HepB carrier from birth with sudden flare ALT >1500 and AST >500

[orientalPearl]

Hi everyone i'm not sure what to make of my 'recovery' so far as I can see some significant drop in my liver enzymes test but still the values are above normal range. How long does it usually take to get all the enzymes back to normal range? I'm currently on Entecavir and Legalon and the cost is really killing me. Any idea what else i can take that will not interfere with Etv ? I read that Chanca Piedra works for some so i'm not sure if its a good idea to take it together with my meds. The doctor says that i can be off Legalon if I have HBeAB but I asked a pharmacist and he says Legalon is just a supplement so I can take it as long as I want it doesn't matter if I have HBeAB or not.
Just would like to know the usual recovery time needed and also to document my current fight with hep B here.

Family history
-------------------
Grandfather(now 79 years old) - drank alcohol and was hospitalized 11yrs ago (currently on Sebivo)
Mother(now 55yrs old) - also drank alcohol and hospitalized at yr 2011 (not on meds now previously on Entecavir)
Me(27yrs old) - did not drink but hospitalized anyway (currently on Etv and Legalon)

Symptoms
---------------
Dark urine and loss of appetite for > 2weeks
Food did not get digested with constant bloating and burping of food >5hrs after meal
Fatigue and mood swings and late menses
Feeling of tightness on right side of abdomen, back pain

Went to the local doctor and did urinalysis, trace blood, leucocytes, ketone, bilirubin and urobilinogen found
Prescribed Ciprox for urinary tract infection and finished 5 day course
Symptom persisted and proceeded with blood test

Blood test result
---------------------
**Blood drawn on 28/12/2012 but result collected 1week later**
Total Bilirubin 32 umol/L
AST 553 IU/L
ALT 1519 IU/L
GGT 95 IU/L
Prior to this test, past blood tests have never had any out of range values for Liver Function Test
Started on Bitter Melon tea for 2 days before seeing the specialist (improved appetite observed)

Hospitalized after seeing the hepatologist with blood test result above
Doctor ordered another set of test
***7/1/2013***
Total Bilirubin 14.6 umol/L
AST 184.9 IU/L
ALT 581 IU/L
GGT 77.3 IU/L
HBsAg 6614.05 IU/ml
HBeAg 1057.61 S/CO
Ultrasound done with no liver enlargement observed (but i can still feel tightness around abdomen)
Doctor started me on Entecavir and Legalon

After 1 week on Entecavir and Legalon
***14/01/2013***
Total Bilirubin 13.1 umol/L
AST 46.4 IU/L
ALT 146.6 IU/L
GGT 52 IU/L
HBeAg 708.3 S/CO

Any feedback is welcome. Hope to hear about the recoveries of others from hep B! Really need something positive right now :)  Thanks everyone!

[stef2011]

Your hbsag is extremely low, by pegintf add on you have about 91% chances to clear hbsag and 100% response

it is extremely important to know if hbvdna is undetectable to prevent entecavir resistance, tdf would have been a better choice and higher probability to clear without peg

hbsag is small and not relevant unless its rise is connected to a rise in hbvdna, in that case it is etv resistance and tdf add on is manadatory as soon as possible

[StephenCastlecrag]

It would be helpful to have your viral load(hbvdna) number. No idea what is causing your bloating and weight gain. Hope you will get better.

[orientalPearl]

After almost a year of not updating my results, here is the latest I got from my bloodwork. Looks like my HBSAG is rising :( My doctor did not give any comment and seem disinterested when I asked some questions so I have no idea what could be the possible cause or whether this is something that is common for patients still on entecavir.

Something to note, I have been leaving skid marks on the toilet bowl (sorry for being gross) and highlighted this to the doctor although it could be a separate issue from hep b. Bloats almost daily after 5pm, and sometimes food feels undigested.
Also I have been gaining a lot of weight lately (>6kgs) even without any change in my diet, in fact i have taken up multiple exercises (mostly cardio) and have not seen any reduction in weight at all.

Anybody can give any insight or advice for current condition? Thanks!

Blood test result
---------------------
28/12/2012
Total Bilirubin 32 umol/L
AST 553 IU/L
ALT 1519 IU/L
GGT 95 IU/L

***7/1/2013***
Total Bilirubin 14.6 umol/L
AST 184.9 IU/L
ALT 581 IU/L
GGT 77.3 IU/L
HBsAg 6614.05 IU/ml
HBeAg 1057.61 S/CO
HBV DNA 94,100 iu/ml

***14/01/2013***
Total Bilirubin 13.1 umol/L
AST 46.4 IU/L
ALT 146.6 IU/L
GGT 52 IU/L
HBeAg 708.3 S/CO

**04/02/2013**
Total bilirubin 9.2 umol/l
Ast 21 u/I
Alt 22.1 u/l
GGT 23.9 u/l
Hbsag 6453.81 s/co
Hbeag 324.55 s/co
Anti hbe 4.261 s/co

30/07/2013
-------------
Ast 24 iu/l
Alt 15 iu/l
Ggt 8 iu/l
Hbsag 445 iu/ml
Hbeag 99.05 s/co reactive
Hbeab 4.5 s/co negative
Afp 3ng/ml
Ultrasound normal n well outlined
Fibroscan 4.8kpa
HBV DNA 31 iu/ml

13/11/2013
---------------
Alt 19 iu/l
Hbsag 193 iu/ml
Hbeag negative
Hbeab positive
Afp 3ng/ml

30/10/2014
---------------
Alt 5 iu/l
Hbsag 328.20 iu/ml
Hbeag negative  
Afp 2ng/ml

[stef2011]

hbvdna, hbsag quant in iu/ml, hbeag/hbeab,ast/alt and fibroscan

[orientalPearl]

I think you misunderstood my question. My mother stopped nucs years back when doctors were still unaware of the danger of mutation from stopping too early. She has been off meds for years now so I dont know if the damage has already been done. I will advice her to do a hbvdna test n fibroscan soon. I'm just worried for her and want to know whats the next best thing to do in her case.

[stef2011]

another point of danger is that when hbsag is low and immune system can control hbvdna and alt the virus will try to mutate and escape this immune pressure........the possibility of hbsag mutation in this situation is very high and a mutation of hbsag might be even worst the the hbv infection itself with very increased HCC risk

since there is no real safety data that can assure no mutations, no hcc risk, no cirrhosis risk when you stop nucs, i think it doesn t worth to stop it

[StephenCastlecrag]

You are right, in the old days, HBeAg seroconversion is regarded as the endpoint, until they discovered HBeAg negative chronic hepatitis. ALT was also the only marker they used to decide on treatment. In my opinion, your mother should always monitor her hbvdna and ALT. A Fibroscan would be most useful and important. So get her viral load, if it is elevated, that is, above 2000iu/ml, do a Fibroscan, then decide whether treatment is required.

BTW, personally, I tend to be more conservative when it comes to older patients, and err on the side of treatment.

[stef2011]

it doesn t make sense to stop etv or tdf if hbv is not cleared and antibodies hbsab stable
of course you can stop when hbsag is very low and immune system might keep hbvdna low and normal alt but nobodies can assure this choice is good for hcc prevention or cirrhosis prevention, i also think that once you start an antiviral the goal must be a rescue of immuen system and lowering of hbsag for future pegintf add on and definitive cure of hbv, why waste years of antivirals without trying pegintf add on and definitive cure

[orientalPearl]

Actually I have a question about stopping etv halfway. My mother had a flare a few years back and was also put on etv but because back then they never check on hbsag n treatment endpoint was hbeag seroconversion, she actually stopped her medication after taking it for less than a year bcos she seroconverted her hbeag in about 10months. What would your advice be for her case? Her first ever hbsag check was with me on 13/11/2013 with a level of about 1200iu/ml. Im worried for her because she has yet to do a fibroscan, just yearly US and bi annual liver function test which is always alt <25 iu/l.

[StephenCastlecrag]

Glad you are doing so well. May that HBsAg continue to decline and then disappears. I totally agree with you that you should not stop ETV until HBsAg turns negative (the best endpoint). However, you may consider stopping ETV after at least 1 year of undetectable hbvdna, followed by close monitoring to see whether hbvdna remains undetectable. If you are adventurous, with the agreement by your doctor, you may add-on Interferon with the aim for a cure.

All the best.

[stef2011]

a safe scenario is hbsab>1000miu/ml and stable, in this case immune control is good but antiviral needs to be kept anyway for 6-12months

[stef2011]

your doctor is not expert at all in hbv cure, hr probably just prescribes

unless hbsab is >250miu/ml there is no safety in stopping antivirals and even if these antibodies are present antiviral must be kept for about a year.having hbsag undetectable and hbsab>250miu/ml does not mean the infection is cleared but only under immune control because cccdna will stay anyway, so this immune control needs time to avoid relapse so antivral must be kept about a year anyway and levels of hbsab>250miu/ml.

hbv vaccine is used to boost hbsab is it declines after hbsag is und and antivirals stopped

[orientalPearl]

Current result shows a continuous decline in HBSAG. From beginning of the year >6k to now <200 iu/ml. My doctor says i can stop ETV once i go below 200 but looking at the old posts at medhelp, I will just continue for another year or so. Thanks StephenCastleCrag, newtr, stef2011, andrey19, Magda123 and Jeff912000 for the support and advice. I will be back in another 6mths with my results. Take care everyone and stay positive always :)

Blood test result
---------------------
28/12/2012
Total Bilirubin 32 umol/L
AST 553 IU/L
ALT 1519 IU/L
GGT 95 IU/L

***7/1/2013***
Total Bilirubin 14.6 umol/L
AST 184.9 IU/L
ALT 581 IU/L
GGT 77.3 IU/L
HBsAg 6614.05 IU/ml
HBeAg 1057.61 S/CO
HBV DNA 94,100 iu/ml

***14/01/2013***
Total Bilirubin 13.1 umol/L
AST 46.4 IU/L
ALT 146.6 IU/L
GGT 52 IU/L
HBeAg 708.3 S/CO

**04/02/2013**
Total bilirubin 9.2 umol/l
Ast 21 u/I
Alt 22.1 u/l
GGT 23.9 u/l
Hbsag 6453.81 s/co
Hbeag 324.55 s/co
Anti hbe 4.261 s/co

30/07/2013
-------------
Ast 24 iu/l
Alt 15 iu/l
Ggt 8 iu/l
Hbsag 445 iu/ml
Hbeag 99.05 s/co reactive
Hbeab 4.5 s/co negative
Afp 3ng/ml
Ultrasound normal n well outlined
Fibroscan 4.8kpa
HBV DNA 31 iu/ml

13/11/2013
---------------
Alt 19 iu/l
Hbsag 193 iu/ml
Hbeag negative
Hbeab positive
Afp 3ng/ml

[orientalPearl]

Hi everyone, I'm back with my last checkup result.
Currently I have seroconverted to hbeag -ve and anti- hbeag +ve. I will update again once my hbsag result is back. Hopefully it will continue to decline. I didnt take Ifn and am still on etv at the moment.

[StephenCastlecrag]

Thank you for your kind words. Just like you and others in this forum, we are here to help each other and in the process helping ourselves.

[mustthinkpositive]

Hiya Stephen,

Modern science and evolution should prevail in the fight against this virus. I agree with you that a cure is on the horizon.

BTW, are you looking for a cure yourself or helping others out there with your expertise. A wonderful member to the forum. Always giving good advice. Thanks.

[StephenCastlecrag]

I am sure a cure will happen in the next few years, that is what I keep saying....

[orientalPearl]

Thanks for trying to answer my question. I'm just very confused over the different progress n stages of this disease. Too many questions to ask..lol.Currently my family is not supportive when I mention IFN even though I told them that it could be a possible cure. Hopefully somebody finds a more definitive cure in the future. Really hope that cure will happen during my lifetime. :)

[StephenCastlecrag]

It is possible to be cured without treatment, just as it is possible to be cured whilst on antiviral treatments. But the percentage is low. Interferon does not cure 100%, but it generally has a better cure rate than antivirals.
Why did your HBsAg decline without a rise in ALT? Good question, I wish I know the answer. It is known that our immune system can eradicate the virus from infected cells without killing the cells. Interferon and TNF-alpha can inhibit HBV replication in a non-cytopathetic manner. Of course, the immune system can also eradicate the virus by killing the infected cells. Our immune system is wonderful when it works, and it is very complex, there is still a lot to be discovered, and a lot for us to learn and understand.

[newtr]

but dont waste time, immune activity is going on so add interferon as soon possible atleast for 4 weeks and test hbsag, then you may decide what to do, continue interferon for 6 months or not. this scheme is not too costly. consider.

[newtr]

in your case it seems that the present hbsag decline is result of previous high alt flare..and see weather the hbsag decline goes on or not. probably it will continue to drop.

[orientalPearl]

Would seroconversion be possible without inf? I mean if the decline is still ongoing then eventually I'll be able to have some immune control right? Also one other thing I don't understand is, how come my hbsag declines without my alt going above normal level? I've been reading Stef2011's post and he is always saying normal alt is actually not so good cos it means our immune system is not fighting.

[StephenCastlecrag]

31 iu/ml is very low - few years ago it would be described as "undetectable". I think the most sensitive assay can detect  20 iu/ml and up. Your HbsAg is below 1,000 iu/ml which is very good. Studyforhope seems to think this is a threshold below which indicate likely immune control. You are still HBeAg positive, given time, you should seroconvert to HbeAg negative. All in all, you are responding well to Entecavir. Keep on taking Entecavir in the short term, in the longer term, you have several options:
1.after HBeAg seroconversion, consolidate for a year or more, then stop;
2.add on Interferon, with the aim to clear HBsAg - stef2011 will give you his comments, LOL.

Just my opinion.

[orientalPearl]

Hi Stephen, I'm back with my HBV DNA result. What do you think of my result? After more than 6mths it is still not UND yet. :(

Blood test result
---------------------
28/12/2012
Total Bilirubin 32 umol/L
AST 553 IU/L
ALT 1519 IU/L
GGT 95 IU/L

***7/1/2013***
Total Bilirubin 14.6 umol/L
AST 184.9 IU/L
ALT 581 IU/L
GGT 77.3 IU/L
HBsAg 6614.05 IU/ml
HBeAg 1057.61 S/CO
HBV DNA 94,100 iu/ml

***14/01/2013***
Total Bilirubin 13.1 umol/L
AST 46.4 IU/L
ALT 146.6 IU/L
GGT 52 IU/L
HBeAg 708.3 S/CO

**04/02/2013**
Total bilirubin 9.2 umol/l
Ast 21 u/I
Alt 22.1 u/l
GGT 23.9 u/l
Hbsag 6453.81 s/co
Hbeag 324.55 s/co
Anti hbe 4.261 s/co

30/07/2013
-------------
Ast 24 iu/l
Alt 15 iu/l
Ggt 8 iu/l
Hbsag 445 iu/ml
Hbeag 99.05 s/co reactive
Hbeab 4.5 s/co negative
Afp 3ng/ml
Ultrasound normal n well outlined
Fibroscan 4.8kpa
HBV DNA 31 iu/ml