Multaq and Liver Damage: The most effective treatment of chronic HCV is antiviral ther- apy—that is, medication that targets a virus. Interferon, a widely known antiviral discussed earlier in this chapter, is the treatment of choice for chronic HCV. Pegylated interferon in combination with ribavirin-—-the most common treatment-—is the most effective treatment for chronic hepatitis C, but the side effects can be substantial. Flulike symptoms (fever, chills, muscle and joint pain, fatigue, weakness) are common, and doctors will prescribe medications to combat these symptoms if they become debilitating. It is also important for patients to maintain their activity levels to build a little muscle and be able to muster the energy to get through the day. Adequate fluid intake is also essential. This is a simple and often overlooked strategy. Many patients report that substantially increasing their daily fluid intake is the most effective method in combating the fiulike side effects that plague pegylated interferon therapy.
Depression, insomnia, irritability, and even confusion are experienced by more than half of patients undergoing interferon therapy. The depression is considered to be somewhat different from classic major depression, but afflicted patients may benefit from a course of antidepressants such as citalopram (brand name Celexa) or sertraline (brand name Zoloft).
Other side effects that don’t seem to follow any regular pattern include headaches, vision problems or dry eyes, weight changes, brictle nails, insomnia, changes in blood levels, a burning sensation in the mouth (known as stomatitis), decreased sex drive, and menstrual irregularities. To some degree, these symptoms are manageable. But in some patients, the side effects can be severe, and supportive medications are able only to “take the edge off” Although treatment may be difficult, physicians who regularly treat chronic hepatitis C are well versed in managing side effects. Key to successful outcome is maintaining the proper dose of medication to ensure that patients have the best possible chance to permanendy rid their bodies of the virus.
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Because of chronic HCV’s complicated makeup—-the genotypes outlined above—pegylated interferon therapy must be customized to each patient. Therapy duration is dictated by the genotype. Pegylated interferon is used, if possible, in combination with ribavirin. The only time ribavirin is not used is when there is a medical contra-indication, such as chronic kidney (renal) failure requiring dialysis or a severe allergy to ribavirin. How well the patient responds to antiviral treatment is determined by two simple lab tests. The first is the alanine transaminase (ALT) test. When the ALT decreases and returns to a normal level, it is referred to as a biochemical response. This does not always occur, but it is a considered a good sign. The most important test in determining treatment success is the HCV RNA, or viral load test. The decline in the viral load is the most crucial aspect of therapy. Typically, a patient is tested at the outset, to determine a baseline or pre-treatment viral load, and then retested to measure against the subsequent viral loads as treatment progresses.
Four weeks after treatment begins, first viral load is measured. If a patient’s viral load is un-detectable at one month, the results are called a rapid virologie response, or RVR. People who achieve an RVR are called super responders. They have an excellent chance of eradicating the virus after they complete their treatment. A small subset of patients who achieve an RVR can sometimes stop treatment early. The determination to stop treatment early is made on a case-by-case basis, and the patient should be informed of the pros (shorter treatment duration, lower cost, and less side effects) and cons (slightly lesser chance for sustained response) of this approach.
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After 12 weeks (three months) of therapy, viral load is measured again. The outcome of this viral load test is referred to by different names, depending on the results. When the virus is undetectable after three months of therapy, the condition is described as a complete early virologie response (cEVR). If the viral load has declined by two logs but is still detectable, the data is referred to as a partial early virologic response (pEVR).
People who achieve a partial or complete early virologic response continue drug therapy. Those who do not achieve a two-log reduction after 12 weeks are called nonresponders (NRs). Unfortunately, nonresponders have less than a 3 percent chance of achieving a sustained viral response even if they complete the full course of therapy. Therefore, therapy is stopped for nonresponders after three months if they do not obtain a two-log reduction.
For patients who remain on therapy, the next viral load test is taken after six months (24 weeks) of therapy. If this test indicates a detectable viral load, as a rule, treatment is stopped because these patients will not achieve treatment success even if they complete a full 48 weeks of therapy.
After 48 weeks of pegylated interferon and ribavirin, another viral load test is performed. Referred to as the end-of-treatment response (ETR), this viral load measurement marks the end of therapy and the beginning of a waiting game. For treatment to be considered a success, the viral load must remain negative for at least six months after the end of therapy. Unfortunately, some patients relapse and test positive during this six-month period. Relapsers should follow up and discuss their situation with a hepatologist and consider options such as enrollment in research clinical trials of new and experimental therapies can be considered.
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would receive the same treatment regardless of the liver biopsy results. Also, a person with a suspected medication-induced liver disease (see chapter 24) may benefit from discontinuing the medication first and then assessing whether or not the liver-related abnormalities normalize. If they don’t, a liver biopsy may then become necessary.