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Sudden Increase in ALT/AST after stopping Ntz and LIv 52 HB increases HbsAg
Hi Stef and Others,

There is a sudden increase in my AST and ALT values after stopping Ntz. I stopped Ntz in August 2011 end and later I started taking Liv52 HB.

Results on Feb-2012:-
ASPARTATE AMINOTRANSFERASE (SGOT )PHOTOMETRY =98.00 U/l M: 0 to 37 - F: 0 to 31
ALANINE TRANSAMINASE (SGPT) PHOTOMETRY = 244.00 U/l M: 0 to 37 - F: 0 to 31

ALKALINE PHOSPHATASE PHOTOMETRY =98.30 U/l M:53 to 128 - F:42 to 98
BILIRUBIN -DIRECT PHOTOMETRY =0.26 mg/dl 0 - 0.3
BILIRUBIN - TOTAL PHOTOMETRY= 0.85 mg/dl 0 - 1.2
BILIRUBIN (INDIRECT) CALCULATED =0.59 mg/dl 0 - 0.9
GAMMA GLUTAMYL TRANSFERASE (GGT)PHOTOMETRY =21.00 U/l M: 0 to 50 - F :0 to 30
PROTEIN - TOTAL PHOTOMETRY =8.30 gm/dl 6.0 - 8.3
ALBUMIN - SERUM PHOTOMETRY= 4.56 gm/dl 3.2 - 5.0
SERUM ALBUMIN/GLOBULIN RATIO CALCULATED =1.22 Ratio 0.9 - 2.0
25-OH VITAMIN D TOTAL= 37.26 ng/ml
HbsAg Quant - 1789 iu/ml



Results on Aug -2011:-
SGOT - 25.90
SGPT - 38.90
HbsAG - 733 iu/ml

Almost SGPT has increased 10 times. Kindly help me. I'm very scared about my situation. If stopping ntz increases ALT ans AST ,we cannot take ntz for life long? please help

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stoppingntz doesn not change your situation but i think liv52 did because hbsag has increased frominactive carrier to cronic hbv

anyway having alt 200 is not bad at all if hbvdna is extremely low or undetactable because it means your immune system see the virus and is fighting, if you find also hbvdna high that would be a big problem

get back to ntz+vitd3 (37 is too low, get it to 80ng/ml)

then check hbvdna too, if hbvdna is low i d go for ntz lead in for 12 weeks and then addon generic interferon+simvastatin+vit d3 to clear hbv
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in case hbvdna is high we have to use tenofovir or see if alinia is able to lower it monotherapy

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do you have also some other (previous) test results ?

I can agree with you that it seams that stooping NTZ couses ATL/AST flare but I wandering if this is the case (should be something else and to be only a coincidence)

how was your qHbsAg before styrting NTZ ? (NTZ decrese this value ?)

how about your HBV DNA - is this increasing / decreasing also ?

(NTZ = alinia ? )
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checking all your tests:

creatinine is a bit high, nothing to worry and easy to correct, do you make gym/bodybuilding, hbv can also attak kidneys

hdl is very low, this is bad because hdl has also antiviral effect.glutathione by injections or liposomal+vit d3>50ng/ml, fish oil omega3 or fish diet, can increase to 65-70 easily

alt 255 is a good flare after we know hbvdna we can understand immune status by comparing hbsag and hbvdna and kinetics

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I didn't check qHbsAg before taking Alinia (Nizonide-Ntz) . After 2 months of taking Ntz it came to 1000iu/ml and after 4 months it even came to 500 iu/ml.

But after that it gradually increased to 730 iu/ml (with Ntz) . So I stopped Ntz and later I started with Liv 52 HB,
After that my qHbsAg has increased t0 1789 iu/ml

My HBV DNA was 9000 Copies/ml  on Decemeber-2011. After that I have not checked DNA Values.
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Stef,

I don't go for gym or any body building exercises. I have normal physique (178 cm/82 Kg) .

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I didn't check qHbsAg before taking Alinia (Nizonide-Ntz) . After 2 months of taking Ntz it came to 1000iu/ml and after 4 months it even came to 500 iu/ml.

But after that it gradually increased to 730 iu/ml (with Ntz) . So I stopped Ntz and later I started with Liv 52 HB,
After that my qHbsAg has increased t0 1789 iu/ml

My HBV DNA was 9000 Copies/ml  on Decemeber-2010 (sorry not on dec2011) . After that I have not checked DNA Values.
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creatinine is a very poor test for kidnesys because big muscles can make creatinine even 1.4 not correlated with kidneys.if you want to be on the safest side take a 24hrs urine test of creatinine clearance that will confirm kidneys function.i stress again this is to be ultra safe side and to prevent in any case.

kidneys function can be improved by making hbvdna und, by fibroguard, by antioxidants like vit d and gluta injection or liposomal

anyway youare still close to hbsag 1500iu/ml which has highest chances to clear hbv, according to the hbvdna level we may think an off label combo like this:
alinia-tenofovir lead in 24 weeks and then recheck hbsag/hbvdna if low

alinia-tenofovir-interferon or peginterferon-simvastatin-vitd3, i am sure you ll clear fast like it happened to otan on such a combo
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since we dont know your baseline hbsag and hbvdna there is another way to think about what happened.

your baseline could have been hbsag 1700iu/ml and hbvdna 9000iu/ml, alinia lowered them and when you stop they just got back to baseline values

the difference can be your immune system is now stronger and made a alt flare trying to clear the infected cells, it is better to act while we have the alt flare and i think alinia is the best to retry now and then add interferon
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" .. After 2 months of taking Ntz it came to 1000iu/ml and after 4 months it even came to 500 iu/ml. But after that it gradually increased to 730 iu/ml (with Ntz) . So I stopped Ntz and later I started with Liv 52 HB,  After that my qHbsAg has increased t0 1789 iu/ml "

so it seams that NTZ is not fully responsible for HBsAg variation (qHBsAg decrease and increase also under NTZ).
Could you please give us the date's when you made the qHBsAg tests (all dates). I was thinking to see that after you stop the NTZ HBsAg increase faster or just increase with the same rate.

could you remember something different during the decrease period vs increase period (what yoe eat, sport or eating or sunbath or .... )
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Before taking Ntz (i.e on Dec-2010 my HBV DNA was 9000 copies/ml (i.e around 3000 iu/ml). Had No idea of qHbsAg. ALT/AST was Normal

I didn’t check my qhbsag before taking Ntz. I started taking Ntz around Jan -end -2011

5th,March -2011 – 1088 iu/ml (During this period Ntz was 1.5 g per day)

2nd April -2011 –    567 iu/ml – During this time I played badminton often and took lot of fruits and fresh juices. Also Included Oat Meal (Ntz was 2g).Also in end of April  started taking Lypo-SphericTM Vitamin C and Lypo-SphericTM GSH – Glutathione + Omega 3 +Selenieum

21st April – 542 iu/ml –Ntz -2.5 g per day

20th May – 606 iu/ml – Ntz 2.5 g

3rd June -2011 – 652 .33 iu/ml – Stopped playing and less physical work. Also added 20mg Simvastanin and stopped taking Vit C and Glutathione

15th Aug -2011 – 733 iu/ml  - So I decided to stop Ntz gradually  and started taking Liv 52 HB and added Vit D 5000 iu/ml

5th,Nov -2011 – 1091 iu/ml – only on Liv52HB + Vit D

24th Feb ,2012 – 1789 iu/ml - only on Liv52HB + Vit D


Thanks

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maybe it is best to retry alinia 2,5g daily and no fruits, liposomal vit c and glutathione, no omega 3 and see

we nedd to keep in mind hbsag less than 1500iu/ml respond to interferon wit h clearance and sme thing may apply to alinia

and 500iu/ml or less might respond like otan to interferon+alinia with hbsag clearance before 24weeks

to me the best thing in this case is: alinia 12weeks or 24 weeks until hbsg gets back to around 500iu/ml and then add on interferon, if hbvdna is detactable higher than 100iu/ml i d add tenofovir too right before making interferon add on so that hbvdna is already und when adding interferon.i think you will clear hbv by 24-48weeks on this combo
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Date     qHBsAg   DqHBsAg      Days         DqHBsAg/ days
30 ianuarie 2011          ?             ?                 ?
5 martie 2011 1088 ?            ?
2 aprilie 2011 567 -521 27.00 -19.30
21 aprilie 2011 542 -25 19.00 -1.32
20 mai 2011 606 64 29.00 2.21
23 iunie 2011 652 46 33.00 1.39
15 august 2011 733 81 52.00 1.56
5 noiembrie 2011 1091 358 80.00 4.48
24 februarie 2012 1789 698 109.00 6.40
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I don't think that is a real connection between NTZ and qHBsAg, even if the daily increase jump from 1.56 to 4.48 when you stoped the NTZ (but also with the NTZ you experience a increase of 1.4 per day )

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what puzzle me is the decrease of 19.3 per day (between 05 march and 02 April ) and after that the decrease is relay slow 1.32 per day (between 2 April and 21 April )
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ya I understand this. But my question is why my ALT got increased to large extent when I stop NTZ? When I was on NTZ , ALT was normal?. I don't understand the logic here
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I can't understand also the ALT variation.

ALT was under the same variation like qHBsAg ? (start to increase in the seme time ...)
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I did not check ALT levels often. I checked once in july-2011(normal) and feb -2012
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retreatment with alinia will tell us if hbsag decrease was due to alinia, please let us know one month results with alinia 2,5g daily, also consider that you may use even 4g daily if you can tollerate because aids patients non responding to lower doses have been treated with 3-4g daily with no severe sides and of course the higer dose the better
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My HB DNA is 6,518,01 Copies /ml.

Please Your comment please.

I Dont know how it got increased to this level. Very Scared
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not alinia for sure......., this is a very high level for you which has nothing to do with inactive carrier you were, nothing to be scared of but if we dont act now you may lose the low hbsag and the chances to clear hbv easily on interferon combos

if you can afford i d go with tenofovir+alinia and add interferon when hbsag gets lower than 1000iu/ml

with this hbvdna the trends are towards hbsag increase if we dont stop relication, although hbsag and hbvdna are not correlated i think this is wht may happen
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chances are tdf+alinia will stop hbsag increase and hopefully stop or make it decrease
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i think we can post hbsag, hbvdna and ast/alt increase during liv52 in a previous inactive carrier with low hbvdna, ast/alt
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Very Scared

How it could increase within 1 yr . from 9000 copies to 6,518,01 copies/ml. I don't Understand? Is it possible?

It is due to sudden stop of Ntz(Alinia)?

Yes you are right. Liv52 HB is Junk one.

I cannot afford tdf? Should I try Ntz alone?
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Whether Ntz(Alinia) can produce mutants ? Any Wild type Mutants are attacking? any Idea?
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don't Understand? Is it possible?

if something that henances viral replication is used this may happen in days, since liv52 research is just smoke i tend to make it responsible for this.the minumum result should have been keep alinia results

It is due to sudden stop of Ntz(Alinia)?

no if you stop alinia you can get back to your baseline status not getting it worse.my sister and a german guy stopped it and both had improved status, normal ast/alt and lowering hbvdna.since alinia act like interferon boosting immmune response and interfering with antigens release inside the cells it cannot make status worse than baseline

alinia does not produce mutants even in hcv which is the most mutant virus, even more than hiv.
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I cannot afford tdf? Should I try Ntz alone?

what about the generic versions of tenofovir?

of course you can try alinia again and i suggest go for the high dose but alinia has little effect on hbvdna and using both alinia and tdf could have made hbsag low

but if you cannot afford both tdf and interferon it is much better to try alinia only for now and see what it can do
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Your VL was 9000 copies and now is 6518. Why do you say that VL has increased when in fact has decreased from 9000> 6518.
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he posted 651801copies/ml
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If you ignore decimal how do you read 6,518,01 Copies /ml? My reading is:
6518 is the whole number and 01 is the decimal.
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he sent me lab result by email but anyway hbvdna pcr has no decimals in the results he just wrote it wrong

his hbvdna is now 651.801copies/ml so his stauts is:
increasing hbvdna, increasing hbsag, increasing ast/alt which confirms the virus is spreding and the alt flare is not immune system fighting but just the virus spreading without immune control

on the contrary if you have increase of alt with decrease of hbsag and hbvdna it means immune system is getting control of hbv infection and killing infected cells

the best scenario is increasing alt flare with hbvdna undetactable and hbsag decrease.this last status reflects the killing of infected cells without any escape for the virus which cannot infect new cells and lose the infected cells which produce hbsg and cccdna
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"My HB DNA is 6,518,01 Copies /ml. "

less than 1 = decimals ( in our case 01 wich is less than 1)

whole numbers (units) ar grater than or equal to 1 in our case 6518
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sorry i have the lab test just do not waste time
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Sorry for my wrong comments i just misunderstood
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what about Tavin from Emcure which is the cheapest tenofovir version?is it affordable?


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http://www.drugsupdate.com/brand/manufacturer/66/505

Tenof - Hetero HC (GenX) [Tenofovir Disoproxil Fumarate]
Strength Volume Presentation Price*  
Tenof 300mg 10 Tenof TAB 500.00  
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Attaching my latest report (April -2012)

April -2012 (07/April/2012):

QHbsAg - 1576 iu/ml
S.G.P.T. (ALT) -   105.3 U/L
S.G.O.T. (AST) - 42.4 U/L
HbeAg - Negative


Results on Feb-2012:-
SGOT(AST)  =98.00 U/l M: 0 to 37 - F: 0 to 31
SGPT(ALT) = 244.00 U/l M: 0 to 37 - F: 0 to 31
HbsAg Quant - 1789 iu/ml
HBVDNA   = 651801 copies/ml

ALT and AST have decreased . Also QHbsAg is decreased bit.  I'm moving from Immune tolerant to  Immune Clearance Phase? (I.e normal HBV Cycle) Any Views Please
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too little difference to say, i d say no difference

maybe also hbvdna has decreased a bit
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what is the HBVDNA numbers? also pls let me know where we can buy TDF in chennai..
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I am glad your ALT has decreased. I would say you are no longer in the Immune tolerance phase because you are HbeAg negative. Are you still in the Immune Clearance phase?
I don't know because I lack the clinical experiences of a doctor. In the Immune Clearance phase, ALT and hbvdna will flunctuate, and you may be in this phase for a number of years. Others may like to comment.
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Thanks for your Comment. Regarding Immune Clearance Phase , I understood in other way around. I thought that Immune clearance phase - becoming more chronic . In sense , usual cycle of HBV where Immune System sees Virus attacks Liver cells. Still I don't understand clearly the HBV phases - Immune tolerance phase & Immune Clearance phase
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I did not check HBV - DNA this time. I would check next month.

Regarding TDF , I don't have idea where we can get it in Chennai. But less cost generics available in India  

http://www.drugsupdate.com/brand/showavailablebrands/505
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Yes, in the immune clearance phase, the immune system no longer tolerates the virus and start attacking the virus infected cells. This battle can be fought many times, each time doing some damage to the liver. Therefore a prolonged period of clearance (attempts to clear) is not desirable. Before the age of 40 (if infected at birth), most hbvers will finally win the clearance war - HbeAg is negative, viral load is very low and ALT is normal -  the immune system is keeping the virus under control. The hbvers is then in the inactive phase. with luck, this phase lasts forever, but after a period of time, the virus mutates into a form that escapes the immune control and starting replicating again, ALT will rise and the  liver is being damaged. This is the so called HbeAg negative hepatitis. Treatment is then needed again.

It is obvious that during the immune clearance phase, there is a chance that the patient may achieve victory simultaneously without any treatment, but on the other hand, the battles may be too hard and too frequent that medical treatment is needed to prevent severe fibrosis/cirrhosis developing.  Whether and when to treat during this phase is a difficult decision to make and best left to experienced Hepatitis
doctors to make.

The above is a very simplified explanation and may not be completely accurate. That is, don't use it to decide your treatment.
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so that definielty means it does make sense to treath CHB patients in immuno clearence phase even if younger than 40yo..
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Yes, in some cases when the patients show signs of liver diseaase, treatment should be started. In other cases, it may be prudent not to rush to treatment, the patients may seroconvert simultaneously. Only an experienced liver doctor should make the call.
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in my case still eag+ and in immuno clearance phase they stronlgy wanted me to start ifn + tfd as ALT were >700
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you are definitely in the phase with the highest chances to clear hbv because the virus has had no chances to mutated to escape your immune response, your immune system has just started attack

the very difficult phase is hbeag negative, in this case chances are so little
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Thanks for your kind reply.

The immune clearance phase is characterized by the presence of HBeAg, high levels of serum HBV DNA, and active liver disease (ie, elevated ALT and moderate/severe necroinflammation on liver biopsy).

Not all biochemical exacerbations lead to HBeAg seroconversion or persistently suppressed serum HBV DNA levels, a phenomenon termed abortive immune clearance. These patients may develop recurrent exacerbations with intermittently undetectable serum HBV DNA with or without transient loss of HBeAg.[8] Such repeated episodes of hepatitis may increase the risk of cirrhosis and HCC.

Source : http://www.clinicaloptions.com/Hepatitis/Management%20Series/Chronic%20Care/Modules/chroniccare_lok/Pages/Page%205.aspx
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1) Do you think that Immune clearance phase is always accompanied by Positive HbeAg ? In my case ,Do you feel that it might had been positive for some time before and  it has become negative now? I checked HbeAg Status before 1.5 years and it was negative at that time .

2) Is possible , one can be negative for HbeAg in all phases of HBV?

Thanks in Advance.
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within the immune clearance phase, I am not sure whether the HbeAg staus can flip flop between positive and negative. But as your quote suggested, transient loss of HbeAg and hbvdna are possible within the clearance phase.
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hi stef and Stephan,

my latest blood report
AST - 121
ALT -319
QHbsAg - 895 iu / ml

kindly tell your advice. again my ALT has increased.
whether my liver is attacked heavily. whether anti viral is inevitable. I accept that there is decrease in QHbsAg but ALT is continuously high for past 4 months. worried please help.
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I don't have a ready answer for you. Hopefully, stef2011 and others will give you their opinions.

It would be useful to know your hbvdna. Personally, I know it is always difficult to ascertain whether you are going to seroconvert your e-antigen naturally or you need to start treatment.
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thanks for the reply. but my e antigen is already negative.
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first thing for every member of the forum:
high alt is good, always good when hbvdna and hbsag go down, it means you have an immune response while a normal alt is useless because it means you have no immune response.

if hbeag has become negative you are clearing hbv and before mutants can escape this immune response i d start intf+ntz as soon as possible.chances are you clear hbv very fast

waiting with no immune modulators......hbv will escape your immune response like in most of the cases and alt will become lower or normal
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I am sorry, your e-Antigen was negative over a year ago and also in April this year. In this case, you may consider whether you have HBeAg negative chronic hepatitis. Your viral load should tell you more. Tenofovir treatment is also effective for e-Antigen negative hepatitis.
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i forgot he was hbeag neg, i thought he just seroconverted hbeag neg.....

tenofovir is not indicated on hbeag neg at all because he can clear hbv he should not treat for simply hbvdna und, tenofovir will likely rise hbsag and lower alt now making hbv clearance much less possible

his best treatment is intf now because hbsag less than 1000iu/ml boosted by ntz, vit d and maybe simvastatin too
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His hbvdna increased from 9000 to 651801copies/ml previously. He was on ntz and simvastatin too (which he stopped when qHbsAg went up). His qHBsAg went up and down. All very confusing to me.
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hbvdna means nothing to immune response on such low hbsag

since he is so lucky to easily have intf response i d go for it as long as hbsag stays low
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Hi Stef and Stephan,

Thanks for your kind reply. I will find good Liver Specialist in South India and consult reg IFN treatment.

Also I will check DNA this end of the month
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Hi,

Could you please share your views on my case.

Whether treatment should be started now? Whether I'm into immune clearance phase or Immune escape phase?

Kindly reply. Thanks in Advance

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i think you should restart alinia, it should make 50% hbsag decrease in 4-8 weeks when you reach this decrease add on intf before hbsag gets stable or rise again on ntz mono
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Hi your reports suggests that earlier you were in immune clearance phase ( i.e when all your statistics were high). Now with your qHbsAg coming down to 895 is really a good news. But i think HBV DNA is also an imp indicator so you should check that too.

But can you please tell that you are under which medication from last six months? Alinia or Liv 52 HB. and what are your dosages per day. I am asking this bcoz I am also on Liv 52 HB from last 04 months and can perhaps extrapolate our results.
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he is on no medication now

he had hbsag, ast/alt and hbvdna increase on liv52hb, so we could say liv52 is useless if not dangerous

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Please find the my latest status after taking LIV52HB for 1 year

Latest Report (Sep -2012)

S.G.O.T. (AST) 39.3 U/L

S.G.P.T. (ALT) 85.3 U/L

HBsAg - QUANTITATIVE : 925.00 IU/mL

Aug -2012
(AST) - 39.8 U/l
(ALT) - 96.9 U/l
QHBsAg - QUANTITATIVE : 461.00 IU/mL Less than 0.05 IU/ml : Negative

July -2012 (on 7th July,2012)

(AST) 56.4
(ALT) 163.7 U/
QHBsAg - QUANTITATIVE : 672.00 IU/mL Less than 0.05 IU/ml : Negative

June -2012  (on 9th June,2012)
AST - 121
ALT -319
QHbsAg - 895 iu / ml


April -2012 (07/April/2012):
QHbsAg - 1576 iu/ml
S.G.P.T. (ALT) -   105.3 U/L
S.G.O.T. (AST) - 42.4 U/L
HbeAg - Negative


Results on Feb-2012:-
SGOT(AST)  =98.00 U/l M: 0 to 37 - F: 0 to 31
SGPT(ALT) = 244.00 U/l M: 0 to 37 - F: 0 to 31
HbsAg Quant - 1789 iu/ml
HBVDNA   = 651801 copies/ml

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MY ALT is fluctuating like anything. Is the antiviral only option?  
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no absolutely no antiviral in ur case, it will increase hbsag and make hbv even more chronic by suppressing your immune response

your best option to clear fast is intf+sim+alinia like otan
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interesting is the also qHBsAg fluctuation.
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also keep in mind that we have two architect kits now:
one with manual diluition, so there is an error of about 500iu/ml possible

authomated kit, no error, this is available from this year 2012, initaly some labs have it since june
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ALT:        244  105    319  163   96.9  85.3
qHBsAg: 1789 1578  895  672   461   925

I think the QHbsAg will come to old base value (1500) and then ALT will come back to normal value
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high alt are followed by hbsag decline while lowering/low alt are followed by hbsag increase

as regards immune system as hbsag declines interferon gamma in the liver increases, the key of evrything is getting hbsag to lower continuatively, if it goes up and down there is no effect.
abbott architect manual diluition test can have an error of 500iu/ml and more, once hbsag is less than 250iu/ml there is no diluition for sure, if the lab is very updated it is possible they are already using the kit with no diluition and results are without error
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Could you fiil out ALT / AST and HVB DNA ? (also could you found any other relation betwen qHBsAg and life stile .... e.g. sport, or diet, or ....)

Date      qHBsAg  
Jan 2011          ?        
March 2011 1088      
April2011 567
April2011 542   
May 2011 606
June 2011 652   
August 2011 733
Nov 2011 1091   
Feb 2012 1789
April 2012 1576
June 2012 895
July 2012 672
August 2012 461
Sept 2012 925
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I did not take DNA PCR since it is costly here, I took the test only on Feb -2012 which is 651801 copies/ml .

Planning to take it on October -2012. Regarding my food, there was not big change at all. I don't take non-veg except egg. Also I do Yoga (Hatha Yoga) thrice in a week.

But last month I did take more of  fatty foods and egg items but not very high. That might me the reason I feel.
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651801 copies/ml is a lot of replication, my guess is your immune system is not able to block reinfection to keep stable decrease of hbsag, intf is the best option here or intf+alinia+simvastatin
the use of an antiviral is not good because making hbvdna totally und it may suppress the immune response you already have because hbcag in virions is the strongest stimulant for immune response, may on and off tdf+intf might be ok but in this case you need expert doctors or researchers with experinece on this on and off vs hbsag and hbvdna response

i dont think you ll ever solve this status in other ways
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also vitamin D3 and Vitamin B12 if taking interferon.  

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Hi Stef

I tried the Lupin website but they do not list alinia or NTZ among their product.  can you direct me to buy the lupin alinia?   Thank you.  
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Hi Stef

I tried the Lupin website but they do not list alinia or NTZ among their product.  can you direct me where to buy the lupin alinia?   Thank you.  
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the drug name is nizonide500 which contains 500mg ntz per pill, alinia is the romark'name for ntz
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Hi All,

Feeling sharp , frequent but short pain near top of right abdomen . (Just underneath my right rib cage ).

Anyone in this forum facing this problem?
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Oct - 2012

AST - 47.6 iu/ml
ALT - 108.5 iu/ml
QhbsAg - 2900 iu/ml


Sep -2012

S.G.O.T. (AST) 39.3 U/L

S.G.P.T. (ALT) 85.3 U/L

HBsAg - QUANTITATIVE : 925.00 IU/mL

My ALT is above 80 for past one year ? I fear my liver is getting damaged . How to bring my ALT to normal. Could you please please reply to this post
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Only Concern is ALT fluctuations.... Please help me . How to avoid the liver damage
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Listen to what stef2011 has to say. He has the best knowledge and understanding of HBV I have seen.

If your ALT is high and you have now liver damage then you can try to ride it out with Pegasys injections. And see maybe your immune system will clear HBV..

Or option number 2 is TDF + Alinia like stef said to lower HBV DNA and surface antigen..

I had 500,000,000 HBV DNA copies in 2007 with e negative Hepatitis B and my alt was only twice the normal values. But Entecavir salesman has put me on ETV rather then interferon. But back then I didn't know that some doctors are so corrupt or plain stupid.

based on your results: I would not worry. ALT flare means your immune system fights the virus so. I would go on interferon for six months and see what happens.. And I would add alinia too.. Bottom line listen to what stef2011 here has to say, his advices are great and  spot on..

Sep -2012

S.G.O.T. (AST) 39.3 U/L

S.G.P.T. (ALT) 85.3 U/L

HBsAg - QUANTITATIVE : 925.00 IU/mL

My ALT is above 80 for past one year ? I fear my liver is getting damaged . How to bring my ALT to normal. Could you please please reply to this post
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Hi ,
My Latest Reports

10/Nov/2012 : (LFT Tests)
ALT : 401.4
AST : 125.7
Rest all the parameters are normal.

26/Nov/2012 :
ALT :152.2 U/L
AST : 57.8 U/L
QHBsAG : 10 IU/mL
HBe Ag : NEGATIVE


29/Nov/2012 :
QHbsAg : 22 iu/ml
Anti - HBS : Negative

08/Dec/2012 :
ALT : 113.1 U/L
AST : 43.3 U/L
QHbsAg : 284.00 IU/mL

My ALT is fluctuating for past 1 year. Is there any chance of Mutatnts? I will take HBV-DNA this week .  

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studyforhope ,
could you please give me your suggestions on my case.
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i think intf with sim or with nizonide is the best choice, as you can see otan cleared hbsag by 16weeks with intf+sim

it is not 100% sure you ll clear as fast as otan but with such low hbsag you are going to clear anyway on intf, just a matter of time

i dont think hbsag mutants are present, ask studyforhope what he thinks and what you may try
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It would be very important to know the state of fibrosis in yor case, since you seem to experience a series of miniflares, which over time can lead to substantial liver damage. While it holds promise to wait for surface antigen clearance by immune attack and inflammation, this can only be tolerated for a limited time without a strong activation of fibrogenesis. Mind you each case is different in their propensity for fibrosis progression, so the best option would be to monitor it with fibroscans.
The best explanation for the ups and downs in your alt and quant surface antigen results is that individual members of the quasispecies residing as cccDna in yor liver grow preferentially until they trigger a new mutant epitope specific cd8 and cd4 response that attacks the liver, causes high collateral hepatocyte necrosis and an elimination of that mutant, combined with a general decrease of surface antigen production even in non specific mutant infected cells, due to the intense cytokines milieu, that will restrict transcription even in non epitope carrying cells, but not a complete removal of their cccDna.

Nevertheless, this partial collateral removal of cccDna might eventually be sufficient to clear enough cells for surface antigen conversion. The question is, can your liver afford the risk of this prolonged attack with an uncertain outcome.

Each time you clear one mutant, another one, if not completely removed by the collateral effect, will grow and spread until it has sufficiently stimulated, by it's virion output, a new generation of specific lymphocytes that start to attack this new clone.

If you start tenofovir, then the virion output of the spared population will be small and further flares will likely not occur, your alt and fibrosis risk will go down.But your chances of clearance will also reduce.
Based on the picture from your last year, chances for such clearance however are not too good IMO.

Thus in summary, if you can determine your fibrosis stage by Fibroscan or biopsy, you have a better base to decide if you want to risk the ongoing battle a little longer or retreat to a safer alternative that is unpleasant in other ways, ie the long term use of tenofovir.
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If your fibrosis score is low enough you could try to further activate the described process, by using interferon as stef suggested. Tight monitoring under physician supervision is advised, since this means putting oil into the fire.But yes, your chances of clearance will go up.
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hi,
Thank you very much for your kind reply.

Fibroscan is available only in 2 or 3 places in India. I will definitively take this and come back to you.  
Kindly answer my question if possible

1) When this battle(ALT elevations)  will end?only after onset of severe Fibrosis ?Which Phase I'm in now? Immune Clearance Phase or Immune Tolerant Phase.  

2) My QHbsAg went to 10 iu/ml which is almost near to clearance where Immune system almost had the full control.Mutant is possible in such low HbsAg level?

Thanks again for your kind reply
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You are obviously in an 'immune cleaance' phase. But than wording does not necessarily mean clearance towords a stable elimination of surface antigen and cccDNA. The variations in how this battle between the virus and the immune system evolves are numerous and only rough rules or predictions can be made.

There is not one mutant  or a dozen mutants  but there are hundreds of deviations in the HBV genome which serve the virus to adapt towards the immune pressure, more the longer the disease lasts in one patient. It is a Darwinian evolution of HBV against the forces that try to eliminate the swarm of viruses in a body  by removing the signals which activate the Tcell system and other mechanisms. Whats left is what is hard to detect or hard to fight in an efficient way, like by cd8 mediated cell lysis. Often a mutation in a critical epitope leads first to "invisibility" by massive destruction of the majority, leaving only a small amount of mutated HBv genomes behind, but this leads later to the evolution of a new set of Tcell clones against the new target, with delay, that explains the new flareup and ALT rise, after the mutant was allowed to rise and spread and then the new Tcell clones start responding and hit again.

At a low surface antigen level, often a new set of previous tolerized HbS specific Tcells start to develop and holding the virus in check with a new set of epitopes to be used for the first time. This is also the power of the artificial removal of the surface antigen with the Replicor drug.  The strength and duration of this new force is however also unpredictable, It will work in most cases, but might diminish with decreasing viral load.
The fluctuations that you experienced are most likely due to alterations in core and e antigen epitopes, regardless if you are e-antigen negative. E-Ag neg patients have a more burnt out core epitope repertoire, because they have had their core repertoire eliminated too often, but sometimes a new immunogenic core mutant grows back, leading to a new flare. Here I am not taking about the precore mutants or the standard core promotor mutants, but epitope mutants.
Altogether, if your fibrosis is not advanced and you can afford the cost and side effects, the use of interferon to push the system into victory might be advisable.
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Thanks a lot for your kind reply. I have one final question. This immune system battle will be associated with  any symptoms like mild piercing pain in the right upper abdomen especially in the Liver area and mild fever . I have the above symptoms for past 3 months .
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The accumulation of immune cells in the liver, called an infiltrate, together with numerous pro inflammatory cytokines, can lead to swelling and the characteristic right upper quadrant pain that you describe. Fever is more rare, it speaks for substantial interferon and other cytokines being produced by that infiltrate.
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thanks for reply. Yes you are right. I Have mild  swelling in the liver area and frequent piercing pain.
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Pro Inflammatory Cytokines are of importance in chronic inflammatory stage. It of course helps HBV virons to replicate more and helps HBV virus growth.

Anti-Inflammatory cytokines are good for host and also it produces sufficient IFIN.
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No, proinflammatory cytokines like eg tnfalpha or interleukin6 are also inhibitory for hbv replication and transcription, but not efficient in the elimination of cccDNA.

Ifngamma in high local concentrations is efficient to eliminate cccdna.It is produced by activated cd8 cells that have encountered their specific recognized epitope presented on the surface of an infected liver cell.

Anti inflammatory cytokines like Il10 will inhibit tcell activation and help hbv to replicate.
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thank you very much for your kind reply
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LKALINE PHOSPHATASE PHOTOMETRY 64.8 U/l                                                  M:53 to 128 - F:42 to 98
BILIRUBIN - TOTAL PHOTOMETRY 0.84 mg/dl                                                           0.30 - 1.20
BILIRUBIN -DIRECT PHOTOMETRY 0.26 mg/dl                                                           0 - 0.20
BILIRUBIN (INDIRECT) CALCULATED 0.58 mg/dl                                                         0 - 0.9
ASPARTATE AMINOTRANSFERASE (SGOT ) PHOTOMETRY 201.3 U/l                       M: 0 to 37 - F: 0 to 31
ALANINE TRANSAMINASE (SGPT) PHOTOMETRY 506 U/l                                          M: 13 to 40 - F: 10 to 28
GAMMA GLUTAMYL TRANSFERASE (GGT) PHOTOMETRY 21.8 U/l M:                      0 to 55 - F :0 to 38
PROTEIN - TOTAL PHOTOMETRY 7.35 gm/dl                                                              6.6 - 8.3
ALBUMIN - SERUM PHOTOMETRY 4.22 gm/dl                                                            3.5 - 5.2
SERUM ALBUMIN/GLOBULIN RATIO CALCULATED 1.35                                             Ratio 0.9 - 2.0


My ALT = 506 and AST = 201.3 which  is very high for almost past 2 years. Yet to take DNA and QHbsAg. Could you please help me on this. Also BILIRUBIN -DIRECT PHOTOMETRY is 0.26 mg/dl  where normal range is  0 - 0.20.
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Hi Stef 2011 and Stephen

could you please comment on my LFT reports . Thank you very much in advance
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Also Iron content of my blood is more

IRON :- 219 μg/dl ( Normal Range : Male : 70 - 180)

TOTAL IRON BINDING CAPACITY (TIBC) : 358.7 μg/dl  Normal Range : Male: 225 - 535 μg/dl

% TRANSFERRIN SATURATION : 61.05% Normal Range 13 - 45.

Is there indication of Cirrhosis? Can you please help me on this?
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you have to check for hbsag quant and fibroscan at least, also hbvdna should be done

liver damage is now a possibility so you d best check fibroscan and then start tenofovir if there is damage.remember that fibroscan is increased if alt were more than 200, in this case you need to wait few months before fibroscan is very reliable
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I do not know how to interpret your LFT results. My concerns, just as studyforhope pointed out previously, are that you have many ALT flares for the last two years. Therefore it is important to know the state of your liver, either from a Fibroscan (mindful of what stef2011said) or a biopsy. You should seriously consider treatment.
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remember that we posted in the past all indian generic brands for tenofovir and there was one brand just 21usd per month

also do not skip the vitamin d suggestion since it helps with fibrosis and immune system
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Hi Stef,

I would check QHbsAg and DNA. Constantly my ALT/AST has been in high range . Hope you remember this. What I should do now? Should I wait for fibroscan?

Also iron content is more . is it indication of cirohosis?
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Thanks for the reply. I would consider taking biopsy . Fibroscan is bit difficult to take. Also I will meet doctor immediately. Do you have any idea of my Iron Conent. It is increased
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iron content is increased in infections and it helps viruses to replicate, proper vit d levels are reported in several studies to help make it normal

there is also liver damage due to iron overload but i am not expert on this and you d better refer to your doctor, although levels dont look so high
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I think there are links between serum iron parameters and chronic hepatitis. It is quite a complicated area, I believe. Best to consult your doctor.
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Hi Sudyforhope , Stef and stephen

Please find my QhbsAg and HBV DNA


BLOOD - SEROLOGY
:‎
HBsAg - QUANTITATIVE  : 83.00 IU/mL  Less than 0.05 IU/ml : Negative
Method : CLIA - ARCHITECT
:‎

HBe  Ag  : NEGATIVE‎
Method : CLIA
MOLECULAR BIOLOGY

HBV VIRAL LOAD BY REAL TIME PCR : 35‎,‎24‎,‎213 ‎IU‎/‎mL ‎( ‎6‎.‎54 ‎logs‎)

The test is done on Roche COBAS TAQMQN ‎48 ‎Real Time PCR ‎
Analyser‎

DNA is very very high.

What I should do? Tenofovir or entecavir ? Which is good for this high viral load ?

Please reply. any possiblity of liver Fibrosis or cirrhosis?
:
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It looks like you have a mutated form of surface antigen, that escapes proper quant measurement.
I would use tenofovir to suppress future flares. These flares can accelerate development of fibrosis and cirrhosis.
Fibroscan or liver biopsy are needed to determine your current fibrosis status.
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Hi StudyforHope.

Thanks for the reply. Please let me know is there any way to detect mutants?

Tenofovir can tackle the mutants?
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Full sequencing would be necessary to detect this kind of mutations.
Tenofovir will work to suppress even those.
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Thank you very much for your reply
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Studyforhope has given you excellent advice and explanation. Treatment should be considered.
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Sure Stephen. I have booked appointment with Hepatologist today.  My only concern is whether doctor will prescribe Tenofovir ? Doctors here are not very updated . They may start from  lamivudine too.
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The following information from www.hbvadovcate.org may convince your doctor not to prescribe Lamivudine.

Researchers Suggest Banning or Restricting Lamivudine to Avoid Drug Resistance
A global team of researchers suggest lamivudine (Epivir-HBV) never be used to treat hepatitis B patients because it frequently leads to drug resistance and sets the stage for resistance to other antivirals, such as entecavir (Baraclude).

Lamivudine, the first antiviral approved for hepatitis B treatment, has fallen out of favor in North America and Europe because of its high rate of drug resistance. But because of its low cost, it continues to be commonly used to treat hepatitis B virus (HBV) infection in Asia and Africa, where the majority of the world's hepatitis B patients live.

This report, published in the July 30 issue of PLoS One, examined the molecular make-up of the virus in many patients who had been treated with lamivudine as well as patients who had never been treated. They found the many untreated patients carry a mutation that allows HBV to quickly mutate and develop resistance to lamivudine.

"Our findings strongly suggest that the use of lamivudine will not benefit ...patients," they wrote because of the high risk of lamivudine resistance.

"Finally, since patients can quickly develop drug resistance to entecavir in the presence of lamivudine mutations, the lamivudine mutations can significantly compromise the efficacy of entecavir," they concluded.

They proposed that doctor screen patients for these mutations before ever prescribing lamivudine,"... to most effectively treat chronic hepatitis B patients by selecting only sensitive drugs."

An unrelated article published in the Annals of Medical and Health Sciences Research, also criticized the over-use of lamivudine in hepatitis B patients in Sub-Saharan Africa. Lamivudine was originally developed to treat HIV, but today African providers use it frequently to treat anyone with hepatitis B (when HIV is not present) because it is inexpensive and more effective hepatitis B antivirals, such as tenofovir (Viread) or entecavir, are more costly or unavailable.

But over-prescription of lamivudine for hepatitis B in this region has:

    Increased drug resistance in African hepatitis B patients
    Reduced availability of the antiviral to both HIV and HBV patients
    And driven up the drug’s cost, which reduces its availability for more appropriate HIV treatment.

Critics say a bioethical dilemma has evolved, where doctors prescribe lamivudine to hepatitis B patients without explaining alternative treatment because they assume the patients don’t understand or are too poor to pay for more effective antivirals.

“Implied consent is no justification to embark on a particular treatment course,” researchers from Njala University in Sierra Leone wrote. “To tackle the growing problems of drug resistance and shortages with respect to lamivudine and other antivirals in HIV/AIDS treatment, health care resources should be prescribed with caution, irrespective of whether implied or explicit informed consent has been sought.”

    Association of Preexisting Drug-Resistance Mutations and Treatment Failure in Hepatitis B Patients
    Source: ww.ncbi.nlm.nih.gov/pmc/articles/PMC3728369/
    Lurking Dangers Behind Overuse of Lamivudine to Treat Non-HIV Hepatitis B Patients in Africa
    Source: ww.ncbi.nlm.nih.gov/pmc/articles/PMC3728885/
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Hi,

Is there any relationship between lower cholesterol levels ( LDL , HDL) and Liver damage.

I have lower LDL  and HDL which is below normal range -  

LDL : 67 mg% (Normal Range :- 85-130)

HDL : 33mg% (Normal Range : 35-80);

Total Cholesterol :  132 mg% (Normal Range : 125 - 200)
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Chronic inflammation reduces the synthetic activity in the hepatocytes. Intense fibrosis is an independent reason for decreased functional capacity of the liver.
Therefore patients with hepatitis tend to have lower cholesterol levels.
This has to be seen however in consideration of the genetic background and other functional impairments like fatty liver and insulin resistance, which typically reduces HDL  more than LDL cholesterol.
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Hi,

One last question . Kindly reply
I met a doctor today  He prescribed me Tenofovir 300mg . Already I'm taking Olmesartan 40 mg for Hypertension. Whether Olmesartan drug will have any interactions with antivirals.

He also asked me to consider  IFN treatment too. Before that he wants to take Fibroscan before that.
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I am not aware of any interactions of olmesartan and tenofovir.That does not mean that they do not exist. Check all drug interactions of tenofovir, also in case you might receive additional medications in the future.
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hi studyfor hope..i need your inside..hep b hbeag positive, high viral load 8 log sgpt around 60 three years before so started baraclude and after 3 month combo with interferon.. only little hbsag decrease so stopped peg intf b..then onwards on baraclude..from 2.5 years dna undo alt normal ..but hbsag continuously around 5 log too high..added pegint b recently no stable hbsag decrease ..many times seen hbsag fluctuations between 60000 iu to 100000  iu in between weeks..does it show any immune response..whenever this fluctuation takes place lympho count increases and platelate decreases..but never found sustained value of hbsag and alt is always normal..what do you think if i stopped baraclude and continue pegintf ..do you think it will be useful to trigger immune system as dna will increase after baraclude discontinuation..i m currently undo dna so do you think stopping baraclude will develope any resistance if again used in future..please give your deep precious views about the condition and future management. waiting for ur kind response..thank u.
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At this time, considering your lab results,  the available treatments or combos are unlikely to bring you to a state of surface antigen seroconversion or loss.
The effect of the antiviral that you take is to reduce the amount of circulating virions dramatically. This in turn reduces the activation of the immune system and threby prevents damaging attacks that cause liver damage and fibrosis. this means your liver disease will not progress and an existing fibrosis might even improve.
The idea that you want to induce an immune attack is only useful when it can lead to final clearance. If it is unsuccessful, more damage is done and the flares will continue, with no eradication.

You should be grateful that with entecavir and tenofovir two antivirals with little and no resistance development are available. They work by reducing the immune attack on your liver, almost completely eliminating liver disease  and that is what mainly matters. It is not clear if they have long term side effects that truly matter, this issue will take a long time to resolve.

While interferon has some chance to achieve a hbsag seroconversion, it is typically only achieved in patients that are already primed in that direction, by showing a low surface antigen before treatment starts.

The arrowhead treatment if it becomes available is not likely to achieve such a seroconversion for you. Only the Replicor treatment combined with immunotherapy has, IMO, a resonable chance to clear someone in your position.

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if i stop baraclude for now after 2.5 undo dna..and see response on intrf without baraclude for few months..and if necessary after few month i can restart baraclude again..do you think this will create baraclude resistance after restart..very high hbsag seems that i started the treatment when i was in immune tolerant phase, 28 years old, e+, high dna, usg normal..just a possibility..please provide your views.
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I do not think that you will develop baraclude resistance in this way. you might also consider switching to tenofovir, that has an even better non resistance behavior.
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thank u studyforhope..may b u have gone through grmr case..he is responding quite good after tenovir discontinuation..so i m thinking of breaking baraclude continuation.
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Hi All,

My Latest result after taking 3 months of Tenofovir

Dec 28 /2013 :
DNA : 68.4 IU/mL (1.84 log)
QHbsAg : 213.56
ALT : 51
AST : 26

Sep 2013 :
DNA : 35‎,‎24‎,‎213 ‎IU‎/‎mL ‎( ‎6‎.‎54 ‎logs‎)
QHbsAg : 83.00 IU/mL
ALT : 506
AST : 201

DNA has decreased to a great extent. But qHbsAG is increasing. Also AST/ALT is about to reach normal .





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very good results by 3 months only, dont worry about hbsag it is about the same as before, i guess it will get stable or go in a lowering trend by 1 year of tdf
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Thanks for the reply. Need to take Fibroscan after 6 months once the ALT is stabilized.  
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Hi,
Could you please tell me whether there is any relationship between Hypertension & Hep -B

I'm taking olmesartan for Hypertension . But last week my BP went to 150/90. My doctor prescribed me amlodipine 5mg & rosuvastatin 10mg and asked me stop olmesartan . Is there any sideeffects on Liver due to above medicines?

Also my HDL is very low which is 27 mg/dL (normal >40)

DIRECT LDL CHOLESTEROL 103 mg/dL

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optimum levels are not 40 but 50 and higher

i used to have it around 40, lipo gsh took it to 65 in few months