LAM+ADV - Rescue Drug if resistance develop...?

Will LAM+ADV leads you to no rescue drug in future? I have been thinking about this for a while....if LAM & ADV will reduce the effectiveness of Baraclude & Tenofovir which are the 1st line treatment with high resistance barrier currently. Unless combo produces different resistance profile......Anyone ever post this Qs to Hepatologist? Pls share..... The reason I asked was my Hepatologist ask me how long could I go on antiviral medication w/o resistance!!! He seems to know something that I don't.....

[Ann8]

just to add in some doubts I missed out - combo will definitely increase the drug resistance but for how long......can Baraclude & Tenofovir be used again if the resistance do develop after certain period of time.

[cajim]

I think your doubts are valid.

It is true that Baraclude & Tenofovir are more potent against VL and resistance than LAM+ADV.  It is also true that the latter have a longer use history therefore more data for analysis.  Could it be just a matter of time when resistance to the former become a challenge?

[stevenNYer]

From what I read and understanding, if you develop resistance to LAM and ADV, ETV and TDF will still work but its resistance profile take a serious hit.  I think this is still being researched.

That's why if you need long term treatment, I don't think people should chance it.  Combo with ETV and TDF as firstline is my thinking.

[Peteshine]

Ok guys,

You are now scaring me..... I am actually on combo treatment: Lumudivine + Adevoir.... I had a call from hepotologist nurse yesterday to check up and also to say they are sending new blood forms out.... My VL has gone done significantly but they are also detecting slight liver irritation..... If for some reason the treatment i am on now isn't effective (as anticipated b4 with interferon) does this mean i will be left with pretty much no more option for treatment? I have also asked for my up-to-date results which i will be posting shortly.....

[Peteshine]

Just another quick question:

Do you think the fact that patients are given different types of combo-treatment because of the cost? Here in the UK it would seem we are given a years supply of Pegy interferon, if that doesn't work its straight onto combo treatment: Lum + Ade.... However, reading on this forum i have seen a complete different approach in other countries for treatment.... My combo is hardly ever mentioned so i am thinking it might have something to do with the cost / NHS where med is free but possibly not the best medication for everyone to benefit afrom due to the cost/patient.... For my next meeting i will possibly mention changing to Bara or Teno..... Are these two much less likely to prevent resistance over the same period of time compared to the ones i am on?

[cajim]

Your inferencing is logical.  In a socialist system universal coverage is provided so it is impossible to provide all with the best typically the most expensive treatment options.  Usually the most cost-effective option is given.  We know Baraclude & Tenofovir are more expensive than LAM+ADV so are their potency.  Hopefully your doctor can value the potency more than the cost of Baraclude & Tenofovir.

After combo treatments the literature talks about other treatments too but hopefully Baraclude & Tenofovir will get the job done.

Best wish.

[stevenNYer]

"Do you think the fact that patients are given different types of combo-treatment because of the cost?"

People usually don't want to admit it but I would say "yes".

The treatment model is way too conservative.  It focuses on lowering DNA (whihc is a good goal and in truth monotherapy will help most achieve this goal), but most don't understand to consider the duration of treatment which makes the resistance issue real important.

I forget your labs but at 27 and Asian birth infected, I would question the logic to treat in the first place.  And since you are combo-ing with LAM and ADV and still have dectectable DNA, I would strongely advocate for ETV + TDF or at least ETV + ADV (if your doctor feels you need long term treatment).  With detectable DNA, you are at higher risk for resistance.  And despite the risk being low, it should still be addressed.  My lay opinion anyway.  

[Peteshine]

So would it be better to either suggest the other forms of combo as listed or to stop medication altogether and see how everything pans out, considering how low my VL actually is.... I have been told more than once that with my personal stats most are not even considered for treatment.... If i stop treatment whats the likelihood i will go to seri-co stage?

[cajim]

To stop HBV treatment, you need to be careful and monitored by the doctor.

[Ann8]

I hv a Q for you :

Did yr Peginterferon alfa-2a treatment brought down the VL? Some clinical trails are pointing to long lasting effects up to fourth year, could it be peg still holding down your VL?

I remembered u said yr ALT was high+high VL, this prompted start of treament so pls work with your Dr before changing the course.....

[Peteshine]

I will have to get back to you in regards to what the Inter-feron actually did for my VL... I was still quite new to HBV and didn't really kno what to look out or expect during the 12 month course... Now that i have a better idea i will definately find out and post for all to see. I think the VL has actually decreased more with the combo-tablet/med i have recently started as of April-May time... i understand this is usually normal when going on tablet form... Its just the fact that i literally jumped down to hundreds from millions that boggle's me..... has anyone else had the same results?

[Ann8]

I hvn't started my treament yet as my ALT is still in the range of 40+ (last 46). I believe Steven VL dropped to UND after combo. You might want to ask your Hepatologist why yr VL still in 600+ range......

[stevenNYer]

"I believe Steven VL dropped to UND after combo."

Yes.  I mono with ADV for over a year but could get it UND.  I think it because I'm still e+ with limited natural immuno-response.  Now if I was prescribed ETV to start with, I might have reached UND since my VL was about 3 million copies (which is low for e+).  If I knew then what I know now, I would have asked for ETV.  When I was diagnosed, HBV was completely new to me, didn't know a thing.  PCP who Dx me actually gave me a LAM prescription.  I decided to see a GI for a second opinion (don't know why I decided on that but was very glad I did).  My GI said no to LAM, and changed it to ADV.  It's no ETV but at least I didn't go with LAM (especially being e+).  Also, my GI didn't want maintain me on combo ETV & ADV. But I asked to switch ADV to TDF, which in the end, my GI agreed to.

[stevenNYer]

Type alert (again) :

Yes.  I mono with ADV for over a year but COULDN'T get it UND.

[stevenNYer]

And...

Also, my GI WANTED to maintain me on combo ETV & ADV.  But I asked to switch ADV to TDF, which in the end, my GI agreed to.

[Peteshine]

Does anyone even know if Baraclude & Tenofovir is available in the UK?

To answer Ann8:

'Did yr Peginterferon alfa-2a treatment brought down the VL? Some clinical trails are pointing to long lasting effects up to fourth year, could it be peg still holding down your VL? '

I don't believe there was a drastic decline in my VL when on peg interferon...

[cajim]

Uxbridge, UK, 25th June 2008 – NICE (National Institute for Health and Clinical Excellence) has announced today, in its Final Appraisal Determination (FAD), that Baraclude® (entecavir) is recommended as an option for treatment of eligible patients with chronic hepatitis B (CHB). Entecavir is a potent anti-viral treatment for chronic Hepatitis B that has been shown to be more effective at suppressing the virus than the most widely used anti-viral treatment (lamivudine)1 and is less prone to the development of treatment resistance.2 The recommendation in this FAD is due to be published as final NICE guidance in August of this year.

[cajim]

Tenofovir is not approved in US for HepB either.  But doctors have access to it.  Our Steven is using it already.

[Ann8]

Baraclude is definitely approved in UK but Tenofovir needs off label prescription.