Management of Emergent Depression and Suicidal Ideation During HCV Therapy

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Management of Emergent Depression and Suicidal Ideation During HCV Therapy

Faculty: Alfredo Alberti, MD

A 33-year-old Italian female was diagnosed with hepatitis C virus (HCV)

infection 5 years ago when she first underwent testing on the basis of her

general practitioner’s advice because of a past history of intravenous drug

abuse. The patient was found to be antibody to HCV (anti-HCV) and HCV RNA

positive with normal alanine aminotransferase (ALT) levels. Since then, her ALT

levels have been monitored every 6 months with normal or nearly normal (< 1.5 x

the upper limit of normal) values. The patient stopped drug use at the age of 25

years but has continued to consume significant amounts of alcohol. She had no

other remarkable medical problems and no symptoms of liver disease.

The patient’s initial laboratory results showed the following:

ALT: 38 IU/L (normal according to the testing laboratory)

Aspartate aminotransferase (AST): 58 IU/L (upper limit of normal: 50 IU/L

according to the testing laboratory)

Anti-HCV: positive

HCV RNA: 2.1 x 105 IU/mL

HCV genotype: 3a

Alkaline phosphatase: 75 U/L

Total bilirubin: 0.5 mg/dL

Albumin: 3.9 g/L

Platelet count: 230,000 cells/mm3

White blood cell count: 5300 cells/mm3

Hemoglobin: 13.2 g/dL

International normalized ratio: 0.9

Alpha-fetoprotein: 3.2 ng/mL

Thyroid-stimulating hormone: 4.6 IU/mL

Ferritin: 416 ng/mL

Hepatitis B s antigen: negative

Upon presentation in your office, the patient’s physical exam is normal. The

patient has a body weight of 52 kg and height of 161 cm. She admits to drinking

approximately one half liter of wine daily and 10-12 high-proof drinks per week.

The liver is slightly enlarged with no enlargement of the spleen. Ultrasound

examination of the upper abdomen reveals an enlarged and hyperecogenic liver

indicative of a discrete grade of hepatic steatosis with no enlargement of the

spleen and normal portal vein.

The patient is taking a benzodiazepine nightly to sleep but states she is not

depressed and denies depression in the past.

You recommend alcohol withdrawal in this patient and offer the assistance of a

specialist to aid in this initiative. During this time, the patient’s liver

enzyme levels are monitored every 3 months. The patient is able to stop alcohol

intake with the assistance of a substance abuse specialist and group meetings

and is seen again by you after 6 months. She states that withdrawal from alcohol

has been difficult but possible with her available support system.

Following alcohol withdrawal, ALT and AST levels are within the normal range,

her ferritin has normalized, and her HCV RNA is 1.2 x 104 IU/mL. Standard

assessment (eg, hematology, thyroid, and autoimmunity screening) shows no

contraindication to peginterferon and ribavirin treatment.

Before starting therapy, the patient is monitored for depressive symptoms using

the Beck Depression Inventory (BDI). Her score is 6, indicating a lack of

significant symptoms.

She is started on peginterferon alfa-2b 80 µg/week and ribavirin 800 mg/day. By

Week 4, her HCV RNA is undetectable by sensitive real-time polymerase chain

reaction assay, indicating that she has achieved a rapid virologic response

(RVR). However, she complains of fatigue and depressive feelings.

At Week 8, her BDI score is 17, indicating moderate depressive symptoms. At this

time her hemoglobin measures 12.1 g/L and thyroid function is normal.

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In light of the HCV RNA response and adverse effects, how would you manage the

patient at this time?

A.

Start a selective serotonin reuptake inhibitor (SSRI) and reduce the dose of

peginterferon to 50 µg/week

B.

Stop antiviral therapy immediately because of the presence of depressive

symptoms

C.

Start an SSRI at high dose with no reduction in the dose of peginterferon or

ribavirin

Jointly sponsored by Postgraduate Institute for Medicine and Clinical Care

Options, LLC.

Release date: October 1, 2008Expiration date: September 30, 2009

Supported by an educational grant from Schering-Plough.

DisclaimerThe materials published on the Clinical Care Options Web site reflect

the views of the reviewers or authors of the CCO material, not those of Clinical

Care Options, LLC, the CME provider, or the companies providing educational

grants. The materials may discuss uses and dosages for therapeutic products that

have not been approved by the United States Food and Drug Administration. A

qualified healthcare professional should be consulted before using any

therapeutic product discussed. Readers should verify all information and data

before treating patients or using any therapies described in these materials.

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