在上一篇[洗腎患者,又有C型肝炎,能接受肝炎的治療嗎?(1)]中,因為引用了台大的劉振驊醫師與高嘉宏教授的研究,為了尊重原作者,我寫了封email給高嘉宏教授,希望徵得他的同意,高教授不但欣然同意我引用他的文章,還在回信中附上他們團隊的兩篇著作,為了感謝他如此大方,當然要好好念一下這兩篇研究,再寫一下心得囉。
上一篇文中提到,大多洗腎患者,因為擔心抗病毒藥物(Ribavirin)所造成的嚴重貧血,所以大多只單用干擾素治療C型肝炎(以下簡稱C肝),高教授這兩篇文章就是在探討:治療慢性C肝的洗腎患者,用干擾素之外,再合併使用低劑量抗病毒藥物(Ribavirin,每天200mg),效果與安全性如何?
由於C肝病毒有好幾種基因型,而這兩篇研究,第一篇是針對第一型病毒治療48週的研究,第二篇則是針對第二型病毒治療24週,除此之外,兩個研究設計幾乎一模一樣,干擾素的劑量會隨著患者的反應(主要是白血球或血小板的數量)來做調整,抗病毒藥物的劑量,則是隨著患者貧血的程度來做調整。如果患者的貧血情形變嚴重,紅血球生成素(epoetin-β)則隨之增加劑量,最高到每週40000單位,哇,這真的很大量。
研究結果顯示,合併兩種藥物一起使用,不管對第一型或第二型C肝病毒來說,都有較佳的成功率,第一型病毒治癒率(SVR)從33%上升到64%,第二型病毒治癒率(SVR)從44%上升到74%。
我們所關心的安全性呢?無法完成療程的比例約為3%(單用干擾素者),以及6%-7%(併用兩種藥者),需要調低藥物劑量者有38-44%(單用干擾素者),以及81-83%(併用兩種藥者),其中70-72%患者的抗病毒藥物(Ribavirin)劑量需要調低。
在眾多副作用當中,幾乎兩種治療都差不多,只有貧血(Hb<8.5 g/dL)的比例有非常顯著的差異,單用干擾素者只有6-8%,而併用兩種藥物者,貧血比例高達70-72%。使用紅血球生成素(epoetin-β)的劑量呢,單用干擾素者每週用量約5833-6667 IU,併用兩種藥物者,每週紅血球生成素用量變成兩倍!(13417-13946 IU)
值得特別一提的是,如果患者得到的是第二型C肝病毒的感染,而病毒量是小於800000 IU/ml的話,單用干擾素的效果,和併用兩種藥物的效果幾乎一樣(66% vs 73%),因此如果考慮避免副作用的發生,病毒量較少的患者可考慮只單用干擾素就好,效果差不多好。
直接講重點,要治療洗腎患者的慢性C型肝炎:
1. 干擾素與抗病毒藥物合併治療,清除病毒的效果較佳。
2. 合併治療,7成患者會有貧血的副作用,紅血球生成素平均用量變成兩倍。
3. 合併治療時,8成患者的劑量需要往下調整。
4. 如果患者為第二型的C肝病毒,病毒量小於800000者,可考慮只用干擾素就好,效果差不多,副作用少很多。
5. (自己的感想) 當洗腎患者要使用這麼大量的紅血球生成素時,一般健保所給付的費用是不足以負擔的,這點可能得請肝膽腸胃科醫師多幫忙…
再次感謝高嘉宏教授的熱心,希望更多人能得到正確的治療資訊。
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