EASL 2012: Ribavirin Dose Reduction Is Effective for Managing Anemia in Patients Using Boceprevir or Telaprevir


Reducing the dose of ribavirin and adding erythropoietin are both good options for managing anemia in hepatitis C patients treated with boceprevir (Victrelis) triple therapy, according to study findings presented at the 47th International Liver Congress (EASL 2012) this week in Barcelona. A related study found that ribavirin reduction also did not impair cure rates with telaprevir (Incivek).

Approval of the first direct-acting antiviral agents has brought about a new era in chronic hepatitis C treatment. While many people look forward to interferon-free regimens, others need treatment now and can benefit from the first-generation HCV protease inhibitors -- boceprevir or telaprevir -- added to pegylated interferon plus ribavirin.

Triple therapy raises the likelihood of a cure and offers the potential for shorter treatment, but it also increases side effects such as anemia (low red blood cell or hemoglobin levels). Various approaches are used to manage anemia including reducing the dose of ribavirin, adding erythropoietin (EPO; brand names Epogen and Procrit) to stimulate red blood cell production, and blood transfusion. Ribavirin dose reduction is risky for patients on interferon dual therapy since it helps lessen the likelihood of post-treatment relapse.


Fred Poordad from Cedars-Sinai Medical Center and colleagues compared ribavirin dose reduction and EPO as anemia management strategies for patients receiving boceprevir with pegylated interferon and ribavirin. Anemia is a notable side effect of boceprevir, which raises concerns for combination therapy because ribavirin can also cause anemia.

The study included 687 treatment-naive patients with HCV genotype 1 enrolled in a multinational, open-label trial. About two-thirds were women, 77% were white, and the mean age was 49 years.

Participants received pegylated interferon alfa-2b (PegIntron) plus 600-1400 mg/day weight-adjusted ribavirin for a lead-in period of 4 weeks, then added 800 mg boceprevir 3-times-daily for 24 or 44 weeks, depending on HCV RNA levels at week 8.

Baseline hemoglobin levels were 12-15 g/dL for women or 13-15 g/dL for men. Participants who developed anemia -- defined as hemoglobin < 10 g/dL -- or were expected to soon reach that level were randomly assigned to reduce their ribavirin dose by 200-400 mg/day or add 40,000 units/week subcutaneous injections of EPO. If hemoglobin fell to 8.5 g/dL, secondary methods of anemia management could be added. If it dropped to 7.5 g/dL, treatment was discontinued.

The primary endpoint was sustained virological response (SVR), or continued undetectable HCV viral load after completion of treatment.


"Early ribavirin dose reduction did not negatively impact SVR compared with early EPO use," the investigators concluded. "These data support ribavirin dose reduction for primary anemia management."


A related retrospective analysis by Mark Sulkowski from Johns Hopkins School of Medicine and colleagues looked at outcomes among patients who developed anemia in pivotal trials of telaprevir.

The Phase 3 ADVANCE and ILLUMINATE trials evaluated telaprevir triple therapy in treatment-naive genotype 1 chronic hepatitis C patients, while REALIZE looked at prior non-responders and relapsers. Control arms i all studies received pegylated interferon/ribavirin alone.

Telaprevir is not as likely as boceprevir to cause anemia -- its notable side effect is skin rash -- but anemia rates among people on telaprevir triple therapy were higher than those for patients taking pegylated interferon/ribavirin dual therapy.


"In treatment-naive and previously treated patients who received telaprevir combination treatment, ribavirin dose reduction was more frequent than in the control group," the researchers concluded. "Ribavirin dose reduction, including dose reduction to < 600 mg/day, had no substantial effect on SVR rates in patients treated with telaprevir combination treatment."

Taken together, these studies indicate that the extra potency of HCV protease inhibitors helps overcome the tendency to relapse among patients who take inadequate ribavirin in dual therapy with pegylated interferon.

In his summary of research highlights on the final day of the conference, Jean-Michel Pawlotsky from the University of Paris said these findings "validate the use of ribavirin dose reduction" rather than adding the expense of EPO to an already costly regimen.



FF Poordad, EJ Lawitz, KR Reddy, et al. A Randomized Trial Comparing Ribavirin Dose Reduction versus Erythropoietin for Anemia Management in Previously Untreated Patients with Chronic Hepatitis C Receiving Boceprevir plus Pginterferon/Riba. 47th International Liver Congress (EASL 2012). Barcelona, April 18-22, 2012. Abstract 1419.

M Sulkowski, S Roberts, N Afdhal, et al. Ribavirin Dose Modification in Treatment-naive and Previously Treated Patients who Received Telaprevir Combination Treatment: No Impact on Sustained Virologic Response in Phase 3 Studies. 47th International Liver Congress (EASL 2012). Barcelona, April 18-22, 2012. Abstract 1162.

Other Source

Merck. Merck Reports Phase III Study Results Evaluating Anemia Management Strategies Used With Victrelis (boceprevir) Combination Therapy. Press release. April 19, 2012.