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Questions for Dr. Palmer
RRichard2005 posted:
Hi Dr. Palmer,

I will be meeting with my doctor on April 24 to discuss treatment options. I am 1b and was stage 1 back in 2006 (will have new biopsy on April 17). I tried the SOC treatment back in 2006 and didn't clear until about week 18 or so and then the virus came back while still on treatment about 6 weeks later.

With that being said, which of the triple therapies do you think would be best for me? Also, how long would I need to treat? Would it depend on how quickly my VL drops?

The only reason I am consulting you is because my husband is military and I will be treated on a military base with a G.I. doctor from the VA Hospital that comes to the base. I met with him once and he seems knowledgeable enough but I want to know as much as possible and be prepared just in case. I don't get to pick my doctor unfortunately so I really have no idea how up-to-date he is on the current treatments.

When we spoke at my last appt. He said he typically prescribes Boceprevir because the VA pharmacy keeps it in stock so it's easier for his patients. He also mentioned my treatment time would just depend.

I have read conflicting things. Some saying since I am a null responder that I would have to do about 48 weeks but I have also read that regardless of previous response it would depend on how quickly my VL drops.

I realize you are not my doctor and cannot give me medical advice but please help me as much as possible. I don't want to only treat for 26 weeks because I do quickly and then relapse because I should have treated longer and my doctor just didn't know that!

Melissa Palmer, MD responded:
It sounds like your husband was a partial responder/relapser to prior therapy. So the following is the protocol:
Lead in of Pegylated interferon plus ribavirin for 4 weeks then
If your husband has an undetectable HCV viral load at treatment week 8 and 24 as per the Boceprevir protocol he will need to complete the three medicine regimen ( Boceprevir, pegylated interferon and ribavirin) at week 36 ( with a 4 week lead in of Pegylated interferon and ribavirin).

If his HCV viral load is detectable at week 8 but undetectable at week 24 he will need to continue all three medicines and finish through week 36 and then administer pegylated interferon and ribavirin for another 12 weeks for a total of 48 weeks.

If his repeat liver biopsy reveals cirrhosis then he needs 4 weeks of peg/riba followed by 44 weeks of triple therapy

Discontinuation of therapy is advised in everyone if HCV viral load is > 100 IU/mL at wk 12 of positive at any level at week 24
RRichard2005 replied to Melissa Palmer, MD's response:
Thanks, Dr. Palmer. Actually, I am the one with HCV (not my husband). So you would recommend victrelis over incivek? I have read that incivek has a slightly higher svr rate but less side effects. I think I'd rather a high svr rate even with more side effects!

Melissa Palmer, MD replied to RRichard2005's response:
Sorry for the confusion.
Victrelis is the only medication approved in the VA system.

Outside of the VA system you could use either. The protocol with Incivek is different and yes the cure rates are higher.
RRichard2005 replied to Melissa Palmer, MD's response:
Oh OK. I will be able to use either as my insurance covers both. My doctor is just a VA doctor that is one of the GI doctors at the Army base we are stationed at.

What would you recommend to someone in my position who can chose either and being a partial responder?
billm57 replied to RRichard2005's response:
from what ive been reading - incivek is much worse as far as side effects and has a higher quit rate than victrelis
billm57 replied to RRichard2005's response:
from what i gather incivek is much harder as far as side effects and has a higher drop out rate

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