1. 5 th Paris Hepatitis Congress Workshop 30/1/2012 Managing complications of DAAs: Case 1 Dr Samuel S. Lee University of Calgary

2. Case 1 51 year old Caucasian man HCV discovered 2009 on routine examination Remote history of injection drug use age 19 No symptoms Alcohol: 8-10 beers/week, mostly on weekends Smokes 3-4 cigarettes/d; occasional marijuana asymptomatic

3. Case 1 Physical exam: weight 81kg, BMI 28 few spider nevi, but no other abnormalities Labs: ALT 2 x N Bilirubin, PT-INR, albumin, N Hb 151 g/L, WBC 7.1, ANC 2.9, plts 145 Ultrasound: coarse liver echotexture – fatty liver? Borderline splenomegaly. No ascites

4. Case 1: further investigations and course HCV genotype 1a 1.1 million IU/mL HCV RNA (2009) Fibroscan: 10.2 kP (stage 3?) Liver biopsy (from 2009): moderate activity, grade 1, bridging fibrosis, stage F3 No previous treatment – patient did not wish to suffer side effects Had heard of ‘new treatment’ and wished to proceed with triple-Rx

5. Case 1: treatment Started triple-Rx with PEG a-2a + RBV 1200mg/d + boceprevir 800mg tid (after 4-wk lead-in) Qual HCV RNA detectable at wk 4 lead-in (no RVR) Wk 8 and 12 RNA undetectable Hb 118, ANC 1.2, plts 101 after lead-in Moderate fatigue, flu-like symptoms

6. Case 1: course Wk 6: Hb 101, ANC 0.9 RBV decreased to 800mg/d Wk 8: Hb 93; fatigue worsening ANC 0.7 RBV decreased to 600mg/d; PEG decreased to 135ug Wk 10: Hb 94, ANC 0,8 Wk 12: Hb 92, ANC 0.7 Wk 16: Hb 89, ANC 0.9; patient working at 60%

7. Case 1: further course Wk 7: metallic taste in mouth. Pt advised to take plenty of water, small frequent meals Wk 10: still slight dysgeusia but improved Weight loss 5kg by wk 16 Currently at wk 24, stable at PEG 135, RBV 600mg, boceprevir. In view of suspected cirrhosis and drug reductions, plan to continue Rx for 48wk

8. AE summary Flamm et al. AASLD 2011

11. Anemia AEs Flamm et al. AASLD 2011

13. Neutropenia AEs