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Please Help Me Interprete Elevated Fibroscan Result (6.8KPa)
Hello Stef2011, StephenCastlgrag, and everybody,
Please help me understand my results below.
Background, I've been a Hep B carrier since at least 1988 (25 years) when I was 16 years old. I'm now 42, Asian male living in the US - where HBsAG Quant tests are still unavailable.
I recently went for Hep B check up, and was mostly happy with the results until Fibroscan came back at 6.8 KPa.
****************************************************************************
Date: January 20, 2014
Genotype: B
FIBROSCAN - 6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended)
(last Fibroscan result was 4.8 KPa approx 2 years before done in another country)
ULTRA SOUND - Normal Abdominal Ultrasound (last check was 2 years before - also normal)
HBV DNA - Not detected (HBV DNA by PCR Quant - Range is 250 - 25,000,000 iu/ml)
Alpha Fetoprotein - 1.66 ng/ml
ALT - 31 [previously 39 (7/2013); 22 (11/2012); 21 (9/2011) ...]
AST - 21 [previously 23 (7/2013); 20 (11/2012); 20 (9/2011) ...]
Vitamin D - 47.3 ng/ml (been taking 5,000 iu/day for at least a year)
Bilirubin - 0.5 mg/dl [the lowest result ever compared to previously 1.5 (9/2013) or 1.9 (7/2013) or 2.4 (11/2012) or
1.5 (3/2009) etc.]
Please chime in on why Normal ALT (31), Normal Ultra Sound, Undetected HBV DNA, but ELEVATED FIBROSCAN!
I was expecting Ultra Sound result to come back as mildly fatty liver to account for the elevated Fibroscan. But Ultra Sound is normal.
Bilirubin is lowest in all the years that I've been testing for it.
FIBROSCAN: This is the first and only commercial Fibroscan facility in Los Angeles since Fibroscan was approved by the FDA in April of 2013. The doctor interpreting my Fibroscan result specializes in Hep C and HIV research and trials who admitted that he was not a Hep B specialist and advised me to see another Hep B Director at a major LA hospital. I have not been able to schedule an appointment with this Director yet (earliest appointment is over 40 days away).
I look forward to your comments and input. Thanks in advance.
Wish you all the best health!
Please help me understand my results below.
Background, I've been a Hep B carrier since at least 1988 (25 years) when I was 16 years old. I'm now 42, Asian male living in the US - where HBsAG Quant tests are still unavailable.
I recently went for Hep B check up, and was mostly happy with the results until Fibroscan came back at 6.8 KPa.
****************************************************************************
Date: January 20, 2014
Genotype: B
FIBROSCAN - 6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended)
(last Fibroscan result was 4.8 KPa approx 2 years before done in another country)
ULTRA SOUND - Normal Abdominal Ultrasound (last check was 2 years before - also normal)
HBV DNA - Not detected (HBV DNA by PCR Quant - Range is 250 - 25,000,000 iu/ml)
Alpha Fetoprotein - 1.66 ng/ml
ALT - 31 [previously 39 (7/2013); 22 (11/2012); 21 (9/2011) ...]
AST - 21 [previously 23 (7/2013); 20 (11/2012); 20 (9/2011) ...]
Vitamin D - 47.3 ng/ml (been taking 5,000 iu/day for at least a year)
Bilirubin - 0.5 mg/dl [the lowest result ever compared to previously 1.5 (9/2013) or 1.9 (7/2013) or 2.4 (11/2012) or
1.5 (3/2009) etc.]
Please chime in on why Normal ALT (31), Normal Ultra Sound, Undetected HBV DNA, but ELEVATED FIBROSCAN!
I was expecting Ultra Sound result to come back as mildly fatty liver to account for the elevated Fibroscan. But Ultra Sound is normal.
Bilirubin is lowest in all the years that I've been testing for it.
FIBROSCAN: This is the first and only commercial Fibroscan facility in Los Angeles since Fibroscan was approved by the FDA in April of 2013. The doctor interpreting my Fibroscan result specializes in Hep C and HIV research and trials who admitted that he was not a Hep B specialist and advised me to see another Hep B Director at a major LA hospital. I have not been able to schedule an appointment with this Director yet (earliest appointment is over 40 days away).
I look forward to your comments and input. Thanks in advance.
Wish you all the best health!
Yes, there are a lot of post by stef2011:
"fibrosis and compensated cirrhosis can be regressed by all the following points:
hbvdna und
healthy diet with no processed foods, no fats, no red meat, few white meat
no fatty liver
low bmi/wieght (overwieght can t regress fibrosis)
being fat and overweight increases fibrosis despite hbvdna und, all points needed"
http://www.medhelp.org/posts/Hepatitis-B/regressison-of-
cirrhosis-48weeks-etvalinia/show/1375048
I wouldn't take daily high dose supps, the reason is you cannot really know what the body really needs, and could hurt yourself even more...but maybe I am wrong.
What I found recently is Angiotensin levels elevated in CHB patients, and correlating with fibrosis/chirrosis stage:
http://www.ncbi.nlm.nih.gov/pubmed/1748416
http://www.ncbi.nlm.nih.gov/pubmed/22277254
..so they thought that maybe, blocking angiotensin helps fibrosis and found that to be true, a lot of ARBs help with fibrosis..Also Vit D reduces angiotensin levels
"fibrosis and compensated cirrhosis can be regressed by all the following points:
hbvdna und
healthy diet with no processed foods, no fats, no red meat, few white meat
no fatty liver
low bmi/wieght (overwieght can t regress fibrosis)
being fat and overweight increases fibrosis despite hbvdna und, all points needed"
http://www.medhelp.org/posts/Hepatitis-B/regressison-of-
cirrhosis-48weeks-etvalinia/show/1375048
I wouldn't take daily high dose supps, the reason is you cannot really know what the body really needs, and could hurt yourself even more...but maybe I am wrong.
What I found recently is Angiotensin levels elevated in CHB patients, and correlating with fibrosis/chirrosis stage:
http://www.ncbi.nlm.nih.gov/pubmed/1748416
http://www.ncbi.nlm.nih.gov/pubmed/22277254
..so they thought that maybe, blocking angiotensin helps fibrosis and found that to be true, a lot of ARBs help with fibrosis..Also Vit D reduces angiotensin levels
One thing worth noting for me was that my baseline right after I was diagnosed in 2012 was 6.8 Kpa. I drank a lot of beer back then on a daily basis. I stopped drinking completely after I found out I had HBV and ate syrimarol - Sylibi mariani fructus extractum for a few months. I have redone a Fibroscan before Interferon and it was 6.6Kpa. During IFN I didn't take it so I don't interfere with treatment and now its back to 6.8Kpa.
Syrimarol is nothing on virus of course so don't think you will be cure, it just helps liver on its regular job.
Syrimarol is nothing on virus of course so don't think you will be cure, it just helps liver on its regular job.
"I had an 6.5 kPa result (there were 10 measurements the highest 8, the lowest 5.5)...I guess the 6.5kPa is the median value?"
Yes, mine too was like that. The average of ten measurements. I went from 4.8 to 6.8 KPa in about 2 years, and not sure why. HBV DNA undetected and ultra sound normal at both times.
"Anyway, this was the only value written on the Results page: 6.5 kPa
Also, IQR 1.5 (don't know what that means). The conclusion on the Results page: grade F0-F1."
My Fibroscan doctor wrote "F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended." The footnotes say IQR means "scatter," one of the factors in the Fibroscan calculation. My IQR was 0.9.
"you have to work on diet and keep values less than 7kpa" ...What kind of diet are you talking about?
That's what I've been asking on this forum. No answers yet. Perhaps because the topic has already discussed in depth before, and no one was in the mood to rehash it once more. I looked through hundreds of posts, but nothing really definitive came about.
I'd like to know what you will find too.
Yes, mine too was like that. The average of ten measurements. I went from 4.8 to 6.8 KPa in about 2 years, and not sure why. HBV DNA undetected and ultra sound normal at both times.
"Anyway, this was the only value written on the Results page: 6.5 kPa
Also, IQR 1.5 (don't know what that means). The conclusion on the Results page: grade F0-F1."
My Fibroscan doctor wrote "F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended." The footnotes say IQR means "scatter," one of the factors in the Fibroscan calculation. My IQR was 0.9.
"you have to work on diet and keep values less than 7kpa" ...What kind of diet are you talking about?
That's what I've been asking on this forum. No answers yet. Perhaps because the topic has already discussed in depth before, and no one was in the mood to rehash it once more. I looked through hundreds of posts, but nothing really definitive came about.
I'd like to know what you will find too.
I had an 6.5 kPa result (there were 10 mesurements the highest 8, the lowest 5.5)...I guess the 6.5kPa is the median value?
Anyway, this was the only value written on the Results page: 6.5 kPa
Also, IQR 1.5 (don't know what that means)
The conclusion on the Results page: grade F0-F1.
Ultrasound exam found everything normal.
"you have to work on diet and keep values less than 7kpa" ...What kind of diet are you talking about?
Anyway, this was the only value written on the Results page: 6.5 kPa
Also, IQR 1.5 (don't know what that means)
The conclusion on the Results page: grade F0-F1.
Ultrasound exam found everything normal.
"you have to work on diet and keep values less than 7kpa" ...What kind of diet are you talking about?
you have to work on diet and keep values less than 7kpa, but that is not a value to be concerned or that indicates need of nucs therapy
fibroscan is not good to see the difference between f0 and f1, anyway a value less than 6kpa is and less is no worry at all, around 4kpa would be the optimum
while if one is to check cirrhosis regression getting values less than 5kpa is very rare, so a cirrhosis regression reaching 4kpa and less is probably f0
while if one is to check cirrhosis regression getting values less than 5kpa is very rare, so a cirrhosis regression reaching 4kpa and less is probably f0
I too would love to learn more here.
My Fibroscan doctor was a HepC researcher who told me he was unsure of his assessment below. He referred me to see the head HepB liver doctor at an LA hospital for a more precise determination.
He wrote simply:
"6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended)"
It's taking about 2 months to set an appointment to see this next Dr. And very pricey too. Outside of my insurance plan just like the Fibroscan was. But this Fibroscan knowledge has been life-changing info for me lately.
My Fibroscan doctor was a HepC researcher who told me he was unsure of his assessment below. He referred me to see the head HepB liver doctor at an LA hospital for a more precise determination.
He wrote simply:
"6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended)"
It's taking about 2 months to set an appointment to see this next Dr. And very pricey too. Outside of my insurance plan just like the Fibroscan was. But this Fibroscan knowledge has been life-changing info for me lately.
why is 6.8 interpreted as F1-F2 ? My result is the same and its in F0-F1.
If you google up the Fibroscan tables it should be F0.
If you google up the Fibroscan tables it should be F0.
I ordered from Advance Life Research a few week before I decided to take IFN in 2013. When the products arrived (cost me $450 all up for the whole set), the manufacturer date was 2009 year of production on the bottom. We are in mid 2013. WTF??
I decided not to take any because I do not want to interfere with the IFN treatment. And also because of the year of production. Not expired but 4 years old. It's a joke for such an expensive products. Plus all the bottles looks dusty and old like on shelves for years.....
I decided not to take any because I do not want to interfere with the IFN treatment. And also because of the year of production. Not expired but 4 years old. It's a joke for such an expensive products. Plus all the bottles looks dusty and old like on shelves for years.....
I was also offered a distributorship opportunity by Cal, which i declined after i had made several purchases.
However, overall i have felt better taking those products tnam doing without them.
However, overall i have felt better taking those products tnam doing without them.
The results you received from Heptech is very strange as I lowered my FibroScan 3.8 points in 6 months, and will test again in September.
My last two orders were all new product. I have also asked the office for an update on their clinical trials and have not received any feedback yet. I will update everyone once I hear somethng. I have been very pleased with the results.
My last two orders were all new product. I have also asked the office for an update on their clinical trials and have not received any feedback yet. I will update everyone once I hear somethng. I have been very pleased with the results.
yes my regression was made of many things, not only heptech for sure, i also had gcmaf and the religious diet change is also a must...
since the discovery of gcmaf activating stemcells i think this was the main thing responsible, heptech took a very long time on their trials which cannot be explained by 1.5years, too fast.but the action of gcmaf is also dependent on inflammation status, vit d and diet, so i think it was a mix to make the fast result
one thing is certain, fibrosis cannot regress without diet changes or being bmi>25, this is a fact on nucs trials
since the discovery of gcmaf activating stemcells i think this was the main thing responsible, heptech took a very long time on their trials which cannot be explained by 1.5years, too fast.but the action of gcmaf is also dependent on inflammation status, vit d and diet, so i think it was a mix to make the fast result
one thing is certain, fibrosis cannot regress without diet changes or being bmi>25, this is a fact on nucs trials
Also one day I have recieved a letter from Cal (heptech sales manager). He offered me to set a distribution line for Russia. Their offer was to sell me big quantity of their products with reduced price. His idea was to save on freight cost when you ship large quantity. I rejected this offer because was not interested. But now looking at Rome70 experience I think the only thing they wanted is to get rid of big quantity of their expired products at once.
Thank you for your reply and data. I am completely ignorant about indicators for fatty liver. Looking at your hbvdna and ALT data, I can see why treatment is not needed. So I am at a loss to explain why the increase in your Fibroscan score. I can only suggest that you repeat your Fibroscan test in a few months time. Some literature indicates fasting/non fasting can influence Fibroscan score, also operator can influence the result.
As for me I have personally tried Heptech but I did not see that much result. The only thing I have noticed is my urina nasty smell and colour. For last three month I had been taking heptech products my fibroscan Kpa did not move at all while it was constantly slowly going down on interferon mono, when I added heptech decline stoped.
Steff I surely know you regressed cirohis when taking heptech but you completely changed your diet and way of living so it is very hard to say how much heptech is responsible for your histology imporovement!
Maybe other members can report their heptech experience?
Steff I surely know you regressed cirohis when taking heptech but you completely changed your diet and way of living so it is very hard to say how much heptech is responsible for your histology imporovement!
Maybe other members can report their heptech experience?
i think the point with heptech is to know if lyophilized products packed like that from 2009 are ok
we should inquire fda or similar institutions in US that take care of this, the product is registered so they should be able to tell us
we should inquire fda or similar institutions in US that take care of this, the product is registered so they should be able to tell us
all those tests not needed and many of the important ones obsolete:
hbvdna sensibility is 10iu/ml, sensibility at 250iu/ml is not accetable (maybe 20iu/ml can be ok too)
hbsag qualitative like your test is useless, you need architect or elecsys for hbsag quantitative in iu/ml
after we have these two tests we can suggest if it is best pegintf mono, sequential tdf and then pegintf add on or monitoring
hbvdna sensibility is 10iu/ml, sensibility at 250iu/ml is not accetable (maybe 20iu/ml can be ok too)
hbsag qualitative like your test is useless, you need architect or elecsys for hbsag quantitative in iu/ml
after we have these two tests we can suggest if it is best pegintf mono, sequential tdf and then pegintf add on or monitoring
Stef2011,
Please see if you could read my Metabolic panel to see me some insight. Cholesterol panel already listed above. Let me know if you will need Blood Panel.
Thanks.
**** Jan 2014 Complete Metabolic Panel:
Glucose: 98 mg/dL 65 - 99
BUN 15 mg/dL 6 - 24
Creatinine, Serum 0.80 mg/dL 0.76 - 1.27
eGFR if nonAmerican 112 mL/min/1.73 >59
BUN/Creatinine Ratio 19 9 - 20
Sodium, Serum 141 mmol/L 134 - 144
Potassium, Serum 4.6 mmol/L 3.5 - 5.2
Chloride, Serum 102 mmol/L 97 - 108
Carbon Dioxide, Total 27 mmol/L 19 -28
Calcium. Serum 9.9 mmol/L 8.7 - 10.2
Protein, Total Serum 7.4 g/dL 6.0 - 8.5
Albumin, Serum 4.5 g/dL 3.5 - 5.5
Globulin, Total 2.9 g/dL 1.5 - 4.5
A/G Ratio 1.6 1.1 - 2.5
Bilirubin, Total 0.5 mg/dL 0.0 - 1.2
Alkaline Phosphate 76 IU/L 39 - 117
AST 21 0 - 40
ALT 31 0 - 44
Please see if you could read my Metabolic panel to see me some insight. Cholesterol panel already listed above. Let me know if you will need Blood Panel.
Thanks.
**** Jan 2014 Complete Metabolic Panel:
Glucose: 98 mg/dL 65 - 99
BUN 15 mg/dL 6 - 24
Creatinine, Serum 0.80 mg/dL 0.76 - 1.27
eGFR if nonAmerican 112 mL/min/1.73 >59
BUN/Creatinine Ratio 19 9 - 20
Sodium, Serum 141 mmol/L 134 - 144
Potassium, Serum 4.6 mmol/L 3.5 - 5.2
Chloride, Serum 102 mmol/L 97 - 108
Carbon Dioxide, Total 27 mmol/L 19 -28
Calcium. Serum 9.9 mmol/L 8.7 - 10.2
Protein, Total Serum 7.4 g/dL 6.0 - 8.5
Albumin, Serum 4.5 g/dL 3.5 - 5.5
Globulin, Total 2.9 g/dL 1.5 - 4.5
A/G Ratio 1.6 1.1 - 2.5
Bilirubin, Total 0.5 mg/dL 0.0 - 1.2
Alkaline Phosphate 76 IU/L 39 - 117
AST 21 0 - 40
ALT 31 0 - 44
Dear StephenCastlecrag and everybody,
Since becoming aware of the Hep B carrier status, I've never undertaken any treatment. There were no symptoms. However, I just wanted to become more vigilant with this disease since about 2009, and hence more testing and self-education.
Please see if you could use my past data to better advise me. Thanks so much.
******* Results as of January 20, 2014 (Latest):
Cholesterol: Total 148; Triglycerides 148; HDL 44; LDL Calc 90; VLDL Calc 14
BMI: 23.6 (151 lbs, 5'7")
UlTRA SOUND: I requested the US sound results on a CD and will be asking a second radiologist in town for a SECOND opinion/reading to confirm. Will update here.
Genotype: B
FIBROSCAN - 6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended) (last Fibroscan result was 4.8 KPa approx 2 years before done in another country)
ULTRA SOUND - Normal Abdominal Ultrasound (last check was 2 years before - also normal)
HBV DNA - Not detected (HBV DNA by PCR Quant - Range is 250 - 25,000,000 iu/ml)
Alpha Fetoprotein - 1.66 ng/ml
ALT - 31 [previously 39 (7/2013); 22 (11/2012); 21 (9/2011) ...]
AST - 21 [previously 23 (7/2013); 20 (11/2012); 20 (9/2011) ...]
Vitamin D - 47.3 ng/ml (been taking 5,000 iu/day for at least a year)
Bilirubin - 0.5 mg/dl [the lowest result ever compared to previously 1.5 (9/2013) or 1.9 (7/2013) or 2.4 (11/2012) or 1.5 (3/2009) etc.]
******* Results as of March 2009 (first visit to Hepatologist - first complete results; Fibroscan was not available as a choice)
AST: 24
ALT: 25
Hep A AB: Reactive
Hep B Core AB: 21.40 (Reactive)
HBsAG: Reactive
HBsAG Confirmation: Reactive
HBsAB Quant: <3 (Negative)
HBeAG: Negative
Hep C AB: Negative
HBV DNA by Quant: <250 (Undetected)
Bilirubin: 1.5
Ultra Sound: Normal abdominal
****** Results as of Sept 2011 (follow up checkup)
AST: 20
ALT: 21
Bilirubin: 2.3 (high)
HBV DNA by Quant: 1761 IU/ML
Total cholesterol: 159
Triglycerides: 140
HDL: 57
VLDL Calc: 28
Alpha Fetoprotein: 1.67
Ultra Sound: Normal
****** Results as of Dec 2011 (French hospital)
AST: 16
ALT: 17
Bilirubin: 0.85
Alpha Fetoprotein: 2.97 ng/ml
Ultra Sound: Normal
Fibroscan: 4.8 KPa
ANTICORPS ANTI-HBs: 3.9 UI/l Titre (Negative)
HBeAG: Negative
HBeAB Positive
HBV Viral Load: 1.68E+02 IU/ml
2.23 log
****** Results as of Oct 2010
AST 24
ALT 24
Bilirubin 1.5
Alpha Fetorprotein 1.73
HBeAg Negative
HBV DNA by Quant Not detected
Appreciate any input.
Since becoming aware of the Hep B carrier status, I've never undertaken any treatment. There were no symptoms. However, I just wanted to become more vigilant with this disease since about 2009, and hence more testing and self-education.
Please see if you could use my past data to better advise me. Thanks so much.
******* Results as of January 20, 2014 (Latest):
Cholesterol: Total 148; Triglycerides 148; HDL 44; LDL Calc 90; VLDL Calc 14
BMI: 23.6 (151 lbs, 5'7")
UlTRA SOUND: I requested the US sound results on a CD and will be asking a second radiologist in town for a SECOND opinion/reading to confirm. Will update here.
Genotype: B
FIBROSCAN - 6.8 KPa (F1 - F2 - Mildly fibrotic liver / biopsy confirmation recommended) (last Fibroscan result was 4.8 KPa approx 2 years before done in another country)
ULTRA SOUND - Normal Abdominal Ultrasound (last check was 2 years before - also normal)
HBV DNA - Not detected (HBV DNA by PCR Quant - Range is 250 - 25,000,000 iu/ml)
Alpha Fetoprotein - 1.66 ng/ml
ALT - 31 [previously 39 (7/2013); 22 (11/2012); 21 (9/2011) ...]
AST - 21 [previously 23 (7/2013); 20 (11/2012); 20 (9/2011) ...]
Vitamin D - 47.3 ng/ml (been taking 5,000 iu/day for at least a year)
Bilirubin - 0.5 mg/dl [the lowest result ever compared to previously 1.5 (9/2013) or 1.9 (7/2013) or 2.4 (11/2012) or 1.5 (3/2009) etc.]
******* Results as of March 2009 (first visit to Hepatologist - first complete results; Fibroscan was not available as a choice)
AST: 24
ALT: 25
Hep A AB: Reactive
Hep B Core AB: 21.40 (Reactive)
HBsAG: Reactive
HBsAG Confirmation: Reactive
HBsAB Quant: <3 (Negative)
HBeAG: Negative
Hep C AB: Negative
HBV DNA by Quant: <250 (Undetected)
Bilirubin: 1.5
Ultra Sound: Normal abdominal
****** Results as of Sept 2011 (follow up checkup)
AST: 20
ALT: 21
Bilirubin: 2.3 (high)
HBV DNA by Quant: 1761 IU/ML
Total cholesterol: 159
Triglycerides: 140
HDL: 57
VLDL Calc: 28
Alpha Fetoprotein: 1.67
Ultra Sound: Normal
****** Results as of Dec 2011 (French hospital)
AST: 16
ALT: 17
Bilirubin: 0.85
Alpha Fetoprotein: 2.97 ng/ml
Ultra Sound: Normal
Fibroscan: 4.8 KPa
ANTICORPS ANTI-HBs: 3.9 UI/l Titre (Negative)
HBeAG: Negative
HBeAB Positive
HBV Viral Load: 1.68E+02 IU/ml
2.23 log
****** Results as of Oct 2010
AST 24
ALT 24
Bilirubin 1.5
Alpha Fetorprotein 1.73
HBeAg Negative
HBV DNA by Quant Not detected
Appreciate any input.
I saw their Redox bottle rotten, as for the fibroshield I think that since the bottle is sealed identically some air gets inside too.
They told me that they discontinued old formula and added 300mg of high purity Schizandra. I was supposed to receive 6 bottles of it but got 2009 old bottles that they deny to exist, a bunch of thieves.
Actually I am not sure that the new formula exists either I asked a few times for product sheets or pictures but never received them, the website has no new products either, actually it was not updated for years.
They told me that they discontinued old formula and added 300mg of high purity Schizandra. I was supposed to receive 6 bottles of it but got 2009 old bottles that they deny to exist, a bunch of thieves.
Actually I am not sure that the new formula exists either I asked a few times for product sheets or pictures but never received them, the website has no new products either, actually it was not updated for years.
what about fibroguard, do you have data on sealed bottles with lyophilized substances.this is the best product of their line and i'd keep using it in the future from time to time for reservatrol, curcumin content
Heptoshield is probably the only one that has no problem. Since it is 100% PPC each capsule has a solid shell. They are fragile I agree, a few pills in a bottle are usually broken but it is not a big deal. The other three components have two part soft shell easily disassembling, the air can get in and out as soon as it gets into the bottle.
So my advice is to put the cotton to fill the space inside the bottle close it firmly and keep in fridge for any unsealed bottle.
So my advice is to put the cotton to fill the space inside the bottle close it firmly and keep in fridge for any unsealed bottle.
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