after 1 year of pegasys

[coletta]

Hello everyone,

Below you can see an overview of my experience with hvb:

June 2010
- hvb adn = 10045 copies/ml
- alt/ast = normal

December 2011 - I started pegasys monotherapy - 180 mg weekly
- adn hvb = not having checked
- alt/ast = still normal

September 2012 - week 42
hbsag quantity = 1235.55 ui/ml

October 2012 - week 46
hbsag quantity = 1467.35 ui/ml
alt = 50 (<35)
ast = 57 (<35)

November 2012 - after 48 weeks of pegasys
I changed doctor since I was simply sent back home and asked to come back in 6 months.
New doctor recommended me to take some blood tests:
- adn vhb = < 20 ui/ml
- hbsag quantity = 1388.82 ui/ml
- vitamin 25oh D = 21,3 ng/ml
- interleukin 28b = genotype TT (it seems that this genotype has higher rates of relapse)

New doctor also recommended some pills - vitamin E, omega 3&6, ursofalk & sylimarin

Today I had an appointment with the doctor and after seeing my blood tests results his comments were:

- I should start tenofovir to make sure that the adn vhb will become und. Tenofovir to be taken eraly in the morning with no food for a better absorbtion? (I thought it should be taken with meal)
- I should not take vitamin D although it is under the optim value. He thinks it is not the most important parameter? (I thought it was very important to keep the value high around 50 ng/ml)
- I should continue taking sylimarin, vitamin E, ursofalk, omega 3&6? (I thought that these should be avoided during treatment)
- We should look into the posibility to go fo a combo treatment with interferon at some point.
- I should check hbsag every 6 months while taking tenofovir.

I will highlty appreciate your comments.

Thank you.

[coletta]

Thank you!

[stef2011]

with such high hbvdna intf is almost sure to fail you should rduce hbvdna and possibly hbsag by antivirals first and then add on intf

check if you can get generics from india or vietnam they are very cheap there

[StephenCastlecrag]

I agree with stef2011 that IL28B is more useful as a predictor of response to Interferon treatment for HCV,and it is ambiguous in the case of HBV. Unless your doctor is an active researcher in this area, I am skeptical about his conclusion that interferon is useless for hbv patients with IL28B, since in your case, you responded with undetectable hbvdna .
It seems to me you now face 3 possible choices:
1. Start Tenofovir
2. Continue Interferon for another 48 weeks
3. Do nothing, check in 6 months

Personally, I favor no.3 but bear in mind I am not a doctor. I am wondering what country you live in, as youn seemed to have access to qhbsaq and il28b tests.

[Andykdu]

Hi,

I have been recently detected with Hepa B. Here are my details of results:

HBe Antigen - Positive(Index 5.30)
Anti HBe Antibody - Negative

HBC Quantitive Real time - PCR viral copies 79750000/ml [Conversion (IU/ml) : 53166667]

Other tests have been done too and report shows ok.... Liver is not yet damaged as the doc said.

I have been prescribed Pegasys injections for a year. Dosage - 1 injection per week by my doctor.

I'm extremely confused as I come from a poor family and cannot afford the injections right away! not sure what will i do? I cannot keep my self strong anymore.

I'm writing this to you as you hv been answering to everyone. I just want to know that i cannot start the treatment right away, what can happen?

I live in the Philippines and meds are so expensive here...

Please reply and let me know.

Regards
Andy

[coletta]

I also knew that intreleukin 28b was more useful for hcv, but when I asked doctor he said that it was useful for all viruses, even for flu...

As I said, always confusing...

you better keep tdf mono for sometimes and check that hbsag declines or stay stable and then add on intf in 6-12months time with another doctor or paying for it yourself using generics

My first experience with interferon was not so easy in terms of sides, especially on blood counts: very low white cells and low platelet count. I was monitored through blood tests weekly.

I should find a doctor willing to take care of this even if I pay for generics myself.

[stef2011]

Is indeed this interleukin 28b genotype T/T such a predictive factor for responders?

no, just few studies with opposite results.only for hcv results were very clear.this test was not performed for me and i have geno d which is less responsive and more hcc risk even if hbvdna und...

you better keep tdf mono for sometimes and check that hbsag declines or stay stable and then add on intf in 6-12months time with another doctor or paying for it yourself using generics

[coletta]

Many thanks Stef and Stephen.

I've seen the doctor this morning again. I must add that he is considered to be an expert in hepatitis matter. He takes part to all conferences abroad which makes me hope that he is updated....

Although I am always confused after I see him and cooperation seems to be not so positive.

His comments were:

Since I have interleukin 28b genotype T/T he finds it useless to continue interferon because this genotype hardly responds. If it was interleukin 28b  genotype C/C and hvb dna genotype A the situation would be different (100% cure with the combo treatment: tenofovir and interferon)

He also added that interleukin genotype T/T can easier lead to HCC and keeping adn hvb und is the best thing to do. Interferon should be used as a back up and added on in case of emergency only: raise in alt, high raise in hbsag, raise in adnhvb.

In the end, a bit irritated from all my questions he insisted that this is the best option for me: tenofovir mono for a non-definite time if things are stable and add on interferon if things get worse.

Is indeed this interleukin 28b genotype T/T such a predictive factor for responders?
The "lucky" ones to carry interleukin 28b genotype T/T have no chance to cure?
Should their goal be only to keep the hvb dna und in order to prevent from HCC?

I cannot continue interferon on my own. I need a good doctor to monitor the course of the treatment....
I think I will give up in hoping for the better.

[stef2011]

- continue interferon and combo with tenofovir (although I stopped interferon for almost 3 weeks now)
- monitor hbsag

[coletta]

Thank you for your valuable answers.

The following seems to be the best way to go:
- raise vit d > 50 ng (5000ui/day will do?)
- continue interferon and combo with tenofovir (although I stopped interferon for almost 3 weeks now)
- monitor hbsag

or.. it just crossed my mind:
- take tenofovir mono and add on interferon lambda when it will be available.  Would this be better?

[stef2011]

Note that the analyzer indicated a very low value below the lower limit of linearity range"

hbvdna has been detected at less than 20iu/ml, you should reach und or not detected status sooner or later by antivirals.intf is not so  potent on hbvdna

[coletta]

Your doctor is very confused! Your hbvdna is <= 20 iu/ml, that is UNDECTABLE!

This is the answer in the medical report:
"hbvdna < 20 ui/ml  
Comments:
- detection limit in linearity range is 20 ui/ml;
- analitical sensitivity = 9 ui/ml
Note that the analyzer indicated a very low value below the lower limit of linearity range"

If hvbdna was und why didn't they simply write und? And what is that analitical sensitivity?

So, why do you need to take Tenofovir???

As Stef also said I need to take Tenofovir to avoid relapsing. If it has any effect on hbsag .... I wish it had, but most probably it doesn't.

I found my doctor a bit more confusing this time.

Anyway I will consider the combo treatment at some point, although it seems that this time I have to pay everything myself or I can wait till I join a clinical trial group, as doctor said.

[stef2011]

yes both doctors are incompetent she should keep intf in the first place since hbsag is around 1000iu/ml or add tdf to it just to boost hbsag decline.actually all other options are not curing or leading to an hbsag decline for sure

[StephenCastlecrag]

I am a bit confused here(just like the doctor, LOL). if you want to maintain a declining HbSag why not continue with Interferon? If you want to maintain undetectable hbvdna, why not just use Tenofovir as the mono therapy in the first place? By starting Tenofovir after stopping Interferon, you will maintain undetectable hbvdna but will it help HbSag to decline further?

[stef2011]

that s to avoid relapse after intf and keep a decreasing hbsag, both ways are applicable:
wait for hbvdna to relapse
prevent by taking tdf

it is best to keep tdf and then retry intf in 1-2 years

[StephenCastlecrag]

Your doctor is very confused! Your hbvdna is <= 20 iu/ml, that is UNDECTABLE! So, why do you need to take Tenofovir???

[stef2011]

Tenofovir to be taken eraly in the morning with no food for a better absorbtion? (I thought it should be taken with meal)

infact, this doctor is confused with entecavir

- I should not take vitamin D although it is under the optim value. He thinks it is not the most important parameter? (I thought it was very important to keep the value high around 50 ng/ml)

infact vit d>50ng/ml is essential expecially to prevent some nucs sides and avoid hbv damage to bones/kidneys

yes to vit E and others if you are hbvdna und you can take alll vitamins

- We should look into the posibility to go fo a combo treatment with interferon at some point.
yes

- I should check hbsag every 6 months while taking tenofovir.
tdf has little effect on hbsag, not sure this is useful