Pegasys or antivirals

[calmama]

Hi, I am a new member of this forum, although I have been reading the posts for a while.
My Hep b history: 42-yr-old asian female living in Ca, usa.  probably got hep b at birth from my mom in Taiwan. ALT had been normal(<19) until Jan. 2011.  Here's the recent trend:
1/28/2011 alt 34 (std 0-33)  ast 27 (std 0-32)
4/8/2011  alt 37  ast 28
6/9/2011 alt 59  ast 37
7/15/2011 alt 28  ast 24
10/18/2011 alt 45  ast 36

Hep b dna:
4/1/2011  305 iu/ml
10/18/2011  6719 iu/ml

HbeAg negative, HbeAb positive
liver biopsy: normal, no damage
No genotyping done (dr said it would not change his treatment suggestions).
Other tests turned out normal.

My hepatologist gave me 2 treatment options:  Take an antiviral for the rest of my life or I can give Pegasys a try.  8% success rate for eAg-neg.  He said for an otherwise healthy young patient like me, the side effects might not be bad.  I can stop anytime I want without consequences.  It will likely fail.  At that time, we can take up on antivirals.

I don't know if 8% is worth a year of trouble.  My main concern is the CNS effects of interferon.  I have 2 very young children (a kindergartener and a 10-month-old) to take care of.  Will the depression/irritability/anxiety affect my relationship with them?  Will I be able to take good care of them during the treatment?  Should I just take the antivirals?

I will see my dr and another 2nd-opinion-doctor in Dec.  Before that, I want to be very informed so I can make the best decision.  Please advise.  Thank you.
          

[stef2011]

hbsag gets lower by a stable nucs regimen, this is why they presented with lower hbsag

[April9903]

Please check the following link for hbsag quantification.

http://www.medhelp.org/posts/Hepatitis-B/find-a-lab-with-hbsag-quantification-in-india/show/1607342

http://www.medhelp.org/posts/Hepatitis-B/hbsag-quant-in-india/show/1472093

[calmama]

To stef,

Thank you for the references.  I read the article about "add -on of peg interferon to a stable nucleoside leading to hbsag loss in 40% patients".  One interesting point I noticed in the abstract was that the median baseline HBsAg was 660 iu/ml (range 50-1754).  If I remember right, people with HBsAg <1500 iu/ml responded to interferon therapy better.  So were these 10 patients in the study specially selected based on their HBsAg level?  If the sample size is bigger and more random (ie. including patients with higher HBsAg level), will the response rate still high?

Another thing, which indian lab is reliable and affordable if I want to ship a blood sample for hbsag quantification?  Thank you.

[stef2011]

these articles are mostly coming out from 2010 liver meetings in europe and US

[stef2011]

statins can decrease fibrogenic activity

http://www.medhelp.org/posts/Hepatitis-B/statins-can-decrease-fibrogenetic-activity-/show/1618469

Add -on of peg interferon to a stable nucleoside, hbsag loss 40%

http://www.medhelp.org/posts/Hepatitis-B/Add--on-of-peg-interferon-to-a-stable-nucleoside--hbsag-loss-40/show/1616137

sim and nucs (talks about HCC study at the end of document with links to the actual study)

http://www.todaysdietitian.com/newarchives/060111p32.shtml

http://www.sawfnews.com/Health/57941.aspx

(diabetes has the highest risk of liver cancer, incredibly higher than hbv/hcv)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677134/

https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B_yFgxI8KNcRMzMxN2NhNTUtMzgzNC00MGJjLWE3MWMtOTk5MzlhYjNkM2E2&hl=en_US

if you google you can find the actual study of US army taking simvastatin for years and results of hcc reduced risk

[calmama]

Thank you for the comments.

I will try to educate myself as much as I can and update my results.

[calmama]

Thank you for your quick response.

I will have a physical exam next week to check my current vit D and cholesterol level.  My vit D level in Feb, 2011 was in the 20s.  I have been taking supplement every day since then.  I haven't checked my cholesterol for almost 2 years (because of pregnancy).  But previously it had been ~170 with hdl 60-80 and ldl in the 90s.  Exercise seemed to boost my hdl from 60s to 70s but had less effect on lowering ldl.  Can you give me the reference about simvastatin's HCC prevention?  I would like to read about it and if needed present it to my doctors.

'pretreatment for 1-2 years with tenofovir, keeping hbvdna fully suppressed for 1-2 years has taken interferon response on combo to 40%, even interferon monotherapy non responders were responders after long time hbvdna suppression by nucs'

Can you give me the reference article(s) about this as well?

Many many thanks.

[4est]

have a look on this link http://www.hepbnet.org/ maybe it will help you to chose for the 2'nd opinion.

[4est]

have a look also on this: http://www.medhelp.org/posts/Hepatitis-B/Sport-and-HBV/show/1617515#post_7354260

maybe a moderate exercise program will be a good option before starting a treatment (and maybe during - but confirm this with a doctor)

also try to have regular coffee (check with your doctor in case of hypertension ...) but if no other concern exist coffee is a good thing - it reduce the fibrosis and during the interferon treatment it reduce the side effects (http://www.aidsmap.com/Coffee-consumption-reduces-side-effects-in-people-on-hepatitis-C-treatment/page/2074096/ - this is for C, but i think that is apply also for B)

try to read also the posts from ASALD and EASL from the last years and you will see that more and more study and  favorable reports are coming from combo and not from mono treatment option, so in my opinion combo treatment will be the next guideline and also this will contain a exit strategy for antivirals.

2'nd opinion is a good thing and try to find a good doctor that has time to discuss and explain to you and challenge the doctor with the results from study, conferences ....

... and let us know what they say and what you decide (it will be a learn for all of us) !

[StephenCastlecrag]

Hi Calmama,

I am not a doctor, so these are just my personal comments.

I think a second opinion is a good move, and hopefully it is another liver specialist. You can visit the HBF website (www.hepb.org), they have a list of Hepatitis B specialists in the USA.

The main CNS effect of Interferon is depression. This is unlikely if you don't have a previous history of depression. It can be remedied by taking anti-depressant during treatment.

Generally, Interferon is more effective for Genotype A, then B, then C. You are most likely B or C. But it works better for female than male. Also Interferon works best when your ALT is higher (yours is not too high) and low hbv dna (yours is low).  But then it is a finite course of treatment and is supposed to have long-term beneficial effect. It is a weekly injection, and most people work, study, and carry on as normal when they are on treatment.

As for taking antiviral for life, that is the "old" thinking. Criteria for stopping antivirals are now emerging, so I think a second opinion is a good idea.

Finally, I noticed you have a 10-month-old baby. During pregnancy, your immune system is suppressed (for the obvious reason), so this may be a factor for the changes in your ALT and hbvdna. I also notice your ALT is coming down the peak of 54. So observing for another 6 months may be another option?

As you can read, I have raised more issues for you than an answer. I hope you can discuss all this with your doctors, and let us know what they say (we all want to learn).

Cheers and all the very best.

[stef2011]

by the way another big mistake of liver specialist (is he saving money for the insurance company??)

genotype is basilar, some genotypes have higher response rates on interferon than 8% (geno A is 11% even mono at 1-5 years).geno b and c have higher hcc risk so treatment is more important if not mandatory when fibroscan gets higher than 8kpa

hbv sequnse is also absolutely necessary to know which antiviral can have best results, resistance mutations are easily already present in cccdna before treatment but if tenofovir is used this can be skipped

bcp and precore mutations, extremely important, hcc risk is increased and therapy might be important dispite no liver damage

[stef2011]

how to weaken hbv before interferon:

making vitamn d levels optimum, this is a general thing to do but on hbvers and willing to do interferon is a must because hbv down regulates vit d too (it is a guess but all viral infections have low vit d so it is probably viruses to depress immune function), check all posts about vit d3 here

vitamin d25oh>50ng/ml, supplements 5000-10000iu needed, calcium and vit25oh checked every months or every 2 months

simvastain treatment to lower cholesterol to:
tot cho<150mg/dl
ldl60mg/dl, hdl has been found to have antiviral effect when >60, but this doesnt increase or decrease interferon results

simvastatin requires alt/ast, cpk, creatinine monthly monitoring, it helps prevent hcc, fibrosis and cirrhosis, it is used on cirrhosis patients to improve liver function and it is antiviral with same potency as tenofovir at least in vitro
interferon works by lowering intracellular cholesterol so this will increase interferon response.sim is always helpful at least for the well proven hcc prevention, heanced liver function and fibrosis prevention

alinia, this has been shown to act same as interferon henancing interferon response in combo, but this is useful only when you will start interferon not earlier

pretreatment for 1-2 years with tenofovir, keeping hbvdna fully suppressed for 1-2 years has taken interferon response on combo to 40%, even interferon monotherapy non responders were responders after long time hbvdna suppression by nucs

[stef2011]

follow posts here since your liver specialist is not update or doesnt want to personalize your treatment and just apply guidelines in a blind way, which is bar to wasted time and money

we have posted many results on the combination therapy to improve that 8% to more than 40% on interferon results, plus there is a new type of interferon close to approval, interferon lambda, with mild sides and more potency.being in US you also luck all type of monitoring to clear hbv or liver damage regression, that's hbsag quant and fibroscan, hopefully available by 1-2 years or as suggested before in the community ship samples to labs in europe or india (we posted an indian one, which is cheap and willing to help)

interferon doesnt work because hbv is able to stop it so you have to weaken virus first and then kick it down by interferon combo.fisrt of all antivirals are not a life treatment if you combo with interferon you can slowly stop them without any problem.