should i take baraclude?

[hepb9919]

I was diagnosed Hep B 13 years ago, and have taken Epivir since 2002. I do blood test and ultra-sound every 6 months and Hep B is controlled pretty well. As you know, Epivir cause virus mutant resistance, and chance is higher for me since I have been on it for 5 years. My doctor gave me 2 choices,
1) "don't fix it until it breaks" - continue with Epivir, move to combo treatment when mutant and resistance evidence shows up.
2) "precautious way" - take baraclude.

What is the better approach? Thanks

Here is my recent blood test result.(all in normal range)
Protein, Total 7.5
Albumin 4.5
Globulin 3.0
A/G Ratio 1.5
Bilibubin, Total 1.0
Bilibubin, Direct 0.2
Bilibubin, Indirect 0.8
Alkaline Phosphatase 70
AST (SGOT) 15
ALT (SGPT) 24

Hep B Viral DNA QT <100
Hep B Viral DNA QT <160
Alpha-Fetoprotein 2.3

[hepb9919]

PS: i forgot to mention, my E antigen is Negative.

[stevenNYer]

When you first treated, Epivir (Lamivudine) was almost exclusively used as Hepsera was just approved back then in 2002. It's fair to conclude the most doctors were still feeling their way on treatment sinc not much information was available, especially on the consequences of Lamivudine resistance.  Even today, many doctors are still feeling their way.  You could only imagine what it was like 5 years ago.

I was shocked to read from your post that you have not developed resistance after 5 years of Lamivudine use.  You are certainly in the minority....lucky, very lucky you.  But this lead me to think you may have already been an inactive carrier with a very low viral load BEFORE you treated.  You risk for resistance is lower if your viral load is low or UND.  Or maybe on your way to becoming an inactive carrier.  In both cases, treatment wasn't even needed.

Now if you were trutly E antigen positive BEFORE treatment and seroconverted to E antigen - and E Antibody + on treatment, the general recommendation is to continue meds for at least 6 months and go off with close monitoring of the viral load via PCR.  That would be the target endpoint.  

So the answer to your question depends on those things.  But in general, treating until resistance develops is a HORRIBLE HORRIBLE plan.  If you develop reistance to Lamivudine, your resitance profile to Baraclude takes a serious hit.  If your doctor feels the best option is with Baraclude, switch NOW.  Why is your doctor waiting???  And if it's the antiviral that is keeping you UND, think about combo treatment with Baraclude.  Treatment should have the goal of minimizing the risk of developing resistance to antivirals , especially if you need long-term, perhaps a lifetime of treatment.

Usually I post at night...but your situation warrants immediate attention.  Talk to your doctor as soon as possible since resitance could happen at anytime for you.

[stevenNYer]

I received a couple of comments on my previous post on private message.  Since the comments on related to this thread, I will respond here.  Before I do, I want to point something out:

It's okay to post on this forum even if you disagree and challenge me my views.  Remember, I am not a doctor.  A different view would cause me to do some research and that's how I learn.

Comment received:   ...the longer you carry on with Epivir without a mutation arising then the less likely the mutation will arise...if your bloodwork results are good and you don't
develop the mutation."

stevenNYer's Comment:  I totally disagree.  What happens here is that if Epivir (or other antivirals) are succesful at reducing the viral load to UND, the risk of mutation is lowered since the adaptive power is reduced due to fewer virus in the system.  But if someone is unsuccessful at reducing the viral load to UND then the risk of mutation goes up significantly.  Research shows Lam resistance at 24% after 1 year, 42% after 2, 53% after 3, and a whopping 70% after the 4th year.  This was presented by Dr. Keeffe so it's reliable stuff.  Now maybe the original posters of this thread responded great to Lam initially and went UND and is now that minority % who still have not developed resistance at year 5.  But following the trend, it will happen.  It's a matter of time.  It must be understood that the virus is in a constant state of trying to overcome external control, be it the immune system or antivirals.

Comment received:  "If somehow Baraclude doesn't work for me, what's next?"

stevenNYer's comment:  Probably Tenofovir.  But Baraclude will have more life if you don't have resistance to Lam.  Before you start Baraclude, I would strengthen its resistance profile by going combo to cross-protect the antivirals against resistance.  Once you develop resistance to an antiviral(s) it will limit the treatment options.  

[hepb9919]

Steven,

Thanks very much for your information. More information about my case. After about 3 years of Epivir (I think it was 1st half of 2005), doctor (same doctor) asked me to stop Epivir for a while, to see if my body can supress the virus without medication. No majic, 2 blood tests taken the next 3-4 months showed DNA growth trend, so I continue with Epivir HBV till now.

[cajim]

According to Dr. Keeffe, "Entecavir is 100-fold more potent than lamivudine or adefovir."  See link below:

http://www.medhelp.org/posts/show/473007

[stevenNYer]

What was your E antigen / antibody status, DNA load, ALT before treatment?

After treatment?

And at the time your doctor asked you to stop Epivir?

Why did you doctor tell you to stop treatment at that time?  The specific justification.

[stevenNYer]

Here's more related comment someone forward to me for feedback:

Comment received:  If you develop Lam, your treatment options haven't changed.  You can still take baraclude.  If you take it now are you going to take the 1mg dose or .5 mg dose?  I presume the 1mg...

stevenNYer's comment:  I totally disagree with that.  Google search how Lam resistance affects Baraclude's resistance profile.  Lam resistance provides the virus with a stepping stone to develop resistance to Baraclude.  If you develop resistance to Baraclude, it doesn't matter if you take the 1mg.  The 1mg is just a higher dose.  The virus already made the adjustment to Baracluded chemical structure.  Does taking 1mg after resistance really help?

Dr. Keffee recommended that Lam should not be use as a mono-therapy for treatment of HepB because of this resistance issue.

Our own HR in past posting indicated that going from one antiviral to the next after its respective resistance is a bad strategy.  HR indicated his patients were treated with Tenofovir for HepB years ago.  Tenofovir will soon be recognized as the new all-star meds for HepB.  So HR and Keffee are way ahead in this game.

They both indicated the importance of combo-therapy to minimize resistance.  I am more incline to follow their advice.

On a side note, do you know that research is already out indicating that for patient who developed resistance to Hepsera, they are having a hard time going UND even with Tenofovir.  Still think resistance is not an issue???

[hepb9919]

What was your E antigen / antibody status, DNA load, ALT before treatment?

A) I couldn't find my 1st blood test result (in 2001), here is the HBV test taken in March, 2004. Should be same. In early 2002, my DNA load is high, and ALT is ~200.

Hep B Surface Antigen - positive
Hep B Core AB -total - positive
Hep BE Antigen negative
Hep BE Antibody positive
Hep B Surface Antibody negative

After treatment?
A) DNA droped to undetectible. ALT/AST back to normal range.

And at the time your doctor asked you to stop Epivir?
A) It's in 2004-2005.

Why did you doctor tell you to stop treatment at that time?  The specific justification.

A) My doctor (not the same one who treated me in 2002) thought after over 2 years Epivir, the resistance risk is high. So he wanted to know if my immune system could handle it without medication. I took 2 blood test in the next 4 months, ALT/AST stayed normal, but DNA number went up. So I resumed Epivir.

Something about my family. My mothter was diagnosed HBV in 1979, was treated by herbal medicine (traditional Chinese way) at that time. She also took Lam since 2004.

My brother started Lam since 1999, no resistance so far.

When I know I'm one of the very fortunate HBV patients that don't have resistance after 5 years of Lam, my brother might be the extreme case (If he could transfer this luck to lottery or stock, ...wow).  I think will that be the case that Lam is particularly good to deal with the HBV my family carries?

Thanks!

[stevenNYer]

So before treatment, it looks like you already went through the eSeroconversion and it may be that you have an active eAntigen - disease.

You say the DNA is high before treatment, what's high?  What are the exact numbers?

And when you stopped Lam, how were the exact DNA numbers?

And I do see your indecision.  You may very well be that few percent that haven't developed resistance to Lam even after 5-7 years of use.  I don't know the reason.  I doubt the doctors know.  So even say after for example (not real stats) 10 years, 95% develop resitance to Lam, there still that 5% of He-Man's and She-Ra's out there.   Probably a personal favorable geneitc disposition (based on your family history).

But personally, here's how I look at it.  The goal is to prevent resistance.  But the time that happens, it's too late.  And you really DON'T KNOW when it will happen.  But we DO KNOW is that its the nature of the virus to evolve and mutate away from external control, so I still think it will happen.  So switching to Entecavir (generic name for Baraclude) would increase the anitviral power and if you are unlikely to develop resistance to Lam, I would think the same would hope true for Entecavir.  The virus would need to make even more complex adjustment to overcome Entecavir.  So if you have nice personal resistance profile of Lam, it would be golden for Entecavir.

For me, it's an easy call, I would take choice 2, the precautious way.  But that me ... and then there's you.

Also remember to post up your DNA numbers.

[stevenNYer]

Especially for you, follow this important thread:

http://www.medhelp.org/posts/show/486232

[hepb9919]

Thanks Steven. that's a great presentation. I schedule an appointment with my doctor to continue discuss about the medical treatment.

[zellyf]

Also note HR's comments about the monotherapy being a very conservative approach.  Please keep us updated!

[drefthemen]

I was diagnose  to have acute