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2008 APASL guidelines for HBV management
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2008 APASL guidelines for HBV management

Hi. Guys:

I have read many posts on HBeAG - with ALT>2xULN and HBV-DNA > 2.0x10(3) IU/ml, should be considered for treatment.

I am in this category and started taking tenofovir on 19Sep2011. I have a question on when to stop medication. From the posts almost every where it says that there is a very slim chance to stop medication, unless HBsAG is changed from positive to negative. The rate of that change is 5% after 4 years on tenofovir.

However, from 2008 APASL guidelines for HBV management (http://www.apasl.info/pdf/GuidelinesHBV.pdf)
Recommendation 9. For oral antiviral agents: In HBeAg positive patients, treatment can be stopped when HBeAg seroconversion with undetectable HBV-DNA has been documented on two separate occasions at least 6 months apart (II). In HBeAg negative patients, it is not clear how long treatment should be continued, but treatment discontinuation can be considered if undetectable HBV-DNA has been documented on three separate occasions 6 months apart. (II).

I am interested the last sentence, if there are 3 separated times with undetectable HBV-DNA, then stopping medication could be considered. For my situation there still chance that I may be able to stop tenofovir?

Could some one elaborate this for me? Thanks
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19 Comments Post a Comment
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Avatar_m_tn

guidelines are made for dum doctors with no knowledge of hbv, drugs and tests.hbv treatment must be personalized and only very updated doctors can do that

the less stupid are european guidelines but even you can understand how stupid can be the ue of antivirals alone.antivirals have no effect on hbv, they lower replication but increase infected cells mainly because hbv doesn t infect or replicate by hbvdna only but also by cccdna inside the cells

so if you had no liver damage you just wasted money, to stop tenofovir you have to combo with interferon for 6-12 months, this combo has 23% seroconversion on a study gilead made but did not expect this result

i dont know if they will make it public but you have nothing to lose by combo with interferon, also because life treatment with a drug is something we all want to avoid since sides on long term are unknown

so check hbsag and see if it is decreasing by tenofovir only, then add interferon+vitd+simvastatin+nitazoxannide and see if hbsag gets 1log or more down, if it doesn t just keep interferon 6 months and stop tenofovir after these 6 month combo, interferon can be kept other 12 months total

of course if hbsag goes down dont stop until negative and when negative hbv is eradicated

interferon will increase your immune response and will allow some time with inactive hbv and normal alt, if you lucky years of inactive virus
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Avatar_m_tn
Thanks. I got it.

Please explain: " they lower replication but increase infected cells mainly because hbv doesn t infect or replicate by hbvdna only but also by cccdna inside the cells"

I understand that tenofovir lower the virus replication. But why tenofovir increase the infected cells? When you say cell, do you mean "liver?" cell

Thanks again
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Avatar_m_tn
Oh, I only got the HBsAG positive, it reads reactive (out of range). I did not have HBsAG quantitive result. By the way, I am in US and I went to GI. Before I went to GI, my PCP only ordered test to check if HBsAG positive or negative, along with other tests, ALT, AST, etc. Do you think next time when I go to GI, should I ask for HBsAG quantative result? or is there a HBsAG quantative test exsits?

Thanks
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Avatar_m_tn

US is one of the worst country in the world, to give antivirals to anybody for life they dont have hbsag quant and fibroscan

we have posted a lab in india that accepts blood samples to check hbsag quantity, check old posts.we choose that lab both because cheap and because willing to accept samples but if you happen to travel in europe, china or even south africa and ghana you may find this test easily

US, canada and australia are the countries without this extremely easy and cheap test, the only explanation is they might slow sales of antivirals since hbsag quantity that reflects infected liver cells increase on most patients on antivirals

fibroscans are missing too while available from 2004, it is the only way to monitor liver damage and improvment during therapy since biopsy can t be done more than once in a couple of years.biopsy has also risks (even death although rare) and many mistkes

LA. boston and new york should have a fibroscan somewhere, canada has them easily
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Avatar_m_tn
Thanks Stev for your explaination on test. Could you kindly answer my question on you quotation?

Please explain: " they lower replication but increase infected cells mainly because hbv doesn t infect or replicate by hbvdna only but also by cccdna inside the cells"

I understand that tenofovir lower the virus replication. But why tenofovir increase the infected cells? When you say cell, do you mean "liver?" cell

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Avatar_m_tn

because the virus in integrated in our dna inside the cell and tenofovir has no effect on this little piece of dna called cccdna, this keep replicating as cells replicate and store all data to remake virus

so while hbvdna in serum gets low, total hbvdna in liver can get higher especially cccdna, so if you stop tenofovir all cells with cccdna inside will start prdcing virions and immune system will try to kill them.if majority of cells in the liver have cccdna most of the liver could get destroyed

thisis the reson why stoping tenofovir can be very dangerous, interferon lowers cccdna by boosting immune system so you can safely stop tenofovir

so the problem is the virus remains untouched because of no activity on cccdna by nucs

be also aware that even if hbvdna is und in serum itis not in the liver, virions at low levels remain
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Avatar_m_tn
Hi. Stef:

I still do not understand your interpretation. Here is my partial understanding:

For example, I am chronically infected with HBV. cccdna are now in my liver cell. Supporse initially, without tenofovir, I have 1E3 cccdna in my liver, then they replicate and at some time it reach an equilibrium and cccdna is now 1E4 inside liver. These cccdna somehow also replicate in my blood. Without HBV infection, the replication of virus in my blood is zero. With the infection, cccdna has produced, say, 1E5 virus in my blood.

Now with the medication tenofovir, it totally cut off the replication path of virus in blood. And now the virus in my blood is zero again. However, I know the fact that tenofovir does not react with cccdna in my liver. In that case, the replication of virus equilibrium in my liver is just like before, and it is still 1E5.

I have used a too simplified model, when I say virus level in my blood is zero, it actually is under detection by the test.

I know I missed something in between. I still do not quite get why:  “they lower replication but increase infected cells mainly because hbv doesn t infect or replicate by hbvdna only but also by cccdna inside the cells”. Why using tenofovir increase infected cells (inside liver?)

Thanks again for you kindly help.

Dan
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Avatar_m_tn
Please ignore my previous post. There was a typo. This one is the correct one I want to send

Hi. Stef:

I still do not understand your interpretation. Here is my partial understanding:

For example, I am chronically infected with HBV. cccdna are now in my liver cell. Supporse initially, without tenofovir, I have 1E3 cccdna in my liver, then they replicate and at some time it reach an equilibrium and cccdna is now 1E4 inside liver. These cccdna somehow also replicate in my blood. Without HBV infection, the replication of virus in my blood is zero. With the infection, cccdna has produced, say, 1E5 virus in my blood.

Now with the medication tenofovir, it totally cut off the replication path of virus in blood. And now the virus in my blood is zero again. However, I know the fact that tenofovir does not react with cccdna in my liver. In that case, the replication of virus equilibrium in my liver is just like before, and it is still 1E4 inside liver.

I have used a too simplified model, when I say virus level in my blood is zero, it actually is under detection by the test.

I know I missed something in between. I still do not quite get why:  “they lower replication but increase infected cells mainly because hbv doesn t infect or replicate by hbvdna only but also by cccdna inside the cells”. Why using tenofovir increase infected cells (inside liver?)

Thanks again for you kindly help.

Dan
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Avatar_m_tn
it is some kind of what you said......

when there is no hbvdna around in the blood by nucs there is a lowering of some immune responses, hbcab in particular, in this situation cccdna keep muliplying with the cells (cccdna is mainly in cells not blood in this situation)

just think about this, you have one cell with 5copies cccdna, when the cell divide for multiplying it will be 2 cells with 10 cccdna (not exactly this but just an example to understand).
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Avatar_m_tn
Hi. Stev:

thanks. this time I understand. One more question, though. I remember from this forum, there is nothing immune system could do to cccdna. Because cccdna has release tons of HBeAG to mask the cccdna, immune system can not 'see' it.

But by your statement, HBcAB can act on cccdna?

If that the case, does that mean if we could somehow increase HBcAB response, there is one more route to attach cccdna, and cure the CHB?

but by common sense (which you guys have and I do not) I again have some mistakes in my argument.

Thanks again.
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Avatar_m_tn

immune system can attak cccnda without killing liver cells by cd8 T cells, the problem is immune system is blind, macrophages and dentric cells which are the eyes of immune system are inactivated and dotn respond to hbv

i am trying gcmaf to activate my macrophages and see if this makes a difference on hbv

sorry i dont understand your ipotesis but the key is all in macrophages and dentric cells and the way hbv inactivates them.if this is done by nagalase like most of viruses and cancers we have found a key to awake immune system by gcmaf.if hbv uses other strategies the only way is lowering hbsag

there should be a researcher to check if hbsag contains nagalase enzym and if infected cells produce nagalase too, but nobody did this i am the first one to check nagalase on hbv infection (it was the highest registered on trials with total macrophages inactivation).
it remains to be confiremed if my nagalase is due to hbv or to other viruses
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Avatar_m_tn
Hi. Stef:

Your comments:

"we have posted a lab in india that accepts blood samples to check hbsag quantity, check old posts"

I have started tenofovir on 21Sep2011. I will do my blood test soon. I have hbv DNA:  82,100,000 range <29 IU/mL.
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Avatar_m_tn
Hi. Stef2011:

I started taking tenofovir on 19Sep2011. Before taking tenofovir, my hbv dna was  82,100,000 range <29 IU/mL. I will do a blood test again on 13Oct2011. After taking tenofovir for 23 days, what do you think my hbv dna will be? I wish it at least down from 10^7 to 10^5.

Also, you stated that: "we have posted a lab in india that accepts blood samples to check hbsag quantity, check old posts.we choose that lab both because cheap and because willing to accept samples". Could you get me the link? I could not find it.

If I want to ship my blood sample to India, how am I going to do that?  

After reviwing all your post, I still do not quite understand this chronic hepatitis. Say if I got the hbv dna under detection, does that mean that my liver will not be damaged by this virus? what about cccdna viruses inside the liver, do they still doing the harm to my liver?

Thank you very much for your kindly help.

Dan
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Avatar_m_tn
Oh, forgot somehing. For my condition: chronical hbv since 1984. Just tested AST, ALT both are more than 2*ULN. hbv dna 82,100,000 range <29 IU/mL. Took tenoforvia for 18 days.

Could I still play 2 hour soccer (not vigorously) every Saturday?

If on weekend I sleep after 12:00 am, but still get 7-8 hour sleep, will that do a big damage to my liver.

Thanks.

Dan
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Avatar_m_tn
hbvdn has nothing to do with immune clearance, it is hbsag undetactable to mean cured

hbvdna means just lowered replication and no liver damage but the virus will still be there

Could I still play 2 hour soccer (not vigorously) every Saturday?
of course you can, only babies at birth or very young guys can get it vcronic

good sleep is 7-8hrs s  always good for immune system

if you are hbeag pos you can combo to make hbsag go down:
interferon, alinia, simvastatin, vitamin d 3

once hbvdna is und for 6-12 months you may think about this combo
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Avatar_m_tn
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Avatar_m_tn

just open a new post for indian members, where to ship blood samples for hbsag quant in india
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Avatar_m_tn
Good day everyone.!
An angel sent forth when i drop in this site.. I'm so thankful for having an information regarding this disease.
   i was checked up by doctor first week of this month when i notice some symptoms of this virus,.. unfortunately i'm positive for having a hepatitis B.

  Gumuho ang mundo ko. lahat ng pangarap ko at pagisiskap nawala lahat.
Hindi ko lubos maisip paano at bkit ako ngkaroon nito. Hanggang ngaun, am so very depressed seems hopeless..

I'm 23 yrs old, only child and only bread winner for my old parents..
Im so thankful ng makita ko itong site n ito,. in some ways, lumakas ang loob ko at nbuhayan ng pag-asa because of your testimony.

Guys,. pls help me to explain the status of my Hepatitis B.  My doctor not explain this enough,. i need your support to know my status and pls inform honestly this status.. God and I will greatly appreciate for your immediate and favorable response.

TEST              CUT OF VALUE(COV)       RESULT         INTRPRTATION
Anti-Hbs              10.00                          2.10               nonreactive
Hbe-Ag                 7.06                          28.06                 reactive
Anti-Hbe              69.90                         73.05                nonreactive
Anti-HBc M         157.46                       439.78                 reactive
Anti-Hav M           117.55                         18.14              nonreactive
Hbsag                                                                           REACTIVE
SGPT   274.9 U/L   (up to 65)
SGOT  112.6  U/L   (up to 50)

   Guys,. i really understand you're feeling right now,.. grabe seems so hard of accepting this at the beginning.. my mother worries alot,. guys pls help gusto ko po gumaling,.. ayoko po iwan ang mga magulang ko,. wala n s kanila tutulong at magtatanggol, dhil isa lng talaga ko, then they can no longer to get a job because they are both old..
   Now, i pray everyday and trust everything God's plan. Everything has reason and purpose,. kaya guys in god's grace makakasurvive tayo!!!  ohh Jesus Christ ,our lord great savior, you're our lawyer, you're our authority and mostly our life,.. you'll greatly save us.. AMEN.

10 minutes
To: all beloved friends
guys,. i would greatly appreciate if you could give me advise or share a significant info reagarding my hepa b status,. my doctors advise me to go at specialist or hepatologist for best advise ,. she recommend to Manila Doctors but not sure if andun pa and specialista n alam, i haven't yet check coz im waiting for my salary by the end of the month before go for 2nd check up.

  Pls, guys mgtulungan tayo,. i will share too all significant and info once i got some...Thanks po.. God Blesses Us!!!
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Avatar_m_tn
Hi. Jerald777:

First of all, do not panic. I am not an expert here. But from my limited knowledge, you might have an acute hepatitis infection, since you stated that you are 23 years old (which means that you are not a very young child), your immune system has the ability to fight off the infection. That means you may get totally normal in 6 monthes. When I say 6 monthes, that means from the day you have attacted the virus. If you are having an acute hepatitis b infection, you DO NOT need to take any medicine.

As I said, I am not an "expert" here. You may want to get more informed response from other member, like stev2011.

Also, you should read the welcome message at the beginning of the forum. The rule here is not to post your question from other people's thread. You should alway post a new thread for your own.

Again, I wish you have an acute hepatitis b infection and get normal in 6 monthes.

Dan
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