2. The graph is based on data submitted to the WHO as of June 1999. Global Prevalence of Hepatitis C Virus

3. A common adverse effect of hepatitis C antiviral therapy Bone marrow suppression Hemolysis of Red Blood Cells

4. Papayannopoulou T, et al. In: Hoffman R, et al., ed. Hematology: Basic Principles and Practice. 4 th ed. 2005;267-288. SCF, GM-CSF, IL-3 SCF, IL-1, IL-3, IL-6, IL-11 Pluripotent Stem Cell Burst-Forming Unit-Erythroid Cells (BFU-E) Colony-Forming Unit-Erythroid Cells (CFU-E) ReticulocytesRBCsErythro- blasts Proerythro- blasts About 8 Days Iron Erythropoietin Erythropoiesis in CKD Erythropoiesis Transferrin Receptors Epo Vit D

5. Transported from plasma to RBCs Phosphorylated to mono,di & triphosphate analogs Neither metabolized nor transported out of RBCs Accumolation of ribavirin 100 fold its extracellular concentration Oxidative damage Extra vascular death of RBCs

6. 54% of treated patients experienced decline in Hg level of over 3 g/dl 10% of men & 7% of women experienced a decline of over 5 g/dl RBCs lifespan from 107 + 22 days in HCV patients not exposed to Ribavirin to 39 + 13 days in HCV patients exposed to Ribavirin - -

7. To maximize the benefits Make the balance

8. The Hemoglobin Sweet Spot 1112139 Hb g/dL Risk 100% 50% At 10 g/dl 80% of ribavirin dose 8.5 g/dl Stop treatment

9. Maintain higher ribavirin doses No reduction in Sustained Virologic Response (SVR) Improve patient quality of life

10. Before considering using Erythropoietin E valuate other causes of anemia (bleeding-Hereditary) O btain CBC A ssess for adequate iron stores Ferritin 50 ng/ml or more TS 20% or more T hyroid function tests Thyroid dysfunction affect Epo response

12. Heme Iron Polypeptide Absorbed as ferrous Absorbed from receptors along the GIT Iron is Coated with the heme molecule in GIT No constipation Iron salts Absorbed after changing from Ferric Ferrous Ferrous Absorbed from receptors localized at the duodenum Iron is free in GIT in huge quantity Usually associated with constipation Not affected by gastric acidity Affected by gastric acidity Higher absorption Limited absorption

13. Heme Iron Polypeptide Can be taken with food, Tea or Coffee 10 tablet give 60 mg of elemental iron 10 tablets in 5-10 days No constipation For a pregnant lady to load iron of 800 mg she will take 134 tablet in 2 month (2 tab/day) Each 1 gm of hemoglobin need 150 mg of elemental iron = 25 tablet Can be taken in 13 day Iron salts Taken on empty stomach compared to 60 tablets give 60 mg of elemental iron 60 tablets in 2 month Usually associated with constipation For a pregnant lady to load iron of 800 mg she will take 800 tablet in 26 month (1 tab/day) Each 1 gm of hemoglobin need 150 mg of elemental iron = 150 tablet Can be taken in 5 month =

14. 100 ng/ml invalid

15. Hemoglobin less than 10g/dl Or Symptomatic and have Hemoglobin less than 11g/dl Or Hemoglobin less than 12g/dl with comorbid cardiovascular or hypoxemic pulmonary diseases

16. Step 1 Insert the TEST CARD Step 2 Apply the SAMPLE Step 3 Read the RESULT in 2 min

17. Sever anemia persists within 2 weeks After reducing the dose of Ribavirin by 200 mg/day from their initial dose

18. Resolution of sever anemia with target Hb 12 g/dl Maintain target ribavirin dose (not less than 80% of original dose) Reduce need for transfusion and or hospitalization Enhance treatment adherence

19. Initiate therapy with Erythropoietin 150 IU/Kg/W Recheck Hgb every 2 weeks Till goals of therapy achieved

20. ESA Partial responder Hgb increase less than1gm/dl After 4 weeks check iron stores If iron stores are adequate Increase Epo dose 25-50% If Hgb at 6-8 weeks is still not at goal.consider further reduction In Ribavirin dose and maintain Epo as needed Monitor Hb accordingly

21. ESA responder Hgb increase more than1gm/dl with Hgb less than 12g/dl in any 2 week period if at target ribavirin dose maintain Epo dose If patient not at target ribavirin dose Maintain Epo dose and increase Ribavirin dose Monitor Hgb accordingly

22. ESA responder Hgb increase more than 12gm/dl If at target Ribavirin dose decrease Epo dose 25% If not at target Ribavirin dose Continue Epo and increase Ribavirin dose Monitor Hb accordingly

23. March 9, 2007