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TOPIC: 2 Q: Riba dose adjustment & length / choice DAA

2 Q: Riba dose adjustment & length / choice DAA 1 month 3 weeks ago #29425

  • Hope8
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I started SOF/LED 10/21 and Ribavirin 10/29. I know I should have waited to start together, but I literally could not make myself wait.

Great results so far with an undetectable viral load at 4 weeks on the DAA, chronic right sided abdominal pain gone and feeling mentally clearer. Have what I think are two small lichen planus lesions—one is gone and the other is fading.

My hematocrit dropped after a week on Riba from 38.7% to 31.2%. I am feeling fatigued and lightheaded with standing at times. I dose adjusted from 1000 mg to 600 mg a day. A week later my HCT is up to 31.8%. Plan is to continue monitoring BUT I was reading the ION trials and it looks like Riba made no difference in the 1a genotypes. So I am wondering if it makes sense to continue or just stop it.

I’ve decided that I want to take a DAA for 24 months to give myself the best chance of SVR 24. I am wondering what the experts think of switching to SOF/VEL for the second 12 weeks since the efficacy is slightly better than what I am.

Would love any advice!

Also thanks for this forum. I have read through a lot of it and it has really given me a lot of courage and support even though many of the posts are old at this point.
1a
IFN x2 responded but relapsed; horrible side effects (weight loss/mood changes)
F2 on fibrotest A2 on acitest
APRI 1.3 which would be F4 so not sure about fibrosis
Current plan is harvoni + riba x12 weeks
4 week labs: HCV RNA undetectable!
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2 Q: Riba dose adjustment & length / choice DAA 1 month 3 weeks ago #29426

  • DrJames
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Hello Hope8,

Welcome to the forum.

Undetectable at 4 weeks is definitely on track!

You are correct that with GT 1a the benefits of adding Ribavirin to Harvoni are minimal. In the context of 24 weeks treatment there is, IMHO, unlikely to be any benefit.

On the topic of Ribavirin the recommended dose is 15mg/kg of body weight, but typically simplified as 1000mg/day for patients < 75kg and 1200mg/day for patients > 75kg. This is usually given as 2 doses. So, that means the dose you are taking is relatively low.

The half life of ribavirin is long so it takes about 21 days to get to its maximum. That means we need a few weeks to see how its going to land side effect wise. You have probably landed but, personally, I monitored the FBC/CBC of my ribavirin patients every 2 weeks. The monitored related to the fact I have not used ribavirin for going on 2 years because... we just don't need to and the treatment journey without it is generally much smoother.

Without knowing your pre-treatment status it's hard to give specific advice but we do know:

For treatment naive patients with GT1a using only 8 weeks Harvoni is *almost* as good as 12 weeks

The results for GT1a with 12 weeks Harvoni are very good, with patients with cirrhosis or HCC being the only common exceptions

In ballpark terms for GT1a

8 weeks Harvoni => 90% cure
12 weeks Harvoni => 95% cure (+5%)
16 weeks Harvoni => 97.5% cure (+2.5%)
20 weeks Harvoni => 98.5% cure (+1%)
24 weeks Harvoni => 99% cure (+0.5%)

The point here is that a) each extra 4 weeks treatment does add to treatment success rates; but b) there are diminishing returns in terms of extra cure rate.

Do you have any of your pre-treatment bloodwork and tests?
YMMV
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2 Q: Riba dose adjustment & length / choice DAA 1 month 3 weeks ago #29433

  • Hope8
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Dear Dr James,

Thank you for your kind reply.

I stopped the Ribavirin this am. Thank you! I already feel better.

Just for background, I am a 50 kg 63 year old woman. I am very fit and from a generally long lived family. I had a blood transfusion when I was 13 after a (undoubtedly unnecessary) tonsillectomy and some unprotected sex in my early 20s.

Recent pretreatment labs:

I didn’t have a viral load before starting.

EGFR 74, creat 0.84
Na 141 alb 4.3
AST 84 ALT 92 Bili 0.8 Alk phos 69
PT 10.8 INR 1
WBC 4.1 Hb 13.4 HCT 39.3 PLT 149
AFP 2.8 (normal <6
I pretty stressed when I had these done.

A week later on a less stressful day I had a Fibrotest 0.53 F2 and a Metavir score 0.56 A2.

I believe I am probably more fibrotic than F2 despite these latter results.

I had a liver biopsy when first diagnosed 1988 with inflammation and one in the late 1990s with some fibrosis already. I don’t have the reports.

I have been through two rounds of IFN. The first was really not a problem. The second was extremely difficult. I had high fevers with each injection. My weight dropped to 44 kg and I was nearly suicidal. I responded both times and relapsed. The second relapse was devastating.

I’d rather take a DAA for longer than I absolutely need to right now than relapse. I was even wondering about taking generic Epclusa for the second 12 weeks because it seems marginally better than Harvoni.

I can’t thank you enough for your help and for everything you are doing to help people with Hep C.
1a
IFN x2 responded but relapsed; horrible side effects (weight loss/mood changes)
F2 on fibrotest A2 on acitest
APRI 1.3 which would be F4 so not sure about fibrosis
Current plan is harvoni + riba x12 weeks
4 week labs: HCV RNA undetectable!
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2 Q: Riba dose adjustment & length / choice DAA 1 month 1 week ago #29449

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Hi Hope,

Those results are not too bad. You platelets being 150 is good.

Over-treating is fine provided you are not getting much in the way of side effects.

An extra 4 weeks gets almost all the benefit of an extra 12 but at 1/3 the cost, but if the extra cost is not an issue I can't say I'd blame you, particularly after failing IFN x 2
YMMV
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2 Q: Riba dose adjustment & length / choice DAA 1 month 5 days ago #29459

  • Hope8
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Thanks for the advice. I have zero side effects since stopping the Ribavirin and my Hb/HCT is rebounding.

The worst thing is not being able to take a PPI because I do have some GERD but if I am careful about my diet I can keep this in check.

I ordered another 12 weeks of the DAA.

Thanks again for all you are doing to help people with Hep C. It is truly amazing how simple and affordable you have made it to access lifesaving/lifechanging care.
1a
IFN x2 responded but relapsed; horrible side effects (weight loss/mood changes)
F2 on fibrotest A2 on acitest
APRI 1.3 which would be F4 so not sure about fibrosis
Current plan is harvoni + riba x12 weeks
4 week labs: HCV RNA undetectable!
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The following user(s) said Thank You: hanknassi, Mar

2 Q: Riba dose adjustment & length / choice DAA 1 month 2 days ago #29464

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Hi Hope, it's very good to know that you've had zero side effects with the DAAs. Completing 24 weeks should be easy enough then, and you've given yourself the best possible chance to reach cure after the previous failure. Just watch your diet as you said to avoid stomach acid issues and it will be smooth sailing. Things look great so far, hopefully they will continue this way and you'll get rid of this virus soon enough. Keep doing what you're doing, all the best.
Last Edit: 1 month 2 days ago by Mar.
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