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CASE 3

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  1. CASE 3 • 48 yo man • HIV positive/HEP C positive 12yrs ago • Tenofovir/FTC/RTV/Lopinavirx 7 yrs • CD4 310/40% HIV Viral Load <40

  2. CASE 3 • Genotype 1a Hepatitis C • Liver biopsy in 2009 reveals 4/4 scarring with ongoing active inflammation • Compensated Cirrhosis and clinically stable • OGD negative for varices and U/S negative for hepatoma/Ascites

  3. CASE 3 2010 • HIV meds switched form TDF/FTC/RTV/LPV to TDF/FTC/RGV • Therapy for Hepatitis C initiated with PEG INF 180mcg/RBV 1200 mg/Boceprevir 2400 mg

  4. CASE 3 • Week 0 HCVRNA 1.67 x 10e7 • Week 4 HCVRNA 4.22 x 10 e4 • Week 8 HCVRNA 1.90 x 10 e1 • Week 10 HCVRNA Not detected

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  6. CASE 3 • Pegasys dose decreased to 135 mcg • Ended up with a fever and was hospitalized with febrile neutropenia…hypotensive…no source of infection found • G-csf initiated and titrated up to daily dosing

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  8. CASE 3 • Pegasys dose decreased to 90 mcg • Ended up with a fever and was hospitalized once again with febrile neutropenia…

  9. CASE 3 • Therapy abandoned • Over the ensuing 3 years…Pmns remained below 0.5 despite G-csf daily…antibodies to GCSF not detected • Bone marrow done and PMN progenitors seen…spleen not huge on U/S • Trial of IVIG given without benefit in regards to increasing PMNs

  10. CASE 3 Early 2014 • Baseline pmns are 0.4-0.5 • Would you retreat with Sofosbuvir/PEGINF/RBV?

  11. CASE 3 Early 2014 • Fighting with private insurance to get Sofosbuvir/Simeprevir • Denied

  12. CASE 3 Late 2014 • Pmns 0.4-0.5 • What should we do?

  13. CASE 3 Late 2014 Sofosbuvir/RBV nowvs wait for • Sofosbuvir/Ledipasvir • ABBVIE quad • Other?