Antiviral TX Strategy

Rules For Adjusting Therapy According To CBC Changes

1. Hgb 10-11 g/dL
• Peginterferon.
  • Do not modify dosage
• Ribavirin
  • If no or minimal symptoms, do not modify dosage
  • If symptomatic, decrease by 200 mg/day and/or consider erythropoietin, particularly if cirrhotic, posttransplant, or HIV/HCV coinfected
• Candidates for Recombinant Erythropoietin Criteria for Use for Hepatitis C Treatment-Related Anemia
  • Rule out other causes of anemia
  • Anemia persists at 2 weeks after reducing ribavirin
  • No hypertension
• Dosage:
  • Epoetin alfa 40,000 units SC/week
  • Darbepoetin alfa 200 mcg SC every other week
• Goal:
  • Hemoglobin 12 g/dL
2. Hgb 8.5-10 g/dL
• Peginterferon
  • Do not modify dosage
• Ribavirin
  • Decrease by 200 mg/d and/or consider Recombinant Erythropoietin Criteria for Use for Hepatitis C Treatment-Related Anemia, particularly for patients who are cirrhotic, posttransplant, or HIV/HCV coinfected
• Candidates for erythropoietin
  • Rule out other causes of anemia
  • Anemia persists at 2 weeks after reducing ribavirin
  • No hypertension
• Dosage:
  • Epoetin alfa 40,000 units SC weekly
  • Darbepoetin alfa 200 mcg SC every other week
• Goal:
  • Hemoglobin 12 g/dL
3. Hgb <8.5 g/dL
• Peginterferon.
  • Do not modify dosage
• Ribavirin
  • Discontinue until resolution
4. WBC <1,500
• Peginterferon alfa 2b
  • Reduce dosage by 50% and reevaluate
• Ribavirin
  • Do not modify dosage
5. WBC <1,000
• Peginterferon alfa 2b
  • Discontinue until resolution
• Ribavirin
  • Do not modify dosage
6. ANC <750
• Peginterferon
  • Reduce peginterferon alfa 2a dosage to 135 mcg/wekk and reevaluate
  • Reduce peginterferon alfa 2b dosage by 50% and reevaluate
• Ribavirin
  • Do not modify dosage
7. ANC <500
• Peginterferon
  • Discontinue until resolution
• Ribavirin
  • Do not modify dosage
• Consider G-CSF in patients who are cirrhotic, posttransplant, or HIV/HCV coinfected, particularly if neutropenia persists despite peginterferon dosage reduction
8. Platelets <80,000
• Peginterferon
  • Reduce peginterferon alfa 2b dosage by 50% and reevaluate
• Ribavirin
  • Do not modify dosage
9. Platelets <50,000
• Peginterferon
  • Reduce peginterferon alfa 2a dosage to 90 mcg/week and reevaluate
  • Discontinue peginterferon alfa 2b until resolution
• Ribavirin
  • Do not modify dosage
10. Platelets <25,000
• Peginterferon
  • Discontinue until resolution
• Ribavirin
  • Do not modify dosage

Next: Endpoints of HCV Therapy