TOPIC: Questions about medication and treatment

Hello all again,

I'm about to start treatment and I would like to know if you could help me with some questions.

I've just got Viekira Pak + Ribavarine and this is the way it was prescribed for genotype 1b for 12 weeks with f3/f4 suspicion that no one knows for sure:

2 pills in the morning after breakfast of ombitasvir 12,5mg, veruprevir 75mg, ritonavir50mg plus 1 pill of dasabuvir and 2 pills of ribavarine 250mg

1 pill of desabuvir 250mg plus 2 ribavarine pills at night after dinner.

- My first question is: Shouldn't the morning pills and night pills be the same? I mean taking 2 pills of ombitasvir, veruprevir and ritonavir also at night instead of just taking dasabuvir with 2 pills of ribavarine?

- My second question is: I have extrasystole due to my anxiety and it happens at the ventricle level, so it's a ventricular extrasystole. I now extrasystoles are benign but since this is the ventricular kind, can't Ribavarine mess with my heart rhythm inducing for instance a ventricular tachycardia? Can I have a heart attack since I'm 36 years old with a BMI of 42?

- Speaking of 42 BMI, can't this mess up with treatment? I know I've asked this before and I was assured by doctor James that it wouldn't, but my hepatologist said that this could make my treatment fail and I could acquire resistance to the drugs. She insisted on that over and over and over. I'm not diabetic, my fat liver is around degree 1 or 2 in ultrasound but "Discrete diffuse fat" on MRI but my insulin resistance is around 39 with a 9.69 Homa index which is crazy high.

Is this possible? From what I've read, resistance is due to the kind of the virus with some individual characteristics not weight, but I've also read some studies that when they studied treatments in retrospect, excessive weight was one of the causes that made it happen. Can someone shed some light on this because I don't want to screw this up.

- Now the main question: I take esomeprazol 20mg (here called Nexium) and I've read that might be an interaction between one of the substances in Vikiera and Esomeprazol. Can I still continue taking esomeprazol before breakfast, wait 30 minutes, taking my breakfast and then taking Vikiera?

Also, how far apart should be the first dose in the morning and the dose in at night. I'm asking this because I don't have fixed hours for breakfast and dinner. Sometimes I take breakfast at 6 and have dinner at 6pm or 8pm, so I would like to take everyday at the same time. What would you suggest?

Here's what it was written on the medication interaction site recommended here at the forum and I have absolutely no idea what it means:

Summary: Coadministration has not been studied. Esomeprazole is a substrate of CYP2C19 and CYP2C9 and concentrations may decrease due to induction of CYP2C19 by ritonavir. Exposure of omeprazole, a model CYP2C19 substrate, decreased by 40-50% with ombitasvir/paritaprevir/ritonavir + dasabuvir. Use higher doses of esomeprazole only if clinically indicated. Description:
Coadministration has not been studied but is expected to decrease concentrations of esomeprazole due to induction of CYP2C19 by ritonavir. If clinically indicated higher doses of esomeprazole may be needed.
Viekirax Summary of Product Characteristics, AbbVie Ltd, January 2015.
Exviera Summary of Product Characteristics, AbbVie Ltd, January 2015.

I apologize for all these questions, but I don't want to screw this up.

Thank you!

I guess the questions are too specific.

Perhaps Dr. James could help me?

Thanks

Hello JohnSmith,

The instructions are correct and can be checked here:

www.drugs.com/dosage/viekira-pak.html

The recommended oral dosage of VIEKIRA PAK is two ombitasvir, paritaprevir, ritonavir tablets once daily (in the morning) and one dasabuvir tablet twice daily (morning and evening). Take VIEKIRA PAK with a meal without regard to fat or calorie content.

The logic is:

a) The PrO part (Paritaprevir, ritonavir, Ombbitasvir) is metabolised slowly enough that once daily dosing works
b) The Dasabuvir gets metabolised (chewed up) fast so you need it twice a day to keep the levels up
c) Ribavirin as a single 1000mg dose is harsh so even though it is metabolised slowly we split the dose to soften the blow...

Can I have a heart attack since I'm 36 years old with a BMI of 42?

Probably not, but a BMI of 42 is not doing you any favors. I have attached my eBook on Weight Loss which contains every bit of good diet advice there is (without the marketing BS). I was a fat kid (nickname tank to start with, then piggy) so have a special interest in weight.

Mostly people do fine on standard dosing, but as a big lad you're right that giving you more than a 5'0 girl would make sense. That said the evidence is that the drugs work for pretty much everyone. If you wanted insurance adding Sofosbuvir (generic) is safe and would push your cure rate to so close to 100% that you could almost call it a sure thing. That said you really don't need to. If you're unfortunate enough to be in the ~ 3% of people who fail we have plenty of salvage options. So you would have a 97% chance of wasting money to cover a 3% risk.

Doses should be as close to the same time as practical but don't sweat a couple of hours either way each day. It ain't gonna matter.

Thank you so much for your reply!

I just have two more questions and I’m gonna start treatment. It’s a relief to know we have other options is the treatment fails.

Can I take esomeprazol 20mg with Vikiera?

What side effects can I expect and what side effects should I keep my eyes on and go to a hospital if it happens while taking Ribavarin? I’ve read anemia is common but what else should I expect?

Thank you very much!

Yes you can take esomeprazole with Viekira: www.hep-druginteractions.org/checker

Coadministration has not been studied. Esomeprazole is a substrate of CYP2C19 and CYP2C9 and concentrations may decrease due to induction of CYP2C19 by ritonavir. Exposure of omeprazole, a model CYP2C19 substrate, decreased by 40-50% with ombitasvir/paritaprevir/ritonavir + dasabuvir. Use higher doses of esomeprazole only if clinically indicated.

The Viekira may reduce the effect of the esomeprazole but the esomeprazole won't hurt the Viekira.

Most people taking Viekira with Ribavirin tolerate it fine. The commonest side effect would be fatigue. Riba rage (a sort of irritability) happens to some.

Hi John, I can see that you're about to start treatment and are putting your mind at rest with some questions before you do. This is good because usually somewhere there is someone with the same or similar queries. I've said it many times but how lucky are we to have Dr James?

I had the viekira pack and ribavirin for my treatment and I am all cured and living a life without HepC. I don't think I had 'Riba rage' (well I don't think I did - nobody said anything!). I think that It did make me tired and headachy but nothing that couldn't be managed and ofcourse it was well worth it.

Jump on in John and good luck.

Coral

That’s great news! I’m really happy for you! Thank you for your kind words. It means a lot to me and makes me calmer. Dr. Freeman is helping me more than my doctors!

I’ve just started treatment and my anxiety and PVCs went up and I’m taking propranol 50mg and clonazepan if I really need it.

I found interaction between Vikeira and Clonazepan but nothing on Ribavarin and Propranolol.

My PVCs (extrasystoles) are driving me crazy. They keep happening all the day long sometimes four per minute and stop and sometimes keep bothering all day long.

Did you experience any of these symptoms?

Dr. James, shoud I be concerned about interactions between both medications and Vikeira and Ribavarin?

I apologize for so many questions but I don’t feel my doctor share my concern about the treatment.

I guess it’s easy to dismiss an anxious patient that thinks that everything will happen and has all sorts of things going on, but it was thanks to my anxiety that I’ve discovered hep c after being discarded several times by doctors saying that my exams didn’t show anything besides a fat liver due to the ALT/AST ratio.

The worse thing for an anxious person if to be right about his anxiety because it makes you neurotic.

This is why I keep confirming everything twice or three times.

Thanks again

Hi John,

With your PVCs they will settle if you exercise, so when you get them, get active.

Coffee is a well known cause, but that would include Coke/Pepsi and Red Bull, V, Max, Monster, etc

Propranolol is a relatively short-lived medication and needs to be taken at least twice a day to get consistent blood levels. It takes ~2 hours to get to maximum effect if you're not taking it regularly.

Really? And I’ve been avoiding to walk on the treadmill because of the PVCs.

But can I take propranolol twice a day and clonazepam if needed without worrying about medication interaction?

I’ve took propranol today and helped me a lot and I always took twice a day before starting treatment because I’ve assumed that it could interfere with the medication, specially Ribavarin.

I couldn’t find anything on the medication interaction website.

heart.arizona.edu/clinical-approach-patients-frequent-pvcs

We need to rule out a structural cause. If there is not a structural cause of the PVCs then either

a) They will get better with exercise
b) They will get worse
c) Exercise will not change them (unlikely)

So, assuming the usual investigations have been done, and there is not a structural cause, either exercise will make them better or worse. If it makes it worse stop, if not... continue.

Hello,

I’ve already ruled out structural causes with several exams. They seem to be anxiety related.

So, I should stop Propranolol?

Hi John,

Propranolol typically helps. Stopping it to see if it IS actually helping would be fine. Curiously sometimes it can make things worse.

So no need to stop it, maybe just try doing a bit of exercise. If that helps, do more exercise. If you're fixed don't change anything, if not, see if stopping the Propranolol helps.

Do one thing at a time so you can know if it was "this change" or "that change" that helped.

Avoid caffeine, taurine in all off tea, coffee, Coke, Pepsi, Red Bull, V, Max, Monster and other sources.

Relax. I had PVCs for good 3 months consistently once. At the time I was in a "if I don't wake up in the morning I don't care" kind of a mood so I just left it. They went away. No idea why they were there, changed nothing, and they went away. That was a few years ago, so presumably not structural heart stuff. Maybe I just ignored them into going away, but, they came, they went, they were annoying, but... shit happens.

PS: I do recommend patients see an expert to rule out serious stuff but doctors are notoriously bad at following their own good advice. Mea Culpa.

It amazes me how PVCs are annoying. It seems that only when you accept them, they go away.

I used to have panic attacks because of them, now it just pisses me off... lol

I’m gonna start walking more often and adopt your attitude toward accepting it.

Thank you so much again for you help. You’re making this process so much easier. I can’t thank you enough.