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Treatment dillema
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Treatment dillema

Here is my case-

I am 33 years old, Indian living in USA. 2 weeks ago, diagnosed with hepb during blood donation (thank god at least I know).

Alt- 54
Viral load 1350 IU
HBEAG - negative
HBEAB - positive

Ultra sound showed slightly thick gall bladder wall

Today I got biopsy results,says focal fibrosis between stage 2 -3.

Here is dilemma, I am travelling to India for 6 week vacation tomorrow. My doctor wants to start entecavir treatment after I come back. I requested him many time to give me prescription and start it today but he wont.his argument is that it might have side effect and I probably I had this since childhood so it's ok to wait for 6 weeks. He will start my treatment on the first day I come back. I told him I can cancel my trip if it is serious, but he says it's not required. I have 3 options-

1. Wait for 6 weeks as he says and start treatment on first day I return.
2. Buy entecavir ( if available) in india and start using it.
3. Cancel my trip.

Any suggestions will be highly appreciated.

Thanks,
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13 Comments Post a Comment
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Avatar_m_tn

first of all you have more drugs and essential tests available in india and not US, not to say cheaper drugs and good doctors.
fibroscan and hbsag quantification are not available in US and these are a must to define hbv status, if you are in india get the labs newtwork already posted to run this test

also biopsy is not a gold standard anymore because it can fail and in the worst way.liver does not have homoegeous damage and hogeneous fibrosis, so you may have fibrosis and pickup a normal section of the liver.the common mistake of biopsy is getting damage 1 stage lower.so check your liver by fibroscan while in india

entecavir and tenofovir have both extremely rare sides, entecavir is faster on cirrhosis regression while tenoffovir is more potent
if you go for entecavir you need to check your hbv mutations and genotypes because entecavir fails on lam muatnts which are present naturally also in patients who never took antivirals.

i had q215s which is a secondary mutation due to lam and adv

as you may see on the board the only way to cure hbv is seqyuetial add on etv or tdf and then peg, easier to find a center and specialist to d this in india or europe than US
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Avatar_m_tn

entecavir is very cheap in india both brand or generic, so it may be much cheaper to get it in india, generic should be around 50USD per month
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Avatar_m_tn
Thank you stef. You gave me lots of hope. Few more questions
1. You are saying cirrhosis is reversible?
2. What's the diffrence between fibrosis and focal fibrosis?
3. If I start entecavir in india and when I come back, if my insurance doesn't cover entecavir and I am forced to use tenofovir , will that switchover be ok?
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Avatar_m_tn
Hepatitis B is a slow-moving disease. Your viral load is low and your ALT is only mildly elevated. In my opinion, you can definitely defer treatment until you return from India.

Are you seeing a Hepatitis B specialist in America? Go to www.hepb.org to find specialists in your area.
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Avatar_m_tn
1. You are saying cirrhosis is reversible?

yes it is if hbv replication is stopped nd oxidative stress in the liver (inflammation) is reduced to normal, it is not known which is the state of advanced cirrhosis where the regression is not possible.

the word used is regression and not reversal for now because fibrosis is totally reversible but histology like nodules is reversible in very long time like 10years or more and registered cases of nodules regression and normal histology are too little for now on hbv.
histology and nodules, if not too advanced, have no effect on liver function.the liver is capable of adapting to new histology if no fibrosis is present

in your case just double check with fibroscan the level of damage, fibroscan is also useful to detect liver cancer risk due to fibrosis, values superior to 7-8 kpa have increased liver cancer risk, it is important to check also hbv genotype, you should be genotype d if you got infected in india

2. What's the diffrence between fibrosis and focal fibrosis?

focal is used for nodules usually, not very expert on this but focal nodules are HCC suspected

3 dont know but i d buy drugs in india with one year supply if cheaper than in US.to sitch from an antiviral to another is not good and you need combo for a long time, it is best to buy same drug and use same
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Avatar_m_tn
Now I am more confused, my doctor just said focal fibrosis between stage 2 and 3, he did not mention anything about nodules, does fibrosis between stage 2 and 3 means nodules?
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Avatar_m_tn
he probably ment just fibrosis stage 2-3
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Avatar_m_tn

in any case beging biopsy subject to mistake by down estimation of damage, and being advanced fibrosis 3 possible:
treatment is mandatory
monitoring improvemnt by fibroscan is mandatory too (biopsy can t monitor fibrosis regression in short intervals every 6-12 months)
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Avatar_f_tn
I think your doctor meant just fibrosis stage 2-3.  I don't think they grade nodules like that.  Nodules are usually assessed as benign or malignant (or uncertain).  BUT, I am far from an expert on this.  If you are worried, do some research on your own, and ask a liver specialist about it when you have a chance.
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Avatar_m_tn
Here are my new test results-

Fibro scan score - 6.4
Hbsag (q) - 2363 IU / ml
HBV DNA 9440 IU/ ml ( increased from 1350 IU /ml)
ALT 42 ( earlier it was 54)

so where do I stand now?
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Avatar_m_tn

very very good starting point, liver has no damage, only very mild fibrosis but 6.4kpa is present also in people with unhealthy diet, overwhight and with fatty liver so may even not correlated to hbv

hbsag is very low in the range with very high response to interferon

hbvdna must get to und, try vit d3 like we did here and i d start tenofovir to make sequential interferon add on when hbsg gets to 1000-1500iu/ml.do not wait because hbsag can go up

alt 42, if due to immune system response very good but this can be due to fatty liver too, did you have ultrasound?did it show any fatty liver?if no fatty liver you have good immune activity
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Avatar_m_tn
so according to fibroscan it's mild fibrosis but according to biopsy its fibrosis betwwen stage 2-3. I idid had ultra sound and it just  pointedf to slightly thickened gall bladder wall nothing else. I am not sure why HBV dna went up so significantly ( almost 8 times).
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Avatar_m_tn

hbvdna is something almost useless, it goes up and down to und with no relevant meaning to hbv infection and its clearance
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