University of Washington

Twenty-Four Week (6 Month) Evaluation

Patient Name ______________________________________

Evaluation Date _________________________

Laboratory Studies

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

[ __ __.__ ]

Positive Negative

HCV-RNA PCR

Urine or Serum Pregnancy Test

Dose Reduction Permanent Discontinuation

Hemoglobin < 10 g/dl
In cardiac patients
>= 2g/dl decrease during any 4 week period. Hemoglobin < 85 g/dl
In cardiac patients
< 12g/dl after 4 weeks of dose reduction.

WBC < 1.5 x 10⁹/l WBC < 1.0 x 10⁹/l

Neutrophil < 0.75 x 10⁹/l Neutrophil < 0.5 x 10⁹/l

Platelet Count < 50 x 10⁹/l Platelet Count < 25 x 10⁹/l

Moderate Depression Severe Depression

Patient Name	______________________________________

Evaluation Date	_________________________

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				[ __ __.__ ]
			Positive	Negative
HCV-RNA PCR
Urine or Serum Pregnancy Test

Dose Reduction	Permanent Discontinuation
Hemoglobin < 10 g/dl In cardiac patients >= 2g/dl decrease during any 4 week period.	Hemoglobin < 85 g/dl In cardiac patients < 12g/dl after 4 weeks of dose reduction.
WBC < 1.5 x 10⁹/l	WBC < 1.0 x 10⁹/l
Neutrophil < 0.75 x 10⁹/l	Neutrophil < 0.5 x 10⁹/l
Platelet Count < 50 x 10⁹/l	Platelet Count < 25 x 10⁹/l
Moderate Depression	Severe Depression