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Hbs+ hbeag+ --- VL after tx...
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Hbs+ hbeag+ --- VL after tx...


Need some thoughts here…

As you may have read going through this thread I’m still Hbeag+ ALT slightly out og range (70-80) and my VL has always beein >100000000.

I had been on Pegasys IFN180 mono tx for 8 months (2 years ago) and then I quitted as I seemed to not responding to tx… (just for you info I have not had any side effect at all but VL was almost always >100000000).

After that I just have my blood tests done every 3 or 4 months, ultrasound every 6 months  …… so I’ll keep on monitoring how this stuff is progressing..

Now.. got my latest labs last week.. and I was really surprised as my VL dropped down to 50000000… yes mate I know this is still high but I’ve never had a result like this in 26years.. Neither had I while on tx…

ALT still around 70 however….

Any ideas?????

thanks to you all guys!!!
Tags: HbeAg, VL, tx
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Avatar_m_tn
hbvdna has very little meaning in terms of infection and it flactuates up and down usually getting to completely undetactable too.it is a very good tool to monitor if therapy is working

your situation is common on asians and with such high viral load you might get some results only from entecavir 1mg+tenofovir combo, nitazoxanide might help too

are you 100% sure you were not immune tollerant and abnormal alt was due to hbv?is your hbeag still positive?
if you drink alcool, are overwheight and eat a lot of fats/meat alt can be that high and it is not due to hbv

i suggest you keep monitoring hbvdna and start drug only if it stops decreasing and reverse to increase

did you ever check liver damage by biopsy or fibroscan?
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Avatar_m_tn
Hi Stefano,

the VL never decreasead even when I was on IFN therapy!  Docs wanted me to quit tx as they told I may have still been in the immune-tolerance phase..

I'm stell eag + .. as I've been being since my birth (I'm now 26 yo)..

I had a liver biopsy in 2007. Everything was good, they found F1 (Metavir) but doctors said there’s nothing to be worried about. I had also ultrasound test once a year and no liver damages were detected.

Thx a lot

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Avatar_m_tn
on immune tollerance it is better to let the virus be, i would check why alt was so elevated

all the drugs can worsen situation because it immune system activates it makes more damage, it is better to wait for immune tollerance to be broken naturally and you will see this from hbvdna getting down and alt getting elevated for sometime, in the meanwhile you don t have to worry because your liver damage is almost none but do check with biopsy again in 2-3 years not more

a saw a study where they broken immune tollerance by  monthly hbv vaccine+antiviral but i'd wait to happen naturally
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Avatar_m_tn
yes mate.. to be honest I often have cheese, salami, meat at meals.. but you know.. I'm 25yo and pretty always hungry!!!!

I wish I could seroconverto into Hbeag- as my mom did (she's hbs+ hbeag-) in the past.. but this is not happened yet after 25 years of hbeag+... so I actually do not now whether this is gonna be lilkely or not..

I also was strongly pushing for AV (ETV, TFV) before starting IFN tx back in the past but doctors didn't suggest that way as AV could be taken for all the lifetime and so far no results shwoing low damage/side effects in th long term have been proven...

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Avatar_m_tn
yes mate.. to be honest I often have cheese, salami, meat at meals.. but you know.. I'm 25yo and pretty always hungry!!!!

there are 2 hepatitis that can happen this way, they can both be heavier than virus infection.fatty liver disease and nash.singns are overwheight, high cholesterol, early signs of diabetes, fat in the liver on ultrasound.daily alcool from as low as a glass or wine or beer can also elevate alt this much
just correct diet and make excercise and see if alt goes down.vitamin E and pcc supplements can help

as to being immune tollerant that's the best situation on hbv, pray to stay like this as long as possible, because it is like having no virus
do monitor and when hbeag seroconversion will happen or hbvdna will get down to ver low/und that's the best moment to try peginterferon+nitazoxanide or if this happens in 2-3 years you might even have interferon lambda available

do not consider tnf or etv, they both are useless on virus and needed only to prevent or reverse liver damage.we have seen that used in combo with peginterferon they can increase svr but do not consider them without interferon

it is also good doctors didn t try etv or tnf with you being immune tolerant because you might have developped resistance without making hbvdna und

i have also seen a study where they used monthly hbv vaccine shots plus antivirals and they could break immune tollerance on most without making alt flares but i don t see the point to breaking immune tollerance since it doesn t make any damage to the liver.this was also a small study so i wouldn t try this
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Avatar_m_tn
as to your monther is she inactive carrier with no liver damage or on therapy?
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Avatar_m_tn
yes, she's inactive!!!!
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Avatar_m_tn
and she's never had any tx!!!
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Avatar_m_tn
good she is like most of hbv carriers, if you have hbsag quantitative test available check her quantity, if it is as low as 500-1000iu/ml she might get rid of it by ntz or even clear it with a possibility of 11% per year
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Avatar_m_tn
could it be tha same for me also in the next future?
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Avatar_m_tn

too early to say we have to wait and see how your immune system works/hbv mutates after immune tollerance

anyway interferon lambda will be available in a couple of years and long treatments by interferon+ntz+etv or tnf will probably make very high eradication rates
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Avatar_m_tn
hey, guys.. not so good news here..

Got my last lab made 3 wks ago..

VL still above 1000000000
AST 198  (range 0-50)
ALT 589 (range 0-50)
GGT 79 ((range 0-50))

still eag+..

Just to summarize i've been on IFN for 7months 2years aog and had to quit tx as qhite bllod cells were too low and I was getting no effect and no results on VL..

What's going on mates???  I really do not want to restart IFN shots tx...
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Avatar_m_tn

well you are in immune clearance pahse but your immune system is too weak, this is what i suggest to my point of view:

interferon has been useless because too much hbvdna, hbeag and hbsag suppress your immune response, so start from boosting immune response

start taking vitd3, 10000iu daily, until you reach a serum level of about 70ng/ml then decrease dose to find maintenance.check serum calcium while on this because a very rare paraormone disease (dont know correctly in english) can increase calcium while on high vit d3

start simvastatin 40mg and check that alt doesnt flactuate too much

then you may try gcmaf from gcmaf.eu for 6 months and see if you get to hbeag negative and hbvdna low/und

this is just a try with no sides effects, no risks
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Avatar_m_tn

another try is use:
entecavir+tenofovir, this will make hbvdna undetactable and improve immune response to interferon overtime

if you have no liver damage this antiviral combo is totally useless on infection but you cn use it because lowering hbvdna will improve your immune response and interferon might start working on a combo like this

so once hbvdna und for 6-12months you may try tnf+etv+interferon+simvastatin+vit d3 +alinia and see if you clear hbsag and hbeag

i dont like this combo because expensive for etv+tnf+interferon, the others are very cheap, but not sure if it will work after all this expense

int'l liver congress 2011 in berlin made a trial on interferon+nucs and 2 cleared hbsag, one of these two was previously non responder to interferon
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Avatar_m_tn

another consideration is, do not waste the chance to clear hbv.

at this stage you have little mutations and if you awake your immune system your chances to clear are much hgiher than hbeag negative

so if you have no problems covering expenses i'd try the first gcmaf way and then the second way in case gcmaf fails

gcmaf needs tests available at redlabs.com:
vdr genotype, because ff/BB genotype doesn t respond to gcmaf
nagalase, to see if hbv is supressing your immune system by nagalase
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Avatar_m_tn
hi stef, thx for your answers, well detailed!

Well, as I'm still eag+ Is there any little chance to get eag serconversion only on combo? Doctors say the latest combo is etv+tfv.. I reallu would not like to get back to ifn shots....
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Avatar_m_tn

you can make etv+tnf and retry interferon when the lambda type will be available, the lambda has fewer sides

as to the potency of tnf+etv i have seen few people with high hbvdna achieving hbeag neg and almost zero hbsag neg.it is early because data on this combo is not public yet so we should wait for the int'l liver congress at end of oct

do start the supplements of vit d3 and sim anyway, they will weaken the virus
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Avatar_m_tn
.. I'm pretty scared as I belive doctors will push me again on pega shots... really do not want.. :(
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Avatar_m_tn

no wthat i know you are italian try to get to cisanello pisa with the doctors i told you or lampertico milan, they are among the best in the world for hbv they will know for sure what's best for you better than me

since youare hbeag pos i will try to get hold on interferon lambda, it has no sides compared to norma interferon, higher rates and if you increase vit d3, coffee 4-5 cups a day, simvastatin 40mg you might even improve the results

there are a couple of hospitals in italy doing the trial, check bms italian website for trial locations.firenze has it for sure, i could not try it because i am hbeag neg
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Avatar_m_tn
do you have any clue on when the lambda ifn would be approved here in italy?
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Avatar_m_tn

patent of alpha expired, in the meantime they will make trials, but this makes no difference to you as long as you have hbeag pos you can get in the trials
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Avatar_m_tn
I could but seems to be unfeasible for me due to costs and logistics...i knew from u that not all hospitals have this trial availabe rigth now..
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Avatar_m_tn
just an addition... I read on www that lambda is being tested on HCV.. will it be approved for HBV also?
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Avatar_m_tn

no it is tested for hbv and hcv, but for hbv they started on hbeag postives only in any case you dont need to rush, you need tnf+etv first to make hbvdna und and then try interferon lambda

these hospitals are doing the trial on hbv only

Ospedale S.M. Annunziata - Firenze- Dr. Francesco Mazzotta
Unità Operativa Malattie Infettive
via Antella,58 - tel 055-24961

Università La Sapienza - Roma - Prof.ssa Gloria Taliani
Dipartimento di Medicina
viale del Policlinico, 155 - tel. 06.49971

these are doing on hcv

Azienda Ospedaliera Universitaria Pisana – Ospedale Cisanello- Pisa - Prof.ssa Maurizia Rossana Brunetto
Unità Operativa di Epatologia
Via Paradisa, 2 – Tel. 050.992111

Università La Sapienza - Roma - Prof.ssa Gloria Taliani
Dipartimento di Medicina
viale del Policlinico, 155 - tel. 06.49971
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Avatar_m_tn

pisa is my hospital so as soon as bms plans for hbeag negative too i will be the first in the list....
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Avatar_m_tn
will you then need to be constantly monitored? I mean do u need to go there once a week or so?
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Avatar_m_tn

dont know it depends on the trial design, but generally it is monthly tests and maybe you can do the tests at a close hospital

but if you are in sothern italy you have to check because below rome/sardinia hospitals are mad houses and you have to double check everything.
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Avatar_m_tn
thx stef.. we shall go on private messaging.. grazie!
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Avatar_m_tn
collected my monthly labs

AST 220
ALT 689
GGT 197
..omg..
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Avatar_m_tn
latest

AST 243
ALT 717
GGT 203..

wondering if at the end of this flares I might turn into eag-....Stef and anybody else's thouthgs are welcome..
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Avatar_m_tn
correlating your age with your blood tests it is possible that now you are in Immune Clarence phase and at the end you go on HBe negative or Hbs negative.

do you have also some otehr tests results ? (qhbsag, hbvdna, fibroscan, ....)
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Avatar_m_tn

u just need to monitor hbsag quant and hbvdna, if both lowering you will seroconvert

osp riuniti bergamo, makes hbsag quant in 2-3 days with internet delivery.hbvdna 1-2 weeks

fibroguard/heptoboost may help if platlets, pt and liver functin are getting worst
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Avatar_m_tn

Well Stef, the problem is that my VL has always been >100000000… so it’s out of range and non countable…. It could be 100000001 or 200000000 so ) do not know how long it takes to go under those limit…

Will try to get Hbsag quant done within December….  
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Avatar_m_tn

get the test done at bergamo, they got the new assay with sensibility 10iu/ml to 180billions o cmqe arriva a bilioni, mentre prima si fermava a 100 milioni
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Avatar_m_tn
thx to all u guys.

So far I'm getting blood tests done evrey 10 days and have started takin milk thistle and vitamin D3 supplements to weaken the virus...

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Avatar_m_tn

by the way check new posts about coffee 4-5 cups a day and vitamin d3 on fibrosis, they are also useful on that

it is also good to lower cholesterol, i posted a study time ago about the link of cholesterol, low vit d3 and insuline resistance on fibrosis development, so supplements like red yeast rice (biostatine) 1 pill a day and low sugar intake and moderate excerccise can all help a little in your situation
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Avatar_m_tn
thx Stefano.... coffee wise I'm ok.. I use to drink plenty of Espresso!!!!
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Avatar_m_tn
got latees VIT25DOH values...23.. is that pretty low isn't it? Shoud I get it to 80/100 right?
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Avatar_m_tn
got latees VIT25DOH values...23.. is that pretty low isn't it?

yes it is very low as in all patients with cronic (chronic) diseases.me and my sister had it at 11ng/ml....

Shoud I get it to 80/100 right?
yes, 10000iu daily necessary and then recheck in 1-2 months.to reach that amount you need dibase liquid.they say to take 2000iu daily but that's for healthy people for us only 10000iu daily can work

if you can afford recheck it every 4 weeks bot vit d25oh and calcium otherwise recheck in 8 weeks.it is about 16euros but some private labs charge even 25 euro or more.
it is lso better to go to a private lab because you pay the same with doc prescription, it is not covered by healthcare
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Avatar_m_tn
you are sure about testing D3 ?

as far as I know they are 2 diferent test for vitamin D
- 1,25-(OH)2-VITAMINA D3
- 25-OH-VITAMINA D

and for your test name it look that you have the second, double check if you got the correct one (D3)
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Avatar_m_tn

attention:
1,25-(OH)2-VITAMINA D3 this test is not needed, it doesn t reflect deficency.ini taly it is extremely expensive and some hospitals dont do it, so no problems to confuse

- 25-OH-VITAMINA D
this is always vitamin d3 which is the only ntural vitamin we have in our blood, some tests detect both d2+d3 but since d2 is only chemical there is no possibility to have wrong readings

remember to avoid the chemical type of vitamin d2 which is not effective, in italy you need prescription for this one and it is not used at all, so again difficult to make confusion.other countires may still use d2, i think this is just to make confusion i see there is a drug makers push in US against vit d3 and correct doses and serum blood ranges, so in US you have to watch out, in italy everything is normal and europe probably too

some old tests still use max normal range 10-62ng/ml, the new tests have correct ranges 35-100ng/ml or 40-100ng/ml
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Avatar_m_tn
thanks for pointing this out.

i was under the impresion that 1,25-(OH)2-VITAMINA D3 is the correct one and not 25-OH-VITAMINA D, so i learn something today :)
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Avatar_m_tn
let's get it to 80 and see...

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Avatar_m_tn
I also wanted to post the following question:  as you see by reading the whole thread I went through an 8months lasting MONO PEG-INTERFERON 180 back in 2008/2009… no side effects at all but it didn’t work so still eag+ and VL >100000000…

The question is: may I have gotten any benefits even if it didn’t’ work? May my immune system have been boosted?
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Avatar_m_tn

if you have no sides at all interferon is not doing a thing, it was all blocked by hbv
the sides effects are due to immune activation so most of them without any side are having no effect at all
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Avatar_m_tn
sounds like I've never made any tx...
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Avatar_m_tn
update 8/11/11:

- AST 118
- ALT 380
- GGT 180

PT: 124 (80-120) ---> high

transaminasis vbalues went down, started milk thistle and vit D3 supplemntes..

any support is highly appreciated...
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Avatar_m_tn

what about hbvdna and hbsag?they should be down too

when hbsag and hbvdna gets down to low levels it is the best time to attck with tenofovir or interferon
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Avatar_m_tn
well stef... will check them in Dec... toggetehr with an Ultra sound... believe me I really wish I could switch to eag-...
do not want to start again ifn tx due to side effects... and i read also TFV has got quite a few of side effects..

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Avatar_m_tn

in the end both etv and tnf have no sides on hbv patients, very very few can have an increase on creatinine

hbeag negative is not becoming free of hbv, it is achived by precore mutations it is worst than you are now with more liver damage and less response on therapy, the time to attack hbv to get rid of it is exactly when you turn from hbeag pos to hbe neg

sine when i was 17yo i was hbeag neg and hbvdna und, this has made no difference to get many mutants along the way and cirrhosis too, so do not be fooled by getting hbe neg and hbvdna und for sometime, it is not a goal....the only goal is to treat to get hbsag low and hbvdna und
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Avatar_m_tn

i am telling you this because while you may think hbeag neg can give you sometime without thinking about a therapy, hbv builds up new mutants during this period and it is not a good choice to allow this

only getting hbsag to 500-1500iu/ml after hbeag neg can be a sing of real inactive hbv and quite safe, not just hbeag neg
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Avatar_m_tn
Many thanks for your valuable suggestions, much appreciate your efforts.

However I recall reading somewhere the end point for Hbeag+ patient IFN therapy was the seroconversions to eag - ..wasn’t it?
Only for eag – patients the goals was to get rid of Hbsag…

Really do not know what to hope… serocovnersions to eag- or keeping eag+ status which has better response to tx..
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Avatar_m_tn
collected last weekly labs

ALT 111
AST 372
GGT 113

PT now in the range 111 (80-120)... so I beleive this means liver is making his function... isn't it..??
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Avatar_m_tn
i will meet doctors in the next days.. really do not want to ga back to ifn... i'll push on TFV /ETV but before this I'd need to get checked for precore mutation rigth?

In case they want me to restart IFN may I have no sx as I did some years ago???
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Avatar_m_tn

the hbeag vision is from adecade ago without no studies, we now know that hbeag negative is still cronic (chronic) hbv with liver damage unless hsag is less than 1500iu/ml, if it is higher the hbvdna und with no liver damage is just for the moment while a low hbsag is a truly inactive carrier.so hbeag worsths nothing now as diagnosis but as long as hbeag is positive you can get rid of hbsag with very high chances on the contrary hbeag neg has very very poor chances

so i do suggest to start tenofovir and see if it is potent enough to lower hbvdna ina short time, otherwise i do suggest to see many liver specialists until you find one for the combo, they have instructions not to use the combo because too expensive for healthcare...i had to push a lot even if i am cirrhosis stage where combo si almost on guidelines because resistance can be deadly at my stage
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Avatar_m_tn

when do you get hbsag nad hbvdna?at ospedali riuniti di bergamo, hbsag about 3 days, hbvdna about 7-13 days
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Avatar_m_tn
latest labs ALT 320 AST 100 GGT 103
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Avatar_m_tn
maybe you should put your ALT / AST / GT / PT / VIT D / VL ..in a tabel and maybe a pattern will be visible.

BTW on the Nov 15, 2011 post you maybe switch ALT value with AST value - just double check.

on the other hand I can see that a maximum was ereach in Oct and now it start to decline (I guess that you are in the last part of immune clerance phase  and maybe a e seorconevrsion can happening )
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Avatar_m_tn
hi all,

got latest lab

AST 70
ALT 240
GGT 76
EAG +
anti-hbe -
VL >1000000000 (out of range)
PT 117 (80-120)

so far I see i'm still eag+ so he combo tx tdf+pega may have higher success rates.. I believe I can start this next month..

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Avatar_m_tn

sorry it got even worst, you lost the little immunity you were achieveing

to me the best option would be tdf+etv 1 year and then tdf+interferon.this because hbeag and hbvdna so high destroy all hbv immune response.by lowering hbvdna to und by tdf+etv (one antiviral only is too weak on such high hbvdna) will rescue your immune response so that interferon add-on when hbvdna und will work

if you use tdf+interferon from begining you will probably have:
hbvdna and hbeag high anyway even in 6-12months
as antiviral rescue some immune response ast/alt may get elevated
interferon will make ast/alt elevated

by sequential strategy you avoid the flares and optimize interferon response
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Avatar_m_tn

it may also happen that tdf makes hbvdna und in 3 months but this is rare, in this case interferon+tdf can work
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Avatar_m_tn
thx stef for replying.. I'm in fact startin with tdf for some weeks/months and then adding ifn... anyhow you're right alt is getting lower but still really out of  range.. isnt this meaning some immune repsonse is still on?
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Avatar_m_tn

yes you are not totally immune tollerant but that little immune response is of n o help
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Avatar_m_tn
thx again stef.

so what is reccomendable now? would it be better wait again? I do belive doctors will suggest combo tx.. starting tfv and then add on pega.. 115 or 180 as last time I got low platelettese values so I had to reduce from 180 to 115..
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Avatar_m_tn

start l-carnitine which will keep platlets higher and go as doctors said tdf first and then add on interferon

i will be starting around february too, i will be doing gcmaf atthe same time, the reports of gcmaf are that it even prevents chemios sides so i guess it will help me with interferon too
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Avatar_m_tn
so we're starting more or less at the same time..
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Avatar_m_tn
here i am my fellows... got latest labs.. not so good mates..

AST 85 h
ALT 308 h
GGT 78 h
Pt 115
VL >1000000000 (out of range)
Colesterol 223 h (120-20)

you see the only one inside the range is pt.. i believe this refers to liver functionality...

What surprised me is the cholesterol which for me seems a little unussal as i'm 26yo and live a healthy life style..no fatty food meals nor alcohol abuse..

any feedback is welcome..

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Avatar_m_tn
sorry colesterol range is 120-200... :)
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Avatar_m_tn

cholesterol is controlled by hbv, cholesterol genes are changed by hbv to make its antigens

re check platlets 115 is extremely low, lowest normal range is 150.if so low start tenofovir as soon as possible and l carnitine.low plt means a lot of damage is being done in the liver

if plt doesn t get in normal range and hbvdna gets low fast by 6 months do ask for tdf+etv combo and then interferon add on, jus tlike i am doing, tdf+etv are very fast to make hbvdna und by 6 months even when so high.interferon with low platlets is a problem
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Avatar_m_tn
Pt was (protrombina). Platelettes are arounf 190

so should I worry for cholesterol?
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Avatar_m_tn

sorry confused it because it should be 1.15

you can use biostatine, it is a red yeast rice supplement, it will ower cholesterol in about 20-30 days, this way you will weaken a little hbv and you will respond better to therapies.once you start therapy you can stop biostatine or lower it to one pill a day
biostatine can be found in farmacia, eroristeria, parafarmacie, it doens t need prescription.use that brand only because it is not sure all red yeast supplements work.i hve seen them at auchan and coop but dont know how reliable other brands are
if doctor agrees you may also use simvastatin with prescription but only updated doctors know use of sim is safe, so you using biostatine is easier

of course do not keep chol so high, there is an increased risk of arterosclerosis and chol related diseases in hbsag carriers because hbv upregulates genes
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Avatar_m_tn
is that harmful? may it be caused by VIT d3 i'm currenlty intaking 10000 daily?
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Avatar_m_tn

no vitamin d3 is protecting your liver from fibrosis and severe liver daamge as clearly shown by a poster at the liver meeting.the liver with vit d reached f1-f2 fibrosis while the others got advanced nodular cirrhosis

high cholesterol and platlets 190.000 are due to hbv, keep in mind that also cholesterol promotes fibrosis and liver damage, it is all linked with hbv and damage.making cholesterol lower you will also prevent fibrosis

by the way i also had tot chol 218 when i had  hbvdna 580.000iu/ml and alt 600, while it decreased to normal with hbvdna und
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Avatar_m_tn

of course my hbvdna and hbsag are much lower than yours because my immune system is much more active, but in my case hbv escaped most of my response

in ur case the chances of success with therapy are higher because you dont have a good immune response yet, so hbv has not mutated yet to escape it

so tdf will make hbvdna und and make some immune response

interferon will boost that little immune response to clear hbv

having hbvdna nd will make impossible for hbv to mutate and escape your response

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Avatar_m_tn
just a further advice... what about dringkn beer/glass of wine in such conditions once a week (1 glass on meals)?
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Avatar_m_tn

definitely poison for us, avoid absolutely

it also decreases immune system damaging dentric cells that are already non reactive to hbv
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Avatar_m_tn
neither once weekly?
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Avatar_m_tn

none, my first acute flare at 19yo was due to drinking even if once a week
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Avatar_m_tn
... so of course i do not mean getting drunk, for sure.. only a glass on meals...

none at all.... :(
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Avatar_m_tn

go for none at all now if you can
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