The Dark Side of Letting Insurance Payers Dictate Hepatitis C Treatment

Imagine that you have a disease and you have two choices of treatment. Both treatments are highly effective at treating your condition. Medication A has mild side effects. Medication B has lots of side effects including, fatigue, nausea, itching, insomnia, and weakness. Pretty much everyone who takes medication B has side effects. Medication A is a pill a day; medication B uses two pills in the morning and one at night, and sometimes additional pills are prescribed that must be taken twice daily. Medication B has the potential to interact with more drugs than medication A does. Which would you pick? I assume you'd pick medication A.

Your doctor would likely recommend medication A. Drug regimens with many side effects means that you are more likely to need assistance from your health care team, perhaps needing additional laboratory tests to monitor your safety. If your doctor has more patients on medication B, then your doctor's schedule will use appointment slots for side effect management, rather than for seeing other patients who also need to be treated.

So, it seems like medication A is the obvious choice. Unfortunately, for many people with hepatitis C, it isn't. In this case, medication A represents Gilead Sciences' Harvoni; medication B represents AbbVie's Viekira Pak or Technivie. Harvoni is not covered under all insurance plans, such as those using Express Scripts. In short, your doctor may want to treat you with Harvoni, but your insurance may not carry it on its drug formulary. Your hep C treatment may be limited to medication B.

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Cures for hepatitis C are an investment worth making

New cures for hepatitis C are helping Medicare beneficiaries live longer, healthier lives. It is disingenuous to look at Medicare spending on these treatments without considering the substantial rebates and competition in the program [“Medicare spending for hepatitis C drugs surges,” news, Oct. 18].

Competition and robust negotiation in Medicare Part D are controlling costs. Private plans command steep discounts on prescription prices under Part D, including groundbreaking cures for hepatitis C. In fact, additional treatment options approved in the past year led to competition-generated savings for a variety of payers, including Medicare. Average rebates on some of these products increased from 22 percent in 2014 to 46 percent in 2015. Average rebate levels in Part D have increased each year of the program. Even the 2015 Medicare trustees report that rebates are substantial.

Moreover, researchers at Harvard University suggest new hepatitis C therapies may generate cost savings for the health-care system over the long run. Medicare is uniquely positioned to take advantage of these savings, as beneficiaries remain in the program once they become eligible.

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HealthWise - Hepatitis C Treatment Is Finished, so Now What? - Lucinda K. Porter, RN

Hepatitis C Treatment Is Finished, so Now What? 
A post-hepatitis C treatment discussion, including how long it takes medications to leave the body.

Dear Lucinda,
I just finished hepatitis C treatment with ribavirin. Now that I have taken the last pill, I’d like to detox and speed the clearing of these drugs from my body. My body feels so toxic; I just want to flush this poison out as quickly as possible. I am wondering if it is better to let the ribavirin linger around for as long as possible post-treatment. On the other hand, if it hasn’t done the job by now, will leaving it in my system longer make any difference? Are there supplements I can take to hasten the detox and build up my immune system?
—A Reader

I loved this question, and pondered it awhile, particularly since I was on ribavirin twice (once for a year). Here’s my reply:

Dear Reader,
It is unlikely that you can flush ribavirin out of your system any faster than it will leave on its own, since the metabolic pathway is complex. I provided a list of drug elimination times at the end of this article, so you can estimate how long it will take the medications to leave your body.

As for using supplements to help with this, the short answer is, no one knows for sure since there isn’t any research on this. I rarely use supplements because the potential burden these place on the liver and kidneys don’t seem worth it, especially since food provides better sources of vitamins and minerals. My thinking was that after finally getting off all the hep C drugs, I didn’t want to add any more burden to my liver. It is like cleaning out a storage shed and then buying more stuff and filling it back up.  Plus, if I failed treatment, I didn’t want to always wonder if it was from the supplements. I did make an exception with vitamins, especially B-12. I was quite anemic and research supports the use of B-12 and ribavirin and favorable treatment outcomes.

Despite this, I was not content to sit back, so I focused on rebuilding health. There is much more to recovering from treatment (especially if ribavirin and/or peginterferon is used), than waiting for the medications to leave the body. If there was a reduction in physical activity, then it may be necessary to become active again.  

Because you took ribavirin, I am guessing that you lost a few red blood cells (RBCs) during treatment. It will take time for ribavirin to be eliminated and for RBC production to be completely restored. It typically takes about four weeks before the body notices the change, with significant improvements in two to three months. The time varies, especially since some people are genetically inclined towards ribavirin-induced hemolytic anemia.

After completing hepatitis C treatment, my health-rebuilding plan included keeping track of water intake, eating well, sleeping a lot, not jumping back into a high stress life, increasing my activity (walking, aerobics class, etc), and building back my muscle strength. I started slowly, but chipped away at it, and was surprised at how quickly I noticed improvement.

I have one more comment. I understand that hepatitis C treatment feels toxic, and saying you want “to flush this poison” out makes sense. I went through the same thing. However, it occurred to me that as long as I called it poison rather than medicine, I would be engaged in an emotional battle wtih the drug. Everything changed the day I started calling it medicine and welcomed it in to my body. Perhaps it is too late for you to do this with this particular drug regimen, but in the future should you need to take medication, try calling it medicine rather than poison. Welcome it in, let it do its precious work, and then thank it as the medicine leaves your body. This small shift in thinking lightened my load.
—Lucinda

Hepatitis C Medication Elimination Times

Have you ever wondered why women can’t get pregnant for six months after treatment that uses ribavirin? It’s because ribavirin can harm a fetus, and it takes a long time for ribavirin to be eliminated from the body. To determine how quickly a drug will be eliminated, you need to know its half-life. The half-life is how long it takes the body to get rid of half of the dose of a particular drug. If you stopped taking the drug, then it will keep eliminating half until there is nothing left.

Each drug has its own half-life, and the amount of time it takes varies, depending on your age, the efficiency of your kidneys and liver, what other medications or supplements you take, and so on. The general rule of thumb is to multiply the drug’s half-life by 5.5 for a rough estimate of how long it takes to leave the body. Let’s do the math.

Start by finding the drug’s half-life. The median terminal half-life is listed in the manufacturer’s prescribing information in the clinical pharmacology section under the subcategory elimination. You can also find this info on the Web, or use what I’ve provided.

Note that some drugs have metabolites, which is another form of the drug created by the body while it processes the drug. For instance, Sovaldi’s half-life is 0.4 hrs, but its metabolite (GS-331007) is 27 hrs. Sometimes the information will be provided in a range. For instance, the mean plasma elimination half-life of Xanax (alprazolam) is 11.2 hours, but the range is from 6.3 to 26.9 hours in healthy adults.

After you know the half-life, then multiply by 5.5. Here’s the math using ribavirin which has a half-life of 120 to 170 hrs:

• Best case: 5.5 x 120 hrs = 660 hrs or 27.5 days
• Worst case: 5.5 x 170 hrs = 935 hrs or around 39 days 

Here are the elimination times for all the major hepatitis C drugs:

• Daklinza (daclatasvir): half-life 12 to 15 hrs = worst case 82.5 hrs or roughly 3 days
• Harvoni (ledipasvir/sofosbuvir): Ledipasvir has the longer half-life in this combination at 47 hrs = 258.5 hrs or almost 11 days
• Olysio (simeprevir): half-life 10 to 13 hrs in those without HCV;41 hrs in those with HCV = worst case 71.5 hrs or 3 days in those without HCV; 225.5 hrs or roughly 9 days for those with HCV
• Peginterferon alfa 2a (Pegasys): half-life 84 to 353 hrs (average 160 hrs) = worst case 1941.5 hrs or nearly 81 days
• Peginterferon alfa 2b (PegIntron): half-life 22 to 60 hrs (average 40 hrs) = worst case 330 hrs or nearly 14 days
• Ribavirin: half-life 120 hrs to 170 hrs = worst case 935 hrs or roughly 39 days 
• Sovaldi (sofosbuvir): half life 0.4 hrs/GS-331007 half-life 27 hrs = 2.2 hrs for Sovaldi/ 148.5 hrs or roughly 6 days for GS-331007
• Technivie (ombitasvir, paritaprevir, ritonavir): Ombitasvir has the longest half-life in this combination at 21 to 25 hrs = 115.5 to 137.5 hrs or around 5 to 6 days
• Viekira Pak (ombitasvir, paritaprevir, ritonavir and dasabuvir): Ombitasvir has the longest half-life in this combination at 21 to 25 hrs = 115.5 to 137.5 hrs or around 5 to 6 days

Knowing the half-life for a drug or supplement can be a valuable tool. For instance, state and private insurance plans are screening for recreational drugs, such as marijuana. If you are trying to get treatment and you indulge in certain substances, it will help you to know the half-life so you can predict if you will be able to pass the tox screen. I’ll leave you with this: if you thought it took a long time for ribavirin to leave your system, wait until you read about the half-life of cannabis.

Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time.  Her blog is www.LucindaPorterRN.com

QUOTE:
“The half-life is how long it takes the body to get rid of half of the dose of a particular drug. If you stopped taking the drug, then it will keep eliminating half until there is nothing left.”