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Treatment options
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Treatment options

Hi all,

I was diagnosed with Hepatitis B over 10 years ago and was confirmed to have chronic Hep B. During the same test I also found out I've got very high cholesterol (almost 2 x ULN). Since then, I've monitored my LFT roughly every 6 months as I am taking cholesterol medication. ALT has hovered around 110%-130% ULN and AST within ULN for the past 10 years.

3 months ago, the virus became very active. My results history:
23 Apr 2011
ALT: 152
AST: 65

26 May 2011
ALT: 242
AST: 134

10 Jun 2011
ALT: 364
AST: 143

17 Jun 2011
ALT: 397
AST: 161
GGT: 69

21 Jun 2011
ALT: 482
AST: 175
GGT: 73

HBV DNA >1.70 e+8 (IU/mL), the date of this test was 10 Feb 2011 and it's the only one I've got. I will ask for this test next week.
HBV Genotype A-1

Liver biopsy performed 25 June 2011 and the results were Portal activity - 3, Lobular activity - 2, Fibrosis - 1
METAVIR activity grade A2, Fibrosis state F1 (portal fibrosis without septa)

I am 29 years old, born in Taiwan, moved to Australia 20 years ago.
My liver specialist's first option for treatment is to go on trial for BMS's Peg-Interferon Lambda test. She's told me the success rate is only 1/3 but has a finite 48 weeks treatment period. I asked her about oral treatments but she said I might have to take the tablets everyday for the rest of my life. I have not started treatment because I am still searching for the optimal option.

For the past 3 weeks, I've been taking Chinese herbal medicine twice daily plus high dose of milk thistle to protect my liver. Last week (9 July 2011) my LFT results improved:
ALT: 265
AST: 97
GGT: 67

I am booked to see another specialist in 4 weeks time. I know I should to start treatment asap.

Two weeks ago, I was learning towards combined oral (Baraclude or Viread) treatment with Peg-Interferon. But the Australian government only supports mono-treatment.

At the moment, I am leaning towards getting interferon (Peg-A) to give my body a chance to fight the virus on its own. Hopefully this will achieve seroconversion from HBVeAg+ and HBVeAb- to HBVeAg- and HBVeAb+.  

I don't think I'll take the Peg-Interferon Lambda trial as it's a strict mono-treatment.

I am also intrigued to take Alinia with Interferon (Peg-A) for possible (albeit very slim) chance of eliminating HBVsAg.

Please, any suggestions would be much appreciated. Thanks in advance.
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27 Comments Post a Comment
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Avatar_m_tn

you should check hbsag quantity by architect, that's the ony way to know if you have chances, as you ve probably seen in posts hbsag<1500iu/ml has the highest chances

do make vitamin d level to 50-60ng/ml and tot chol<150 ldl60 this way you will weaken the virus and improve interferon sensibility.to lower cholesterol i am using red yeast rice which contains natural lovastatin just because it has almost no sides but simvastatin is the one shown to have the higher potency on hbv

as toliver damage f1 is nothing, even people with fatty liver or just trash food eaters (fast foods, lot of meat, fats, no vegetables) have f1.in any case you can reverse this by hepatitistechnologies products, just avoid fibroguard if you start interferon because fibroguard lowers interferon response

i do suggest combo or wait for better drugs or see if gcmaf actually works on hbv.

it would be good to try staggered interferon+telbivudine this is sure to lower hbsag but do not go over 6months because of possible  PERIPHERAL NEUROPATHY sides, vitamin d should be able to prevent this as shown in a recent research on telbivudine.with stricked monitoring for myophaty this is the best try even with high hbsag:
interferon+telbivudine+alinia+vitamind3 supplements, use of simvastatin before start of this combo and after better use red yeast rice with coq10 or nothing for choesterol just for extra safety as regards PERIPHERAL NEUROPATHY

after 4 to 6months of telbivudine as soon as hbsag drops 1log i'd stagger with tenofovir, researcher said this combo worth a try for shorter than 6months because  PERIPHERAL NEUROPATHY developped after 6months, the good news is that almost all patients had a minimum of 0.5log hbsag drop and a maximum of more than 1log which puts you in the range of high chances of clearance even with interferon mono.so since almost all hbeag negative are in the 3log range (3000-9000iu/ml) 1 log drop takes you to 300-900iu/ml which has a very high chances of clearance

if we add having good vitamin d levels, low cholesterol and alinia the chances should be very very high

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Avatar_m_tn
It seems to be that you are in the immune clearance phase. Actually your conditions are ideal for treatment by Interferon: activity grade 2, high ALT, and Genotype A. The only non-ideal condition is high hbvdna.

I don't why you are not keen on the Interferon Lamda trial as you will be well monitored. Is your specialist from RPA, Sydney?

In your next test, be sure to test your HBeAg and HBeAb status as you may have already seroconverted to HBeAg-ve inactive state.

Why take Chinese herbs? It will only mask your ALT numbers. Just my opinion.
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Avatar_m_tn
Hi Stef2011, you are a godsend. Many thanks for your informative reply and your contribution to this community.

Up until a week ago, I've always thought my high cholesterol, low vitamin D and chronic hepatitis B were three totally unrelated problems with my biochemistry.

9 months ago, my cholesterol specialist diagnosed me with Familial hypercholesterolemia and put me on Vytorin 10/80 (80mg simvastatin). It did bring my cholesterol to within ULN but also gave me muscle pains. 3 months later, I decided to half the dosage myself and the muscle pains went away.

About 2 months later, my ALT and AST started to flare. Maybe the drop in simvastatin jump started HBV viral activity.

Now that I know simvastatin actually helps with fighting HBV, I'll go back to 10/80 dosage and increase my vitamin D supplement intake.

I remember having some red yeast rice as a kid and absolutely hated it. But I think it is mainly due to how my mum cooked it. I guess I'll have to find a way to like it.

I will have a blood test next week and ask for HBV DNA count, HBVsAg count, LFT, cholesterol and vitamin D. After which, I should be able have more confidence on making treatment decisions.
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Avatar_m_tn
I will ask for HBeAg and HBeAb test next week, thanks for your advice.

My specialist is from Storr Liver Clinic at Westmead.

Reasons why I am leaning against the Lambda trial are:
a) Treatment is limited to 48 weeks finite period, followed by 24 weeks post treatment follow up. I remember reading that interferon treatment can be continued past 48 weeks if signs are showing that it is working. If it is effective, wouldn't they ask me to stop treatment?
b) If I am part of the trial, I am pretty sure they won't let me take Alinia or anything else in order for the trial to be completed in a controlled environment.
c) The stated benefit to Lambda is fewer side effects, not actually improve treatment efficacy.
d) My wife is currently pregnant (first baby due in 2 months! yay!) and I think it makes me not eligible.

I am open to listening to your opinion if you think I should still go on lambda trial.

I asked for combined treatment to lower HBVDNA to give interferon a better chance. But according to the clinic, Australian government only supports mono treatment. Unless I pay for everything myself.

As for chinese meds, my GP also advices me against it. But it was prescribed by senior, experienced and trusted extended family member. So far, it's the only thing that I can think of leading to lower ALT and AST.

I am interested to find out what you mean by masking ALT number?
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Avatar_m_tn
The most recent test I've got for HBVeAg was 10 Feb 2011, which was at the start of the current flare.

Results:
HBVsAg +
HBVeAg +
HBVeAb -

HBC Ag/Ab -
HBC Ag/Ab Ratio 0.16
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Avatar_m_tn
gave me muscle pains

this is due to coq10 depletion, try nano q10 from sollgar and normal coq10 and take 200-300mg daily distributed during the day.with coq10 the higher the better is not true so after 300mg you my just try and see if muscles pains persist.
if you get rid of pains retry 80mg dose, the 40-80mg dose are the most potent on hbv

you may also try bitter melon becuase research showed equal potency as rostiglitazone and this has also effect on hbv

metabolic syndrom (syndrome), fatty liver, high cholesterol are all ways hbv tries to take control of our body and get more food to make its antigens, so if you change your diet like i did for my fatty liver this wont help hbv.if you have a chance check insuline resistance too because this is another factor that lowers interferon response and makes hbv stronger.
i use 1liter of bitter melon tea at meals

About 2 months later, my ALT and AST started to flare. Maybe the drop in simvastatin jump started HBV viral activity.
alt jump is a good thing, it means you are infected infected cells if after alt rise hbvdna and hbsag decrease.i think definitely an effect of sim, also interferon and sometimes nucs make a alt rise when you respond

I remember having some red yeast rice as a kid and absolutely hated it. But I think it is mainly due to how my mum cooked it. I guess I'll have to find a way to like it.

it is better to take pills where monacolins quantity is standard but dont mix sim and res yeast rice.the goal is totchol<150, ldl60
hdl and vitamin d level have a direct antiviral effect so concentrate on these two.hdl can rise by panthetine and niacin but niacin has sides effect on liver so i think panthetine is much better, it has no toxicity at any dose, the doses used are 600-1200mg daily so i do go for 1200-1300mg distributed during the day

also omega3 fish oil wth EPA 1800mg – DHA 900mg helps, most formulas are fake with very little epa and dha

more confidence on making treatment decisions.
yes it is definitely better to improve all these easy parameters before starting
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Avatar_m_tn

by the way i didn t noticed you are hbeag positive, definitely immune modulators are btter than nucs for you, check also hbcab igm quantity because any value higher than 0.2s/co has very high chances of response on interferons

interferon lambda is definitely a good choice, you will find a way to get drugs in combo indipendently from your doctors....(indian is very easy to get etv or tnf and they are very cheap)
me and researchers in pisa were thinking about it but since i am hbeag neg there was no way to do it, after this i got to know about gcmaf so i opted for this, in case this wont work i'll definitely try lambda when available, especially for the combo interferon lambda+telbivudine which should have no PN sides at all since this type of interferon has effects only on the liver and higher potency too

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Avatar_m_tn
http://www.medhelp.org/posts/Hepatitis-B/nizoral-tablets-might-damage-hbsag--in-vitro-reduction-72/show/1550189

consider also ketoconazole, with close hbsag quant and liver function you can check if this in vitro result can be achieved in vivo too.
drug makers will never make trials on these extremely cheap  and old generics like nizoral or alinia but actually we dont need them at all we can just make perfect monitoring and check results ourselves
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Avatar_m_tn
My specialist is from Storr Liver Clinic at Westmead.
======================================
I was thinking of Prof Strasser from RPA.

Reasons why I am leaning against the Lambda trial are:
a) Treatment is limited to 48 weeks finite period, followed by 24 weeks post treatment follow up. I remember reading that interferon treatment can be continued past 48 weeks if signs are showing that it is working. If it is effective, wouldn't they ask me to stop treatment?
============================================================
Yes, in China, Interferon treatment can go beyond 48 weeks because it is not working, not because signs are showing that it is working.Western doctors follow guidelines and a course of Interferon treatment is 48 weeks. Ask you specialists about measuring HBsAg quantity to predict the outcome of Interferon treatment.

b) If I am part of the trial, I am pretty sure they won't let me take Alinia or anything else in order for the trial to be completed in a controlled environment.
============================================================
Alinia is also an immunmodulator. It is untested. Stef2011 takes it but Stef2011 has access to very good medical advice and he can monitor his own progress very well. No doctor in Australia will advise you to take Alinia, you will be own your own, perhaps with help from Stef2011.

c) The stated benefit to Lambda is fewer side effects, not actually improve treatment efficacy.
============================================================
Here, we are talking of a chance to get rid of HBV, and not just controlling it as with the antivirals.

d) My wife is currently pregnant (first baby due in 2 months! yay!) and I think it makes me not eligible.
=============================================================
Interferon can affect your fertility (I think), but since your wife is already pregnant, so I don't see how it will affect you, unless you plan to have another child in the near future. This, you have to discuss with your doctor.

I am open to listening to your opinion if you think I should still go on lambda trial.
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Look, it is your choice. Interferon gives you a chance to get rid of hbv altogether and it has a finite treatment period. Antivirals will let you control your hepatitis and usually you have to take them for a long time. Talk it over with your specialists, it seems to me you are not asking the right questions.

I asked for combined treatment to lower HBVDNA to give interferon a better chance. But according to the clinic, Australian government only supports mono treatment. Unless I pay for everything myself.
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Some years ago, doctors had this idea too, lower hbvdna before Interferon treatment. So they did clinical trials using Lamivudine as pre-treatment for Interferon. The results were disappointing, there was no difference in efficacy. So Interferon remains as a mono treatment. But Stef2011 thinks that combination treatment of Interferon with a nucleo(t)side should be considered again and I agree with Stef2011. Indeed there are trials on-going now testing Interferon with Entecavir. The idea is that we should use oral antiviral to reduce hbvdna to zero before starting Interferon. (Stef2011 will correct me if I am wrong). Remember, nowadays, we have better assays to monitor hbvdna and HBsAg quantity.

As for chinese meds, my GP also advices me against it. But it was prescribed by senior, experienced and trusted extended family member. So far, it's the only thing that I can think of leading to lower ALT and AST.
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In China, they use herbal medicine to lower ALT, but it is only a short term solution. It is treating the symptom and not the cause.

I am interested to find out what you mean by masking ALT number?
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When you are using the herbal medicine, your ALT is usually lower, but western doctors use ALT number to gauge the activity of our immune system as it is our immune system that is killing the infected liver cells and thus releasing the ALT enzyme within these cells. All HBV treatments, oral and Interferon, are optimal when our own immune system is active.

Just my opinion, I am not a doctor.
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Avatar_m_tn

i think that if you have access to hbsag quantification (i believe they do in the hospital otherwise they cannot make trials), fibroscan and bimonthly liver function/kidney function/hbv markers checkups you are ok with all the drugs i suggested, they are all free of sides and approved for babies even one year old, so no big deal except for nizoral and to a much lesser degree simvastatin

but as long as you are monitored bimonthly at start and then every 4 months after 6months everything is ok

fibroscan and ultrasound every 4-6months

at this point is all a matter of expense and australian coverage but if you enter the lambda trial i think they do all the close chekups i posted......you just have to cheat about monotherapy and if hbsag decreases a lot you just switch to another hospital and start immediately interferon alpha when you finish with lambda

as to the cost of alinia and sim they are very cheap, alinia generic is made by lupin is called nizonide500 and the cost is about 130usd for 1000pills in india

i would not combo with tenofovir and entecavir if using lambda i thin that lambda+alinia+sim should have a great impact on hbsag anyway
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Avatar_m_tn

as i posted earlier an hbsag quant and hbcab igm quantitative can help very much to guess possible resoponse.

before starting the treatment:
vitamin d 50-60ng/ml
nizonide500 pretreatment mono at 2g daily
simvastatin to get best chol values to weaken hbv
panthetine 1300mg daily, to increase hdl
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Avatar_m_tn

as to pretreatment with nucs to make hbvdna zero

this is also a good strategy because both hbvdna and hbeag are immune suppressive more than hbsag, so hbvdna zero may reduce immune suppression but i'd skip this and go straight for lambda

another good test is hbeag quantification altogether with hbsag and hbcabigm but i dont know if you have this one available too.

we have also data from a chinese guy who tried conventional interferon+alinia, unfortunately we ve lost follow up, i think he stopped the normal interferon alpha because of severe depression.the worse sides effects of interferon alpha are on brain function and depression

DATE DNA     ALT AST HBeAB HBsAg HBeAg HBsAb HBcAb
8-6-2010 851c/ml                          80,49

12/04/10  add NTZ                         2,18        6538,00      365        <2.00         0,01
21/03/10  17300000c/ml 143 87
01/02/10               35       30
09/11/09 start INF         94 49
03/11/09 9110000c/ml   80       42   8,24 4581,00 1000   2,86         0,003
15/06/09  12100000c/ml 179 97
23/06/08             118       53
27/06/2007     122       68
25/06/2006      80       40



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Avatar_m_tn
values got messed up posting here....


DATE DNA     ALT AST HBeAB HBsAg HBeAg HBsAb HBcAb
8-6-2010 851c/ml                                                  80,49
12/04/10  add NTZ                         2,18      6538,00      365        <2.00         0,01
21/03/10  17300000c/ml 143  87
01/02/10                     35   30
09/11/09   start INF        94 49
03/11/09 9110000c     80 42   8,24 4581,00   1000   2,86         0,003
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Avatar_m_tn
2.18 is hbeab antibody, 8.24 was the baseline value.hbeab detactable is equal to less than 1
6538.00 is hbsag, the baseline value was 4581
80.49 and 365 is hbeag.the baseline value of hbeag was 1000

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Avatar_m_tn

as you can see before alinia interferon was getting much worst than baseline and in 2 months of alinia everything got reversed:
hbvdna 851c/ml which is an increadible lowering for any mono therapy interferon or nucs, very rare on etv and tnf too it is 5log drop in 2 months

hbeag lowered from 365 to 80.49

too bad they did not check hbsag and the doctor was absolutely incompetent.the doctor thought it was interferon to make the increadible response and increased from 300U to 500U, the guy had severe depression and never posted again, i guess he stopped treatment
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Avatar_m_tn

he started with the worst situation for interferon, such high hbvdna and hbsag have no hope on interferon mono anyway addition of alinia reversed anything

i think that as shown on hcv trials alinia is able to restore interferon response and improve it, this is something we do need on hbv treatments because hbv can stop both our body natural interferon and the injected interferon and make it totally useless
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Avatar_m_tn
I am currently using chinese meds and milk thistle to protect the liver from further damage. Like you said, it's short term until I go on western treatment.

I'll ask my GP if she will actively monitor my progress through fortnightly blood tests.

At the moment, I am still thinking of not taking Lambda trial so I am open to co-treatment.
I don't want to be selfish to go on trial to receiver the newer drug and cheat by getting additional treatment. This will not help the study and Hep B community.
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Avatar_m_tn
Thanks for your suggested pre-treatment, it seems so obvious to prepare my body to get it into a condition that favours interferon. I wonder why medical professionals here haven't suggested cholesterol and vitamin D levels in the fight against HBV.

I will try and get fortnightly blood tests on LFT, lipids, vitamin D, HBVDNA, HBVsAg qty, HBVeAg qty and IgM HBcAb during treatment. And also report back to this community.
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Avatar_m_tn
Just found out that I am not eligible to receive any form of interferon treatment (lambda or alpha) whilst my wife is pregnant. I am not sure if the same rules apply outside Australia.

She is due in two months, during which I must continue to test ALT and AST and start oral treatment if figures go up.

I was told there is going to be a new trial which will probably open in 3 months. The trial is combined tenofovir and interferon. I will probably wait for that.
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Avatar_m_tn
I find it weird that you are not eligible for any Interferon treatments whilst your wife is pregnant. It is like you are not allowed to have a cold whilst she is having a baby. I am sure it is for non-medical reason, would appreciate if you ask your specialists why.

Once you are on a clinical trial, you are not allowed to take any other medications without approval, otherwise it will simply destroy the validity of  your result in the trial.

I am not sure that it has been clinically proven that the herbs protect your liver. It is widely used in China, so I can't comment. You should inform your doctors what you are taking before starting treatment or going on a trial.

I am not sure why you need to test every two weeks. At you say in your biopsy report, your liver is in stage 1, which is pretty good. If you want to experiment with various combinations, make sure you know how to monitor your progress. Currently HBsAg quantity assay is not available in Australia and you need a prescription to do all the testings. So make sure you have a GP that will work with you. I don't think any specialists will.

Sorry to be such a pain, but you must ask questions. Stef2011 is different, he knows more than your average doctors about Hepatitis B and he knows what all the numbers mean.

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Avatar_m_tn
Male patients are not allowed to take interferon if their partner is pregnant because they don't want to get into a situation where if the baby is lost, patient might relate it to the treatment. I didn't probe them on how silly that sounds. I don't like this as my wife and I are planning to have more kids.

I haven't told my doctors about chinese meds, I know they will disapprove it and ask me to stop using it. One can put down my recent improved LFT results down to chance or it could be from using chinese meds. Either way, it's short term until I go on western meds.

At the moment, I am monitored fortnightly just in case my LFT flares again, if so I'd have to start oral treatment asap.

I am beginning to understand more and more what each of the numbers mean. I've learned a lot more from this community than from my specialist. They are far too busy to give me the attention and not enough question time that I would like.
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Avatar_m_tn
Interferon is a natural substance produced by your own immune system when it encounters infection. The fluid-like symptoms when you have a cold are caused by Interferon. So this explanation that patients are not allowed to take interferon if their partners are pregnant sounds stupid to me.

Ask your Liver specialists if you have any questions, your GP does not know much because they have seen very cases of Hepatitis B in Australi.

Being of  Genotype A, your prognosis is better than others.

I won't be surprised if you seroconvert to HBeAg-ve and HBeAb+ve in your next test.

All the best.
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Avatar_m_tn

the rise in alt/ast is a good sign, absolutely not a bad sign, and immune modultors are the best choice if this happens.nucs just kill hbvdna but immune response too although tenofovir has shown 16% hbsag eradication at about 3 years on hbeag positive the percentage is so low that i'd never suggest a nuc monotherapy except for those with liver damage

i suggested 2weeks checks at start because the combo was quite particular but you can do so close checks the first month only and then go for monthly checks.after 6mnths you will be able to know what the kinetics are and if no sides at all you can monitor every 3-4months.
these are the time point blood checks for research, of course normal doctors check much less
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Avatar_m_tn

by the way if hbsag quant in iu/ml is not available in australia you may check with labs in india or china and send samples to them

i dont know how blood test are delt in aust but here you can ask private labs to draw blood as instructed for hbsag quant by architect and have them sent to other labs to make the test or just have a nurse to make this at home and then just ship by fedex.
hbsag is an extremely easy and stupid test and extremely cheap compared to hbvdna pcr, this is the main reason some countries are not using it yet
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Avatar_m_tn
Just got my blood test results back, unfortunately I wasn't able to get HBVsAg qty nor HBVDNA qty.

23 July 2011 (last result 9 July 2011)
ALT: 260 (265)
AST: 160 (97)
GGT: 78 (67)

ALT dropped a little bit, but AST went up substantially.
I think this may be due to increasing Simvastatin dose from 40mg to 80mg daily.

Wondering whether I should go back to 40mg Simvastatin.
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Avatar_m_tn

yes due to sim probably but ast is not important, follow alt and check that they dont rise too much and for too long time

alt/ast activity alone is not correlated to liver damage, if you checked the article it says that alt rise is probably not correlated with liver damage but to assestments in the liver.usually the alt gets back to normal with time

all this said we are looking for a alt rise because it means immune activation but we do need hbsag nd hbvdna to understand if it is toxicity, immune activation or more virus activity

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Avatar_m_tn
In a routine LFT on 20 Aug 2011, my GP called me to go the following day and told me the bad news. My ALT flared to 1,180 and AST to 583. My GP told me to go to hospital emergency ASAP. At ER they did another LFT, the results came back and ALT worsened to 1,400.

I was admitted to acute assessment unit, but being a Sunday, no doctor was available to speak to me until Monday. I discharged myself from the hospital and came back the following day. On Monday, in was able to see a liver specialist. I was prescribed Tenofovir and have started treatment. I feel more fatigued and slight discomfort around the liver area at times.

At the moment I am most concerned with liver damage. Any suggestions? How long after taking tnf will I see ALT come back to normal range?
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