To treat or not

[lml910]

I was diagnosed with Hepatits B few years ago.  Initially my VL was 700 but recently it has jumped to 175,000 and I am precore mutant.  My liver enzyme and functions are all normal, including my ultrasound.  My GI recommends that I start treatment with Baraclude.  He said a liver biopsy is unnecessary since I have the precore mutant strain.  Since my ALT is normal and there is no liver damage, should I start treament?  I have done research on the internet and there are different opinions.  Some websites recommend a liver biopsy before treatment to see if there are any liver damages.  Others said regardless of viral load, if no liver damage, no treatment is necessary and just monitor the disease.  

I know once I start treatment, it will be for lifetime and I also worry about drug resistance.  I don't want to start treament unless it is necessary.  Can anyone tell me if I should treat?  Thanks.

[lml910]

Thank you all so much for your valuable opinions.  I will post my question in Geocities to see what type of replies I will get.

[babamamagogodede]

It is viral load that to treat. A recent journal from Taiwan pointed out only high viral load is enough to cause very high risk of hepatocellular carcinoma. ( 13yr: ~15%) ~1.5%/yr
If your have average 40 years left. You average loss 0.6 yr per year at your 30's.
It is very bad news~( You have 1.5%  to loss 40 years every year because you got HCC, so you loss 0.6 year per year compared healthy youngs. Healthy youngs could full around 4 months per year and do as good as you)
I very oppose any oral medication as first line therapy because none of them offords good chance for long term remission. If you are young, try peginterferon first.

[stevenNYer]

Good posts by all.

Opinions will certainly differ.  I think the decision is based on multiple factors, including your age, viral load, level of liver damage, even level of access to meds, and if you are at risk for adverse effect from antivirals.  For example, if you are 35yo and was previous inactive carrier, you probably don't need a biopsy since your mutant strain was probably a recent immuno escape during seroconversion.  If you are 55yo and have no idea when you seroconverted and don't know much about your disease history, you may want to do a biopsy to assess level of liver damage, then decide on treatment.  Also, the younger you are the more you have to factor in the resistance issue because as you said you may need lifetime of meds.  But on the other hand, if you are older and have already a bad kidney, you may not want to treat since certain anitvirals could affect kidneys.

My opinion is to take your MD advice to treat since your MD seem to know about what he/she is doing by suggesting Baraclude, a potent antiviral with a excellent resistance profile.  Now if you are in your 30, you may even think about taking a second antiviral (like Hepsera or better the soon to be approved Tenofovir...hopefully)  to cross protect against resistance because you may need to take meds for 40 plus years and to do so without viral resistance is a tough goal.

Here's my thinking, if you have a confirm precore by genotyping, the virus will continue to replicate into high, perhaps gigantic numbers.  It has the potential to cause serious liver damage.  And due to it's greater adaptive power in larger numbers, you will be at greater risk for resistance for antiviral if you start them later on.  And lastly, higher viral load is correlated to higher incident of liver cancer.  So many doctors will treat with the goal to just lower the viral load.  So if I would you I would take a preventive measure to gain a upper hand now.

Hope this helps....good luck.

[zellyf]

I pulled this from an email thread...a response from a doctor:

"As for high, I don't see copies below 1 million as being high.  It's really
interesting to see how much priority lowering viral load to undetectable has
grown with the increased availability of antivirals."

*** I agree with Michelle....sorting out inflammation is the KEY..and not
viral load by itself. Anti-virals are being pushed by the Industry for
various reasons.

Just a thought.

[zellyf]

I am just a patient...possibly on my way to precore status like you.  My understanding is that ONE standard for deciding on treatment and then on what course of treatment is to  know your viral load, your ALT (series and not just one or two) and you need a biopsy.  If two of the three indicate activity then you should initiate treatment.  You cannot assess liver damage on ultrasound.  U/s can miss fibrosis.  So can CT and MRI.  

Of course, different doctors have different opinions and some are more aggressive than others.  Have you joined the hepb mailing list?  I would urge you to  posit your question there for more answers. http://www.geocities.com/Heartland/Estates/9350/hblist.html

Also, search the archives here the  see if hepatitis researcher has answered this question.  I know he has spoken to the best treatment options for mutant hepB. Maybe stevenNYer will have a lead.

I don't necessarily recommend trusting the opinion of any ONE doctor unless it is someone whom you know has had a lot of experience treating your particular brand of hepatitis B.  Even the difference between the precore and the wild type presents different strategy options.  I stuck with my internist for too long because I wanted to believe him even when I suspected I shouldn't.

Best.

[KDH59]

Go with your DR. he knows best. Maybe you can clear it before a lot of damage starts. Just trust in him. This is a support network that know the treatment inside out...We are not DRs so get a second GI and see what he says.. IT IS ALWAYS BEST WHEN YOU ARE FIRST STARTING OUT TO FOLLOW THE DOCTOR. I am a NON-responder to treatment and my liver has 25 years of damage.. So get a plan together and stick with it. GOOD LUc MY FRIEND>.........................Kirk