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YOUR OPINION PLS - - RARE CASE?
Jun 9, 2004

In 2003: To recap, my father has finished his peg intron and rebetol for a yr without achieving an undetecable VL. his VL was about 57K; his enzymes were 46 & 52 a bit above the normal range.

He then took a 6 mons break. During that 6 mons break, his VL has risen to about 310,000. In Septbember 2003, he started with Pegsys and rebetol, in October-November 2003, his blood test was normal as far as the enzyms are concerned. but has not done or performed a VL test (since this test is very expensive overseas)

Few days ago, i was told by my dad his VL is now about 250,000. That is a drop of only about 60K in 8 mons of treatment with Pegsys and Rebetol. That is really bad. HIS LIVER enzymes however, were in the normal range: ALT 20; AST: 22.

My dad's biopsy as of March, 2001 was Chronic Heptatis with Moderate Activity grade II and focally brdiging fibrosis stage III. His Genotype is 4.

What should my father do? Should he continue for a yr or more? or should he stop? My father is concerned the virus will go up. He is encouraged by the fact his enzyms are normal.

I heard Maitenance therpay might be warranted. What do you think? If so, should he wait for the full yr and then start with maintenance? Should he take a break before maintenance. Is 90ML dosage a good start?

Any information is really appreciated.

Should we be thinking about transplant at this stage? my dad is 59.

Response from Dr. McGovern

Unfortunately, it appears that your father is not going to be cured of his hepatitis C with the treatments we have at our disposal today.

Your question about maintenance is a good one. There are a few trials which are trying to answer this question right now. One trial is called "HALT-C" which has enrolled prior non-responding patients with advanced fibrosis (ie. cirrhosis or "bridging fibrosis" like your father has) into a treatment phase with full dose peginterferon alfa 2a and ribavirin. If they have a response they receive the full treatment course. If they don't respond, then they go onto maintenance peginterferon only (90 ucgm) per week versus no treatment. The object is to see if "maintenance" can decrease the chance of decompensated liver disease or risk of hepatocellular carcinoma.

Unfortunately we don't have data to prove that this is the right thing to do, but your father could discuss this trial with his physician to see what they both think is the best thing to do right now.

It is too early to be thinking about transplant since your father doesn't have cirrhosis. Also these prior course of interferon which he has undergone have probably improved his liver disease since his liver function tests have improved. Several studies show that even in patients who don't get rid of the virus, many of those patients still have improvement in their liver disease. I suspect your father has benefitted from treatment.

Best wishes to your father. Dr. McGovern



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