Does Peg INF effective for HBeAg Psitive patients?

[Mars86]

I'm on etv since 9 months , DNA still detected 5000 iu/ml , I was advised to continue using etv for another 3 months then add on peg INF , is this a good choice or what ?  ... HBsAg is 133000 iu/ml ... raised through the last 3 month significantly as it was 89000 iu/ml

your suggestions and thoughts will be helpful :)
Thanks

[StephenCastlecrag]

This the results from a 96 week study of ETV v ETV +TDF:

Rates of adverse events and serious adverse events were comparable in the combination therapy and entecavir monotherapy arms.
However, more patients discontinued treatment prematurely in the combination therapy compared with the monotherapy arm (3% vs 1%).
Notably, just 2% of combination entecavir/tenofovir recipients and 3% of entecavir monotherapy recipients experienced serum creatinine increases (≥ 0.3 mg/dL), a possible indicator of kidney impairment, which is a potential toxicity of tenofovir.

http://www.hivandhepatitis.com/hepatitis-c/hepatitis-c-topics/hcv-treatment/3349-aasld-adding-tenofovir-to-entecavir-offers-no-additional-benefit-for-hepatitis-b-patients

[Mars86]

Thanks a lot , but are there any risk in this combo ?

[StephenCastlecrag]

Thanks. So you went from 170*10^6 (8 log) to 5700 (3 log). So that is a response from ETV. Your ALT remains normal.
It is still my opinion that you should be patient and test again in another 3 months to see whether you need to change your treatment.

A flare is normally defined as 1 log increas (ie. 10-fold) increase in hbvdna, together with an increase in ALT.

[Mars86]

ok stephen ,

HBV DNA in Jan > 170 * 10^6 iu/ml
HBV DNA in jul = 4000 iu/ml
HBV DNA in oct = 5700 iu/ml
for all of above readings ALT was in normal range and never goes high
all of last readings was performed in the same Lab , the best one in cairo, Egypt.
I was on etv mono since jan 2012

[StephenCastlecrag]

You are giving us several numbers for your hbvdna (4000, 5700, 5000). I cannot give you an explanation. In Australia, doctors preferred their hbvdna to be tested at the same lab for comparison. I don't know where you live and I don't know the standards of your testing labs. As for mild enlargement in the liver, I have no idea what it means. What was your ALT when the imaging was taken and what were the diagnosis from the imaging?

[Mars86]

yes I consulted another one , but he advised with tdf + etv combo because in last july DNA was 4000 iu/ml then after 3 months in oct it raised to 5700 iu/ml as well there is a mild enlargment in liver , wut do you think ?

[StephenCastlecrag]

You doctor should know that it has been clinically shown that tdf + etv combo treatment is not superior to etv monotherapy. As long as your hbvdna is coming down and your ALT is normal, I think you should be patient. If you doctor treated you when you were in the immune tolerance, then I would suggest you consult another doctor.

[Mars86]

ur advice is required :)

[Mars86]

Thanks a lot Stephen ,, I just advised my new doctor and he advised with the combo tdf + etv , asked me to do monthly test related to kidneys as a tdf has a direct effect on kidney , it seems that i'm on the right path , as I felt that etv is not enough in my case personally as I was treated in immune tolerance phase with no fluctuation in ALT/ASt before till now.

[StephenCastlecrag]

I think your doctor advice is sound. We don't know what your conditions were at the start of treatment, so cannot comment on your response. The goal of treatment is to reduce viral load and normalize ALT. Entecavir has high genetic barrier to drug resistance mutation, so there is no need to switch medication if response is not optimal in the first 6 months. Below are some data for you to compare with. Make sure you take Entecavir on an empty stomach.
I don't know what is the significance of a rise in HBsAg , I think hbvdna and ALT are more important. As for adding INTFN, it all depends on what you want to achieve and the state of your treatment progress. Others may give you better comments.

Entecavir

Entecavir was approved in the United States in March 2005[Entecavir PI US] for the treatment of chronic hepatitis B virus (HBV) infection patients with evidence of viral replication and either evidence of persistent elevations in aminotransferases or histologically active disease (Table 2).[Entecavir PI US; Entecavir PI EU] Entecavir has been studied in treatment-naive patients, patients with lamivudine-refractory disease, and patients with decompensated cirrhosis. In lamivudine-naive HBeAg-positive patients treated with entecavir, HBV DNA was suppressed to undetectable levels in 67% of patients and hepatitis B e antigen (HBeAg) seroconversion occurred in 21% of patients after 1 year (Figures 1A and 1B) Figure 1.[Chang 2006] Cumulative rates of HBV DNA undetectability increased to up to 80% and 94% at 2 and 5 years of entecavir therapy, respectively.[Gish 2007; Chang 2009] In patients with HBeAg-negative chronic HBV infection, HBV DNA was undetectable in 90% of patients after 1 year of therapy (Figure 1C) Figure 1.[Lai 2006]

The efficacy of entecavir in nucleos(t)ide analogue–naive patients was confirmed in several large investigator-initiated clinical studies. Indeed, a European cohort study of both HBeAg-positive and HBeAg-negative patients showed that 79% of nucleos(t)ide analogue–naive patients achieved a virologic response during the first year of entecavir treatment,[Reijnders 2010a] and this response rate increased through prolonged therapy.[Zoutendijk 2011] Preliminary results of an Italian study enrolling predominantly HBeAg-negative patients demonstrated that entecavir therapy resulted in undetectable HBV DNA levels in 91% and 97% of patients at 1 and 2 years, respectively.[Lampertico 2010a]

Very low rates of entecavir resistance (1.2%) have been reported in nucleos(t)ide analogue–naive patients through up to 6 years (Figure 2) (Management Guidelines).[EASL HBV; Zoulim 2009; Tenney 2009]

[Mars86]

ur advice is required :)