Management of anemia induced by triple therapy in patients with chronic hepatitis C: Challenges, opportunities and recommendations

• Published in: Journal of hepatology 2013-12, Vol.59 (6), p.1323-1330
• Main Authors: Romero-Gómez, Manuel, Berenguer, Marina, Molina, Esther, Calleja, José Luis
• Format: Article
• Language: English
• Subjects: Anemia; Anemia - chemically induced; Anemia - therapy; Boceprevir; Drug Therapy, Combination; Epoietin; Erythrocyte Transfusion; Erythropoietin - therapeutic use; Gastroenterology and Hepatology; Hepatitis C virus; Hepatitis C, Chronic - drug therapy; Hepatitis C, Chronic - virology; Humans; Interferon-alpha - administration & dosage; Liver Transplantation; Pegylated interferon; Polyethylene Glycols - administration & dosage; Protease inhibitor; Protease Inhibitors - administration & dosage; Recombinant Proteins - administration & dosage; Ribavirin; Ribavirin - administration & dosage; Telaprevir
• ISSN: 0168-8278; 1600-0641
• DOI: 10.1016/j.jhep.2013.07.014

Summary The addition of protease inhibitors, boceprevir or telaprevir, to peginterferon + ribavirin (PegIFN/RBV) increases the frequency as well as the severity, and hence, clinical relevance of anemia, which has now become one of the major complications associated with triple therapy. Most significant factors associated with anemia in patients receiving triple therapy include older age, lower body mass index (BMI), advanced fibrosis, and lower baseline hemoglobin. The variability in inosine triphosphate pyrophosphatase ( ITPA ) gene, which encodes a protein that hydrolyses inosine triphosphate (ITP), has been identified as an essential genetic factor for anemia both in dual and triple therapy. The correct management of anemia is based on anticipation, characterization and therapeutic management. Basically, anemia can be characterized in 3 types: ferropenic (mostly in fertile women), thalassemic type hemolytic anemia, and anemia from chronic processes. Functional deficit of iron should also be excluded in patients with normal ferritin and lower saturation of transferrin. Ribavirin dose reduction and epoetin, sequentially, are indicated in the management of anemia. Epoetin non-response can be caused by lack of time, type of anemia, functional iron deficit or erythropoietin resistance. In the transplantation setting, adding a protease inhibitor to PegIFN/RBV results in a significant increase in the incidence and severity of anemia and, as a consequence, a greater need for epoetin, transfusions, and ribavirin dose reductions. Packed red cell transfusions are utilized when hemoglobin decreases to less than 7.5 g/dl and/or there are clinical symptoms and/or there is no response to other therapeutic measures.