Hepatitis C Management

Ask The Experts

Question

A male patient develops anemia after 4 weeks of treatment with ribavirin and pegylated interferon (PEG-IFN). Currently, his hemoglobin has dropped from 14.3 to 10.3, with significant fatigue. At what point should you treat the anemia? Are other laboratory studies needed? Do you give epoetin alfa?

This patient has had a greater than 25% drop in hemoglobin and is symptomatic, which favors intervening. Data show that reducing the dosage of ribavirin, especially during the first 12 weeks of therapy, may delay or decrease early virologic response (EVR) and sustained virologic response (SVR). Therefore, the better option would be to institute an erythropoetin analog. Also, remember there will be a lag time between the first injection of epoetin alfa and the rise in hemoglobin. Often, a temporary dose reduction is needed during this time.

There are now Black Box warnings for the use of epoetin alfa, and special attention must be made to maintain the hemoglobin below 12 during treatment. The patient’s iron saturation and ferritin levels need to be measured prior to starting treatment. Many insurance companies are now requiring these values before authorizing payment for the medications.