Patient Name ______________________________________ Evaluation Date _________________________
If you answer YES to any of the following questions, then this patient should not be treated.
No Yes Has the patient had ascites?
Has the patient had encephalopathy?
Has the patient had variceal bleeding?
Does the patient have a history of significant or unstable cardiac disease?
Has the patient ever had severe depression?
Has the patient ever been hospitalized for a psychiatric disorder?
Has the patient ever felt suicidal or had a suicide attempt?
Does the patient have thalassemia or any blood disorders?
(e.g. hemoglobinopathy, hemolytic anemia)?
Does the patient have Wilson's disease, hemochromatosis, hepatitis B,
autoimmune hepatitis, PBC, PSC, alcoholic liver disease or other
cause of chronic liver disease?
Is the patient pregnant, planning to become pregnant or breast feeding?
Has the patient had a transplant (e.g. liver, kidney, bone marrow, heart)?
Does the patient have normal Alanine Aminotransferases?
Does patient have hypersensitivity to Interferon or Ribavirin?
WBC (x 1000)
[ __ __.__ ] Neutrophil count (%)
[ __ __ ] OR (x 1000) [ __ .__ __ ] Hemoglobin (g/dl)
[ __ __.__ ] Platelets (x 1000)
[ __ __ __ ] Reticulocyte count (%)
[ __ .__ __ ] OR (10 9/l) [ __ __ . __ ] AST (IU)
[ __ __ __ ] ALT (IU)
[ __ __ __ ] Alkaline Phosphatase (IU)
[ __ __ __ ] Total Bilirubin (mg/dl)
[ __.__ ] Serum Albumin (g/dl)
[ __.__ ] Prothrombin Time (seconds)
[ __ __.__ ] Prothrombin Time INR
[ __.__ ] Glucose (mg/dl)
[ __ __ __ ] BUN (mg/dl)
[ __ __ ] Serum Creatinine
[ __ .__ ] TSH
[ __ __.__ ] HCV-RNA Genotyping (optional)
[ _________ ] Positive Negative HCV-RNA PCR
Urine or Serum Pregnancy Test
Eligible Treatment Candidates
If you answer YES to all of the following questions, then the patient is a good candidate for treatment.
No Yes HCV-RNA positive
Hemoglobin >= 12 g/dl for females or >= 13 g/dl for males
WBC within normal limits
Neutrophil Count within normal limits
Platelets >= 70,000/mm3
Prothrombin time <= 3 seconds prolonged or INR ratio <= 1.5
Serum Albumin >= 3.0 g/dl or within 20% of lower limit of normal
Serum Creatinine <= 1.4 mg/dl
TSH within normal limits
Total Bilirubin within normal limits
(unless Gilbert's disease is present, then indirect bilirubin should be <= 3.0 mg/dl)
ANA negative (<= 1:160)
Females of childbearing potential and males are willing to use effective contraception during treatment period and for 6 months post treatment.
**Eligible Treatment Candidates, but these patients must be treated with Extreme Caution:
- Patients with history of Pulmonary infiltrates or impairment
- Patients with Creatinine Clearance < 50 ml/min
- Patients with Diabetes Mellitus
Treatment Dosages and Administration
Rebetron Body Weight Rebetol Capsules Intron A <= 75 kg 2 capsules qam po
3 capsules qpm po
3 million units SQ TIW > 75 kg 3 capsules qam po
3 capsules qpm po
3 million units SQ TIW
Length of Treatment: Treatment Naïve: Genotype 1 should be treated x 12 months
Non genotype 1 should be treated x 6 months
Treatment Relapsers: Genotype 1 should be treated for 6 months
Non genotype 1 should be treated for 6 months
Infergen Treatment Naïve: 9 mcg SQ TIW x 6 months Previously Treated: 15 mcg SQ TIW x 6 months
Dose Reduction: Can include either interferon or ribavirin.or both drugs For hemoglobin abnormalities you can just reduce the ribavirin to half dose, for other abnormalities (except psychiatric or emotional) reduce interfeon to half dose. If using combination therapy reduce both drugs for psychiatric or emotional abnormalities.