Since you didn't proide a link....

I vote "B."

What wouldl ya'll do???

Select the optimal management choice by clicking one of the answers
below.
The CME-certified case will then load, providing feedback on your
selection and the opportunity to test your ability to manage this
patient's disease by continuing the case.

CME Information  |  Learning Objectives  |  Disclosures

Retreatment of a Patient With Chronic HCV Infection and Previous
Treatment Failure

Faculty: Tarek Hassanein, MD

The patient is a 55-year-old male who was originally diagnosed with
hepatitis C virus (HCV) in 1997. His medical records from his previous
healthcare provider indicate that he had HCV genotype 1b infection. A
liver biopsy was conducted 8 years ago that illustrates F1 fibrosis,
mild inflammation, and 20% steatosis. His HCV RNA at that time was
2,234,400 copies/mL, and he weighed 210 lbs.

At that time the patient requested therapy after his biopsy and was
treated (3 million units of interferon alfa-2b three times weekly and
ribavirin 800 mg/daily) for a full year. His HCV RNA levels were as
follows:

   * Week 12 of treatment: 18,000 copies/mL
   * Completion of treatment (Week 48): 8050 copies/mL
   * 1 month posttreatment: 15,050 copies/mL

The patient remembers that the general adverse effects included body
aches, headaches, minor depression, and insomnia. There is no
information on cytopenias in his records; however, it is noted that
his liver enzymes normalized while he was on treatment.

Now, 10 years after his initial diagnosis, the patient comes to your
office because he has been feeling tired and is considering
retreatment. His lab results are as follows:

   * HCV RNA: 1.8 million IU/mL
   * Aspartate aminotransferase (AST): 68 IU/L
   * Alanine aminotransferase (ALT): 85 IU/L
   * Total bilirubin: 1.2 mg/dL
   * International normalized ratio: 1.3
   * White blood cell count: 4800 cells/µL
   * Hemoglobin: 15.2 g/dL
   * Hematocrit: 45.5%
   * Platelets: 216 k/µ L
   * Thyroid-stimulating hormone: 2.5 mIU/L

You repeat the biopsy and find that his fibrosis has progressed to
stage F2. Laboratory results and physical examination confirm the
absence of other significant comorbidities or coinfections. Screening
for depression with the Beck Depression Inventory (BDI) indicates he
has mild depression (score: 14). The patient confirms that he has had
periods when his depression has worsened throughout his life. His
current weight is 205 lbs and he leads a relatively sedentary
lifestyle.
Click your choice below.

You will enter the CME-certified program and get immediate feedback.
Then you will be able to continue to manage this patient.

What is your next step for managing this patient?

A.

Monitor liver enzymes and fibrosis every 6 months and initiate
treatment if his liver disease worsens

B.

Prescribe a prophylactic selective serotonin reuptake inhibitor (SSRI)
antidepressant and initiate treatment with peginterferon alfa or
consensus interferon plus weight-based ribavirin

C.

Refer to a psychiatrist before initiating HCV treatment

Ok, he's now a 65 year old hepper.

It apparently took almost a decade for him to progress from F1 to F2.
His LFTs aren't bad - higher than normal but lots of us were WAY higher than
that, pre-treatment (mine were double his). He's in the low normal ranges for
plates and WBCs, his bilirubin is marginally above normal range, his TSH is
dead-nuts in the middle of normal.

I don't see a *good* answer in the three choices.

A. doesn't address the depression, and doesn't do much for his illness. Given
his history, 6 month periodic testing will only serve to fatten up the lab's
revenue. Yearly testing would be adequate.

B. slams him right into therapy, without dealing with his depression.
    Bad doctor! Bad, BAD doctor!

C. sounds like he's being turfed.

What I'd do:

Put him on an anti-depressant immediately, recommend he start getting some
exercise - a half-hour walk each day would be a start - and schedule another
office visit in one month. At that time, revisit the outstanding question:
treat now, or don't treat. It's possible the anti-D will change his outlook at
that point. If he still wants to do the treatment, put him on Pegasys and WBD
Riba, run the VL test at 12 weeks, and if he isn't clear by then, recommend
discontinuation in favor of waiting for the Next Big Thing to emerge.

Cheers

/greyhackles

What wouldl ya'll do???

Select the optimal management choice by clicking one of the answers
below.
The CME-certified case will then load, providing feedback on your
selection and the opportunity to test your ability to manage this
patient's disease by continuing the case.

CME Information  |  Learning Objectives  |  Disclosures

Retreatment of a Patient With Chronic HCV Infection and Previous
Treatment Failure

Faculty: Tarek Hassanein, MD

The patient is a 55-year-old male who was originally diagnosed with
hepatitis C virus (HCV) in 1997. His medical records from his previous
healthcare provider indicate that he had HCV genotype 1b infection. A
liver biopsy was conducted 8 years ago that illustrates F1 fibrosis,
mild inflammation, and 20% steatosis. His HCV RNA at that time was
2,234,400 copies/mL, and he weighed 210 lbs.

At that time the patient requested therapy after his biopsy and was
treated (3 million units of interferon alfa-2b three times weekly and
ribavirin 800 mg/daily) for a full year. His HCV RNA levels were as
follows:

   * Week 12 of treatment: 18,000 copies/mL
   * Completion of treatment (Week 48): 8050 copies/mL
   * 1 month posttreatment: 15,050 copies/mL

The patient remembers that the general adverse effects included body
aches, headaches, minor depression, and insomnia. There is no
information on cytopenias in his records; however, it is noted that
his liver enzymes normalized while he was on treatment.

Now, 10 years after his initial diagnosis, the patient comes to your
office because he has been feeling tired and is considering
retreatment. His lab results are as follows:

   * HCV RNA: 1.8 million IU/mL
   * Aspartate aminotransferase (AST): 68 IU/L
   * Alanine aminotransferase (ALT): 85 IU/L
   * Total bilirubin: 1.2 mg/dL
   * International normalized ratio: 1.3
   * White blood cell count: 4800 cells/µL
   * Hemoglobin: 15.2 g/dL
   * Hematocrit: 45.5%
   * Platelets: 216 k/µ L
   * Thyroid-stimulating hormone: 2.5 mIU/L

You repeat the biopsy and find that his fibrosis has progressed to
stage F2. Laboratory results and physical examination confirm the
absence of other significant comorbidities or coinfections. Screening
for depression with the Beck Depression Inventory (BDI) indicates he
has mild depression (score: 14). The patient confirms that he has had
periods when his depression has worsened throughout his life. His
current weight is 205 lbs and he leads a relatively sedentary
lifestyle.

What is your next step for managing this patient?

A.
Monitor liver enzymes and fibrosis every 6 months and initiate
treatment if his liver disease worsens

B.
Prescribe a prophylactic selective serotonin reuptake inhibitor (SSRI)
antidepressant and initiate treatment with peginterferon alfa or
consensus interferon plus weight-based ribavirin

C.
Refer to a psychiatrist before initiating HCV treatment

Well of course he's depressed, he's been feeling like crap for ten years!
Hm, why an SSRI antidepressant?
Like Grey says, this boy needs a bit of exercise, and I'd add some
nutritional and diet counselling to the program.
Give him a few months to get in better physical condition, and for the anti
Ds to kick in, then discuss a second round of tx, as in B, but with Infergen
added to the mix as long as he can handle it. Cross all fingers and check
things out at 12 weeks.

Thanks for posting this, Amzolt-- it's interesting.

One thing I wasn't clear on was whether previous treatment was
pegalated interferon 2b or not.  Also, for his weight 800mg of riba
was too low a dose for genotype 1.  Maybe if it was done right the
first time it would have worked.  

Don