It is entirely usual that there are residual solvents present. They are the main reason that the purity is 99.x%

In the Daclatasvir we use the residual solvent is Ethyl Acetate CH3COOH (this is in nail polish remover and model airplane glue).

Ethanol is CH3CH2OH, and is a similar solvent.

If you think back to high school chemistry you probably remember dissolving crystal in liquid (solvent) and then mixing two things to make something else. This is the same as on industrial scale – the crystals of pure material are made in a solvent and it is increasingly expensive to remove all of it so we settle for 99.x% purity.

GPs are not suitably qualified to manage treatment unless they have undertaken the ASHM s100 hep C prescribing course.

I would have to disagree with this disparaging view of the skills base and capabilities of Australia’s GPs. Remember that both GPs and Specialists entered medicine from the top 0.5% of the academic results in that particular year and all did the same medical degree. I’m a GP and graduated in the top 3 of my year. As a group we GPs may have been financially a bit stupid to go down a more holistic path, but we are not, on the whole, a bunch of morons incapable of learning new skills without having our hands held.

Skills relate to what you do a lot of, have an interest in, and take the time to learn about. A Gastroenterologist or ID doctor with no experience in Hep C treatment (that being the majority) are no more or less qualified than a GP.

Several hundred GPs across Australia have completed the course over the past few years and there is a course running in Sydney in March. It is exactly the same with HIV treatment.

As far as I know none of the several hundred GPs across Australia who have completed the S100 course over the past few years received instruction in drugs that at the time did not exist. Calling them qualified after having completed a course that did not cover the relevant material seems unjustified.

One of the problems for doctors coming from the Interferon/Riba age is the notion that using Riba is a good idea. For most patients it is not, it is at best a DAA saving strategy. If you read this http://fixhepc.com/forum/gt3/369-gt3-high-svr-rates-with-daclatasvir.html (the largest trial of Sof/Dac+/-Riba ever with n=46 there is exactly zero evidence that it helps in any subgroup of F3/F4 GT3 taking 24 weeks treatment. On this note I have just seen a Specialist put an F4 patient with GT3 into hepato-renal failure by, 6 weeks into a 24 week treatment, adding in Riba to a patient with VL 0 at 4 weeks and then normal liver function. 5 days in the patient started to feel bad and went yellow. At 7 days he stopped the Riba. His local GP did some bloods that looked a bit dire. I’ve been monitoring him quietly getting better.

I would agree with you that anybody prescribing Riba should be aware that it can make things go pear shaped very fast.

Only specialist GPs are qualified to manage issues like drug/drug interactions.

Managing drug interactions is a routine part of medical life. Every GP does it every day, and given GPs do far more prescribing we routinely deal with far more interactions than Specialists. We also routinely use computerised software that provides decision support and annoying interaction warnings (unlike many Specialists who still use paper). In the GP Cheat Sheet there is a dedicated interactions checker my 7 year old could use with 2 minutes instruction.

Fortunately or otherwise these medications will be dual listed as S85 and S100 so no special training for GPs will be required although if Riba is going to be used you could make an argument some training about using it is essential.

As always seeking out a doctor who has an interest and experience dealing with your particular problem is a smart idea.

Fantastic news……

Take 24 weeks treatment. God smiles on those who take 24 weeks more often, so sayeth the statisticians.

You need to take 24 continuous weeks of treatment to achieve the best results.

If you take 12 weeks your success rate will be ~ 85% ie 15% fail rate (1:6) 1 chance in 6 of relapse

If you take 24 weeks your success rate will be ~ 95% ie 5% fail rate (1:20) 1 chance in 20 of relapse

1:20 is much better odds than 1:6

We assess treatment success in the weeks following FINISHING treatment

SVR4 = Undetectable (UND) 4 weeks after treatment stops and means 96% chance permanent cure
SVR12 = Undetectable (UND) 12 weeks after treatment stops and means 99% chance permanent cure
SVR24 = Undetectable (UND) 24 weeks after treatment stops and means 99.8% chance permanent cure

Hi Jonathan,

Let’s start by saying I don’t have any practical experience treating DAA recurrence so this is only a combination of book knowledge and background knowledge. I would advise taking your specialist’s advice, but here are some things to consider.

NS5A RAVs don’t necessarily render NS5A inhibitors useless because resistance is invariably relative. Here is what it looks like on a petri dish:

The white disc contain antibiotic and the clear area around them gives a visual of how effective they are (or how resistant the bacteria are to being killed). The antibiotic concentration falls off with distance from the disc and where you see the bugs growing is where the antibiotic falls below the MIC (Minimum Inhibitory Concentration).

So if I was 1a I would have 12 weeks of Sofosbuvir+Daclatasvir+Simeprevir and I would be considering increasing the 12 towards 24 weeks on the basis is 8 weeks works for F0, 12 weeks for F1-3, and 24 weeks for F4 it is probably more like

F0 8 weeks
F1 12 weeks
F2 16 weeks
F3 20 weeks
F4 24 weeks

The trials divided people into cirrhotic and non cirrhotic and found the 12 vs 24. This was to make 2 statistical buckets rather than 4 buckets without enough n.

Fibrosis is a spectrum from none to lots so if we need lots of treatment time for high fibrosis we “probably” would be better to use a bit more than 12 weeks for F2 and F3. Can’t prove it. Can’t show you evidence, but makes logical sense to me.

It’s not directly applicable to you but the recent trial n=468 for F3/F4 GT3 patients failed to show any benefit for 24 weeks Sof+Dac+Riba versus Sof+Dac alone. http://fixhepc.com/media/kunena/attachments/391/CCO.pdf