Page 22 - The Flying Publisher Guide to Hepatitis C Treatment

22 | Hepatitis C Treatment

treatment initiation and stay at the same level throughout the
remaining therapy period, up to 48 weeks. Severe anemia, with
hemoglobin levels <10 g/dL, occur in approximately 10 - 15% of
patients. IFN induces bone marrow suppression, while RBV cause
hemolytic anemia. Recently, genome-wide association studies
have identified an inherited genetic polymorphism at
chromosome 20, in the inosine triphosphatase gene (SNPs:
rs1127354 and rs7270101), as predictive for RBV induced anemia
(Fellay 2010). The presence of A/A and A/C vs. C/C genotypes
predicts protection from RBV induced hemolytic anemia during
the early stages of treatment.
The management of anemia follows several successive steps:
– RBV dose reduction by 200-400 mg/day, when Hb level
decreases between 8.5 - 10 g /dl;
– Discontinuation of RBV when Hb level declines to <8.5g/dl;
– Epoetin administration in patients with early onset of
anemia, in order to prevent treatment interruption. Use of
recombinant human erythropoietin-stimulating agents has
been associated with higher SVR rates and with reduced
dropout rates (Sulkowski 2009).
RBV induced anemia can precipitate occult coronary artery
disease, especially in older patients (due to age related reduction
in creatinine clearance). An accurate estimation of the
glomerular filtration rate and the administration of a lower dose
of RBV are recommendable in elderly patients.
Neutropenia (with absolute neutrophil count – ANC less than
9
1.5 x10 /mL) and thrombocytopenia (less than 50 000
cells/mm3) are also common. Consequently, eligibility for
treatment may be restricted in patients with advanced liver
cirrhosis.
The following decision tree is recommended for the
management of neutropenia and thrombocytopenia:
– PegIFN dose reduction, when ANC< 750 cells/mm3 and
platelets count < 50,000 cells/mm3;
– treatment discontinuation, when ANC < 500 cells/mm3 and
platelets count< 25,000 cells/mm3. If neutrophils or platelets