How long to wait before retreatment

This topic has 20 replies, 9 voices, and was last updated 7 years, 11 months ago by beaches.

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4 August 2016 at 5:16 pm #21836
Gaj
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- Total: 1,431
- Guardian Angel
@gaj
Hi Meg,

After your comment about the percentages I went back and did some research as previously I took your comment of 95% for 8 weeks and compared that to the overall 12 week results for F0-1 1b’s of 99% per the combined ION trials. ~~Anyway, I found this report where comparing like for like in the ION 3 trial the difference was actually 2.3%. So not a huge difference but significant if you are one of those patients.~~ A closer look shows ION 3 naive for just 1b as equal at 98% for both lengths. Personally I think I would be more comfortable with 12 weeks but maybe have a chat with Dr James?

(Note: in the ION-3 study of Harvoni—treatment of naïve patients treated for 8 or 12 weeks with Harvoni who had an HCV RNA (viral load) of less than 6 million IU/mL—the difference in cure rate was -2.3%)

http://hcvadvocate.org/hepatitis/factsheets_pdf/GT1_Harvoni.pdf

And the eight week treatment doesn’t actually increase the risk of resistance as such. However doing 12 weeks Tx means there will be a better chance of SVR and if you SVR then you can’t develop resistance.

G3a since ’78 – Dx ’12 – F4 (2xHCC)
24wk Tx – PEG/Riba/Dac 2013 relapsed
24wk Tx – Generic Sof/Dac/Riba 2015/16 relapsed
16wk Tx – 12/01/17 -> 03/05/17 NS3/NS5a + Generic Sof
SVR7 – 22/06/17 UND
SRV12 – 27/07/17 UND
SVR24 – 26/10/17 UND
4 August 2016 at 10:31 pm #21839
Meg
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- Total: 95
- Guardian Angel
@meg
Hi Gaj I hear you! Yes I have spoken to my GI in Brazil as well as to Dr Freeman ( on a GP2U consultation) and both have told me that since I already have the third bottle of generic harvoni with me and unless I develop real bad sides from now on (I complete 9 weeks of tx tomorrow) It is better to do the 12 week tx – in spite of meeting the 8 week guidelines – as an insurance and reassurance of SVR. So I cut a deal with myself so to speak and I will play by ear and see how my 9 week labs and ultrasound results will come out next week. I am very curious specially about level of fibrosis – if it had a regression. Thanks again for “following” up on me and all your support.

Blood transfusion in 1992 – Diagnosed in 2007
Tx naive -G1b – F1
VL 2.270.000
ALT 40
Start tx June 4th/2016 with DAAs – Sof/Led from India
Bloods on two weeks of tx (June 18th)
AST 17 – ALT 10 – GGT 19
Virus UND
Bloods on six weeks of tx (July 16th)
AST 17 – ALT 8 – GGT 12
Virus UND
EOT on August 8th (did 9 weeks and 3 days)

SVR 4 Virus UND (September 7th)
AST 13 – ALT 5

SVR 14 Virus UND (November 12th)
4 August 2016 at 11:42 pm #21840
Meg
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- Guardian Angel
@meg
Hi again! Going back to the original topic I just saw on a facebook Hep C forum that someone who thought had relapsed at SVR12 is now UND at SVR24! Something Dr Freeman said at the time – about two months ago- to wait until next bloods to make sure it was really a relapse. It wasn’t. Such happy news I just had to share it here. Also a good example (there must be lots and lots) that it is better not to rush into re-treatment – unless there is a F4 and psychological aspects that Dr Freeman mentions in his OP.

Blood transfusion in 1992 – Diagnosed in 2007
Tx naive -G1b – F1
VL 2.270.000
ALT 40
Start tx June 4th/2016 with DAAs – Sof/Led from India
Bloods on two weeks of tx (June 18th)
AST 17 – ALT 10 – GGT 19
Virus UND
Bloods on six weeks of tx (July 16th)
AST 17 – ALT 8 – GGT 12
Virus UND
EOT on August 8th (did 9 weeks and 3 days)

SVR 4 Virus UND (September 7th)
AST 13 – ALT 5

SVR 14 Virus UND (November 12th)
18 November 2016 at 12:41 pm #24358
vitrus
- Topics: 1
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- Total: 36
- Treatment Warrior
@vitrus
Many NS3 RAVs resulting from treatment generally disappear by themselves in about more than 1 year. Ns5b sofosbuvir-emergent RAVs – in about less than 1 year.
However, acquired NS5A RAVs persist, requiring retreatment with drugs having considerably different resistance profile/mechanism of action/high bareer to resistance.
Results from a small 3-year follow-up study (presented at AASLD 2016).

http://www.natap.org/2016/AASLD/AASLD_61.htm

There are drugs in development that target not the virus, but host proteins, and were shown to work in early trials. However, different direct acting antiviral drug combinations were also shown to be effective for retreatment in many cases.

Gen 1b
VL pre treatment 29000 ME/ml
AST 32 ALT 94, F0
Started treatment 13 January 2017
Generic sofosbuvir/velpatasvir (Incepta)
VL 9 days into treatment <300 (undetected)
AST 13.8 ALT 22
Side effects: mild dehydration, not a problem at all if I drink water at night, nothing to worry about
Diet and gastric ph are very important with velpatasvir. One must think what and when to eat to keep gastric pH low. Side effects disappeared 2 weeks after, unless I ate anything < 4hrs before the pill. SVR60.
21 November 2016 at 12:01 pm #24384
Dr James
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- Guardian Angel
@fixhepc
I find the whole “wait for the RAVs to become un-measureable” logic flawed.

Accepting the observation that some RAVs become unmeasurable over time, to me the question is “does that matter?”

Go with me on this.

Say you have no measurable RAVs at baseline, and treat, but fail. What does this mean? It means you MUST HAVE HAD RAVs at baseline, despite the fact we could not measure them, and this is why you failed.

Post treatment we may be able to see the RAVs (because we have killed just about everything else) but we need about a 10% population to see them. Now consider this:

Starting viral load 1,000,000
Limit of detection 10

Almost all patients become undetectable (99.5%) but 5-10% fail to SVR. It follows that when they are undetectable they have < 10 RAVs, or to put it another way from that initial population of 1,000,000 there were only 0.001% RAVs Conjecture - generally RAVs are at such low levels we can't measure them, despite the fact they exist. Now with biological systems we see decay in terms of 1/2 life - the time taken for something to fall by 1/2. If it takes say 1 month for RAVs to fall by 1/2 it will take 2 to fall to 1/4, 3 to fall to 1/8. Even at this rapid rate it will take 20 months for 1 million RAVs to decay to 1 RAV (2**20 == 1 million). To me one of the best reasons to delay retreatment is to wait for better, more potent drugs and particularly triple and quadruple regimens. If this was HIV nobody would suggest waiting to RAVs to decay before changing regimens but prices are different and there are more options about that. The first of my originator Harvoni failures are coming through at SVR12 and 24 following 24 weeks generic Sof+Dac+[Simeprevir or Asunaprevir]+Ribavirin. The Simeprevir was originator out of Egypt, and the Asunaprevir originator out of Russia The combinations of Viekira-pak+Sofosbuvir and Zepatier+Sofosbuvir, both +/- Ribavirin are also looking good with patients in the USA using originator V-pak/Zepatier and generic Sofosbuvir. http://www.aidsmap.com/Treatment-intensification-with-sofosbuvir-permits-cure-after-failure-of-previous-HCV-treatment/page/3014995/

YMMV
21 November 2016 at 12:07 pm #24385
beaches
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- Guardian Angel
@beaches
Thank you.
Does this mean I should do an SVR24 test?

Genotype 1a
Diagnosed in 2004, had HCV for all my adult life. Until 2016!!!!
Harvoni treatment, started 19 March 2016
4 week results Bilirubin 12 down from 14 pre treatment,
Gamma 25 down from 52, ALT 19 down from 63, AST 19 down from 47,
VL <15 down from a lazy 6 million or so

EOT Results
Bilirubin 10, GGT 18, ALT 19, AST 21, VL UND

12 Weeks post EOT
Bilirubin 11, GGT 16, ALT 22, AST 20, VL UND
Cured baby
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