Immune tolerant or break immune tolerant phase?

[freewind2013]

Hi everyone
  I am a chronic hepatitis b carrier, probably type B or C, since born. I am 25 years old right now.  My recent check shows  HBsAG and HBeAg are positive with high HBV DNA count. My ALT is normal as defined by my family doctor (i didnt check the exact number). Not sure of AST.  My doctor said I am still in immune tolerant state.  I am wondering of following questions
1. its is possible to stay in immune tolerant state for lifetime? (from research paper i read, most of ppl enter immune  clearing phase in 30 to 40s, so my guess is not?? i need confirmations)
2. Is it better to stay in immune tolerant phase or to break immune tolerant state? ( for this question, i cant rationalize a good answer. Since in immune tolerant phase, there is minimal liver damage, but high viral replication and high viral load (high HBV DNA). Minimal liver damage is always a good thing I guess. IN THE OTHER HAND,  breaking of immune tolerant state means high degree of liver inflammation for a period of time with HBeAg seroconversion and low HBV DNA. After immune tolerant most of people enters inactive (HBeAg negative) carrier stage (low HBV DNA, normal ALT)  and maintains that way. So low HBV DNA is also a good sign. Then which one is favoured???)
3. If breaking immune tolerant state is favourable,
    a) how to break it (increase in immune system? taking drug?)
    b) how to mimic liver damage during immune clearing phase (that is my major concern here)
4. Does entering immune clearing phase define as a Hepatitis B patient instead of carrier then? ( or the term carrier does not really mean anything)

Hopefully someone can give me advises to those question while i look deeper into individual research paper.
Thank you in advance.

[stef2011]

http://www.medhelp.org/posts/Hepatitis-B/HbsAg-quantity-in-Phnom-penh--Cambodia-or-Ho-Chi-Minh-City---Vietname/show/1430388

as regards vietnam a member had a very good experience with a very good doctor better than what is available in US as regards tests and drugs

[kinetix1208]

Thanks a lot for all the inputs, i'll weigh things up considering all of this.
cost of flights, chances of having a doctor in other countries, availability of drugs, etc.

Maybe in a few years, tenofovir will be available here because of high rates of hiv cases seen every month.

[stef2011]

maybe u ll never reach any fibrosis, ast/alt and hbvdna are not correlated with fibrosis on hbeag pos

check the cost of flights, laws in ur country about taking your drugs and prescriptions in india or vietnam which have genrics

i think the main problem of philippines is corruption since you have no healthcare you should use indian generics only otherwise it is obvious you dye of liver diseases if you cannot afford US drugs you must take the generics not dye

[kinetix1208]

you're right, it's good to clear hbv rather for the liver.
but it's really a dilemma for me, i don't want to take etv either. If only i have access to all those things, tdf+pegintf, i would really like to do it.
but in our case, most Filipinos will just die from liver diseases, i'm lucky enough to have enough income and somehow manage to monitor my condition.

That's why many alternative medicines here are marketed just to give hope to other hbvers who can't afford medicine.

Anyway, i really wanted to take tdf but no access to it. I'm thinking of what you have said in getting off to other countries and have prescription on tdf. I don't know if how many months i will get a prescription.

From experience, how many months will it take in my condition to be in advanced fibrosis stage?

[stef2011]

you have probably no damage to the liver, on hbeag pos hbvdna and alt levels are not correlated with liver damage, you are also young, you shoould go to treatment just as a precaution and to clear hbv

most doctors initaly probably would monitor or put you on pegintf+tdf like gmr, tdf to lower hbvdna and when very low add on pegitf.this is about 6 months tdf and then tdf+pegintf
another choise can be tdf+etv to make hbvdna und in  a very short time since yours is too high and then tdf+pegintf, it all depends on updated and experience docs being available

making just etv can be very wrong because you are too young and taking nucs for most of your life is not good, i d treat to try to clear hbv not for the liver

[kinetix1208]

Being in immune clearance phase is really something, and i guess hard to manage.

Aside from biopsy, is ultrasound ok for me to be tested? Or will be just the same result with the fibroscan? since liver is inflammed. I never had an ultrasound before.

[stef2011]

not only researchers this is routine in italy since nucs mono is useless most doctors are making combo just like for hcv.
we are probably very different because all hbv drugs are free of charge so less problems as regards costs/health insurance which doesn t pratically exsist in italy

[kinetix1208]

Probably we don't have the resistance test but i will ask.

HBsAg quantification is i guess available here, the doctor mentioned about it and told me to do it, it is available here in one laboratory. but i'll confirm it if it is abbott architect.

[StephenCastlecrag]

With high ALT, your liver is inflamed, Fibroscan cannot give you a reliable indication of your fibrosis stage. An experienced liver doctor may be able to, but as the report clearly said - it is a grey area. So you have to wait until your ALT is normal to do another Fibroscan, or you do a biopsy.

[kinetix1208]

But if there is really no choice, can i take the etv?  just to lower down my ALT and HBVDNA? Probably my concern right now is to minimize the liver damage and getting into cirrhosis.

And after a while, if i can get a prescription on tdf, i'll just switch from etv to tdf? Is this just ok?

[StephenCastlecrag]

Mmm, I disagree. It is true that transition from Immune Tolerance to Immune Clearance phase is most likely to be caused by accumulated genetic changes related to the e-antigen. Some research indicates a rise in the percentage of precore mutants before seroconversion. This was a troubling thought as it implies all natural seroconversions will lead inevitably to chronic HBeAg negative hepatitis. However, I read a latest research by Timonthy Block of HBF that the percentage of precore mutants decreases after seroconversion. All these are based on my own understanding, so it can be totally wrong. I think we still need more research.

However, there are numerous papers that indicate natural seroconversion is more durable and many patients do remain in the Inactive phase for a long long time.

As for Tenofovir  first and then Interferon, this treatment will take at least several years - at least few years of Tenofovir to reduce viral load to undetectable then at least 48 weeks of Interferon. I know your local researchers are very confident about this treatment, I would still like to see the results from a large group of patients, their baseline characteristics, especially genotypes, to be sure.

[kinetix1208]

it is also indicated in the comment:
-----------
A liver stiffness value of 11.9kPa falls within the gray zone. While this may be indicative of intermediate fibrosis (Metavir F2-F3), liver fibrosis assessment is less realiable within the gray zone. Correlation with other clinical parameters including a liver biopsy should be considered.
-----------
so is this normal with high ALT?

[kinetix1208]

Currently my hbvdna is > 110,000,000 IU/ml and sgpt is 852.18 U/L

[stef2011]

e natural seroconversion is not ok because most of these seroconversions are bcp or precore mutant while on treatment it is possible to avoid this, i think the best is gmr treatment, tenofovir first and then interferon add on

do not use etv because hbv clearance is about 5% vs 16% of tenofovir and with intf add on it gets to 24%, i have no idea about the cost of the flights in asia but in europe there are many low costs flights less expensive than a bus ticket, take a flight to vietnam or any close country to see a doctor and get tdf prescription

[4est]

as stef2011 and  StephenCastlecrag already notice high ALT can cause that  Fibroscan result to be not than accurate, also this is specify on your list result "For Hepatitis B with elevated ALT".

[4est]

how about your ALT and HBV DNA (do you have any new result on this)?

[StephenCastlecrag]

Stef2011 will give you better  comment. Because your ALT is elevated, Fibroscan is not than accurate, as you can see only 1.4 (13.3 - 12.0) kpa between minimal fibrosis to Cirrhosis. Because of your ALT (800), you are most likely in the Immune Clearance phase - the question is: can you achieve the e Antigen seroconversion naturally?

[stef2011]

how is it possible you have no hiv drugs in the philippines?my opinion is they dont work on hiv but i dont see why they are not sold in the philippines

[stef2011]

if your alt is 800 fibroscan is not reliable now because most of the reading can be inflammation, you have to retest in 6months when alt is less than 200 and inflammtion is less, better start treatment anyway

is it ok to take entecavir? does it lessen the chance of getting into cirrhosis?

it is ok if you can make resistance test, is it available in the philippines?this because if you have    the resistance to entecavir is more than 50% while tenofovir doesn t require this test because it has no resistance

around 10% hbvers carries lam mutants
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1803124/

[kinetix1208]

just got my result from fibroscan, it's 11.9kpa, very high, and according to
the result:

For Hepatitis B with elevated ALT:
Minimal or No Fibrosis  = 7.5 - 12.0
Advanced Fibrosis >12.0 - 13.4
Cirrhosis > 13.4

so i'm in the gray zone, but close to advanced fribrosis. now i'm scared.
what should i do the normalize my liver?

the doctor told me to take entecavir, i talked about tenofovir but hesistant in prescribing it to me since this is not approved yet in the Philippines, this is sad.

is it ok to take entecavir? does it lessen the chance of getting into cirrhosis?

I hope i was still in immune tolerant phase. :(

[judas13]

   it sad to say that some of our doctors here in the philippines are not so good to handle HBV patients and it happened to me personally that makes me doubtful and cautious about thier profession. this case is very rampant now in our country and our government do nothing about this. very FRUSTRATING.!
  im very thankful i came up this forum ,it gave me a lots of informations and educates me as well that i cannot find to some ignorant doctors.!
pls let me know if you find a good doctor.
  

[stef2011]

you can also add that hbv clearance on hbeag positive is irrelevant on entecavir and 16% on tenofovir at 3years, so entecavir is a total failure also in clearance rates in your case

the highest clearance was on tenofovir+peginterferon like gmr treatment, it reached 24% hbv clearance in ashort time, dont remember if 6 or 12 months, this 24% could rise much more in  personalized hbsag tdf+pegintf long term treatment like tdf+pegintf for 2 years or more

[kinetix1208]

I'll try to talk to the doctor about this, she is a new doctor to me because i keep on changing doctors everytime i notice that they don't know anything. Hopefully it would be a good discussion, i'll ask her about tenofovir and her thoughts about it.

There is a fibroscan in the hospital but i will also confirm it. Hoping also that they have test for hbsag quant in iu/ml as well.

Thanks a lot.

[stef2011]

i guess the best way is get a big pharmacy in the philippines to get it for you after you find a doc to prescribe and monitor or directly move to a close country for monitoring since you even miss all the tests to monitor response in the philippines

i remember vietnam goverment pharmacies started generic cheap peginterferon too and they have all tests like hbsag quant, hbvdna and fibroscan to monitor