the facts are:
etv failure and partial response in ur case
resistance can be confimed by test only and even if negative it is not sure you have no resistance, test sensibility is poor
why keep entecavir if:
tenofovir is more potent
tenofovir is safer on cancerogenesis
tenofovir has no resistnce
tenofovir costs 50% less than etv or more
this is not to promote tdf use but it is definitely better especially in ur case, i d make add on 6 months and then stop etv
you do have resistance, entecavir doesn t work if hbvdna is not und
you must add on tenofovir as soon as possible
change doctor he said many fantasy things, as regards alt it is best they dont get normal when hbvdna gets und so hbsag goes down faster
I tend to agree with your doctor that the variations in your DNA is not that significant. An order of 1 magnitude (i.e. 10 folds) is usually considered significant. I wonder why your ALT is still elevated - how is your weight?
hbvdna over 137iu/ml after more than one year is definitly resistance mutants, especially after being und, it is also useless to take an antiviral with such an hbvdna detactable it can only worsen and cumulate mutations fast
I have always been troubled by VBT (virological breakthrough, a 10-fold increase in hbvdna) during treatment. Does it mean it is a GR (genotypic resistance, mutation confirmed by testing)? Apparently VBTs happen quite a bit and not all VBTs are GR. In these cases, the hbvdna goes down again without change of medication.
According to research literature, all VBTs should first be confirmed, i.e. test again in 1-3 month time. Patients will also be asked whether they have been taking the medication faithfully. In the case of high-genetic-barrier-to-resistance drugs like Entecavir and Tenofovir, a genetic test to confirm resistance is the golden standard.
What is a 10-fold increase of "undetectable"? Researchers use the lower limit of detection of 29 iu/ml as the baseline. So a rise from undetectable to > 290 iu/ml is technically a VBT.
As for achieving undetectable viral load by week 24 of treatment to signify a response, some researchers believe in the case of newer NAs such as ENT and TDF, the drugs should be given a longer time because of their high barrier to mutation and because trials showed most patients do achieve a response given time.
So because each person is different, I don't think we can be too arbitrary in deciding VBT and GR. Here, I will put my trust in experienced specialists, after all they have seen more real-life cases.
Just my opinion.
I tend to disagree with @StephenCastlecrag (sorry Stephen) because we discuss this variation under treatment.
Usually, without any treatment I tend to agree that some variation are normal, but not under treatment,
@Aydin1358 From what country are you ? Do you use generic Entecavir or du you change your Entecavir provider in last year ? (I was thinking that maybe the concentration was not corect or you had a fake Entecavir )
before taking Entecavir, you was a naive patient or you take some other HBV medication (e.g. Lamivudine)?
You say that you have a family vith HBV history, was your mama tretaed with Lamivudine before you where born ? (I was thinking that maybe you had a HVB resistant to Lamivudine from your mama)
@StephenCastlecrag An order of 1 magnitude (i.e. 10 folds) is usually considered significant - from 100 to 1000 is 1 magnitude from 10000 to 100000 is also 1 magnitude. are this with the same signification ?
i disagreee too, resistance tests cannot detect mutants until too late because sensibility is too poor (population 25%), etv has also resistance for hbsag mutants but these tests are not available
what is the goal of these studies?keep selling drug and trying to tell patients keep using it?
hbvdna und as soon as possible is the minimum result from these antivirals when there is liver damage, if they dont get this result the antiviral is useless
@StephenCastlecrag An order of 1 magnitude (i.e. 10 folds) is usually considered significant - from 100 to 1000 is 1 magnitude from 10000 to 100000 is also 1 magnitude. are this with the same signification ? Yes.
Virological breakthrough and resistance in patients with chronic hepatitis B receiving nucleos(t)ide analogues in clinical practice
Virological breakthrough (VBT) is the first manifestation of antiviral drug resistance during nucleos(t)ide analogue (NUC) treatment of chronic hepatitis B (CHB), but not all VBTs are due to drug resistance. This study sought to determine the incidence of VBT and genotypic resistance (GR) in patients with CHB who were receiving NUCs in clinical practice. Records of patients with CHB who were receiving NUCs were reviewed. All patients with VBT were tested for drug resistance mutations. Of 148 patients included, 73% were men and mean age was 44.9 years. During a mean follow-up of 37.5 ± 20.1 months, 39 (26%) patients had at least 1 VBT. Of these 39 patients, 15 (38%) were not confirmed to have VBT on retesting, and 10 of these 15 had no evidence of GR. The cumulative probability of VBT, confirmed VBT, and GR at 5 years was 46.1%, 29.7%, and 33.9%, respectively. In multivariate analysis, failure to achieve undetectable hepatitis B virus (HBV) DNA was the only factor significantly associated with VBT. Among the 10 patients who had VBT but no confirmed VBT or GR and who were maintained on the same medications, serum HBV DNA decreased in all 10, and nine had undetectable HBV DNA at a mean of 6.8 months after the VBT. Four patients had persistently undetectable HBV DNA, six had transient increase in HBV DNA during follow-up, and none had GR. Conclusion: VBT was common in patients with CHB receiving NUCs in clinical practice, but nearly 40% of the VBTs were not related to antiviral drug resistance. Counseling of patients with CHB on medication adherence and confirmation of VBT and/or GR can avoid unnecessary changes in antiviral medications. (HEPATOLOGY 2011;)
The gold standard of resistance is by genetic testing.
"i disagreee too, resistance tests cannot detect mutants until too late because sensibility is too poor (population 25%), etv has also resistance for hbsag mutants but these tests are not available"
By sensitivity, I take it that you mean the % of mutants in the population of wild type is too low? This may be so. We now know the hbv viruses in our liver are a population consisting of many quasispecies. However, not all mutants will go on to become the dominant type. I am sure the composition of this population of quasispecies will change constantly. In the case of ENT and TDF, mutants need to acquire and hold more than 1 mutation together, exist in many infected cells, in order to become selected to become the dominant type. That is why to confirm ENT or TDF drug resistance, genetic testing is the golden standard.
Hard to see a role for HBsAg mutant in drug resistance, since NAs do not interfere with the production of the surface antigens.
Thank you for all the responses.
I am waiting for my results to get in two weeks.
Should I switch to only Tenefovir or a combination of Entecavir+Tenefovir?
Another question : Why still my Hbeag negative, if my DNA is not undetectable? Does not it mean that I have servoconverted ? Here in Canada I can not easily change my doctor, but he has a good personality and I can discuss with him. Which kind of test I can ask him to do to confirm my resistance to Entecavir?
My ALT never get normal during these two years. Lots of fluctuations.
I do not drink alcohol and I am in pretty good shape. I weigh 76 kg