Need advice before seeing doctor again

[ShawshankHK]

Guys in the community,

Thanks in advance for helping. I am asking for my wife, we're in Hong Kong. We know for long that she's a HBV carrier. After she delivered a baby at 2013 year end we went for a check, and realized it has turned active (ALT >100). Below is her result. I have consolidated multiple tests taken within 5 days to reveal a quick overview (please see below).

We have seen 2 doctors at 2 different hospitals. Here are what they recommended so far:

Doc 1: "we rarely recommend interferon because of low success rate and possible waste of one year valuable time; recommend taking anti-viral (but have not discussed which one yet)"

Doc 2: (Here we mentioned we planned to have a 2nd child), then he said "You can choose interferon or anti-viral, though with interferon you cannot prepare to get pregnant, I recommend Entecavir more than Tenofovir because Entecavir is safer, you can switch to tenofovir after delivering your 2nd baby." After we emphasized that she turned active after delivering the 1st baby, the doctor said "you can wait and come back in one month, see if things turn better, we can monitor for up to 6 months, should situation gets worse, we need to get on with anti-viral"

So my question is:

1. How likely is it for my wife to retreat to "immune tolerance" naturally post natal?

2. What's standard treatment for her situation, especially on choice of antiviral?

3. We suspect that she has rheumatism (failed to mention to either doctor), but not confirmed yet, does it mean she cannot use interferon? I ask because a Chinese doctor we know told us she cannot use interferon because interferon induces rheumatism even.

4. One old question that bothers me the most, probably you guys have a better answer: What if resistance happens to even tenofovir? How do you guys look at the treatment landscape in - say - 15 years time, when tenefovir resistance may probably show up (I have no evidence so please also let me know what's the "theoretical" years tenefovir could hold up for majority of us!)

Thanks a lot and apologize for loads of questions!


ShawshankHK


============
My wife's data:

HBsAg: 1128 IU/ml
HBsAb: <6.4 mIU/ml
HBeAg: 224 CI
HBeAb: <30 INH%
HBcAb: 99.9 INH%

ALT:                116 @ Jan 4; 195 @ Jan 6; 173 @ Jan 8
AST:                130 @ Jan 4; 130 @ Jan 6;  98 @ Jan 8
Bilirubin Total: 16.4 @ Jan 4; 11.7 @ Jan 6; 9.4 @ Jan 8

HBV DNA: 5.4x10^5 copies/ml, 1.1x10^5 IU/ml

[ShawshankHK]

Stef,

Thanks for your explanation, that does made me understand better about vitd and hbv's impact on bone issue through vitd.. indeed a brand new world for me..

We will ask doctor to book these tests for us.

ShawshankHK

[stef2011]

as regards bone pain/vit d, it is not related to the infection in the liver directly but to the control of our immune system by hbv which changes many genes and especially vit d pathway, so the only way to know if that is the case is:

control of vit d levels which is for sure less than 50ng/ml
control of bone mineral density by MOK

than one starts vit d3 supplements and after 6-12 months recheck bone mineral density by MOK to see if there is any improvment.

improvment in pain with vitd25oh around 90-100ng/ml is sure because there is a lowering of some cytokines correlated with pain (vit d can work as antiflammatories and pain killers drugs with no sides when serum levels are 90-100ng/ml especially on mild states)

[ShawshankHK]

Stef,

Thank you for your kind advices. I have read some overview articles about Rheumatoid Arthritis and HBV from the links you gave me. It looks like my wife is not serious enough to qualify a Rheumatoid Arthritis. I will mention to doctor about her occasional joint pain and limb bone pain, and do tests as necessary, to see if that's a consequence of HBV infection (although she's been immune tolerance since about 10 years old until recently).  

We will keep the ped on top of tenofovir option in mind too. We actually asked our first doctor but he said they don't use that combination. I will mention it to our 2nd doctor tomorrow (much younger, about 30, while first one is like 50 years old). I hope her arthritis (if true) does not disqualify her from a potential peg therapy.

We will see our 2nd doctor tomorrow, and will post our progress. Hong Kong has a large base of HBV patients so luckily there are a pool of experienced doctor, however even then to find an experienced/responsible/sensible/willing to customize therapy doctor is not that straight forward..

Still have a lot of hope on ARC 520 and Rep 9AC' !!

Thank you again for your kindest help Stef, really appreciate it.

ShawshankHK

[stef2011]

it is all safe with antivirals the problem is exactly the go like a guide book without no indepth knowledge of what is behind the choices...this of ocurse limits the therapies to managment and no cure

tenofovir to start with is good choice but if there is no baby keep the peg add on option after 12 months on tenofovir, peg has very high chances to clear once and for all with such low hbsag

you can review easily all vit d studies per diseases by this wonderful website

http://www.vitamindwiki.com/Rheumatoid+Arthritis
http://www.vitamindwiki.com/VitaminDWiki

[ShawshankHK]

Stef,

Really appreciate your response, I also feel that tenofovir is a better choice than entecavir for her situation.

On rheumatism, thanks a million for that, which is an angle that we never thought about. We'll definitely go for that vitd test.

On the alternative off label strategy you mentioned, I can understand the rationale behind and will try to explain that to the doctor(s), but like you said I also have a feeling that they are generally very risk-averse, like to read off the guide book and offer the safest option.

With all that said, we are not extremely desperate either, I have a lot of hope on Rep 9AC, and Arc 520. I know you look forward to Rep 9AC too but not sure what you think about ARC 520. I do believe a functional cure is not far ahead!

Really thank you for your answers Stef, that helped us a lot. I'll keep posting about our progress.

ShawshankHK

[stef2011]

another off label strategy to clear hbv:

telbivudine plus tenofovir 12 months, discontinue telbivudine and add pegintf for another 12months

tenofovir protects from telbivudine resistance
telbivudine rescue immune system faster than other antivirals for pegintff add on

to cure hbv you need a researcher or very expert liver specialist, a simple liver specialist is not expert enough on these strategies

of all choices tenofovir must be present because it has the highest chance to clear hbv in your situation (no entecavir or other antivirals).tenofovir makes no problems for the baby but pegintf cannot be added while pregnant so tenofovir until delivery would be best choice and then peg add on after delivery