need to keep a positive mind in this journey and I will.

Thanks for the support

Chris

Thanks for your reply DrJames

The side effects of Riba scares me because Epclusa has not been pretty so far. More tiredness would lead to inability to do my job and I can't allow that in my life right now. I would prefer extend the treatment if necessary. Too many questions and so little answers.

Looking forward to discuss this privately DrJames

Thanks

Chris

Finally got a final blood test done and am waiting for the results. A separate CBC showed a change in ALT from 35 to 13 7 months post treatment (Harvoni) and my platelet counts are slowly rising , 132 on the last test and 143 on the most recent. The Hep C results can take 3-4 weeks but they notify your doctor if you have any viral load so no call after 2 weeks is a good sign

While on the treatment my WBC MONOCYTES were at 9.4 which my FD was concerned about but this test put them at 7.0 so I am chalking that up to the Harvoni.

Hi Chris,

Sounds like you're having a tough time but Dr James is, as you have already found out, right behind you. That should reassure you, as everyone on this forum knows.

I would certainly takes the Riba, potential side effects and all, if I were in your shoes. As with most things in life, anticipation is usually worse than reality.

With best wishes for 2019,

RSF

PS Have you ever read 'Love, medicine and miracles' by Bernie Siegel MD? It is about the way positive thinking influences health outcomes but also much more and how, practically, to help yourself. If your view of the treatment you are having is that it will work, you measurably increase the odds that it will. Further, you can minimise side effects of treatment using the visualisation techniques Siegel employs with his patients. R.

Hey guys, I really had no idea there weren't that many 2b's! I am 4 weeks post treatment with Epclusa and feeling great. Was undected at week 4 and had AST ALT levels normalize then from 288 ast and 162 ALT not sure what my virial load was. Fibroscan was f0-f1 and have had the virus since 2012. Do we 2bs really have a 100% cure rate on here? I hope so! Thanks guys

Thanks very much DrJames

I think my options now is to add Riba half way treatment or not to add it. My question is should I add it regardless of my results next week or only if I'm not clear?
This is important in term of timing because if you think I should take riba regardless of the results I can order them right now and start taking them next week.
Answering your question, I'm in Australia but I self funded my treatment. My experience ordering 12 week Epclusa was very good in terms of I got them on my door 8 days after I put my order.

That leads me to another question, do I need prescription from my GP to get Riba? How are Riba's side effects compare to epclusa?

Very confuse right now so I would really appreciate your help

Thanks very much

Chris

Hello RockHard,

11.6kPa is less than the 12.5kPa for cirrhosis but, given this is a spectrum you are much closer to cirrhosis than not. As you say, for F4 GT3 patients the recommendations are 12 weeks Epclusa with Ribavirin or 24 weeks without.

If you were my patient I would have discussed this in a conversation like GT3 is harder to treat, it's harder with cirrhosis (which you are close to) so what do you think about Ribavirin?

What country are you in? There are all sorts of rules that restrict what can be used and the options for retreatment also vary. For example, in Australia all I could give you would be 12 weeks Epclusa so the decision here is 12 weeks with Riba or 12 weeks without - there is no 24 week without option. For a patient in Australia, the only way to do 24 weeks without would be 12 weeks PBS funded, and 12 weeks self-funded generic.

All other things being equal I would be happier if undetected at 4 weeks than if you're still detected.

Yes we could add Ribavirin in later. It's probably not as good as earlier, but probably better than not at all. The "probablys" relate to the fact it's not done very often so it's a best guess, rather than something backed by solid research. I know eminent doctors like Professor Ed Gane would add it in if things did not seem to be going according to plan (at least that's what he suggested last time I asked!).