Hepatitis C: Anemia And Other Side Effects During Treatment

[Guest guest]

Hepatitis C: Anemia And Other Side Effects During Treatment

Related Article : Preparing For Treatment

Side effects during treatment are seen in almost 80 percent of people treating with peginterferon and ribavirin HCV therapy. As patients the early recognition of those side effects is needed in order to avoid discontinuation or a dose reduction in therapy. Compliancec to HCV treatment is an important factor for achieving SVR.

What we know is 100% compliance with the peginterferon and ribavirin regime always produces better results than 80 or 90% compliance.

From : Palmer, MDClinical Professor of MedicineDepartment of Hepatology

Importance of Adherence to HCV Regimens

Key Points

"Approximately 60% of patients with HCV in the United States adhered to prescribed therapy",''Indeed, studies have demonstrated that exposure to weight-based ribavirin vs fixed-dose ribavirin is associated with improved early virologic response and SVR rates"

'Reduction of the incidence and severity of treatment-induced anemia with erythropoietin has been shown to encourage adherence and to enable patients to remain on higher doses of ribavirin''

''Therefore, to improve adherence, practitioners must evaluate all HCV-infected patients at baseline and during therapy for psychiatric symptoms and initiate antidepressants or antipsychotics promptly, as needed.''

Read Full Article Adherence to Hepatitis C Therapy

From the American College of Gastroenterology

Peginterferon suppresses the bone marrow and ribavirincauses hemolysis. As a result, it is essential thatblood counts be assessed at regular intervals duringHCV treatment. When treatment is first initiated bloodcounts should be assessed at a minimum of oncemonthly until the hemoglobin, WBC, absolute neutrophilcount and platelet count are stable. However, somephysicians will assess blood counts more frequently, at2 week intervals, until these values are stable. Liverchemistries can be monitored less frequently butfor convenience are generally assessed at the samefrequency as hematologic testing. Thyroid functionshould be assessed at baseline and at 3 month intervalsunless patients develop symptoms of either hypo- orhyperthyroidism. Pregnancy testing should be performedby females who are capable of conception at monthlyintervals.

Hepatitis C Treatment and Anemia

During your hepatitis C treatment period, youwill have your blood drawn on a regular basis tocheck many lab values, including hemoglobin. It isimportant to have the labs drawn when instructedby your doctor’s office.

Why Your Body Needs Hemoglobin

Just like a car, your body needs fuel to run. Hemoglobin, or Hb,is important because it transports oxygen in your blood to allparts of your body. Think of the oxygen carried by hemoglobinas the fuel your body needs to stay alive and run efficiently.Hemoglobin is a substance found in your red blood cellsthat carries most of your oxygen. Although other substancesin your body, such as water and plasma, also carry oxygen,hemoglobin is unique because it can carry four times asmuch oxygen throughout the body.

How Hemoglobin Fuels Your Body

Because Hemoglobin contains iron, it is an excellent vehiclefor transporting oxygen and carbon dioxide. When red bloodcells fill the air sacs of your lungs, they take up oxygen. Thehemoglobin in the red cells combines with the oxygen to forma compound called oxyhemoglobin. When the red cells travelthrough the rest of your body, they give up the oxygen to thetissues. In the tissues, hemoglobin takes up carbon dioxide(waste material) and releases it in the air sacs of the lungs.

The carbon dioxide is then exhaled.

What Causes Anemia

Anemia is caused by low levels of red blood cells, orhemoglobin, in your blood. A severely anemic person’s bloodcannot carry enough oxygen to meet the needs of the bodytissues. As a result, over time the person becomes tiredphysically and mentally, and feels cold.When on interferon and ribavirin treatment for Hepatitis C, areduction in hemoglobin very commonly occurs and in mostcases, it is maintained at levels below the normal laboratoryranges, returning to normal after treatment is completed orstopped. Anemia is an expected side effect of treatment withinterferon and ribavirin.

In addition to anemia caused by interferon and ribavirin,anemia can be caused by kidney disease, lack of vitamin B12or folic acid in your diet, an inherited blood disorder suchas sickle cell anemia, blood loss from an injury or accident,gastrointestinal bleeding, or lack of iron.

Symptoms of Anemia

Have you ever held your breath for longer than a minute? Doyou remember how you were afterward? With anemia, youwould feel tired all the time. Even extra sleep will not helpan anemic person feel better. If you are anemic, you mayexperience:

• Extreme fatigue and weakness• Feeling tired• Difficulty sleeping• Difficulty thinking clearly• Headache• Dizziness or fainting• Cold• Paleness

Treatment for Anemia

Your doctor will monitor your hemoglobin levels by looking atyour blood test results. It is not uncommon for hemoglobinvalues less than normal to be followed closely without anychange in medication or other treatments. He may reduce thedose of ribavirin. However, there may be a time when your doctordiscusses a separate treatment called Procrit® or Epogen® forthe anemia and the side effects you are experiencing.Procrit® or Epogen® is identical to erythropoietin (e-RItH-ro-POIe-tin), the substance your kidneys normally make. It stimulatesyour bone marrow to make new red blood cells. As a result,more red blood cells can carry oxygen to the body, which mayincrease your energy level and provide relief from the symptomsof anemia, such as fatigue and shortness of breath. Procrit®or Epogen® is available only by prescription. It is an injectiongiven underneath the skin like the

injection of interferon you arealready receiving. Your doctor will tell you what dosage is rightfor you. Studies have shown that you feel better during hepatitisC treatment when taking these medicines.

Precautions

Before administering this medication, tell your doctor orpharmacist if you are allergic to epoetin, human albumin, orany other drugs. Always tell your doctor and pharmacist whatprescription and non-prescription medications you are taking,including vitamins.

Administering Your Medication

Store the medication in the refrigerator. Do not allow themedication to freeze. Take your next dose from the refrigerator1 hour before using it; place it in a clean, dry area to allow itto warm to room temperature. Avoid shaking the vial. Use avial only once, and do not reenter a needle into a vial. Discardunused portions and outdated medication.

Before you administer your medication, look at the solutionclosely. It should be clear and free of floating material.Observe the solution container to make sure there are noleaks. Do not use the solution if it is discolored, if it containsparticles, or if the container leaks. Use a new solution andcontact the pharmacy to report the damaged one.It is important that you use your medication exactly as directed.

Do not change your dosing schedule without talking to yourdoctor’s office. Do not stop your therapy on your own becauseyour ability to continue interferon and ribavirin could behampered. Call the doctor if you have any questions or concerns.

Side Effects

Side effects are uncommon but they can occur. Procrit® orEpogen® sometimes causes a flu-like reaction with chills,shivering, sweating, muscle aches, and bone aches. Theseeffects may appear 1–2 hours after an injection and usually goaway within 12 hours. They may go away during treatment asyour body adapts to the medication. However, tell your doctor ifany of these problems continues or worsens. Your doctor shouldcarefully monitor your blood pressure and hemoglobin for rapidincreases, which should be avoided. An extremely rare sideeffect of Procrit® or Epogen® is to cause your red blood cells tostay very low. Your doctor will monitor your blood to detect this.Complete Product Information is available from yourpharmacist. The information will provide you with a completelist of possible side effects and other details concerning themedication

Flu-like Symptoms

(fever, chills, headaches, fatigue, muscle aches)

• One hour before your injection, take 2regular strength acetaminophen (Tylenol®or generic), or 2 ibuprofen (Advil®, Motrin®,or generic). You may repeat every 4-6 hoursafter your injection as needed.

• Do not take more than 2000 mg ofacetaminophen in 24 hour period.• Do not take more than 1600 mg ofibuprofen in 24 hour period.• *If you take both acetaminophen andibuprofen in the same 24 hour period,do not take more than half the maximumdaily dose listed above for each product.*• Increase your daily intake of fluids (nonalcoholicand non-caffeinated).

We recommend 8–10 glasses (8 oz.) ofwater or other clear beverages each day.

• Take pegylated interferon injections in theevening or at bedtime to sleep throughmost of the flu-like symptoms.

Depression & Irritability

Depression is the most common psychiatric disorderprecipitated by peginterferon and ribavirin therapy.Many patients develop depression as a side effect ofinsomnia and severe fatigue associated with anemia.Treating insomnia and enabling these patients toobtain better sleep significantly improves depressionin many patients. Many anti-depressants enhancesleep as a side effect and these agents are veryeffective in treating depression in patients receivingpeginterferon and ribavirin with insomnia. In patientswhose depression appears unrelated to insomnia, otherantidepressive agents will likely be more effective.

(signs of depression include feelings of deep andconstant sadness, hopelessness, crying, majorchanges in mood, loss of interest in things youenjoy, trouble sleeping/concentrating)

• Avoid stressful situations if possible, andlearn relaxation techniques.• Include light exercise in your daily routine.• Become a volunteer for someone lessfortunate than yourself.• Seek professional help. Be sure tonotify the clinic if these feelings persist,there may be medications available byprescription to help you.• If you experience thoughts of harming orkilling yourself or others, call the clinicimmediately!

Mild Hair Thinning

• Shorter hairstyles may reduce hair loss.• Don’t wash your hair excessively. If youwash your hair daily, try switching to everyother day.• Avoid using blow dryers and chemicaltreatments on your hair.• Hair growth will return after treatment isdiscontinued.

Loss of Appetite

(10-15 lb. weight loss is common)

• Eat frequent small meals throughout theday, even if you aren’t hungry. “Grazingâ€rather than 3 large meals is often helpful.• A light walk or short exercise before mealscan increase appetite and decrease nausea.• Try protein powder shakes, or dietarysupplements (Ensure®, Boost®, Sustacal®,Slim Fast®) in addition to regular meals.• Eliminate any metallic taste in your mouthby brushing regularly. Some people havefound that eating a small amount of darkchocolate, yogurt, or honey before a mealhelps to reduce the metallic taste. Freshlemon in ice water is also helpful.Nausea, Vomiting, and Diarrhea• Drink plenty of fluids (non-alcoholic andnon-caffeinated).• Taking your ribavirin with food mayreduce nausea.• For occasional diarrhea, switch to blandfoods such as bananas, rice, applesauce,and dry toast or crackers until

diarrhearesolves. Then gradually return to anormal diet.• Take over-the-counter medications fornausea and diarrhea. If these do not help,call the clinic for prescription medications.• Any vomiting or diarrhea lasting more than3 days should be reported to the clinic

Dry, Itchy Skin and Mild Rash

Also see : Hepatitis C : Dry Mouth/Causes and Solutions

•Take short, warm (not hot) baths orshowers. Use a moisturizing soap (ie,Dove® or Aveeno®).• Use unscented skin lotions. Eucerin®,Curel®, and LacHydrin® creams are veryhelpful.• Be sure to use sunscreen (at least SPF15), as patients on medication are moreprone to burning.• Try over-the-counter hydrocortisone creamsor Benadryl® spray.• If itching persists, call the clinic for furtheradvice and/or prescription medications.Skin Irritation at the Injection Site• Painless, red irritation of the skin at thesite of the injection is common.• This resolves on its own within 7-10 days.To minimize this reaction, remember torotate the site of your injections.

Chest Pain

• Chest pain is an uncommon side effect ofthe medication that should be reportedimmediately to the clinic. Proceed to thenearest emergency room if necessary.

Insomnia (inability to sleep)

• The medicines for hepatitis C can sometimesinterfere with your normal sleepcycle. Getting a good night’s rest will helpwith some of the flu like symptoms. If youhave trouble sleeping, call your clinic forsuggestions/medications.

Chronic Diseases Exacerbated or Precipitated by Antiviral Therapy

Several chronic conditions can be exacerbated or precipitated by peginterferon and ribavirin therapy. Some of these diseases may require that the patient be seen by a specialist in that area to assess the risk of HCV treatment on that disease and to treat the disease if an exacerbation occurs

Cardiovascular disease

As the hemoglobin declines, patients with coronary arterydisease may experience angina. Patients with knowncoronary artery disease may wish to consult a cardiologistprior to initiating treatment.

Seizures

Peginterferon reduces the seizure threshold. Patients witha history of seizures may develop seizures after initiatingpeginterferon treatment even if their seizure disorder had beencontrolled for many years. Patients with a history of seizuresshould be seen by a neurologist prior to initiating HCVtreatment and possibly on a regular basis during treatment.

Psychiatric disease

Peginterferon may precipitate and exacerbate many psychiatricdisorders. The most common psychiatric symptom experiencedby patients receiving peginterferon is depression.This can develop even in patients without a prior historyof depression. Depression may be so severe that suicidalthoughts may develop. Uncontrolled psychiatric disease isa contraindication to utilizing peginterferon. Patients withactive but well controlled psychiatric disease should see apsychiatrist prior to initiating peginterferon and for at leastseveral weeks after treatment is initiated to identify patientswho might need adjustment of psychiatric medications.

Retinal disease

Peginterferon has been reported to cause blurred vision andchanges to the vascular supply of the retina. Patients withhypertension and diabetes mellitus are at increased riskfor retinal disease. It is recommended that patients with ahistory of hypertension and/or diabetes mellitus undergo aretinal examination prior to initiating peginterferon therapy.However, not all experts agree this is necessary and wouldonly consult an ophthalmologist if a patient developed visualchanges during treatment.

Diabetes mellitus

Treatment with peginterferon may precipitate the onsetof diabetes mellitus or alter the patient’s eating patternsand glucose utilization and lead to either hypo- orhyperglycemia in a patient with previously controlleddiabetes. Patients with insulin resistance, type-2diabetes and an elevated hemoglobin-A1-C have beenshown to have a lower SVR during treatment. For thisreason, patients with poorly controlled diabetes andmarkedly elevated hemoglobin A1-C should probablysee an endocrinologist for better diabetes managementbefore initiating treatment.

Autoimmune disorders

Peginterferon may exacerbate as well as precipitateautoimmune disorders. As a result, autoimmune diseasesare generally considered relative contraindications to HCVtreatment. Many patients with chronic HCV have severemyalgias, arthralgias and a positive rheumatoid factor. HCVis known to cause these findings in the absence of truerheumatoid arthritis and many patients with chronic HCV areincorrectly diagnosed with rheumatoid arthritis when this wassimply secondary to chronic HCV. Eradication of HCV RNAin these patients is associated with resolution of arthralgiasand loss of rheumatoid factor. Having the patient see arheumatologist to clarify if the patient has true rheumatoidarthritis or a reactive arthritis secondary to HCV may benecessary in some patients

Source

http://Hepatitis Cnewdrugs.blogspot.com/2010/12/hepatitis-c-anemia-and-other-side.html