RIVERSIDE COUNTY: Woman on a mission to get clean needles to drug users

Motivated by friends' deaths, she is setting up a nonprofit group and lobbying local officials -- with some offering resistance and some expressing support.

Growing up, Katie Chamberlain walked the straight and narrow as a “dorky straight-A student.”

The Riverside resident attended a Christian school until ninth grade. The stark reality of drugs hit home the second week of classes, when a classmate died of a heroin overdose.

Over the years, the 27-year-old watched with sadness and despair as too many friends fell victim to illegal narcotics.

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Drug costs a bitter pill

TALLAHASSEE

An estimated 17 percent of America’s prison population could have hepatitis C, a severe viral disease that can lead to cirrhosis, liver failure and cancer if left untreated.

There is a cure. A miracle drug with a 95 percent recovery rate was introduced in 2013. But Sovaldi has an extremely high cost: $84,000 for a standard treatment, although costs can vary with the length of the treatment.

Late last year, Gilead Sciences, which makes Sovaldi, won approval for an even better hepatitis C drug, which doesn’t have to be taken in combination with other drugs that have major side effects. But Harvoni costs about $1,125 per pill, with a standard 12-week treatment priced at $94,500

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Tainted-blood-transfusion-Hepatitis-C - DESPERATE to start a family, Janice Cox and her husband tried for a baby for five long years.

But their dreams were shattered when, earlier this year, fertility investigations revealed that Janice had hepatitis C. She contracted the deadly disease against the odds from her mother who became infected after receiving contaminated blood during a kidney transplant in 1973.

There is just a six in 100 chance of the disease passing from mother to child in the womb. Now Janice fears she is among a new generation of victims, many of whom may not even know they are infected.

Self-employed Janice, 36, who lives in Bedfordshire, said: “I am absolutely horrified that so little has been done to stop the spread of this devastating illness.

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What the Heck are RAVs? —Alan Franciscus, Editor-in-Chief

RAVs are resistance associated variants.  RAVs occur during (viral breakthrough) and after treatment (relapse) with direct acting antiviral medications (inhibitors—protease, polymerase, NS5A).  In other words, someone is treated and not cured.
 
This can lead to a particular class of drugs (protease, polymerase, NS5A inhibitors) not working as well because a person has developed drug resistance.
 
In clinical trials of the direct acting antiviral medications, approximately 1% to 7% of the trial participants were not cured.  In real world settings it is likely higher because of many issues such as missed doses, LIFE, and various health and other issues not addressed in clinical trials.  
 
In this month’s Snapshots, I wrote about a couple of studies that addressed re-treatment.  To overcome the RAVs and other negative predictors of treatment response (previous treatment non-response, cirrhosis, etc.,) ribavirin was added to both re-treatment groups.  As a result, 75%-100% of the patients were cured.  There are drugs being developed that have a high barrier to resistance that will replace ribavirin.  Thankfully we have ribavirin now to help people in need of re-treatment and cure and, importantly, to prevent further hepatitis C disease progression.
 
The approach to retreatment of RAVs is rapidly evolving.  Some physicians are beginning to test for RAVs, but it is far from being a routine test.  Talk with your medical provider if you have questions.

If you are being re-treated with a direct acting antiviral medication, it is important to find an expert to consult with about the best HCV treatment regime for you.  

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.”  

Understanding HCV disease progression rates among PWID

The Hepatitis C virus (HCV) infection is a chronic blood-borne viral infection that affects an estimated 160 million people, or 2-3% of the population world-wide. Alarmingly, chronic HCV infection accounts for one-quarter of the cases of cirrhosis and hepatocellular carcinoma (HCC). If HCV is left untreated, chronic liver disease will occur in 60-70% of the cases, cirrhosis in 5-20% of the cases, and 1-5% will die from decompensated cirrhosis or HCC.

In most high-income countries, such as the United States, where drug injection is the primary route of HCV transmission, the disease is concentrated among people who inject drugs (PWID). While it is estimated that 50-80% of PWID are chronically infected, fewer than 5% of PWID have received treatment.

In a new study, "Hepatitis C virus (HCV) disease progression in people who inject drugs (PWID): A systematic review and meta-analysis," published in the International Journal of Drug Policy, a team of researchers from New York University's Center for Drug Use and HIV Research (CDUHR) assessed existing data on the natural history of HCV among PWID. A total of twenty-one studies examined over 8500 PWID, who contributed nearly 120,000 person-years at risk, for the study of four major HCV-related outcomes included in the synthesis.

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Surge in Youth HCV Presents Hepatologists With Tough Choices

Recently Mark S. Sulkowski, MD, of the John Hopkins University School of Medicine, in Baltimore, saw a teenage patient who had contracted hepatitis C after starting to shoot up as a 12-year-old.

The case is but one in a spike of new infections with the hepatitis C virus (HCV) being driven largely by an epidemic of injection drug use, particularly among adolescents and young adults, according to the Centers for Disease Control and Prevention.

“Sadly, with the heroin epidemic, I’m increasingly seeing teenagers in my practice,” Dr. Sulkowski said earlier this year at the inaugural midyear meeting of the American Association for the Study of Liver Diseases.

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