1. CASE 2 48 yo man IVDU in past….last used 27 yrs ago Stable social situation Currently receiving social assistance with provincial drug coverage No comorbid disease

2. CASE 2 Hepatitis C disease parameters Secondary workup negative…no co- infections HCVRNA 3.65 x 10E7 iu/ml genotype 1a

3. CASE 2 Hepatitis C disease parameters AST>ALT Platelets 71 INR 1.5 Bilirubin 38 mmol/l

4. CASE 2 Hepatitis C disease parameters Clinically…no previous ascites/edema, encephalopathy or GI bleeds Imaging…coarse liver/14cm spleen/no free fluid/no varices seen OGD…no varices

5. CASE 2 Under what circumstances would you not treat a cirrhotic patient for Hepatitis C? Ascites…previous vs current Encephalopathy Portal Hypertension without previous bleed/with previous bleed Are there biochemical exclusionary criteria for treatment

6. CASE 2 Treatment initiated with Peg INF/1400mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Severe nausea/intolerable…RBV decreased to 1200mg/day

7. CASE 2 Peg INF/1200mg RBV (90kg) Week 4-8 Increasing abdominal girth/soas responsive to a slow diuresis with furosemide and salt restriction No encephalopathy SBP prophylaxis initiated

8. CASE 2 Peg INF/1200mg RBV (90kg) Week 4-8 Increase in bilirubin from 40 to 75 then stabilized Inr increased from 1.5 to 1.7 then stabilized Plts decreased from 80 to 40 then stabilized Renal function stable throughout with creatinine at 55 mmole/l

9. CASE 2 Peg INF/1200mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1

10. CASE 2 Peg INF/1200mg RBV (90kg) Week 8 Stable clinically with 1.5 kg of weight loss weekly and tolerating therapy day-day relatively well Warned of concerns re: stalling of HCVRNA but decision to continue therapy made

11. CASE 2 Peg INF/1200mg RBV (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1 Week 12 HCVRNA…5.40 x 10E1 WHAT WOULD YOU DO TODAY?

12. CASE 2 Peg INF/1200mg RBV (90kg) Week 12 Boceprevir access arranged and therapy initiated at 800mg Q8H

13. CASE 2 Peg INF/1200mg RBV/Boceprevir 800mg Q8H (90kg) Week 12-16 Adherent with all meds and Boceprevir addition tolerated well Erythropoietin initiated at week 15

14. CASE 2 Peg INF/1200mg RBV/Boceprevir 800 mg Q8H (90kg) Week 0 HCVRNA…3.65x 10E7 Week 4 HCVRNA…1.12x10E2 Week 8 HCVRNA…8.80x10E1 Week 12 HCVRNA...5.40x10E1 Week 16 (week 8)….undetectable

15. CASE 2 Questions: Do you think the dose reduction of RBV by 200mg stalled the progress of therapy? How long will you treat…is response guided therapy appropriate for this naïve patient? If week 16 (week 8 of triple therapy) was still detectable would you have continued with therapy?