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Robert Brown MD:
Side-effect management is the biggest challenge in the treatment of hepatitis
and it requires a multi-pronged approach. The first step is patient education.
We spend a lot of time, both the physician and our nursing staff, educating
the patients on side-effects, what to expect and the simple mechanisms
they can use to manage those side-effects like rest, fluids and nonsteroidals
or Tylenol.
The second approach is managing side-effects as they come up. Here, close
contact with the patient, having a good relationship where they feel they
can report those side-effects to you and use of antidepressants, sleeping
medications, analgesics as needed to try to get our patients through the
therapy.
David Bernstein MD:
Depression is a frequent complication of therapy, occurring anywhere from
30-50% of the time. It's very common to use, therefore, antidepressive
treatments. The most common ones used are the class of SSRIs.
Rajender Reddy MD:
We have to understand that these do not have an immediate effect. It will
take a week or two before one sees some sort of response to the SSRIs.
In some patients where there is a background history of depression, a
preemptive use of SSRI might be quite a viable option.
David Bernstein MD:
Ribavirin commonly causes a hemolytic anemia. That hemolytic anemia seems
to have two components to it: direct hemolysis and lowering of thrombopoietin
levels.
The ribavirin-induced anemia is currently treated two ways. The standard
of care is by dose-reduction.
Robert Brown MD:
More recently, there has been an interest among clinical investigators
at using erythropoietin rather than dose reduction in an attempt to maintain
hemoglobin levels and prevent ribavirin dose reduction. This is based
on the thought that ribavirin dose relates to the likelihood of having
a sustained virologic response and thus maintaining the ribavirin dose,
which can be done, in most cases, with the use of erythropoietin, will
improve virologic response rates. This has not yet been demonstrated in
clinical studies, though there are trials underway investigating the use
of erythropoietin.
David Bernstein MD:
The neutropenia seen with pegylated interferon is an interesting phenomenon.
It tends not to be as severe as initially thought. In a small subset of
patients where treatment is required, colony-stimulating factors can be
used to increase white cell counts.
Rajender Reddy MD:
Fatigue may be a factor and limited experience suggests that Ritalin can
be used to improve their functional capability. Additionally, certain
other measures can help them tolerate treatment better. For instance,
exercise, a healthy diet, drinking a lot of fluids may all help in the
patient's ability to handle therapy.
It's important to have a good social support system, someone who is monitoring
their response to treatment, particularly with regard to side-effects.
So that they can communicate with the treating physician about some of
the side-effects that the patient may not perceive or may not think unimportant
How does timing of interferon administration affect the occurrence of
side-effects?
Robert Brown MD:
Some people feel that the timing of the pegylated interferon administration
can be used to ameliorate the side-effects. I think that this has to be
very individualized.
David Bernstein MD:
In the group of patients that develop side-effects four to eight hours
after taking the shot of pegylated interferon, it's best to give it at
night, if they work during the day. It's probably best to recommend that
patients take it on Friday if they work Monday through Friday so that
if they're having side-effects, they're generally Saturdays and Sundays.
Many patients will develop side-effects from a pegylated interferon injection
24 to 48 hours after therapy. That time course is not predictable, but
it tends to repeat itself. Therefore, patients, after they've taken a
few doses, can figure out when it's best for them to give themselves the
injection to minimize side-effects and interference with their lives.
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