Questions? Trying to educate myself.

[NashPred]

Ok, so I’ve been really trying to educate myself about HBV and HBV/HCV co infection over the last couple of days. I’ve learned a lot, but it’s been difficult to rap my head around all this info with the brain fog from the meds I’m on right now (just typing this seems to take forever) and I need help with a few questions.

1. I am e-antigen negative and anti-eAg pos. Can e-antigen seroconvert back and forth between neg and pos? After it is neg, does it tend to stay that way? Any help on understanding eAg status.

2. When someone is co infected with HBV/HCV how do you determine which virus is dominant?

3. Is there anything I can look for in my blood work to determine the dominant virus?

4. Can anyone point me to case study/trials involving treating HBV/HCV co infection with Peg IFN and Ribavirin? I found one, but I think only IFN was used in that study and not Peg IFN.

5. At the start of my treatment, I was getting blood work done every 2 weeks. After the first month, they started checking my blood monthly. Is it better to keep checking every 2 weeks with HBV/HCV co infection?

Sorry for all the questions, but I am trying to learn and arm myself with some knowledge. Knowledge is power and chances are I will need to deal with this for life.

Thank you so much for any help or training aids you can suggest. BTW the HepB welcome page has helped a lot so thanks for that. I reference it often.

[stevenNYer]

>>>The elusive blue M & M….I like that analogy. M & M = mutants and mutations. I will keep an eye out for those blue M & M’s.<<<

Haha..."mutants and mutations".   I used M&M for that reason.  It was by design.  And I'm sticking to my story ;)

[zellyf]

Ooh, got it.

Glad you got some info.

[NashPred]

Oh...I think I see what happened...

I read the artical you talked about and by me clicking on certain links on that site, I happened to stumble across this aritcle on co infectoin:


http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1224851#B44

I meant the article in the link/URL I posted when I refered to it being a few years old.

[zellyf]

Weird...it says its from February 2008...are you reading this...

# Treatment of the HBV-Infected Patient: When to Start, When to Stop, and When to Change TherapyEmmet Keeffe, MD, MACP, reviews the indications for treatment and duration of therapy in hepatitis B, as based on current best evidence.Emmet B. Keeffe, MD, MACP (Expert Column, February 2008)

[NashPred]

Thanks...I learned from that article AND.....by following some links, it l helped me to find this article about HBV/HCV co infection.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1224851#B44.

It's long but VERY interesting (atleast to me) even though it's a few years old. And for some reason, when I pull it up on my computer, it goes to the bottom of the page first. So if anyone wants to read it, you may have to scroll to the top. (maybe it's just my computer)

Table #4 shows some data on treatment of co infection with different treatment approaches.

I read over it once and and skimmed over a couple of more....but right now with my brain fog, I'll need to read over it several times before I'll fully understand it.

[zellyf]

http://www.medscape.com/viewarticle/570478

There might be info in here for you.  I'm not sure if it deals with co-infection...its a long article.

[NashPred]

The elusive blue M & M….I like that analogy. M & M = mutants and mutations. I will keep an eye out for those blue M & M’s.

My HCV RNA was 5.9 million prior to tx, so I guess I’m pretty sure that HCV is/was dominant and is suppressing the HBV.

I will ask my Dr. what his plans are for coming off IFN/Riba and then treating and monitoring the HBV. I’m sure now that I will need an anti viral for HBV because immune system has been relying on the IFN and won’t be able to hold the HBV virus in cheek on its own until it recovers. I’ll let ya’ll know the Dr’s thoughts on this… if I can get some solid answers from him.

Thank you for all of the assistance…..You guys are the greatest!!!

[stevenNYer]

Great thread.

A comment of the "e".  Don't think of it in black or white.  The virus is in a state of a slow complex evolution.  So if your "seroconverted" to eAntibody positive.  The virus is trying to make adjustments to overcome the eAntibody.  Once a few makes it and reproduces itself, they will replicate to higher numbers if your immune system can't hold them.   Of course this doesn't happen in a day or two.  It's a slow dance.  But if they are successful, these mutants will become the dominant species, thus the eAntigen - active disease.  The ability to detect them depends on the sample drawn and the test methodology.  You will likely detect them if there are 10-30% of the mutants in population.  So in reality, many people have mutant strains in their system, it just that it's missed on the testing.  It's like that rare Blue M & M.  You know it's in the bag but you may not get it on your first giggle.

Now, if you are stable eAntigen - , eAntibody +, detected BCP, and with 18900 VL, it's a sign of e- active disease.  You probably need long term treatment.   After you come off interferon, you may stay UND for HepB for a good number of months, but research indicates that eventually the VL will go back up again.  

There's good news, since you push your HepB VL to UND on interferon, you may be able to take a monotherapy with a potent antiviral (such as Entecavir or Tenofovir) to hold the virus.  Since your VL is UND, the virus adpative power is decreased and the resistance profile is enhanced.  Thus, it is best to treat with antiviral while you are UND.  So be sure to discuss this with your doctor...eventually.   And it would be wise to ask to clarify your VL numbers.

As for how do your determine the dominate species.  You check which virus has the high VL in your blood.  Between type (B and C), you could tell pretty easily.  Then you gentoype.   But things could change once you come off treatment.

[zellyf]

You're a quick study, Nash!  In your case, where you already are dealing with a mutation I don't think you want to start out with LAM.  That is a layman's opinion, of course.  

Really glad that your treatment has been such a great success so far!

[NashPred]

Yeah, I think Steven had mentioned that my Dr would probably start me on Baraclude after I completed my 6 months of Peg/Riba tx and then see what happens with labs and go from there.

I looked at the Resistance Chart you posted and some other posts regarding resistance, and I get the feeling that if he tries to give me LAM to start out with, that would be a no no. Correct??

[zellyf]

Okay so I would go with the reading on the lab results themselves.

Yes, viral load is also HBV DNA...totally appropriate.  Your viral load is (was?) high for an eAg-neg.  You should probably research if it would be appropriate to move to an antiviral after peg.  I don't know much about that.

I do know that about some doctors but, you have a right to ask questions. Easier said, right?

[NashPred]

Great explanation! That sheds a lot of light for me.

Now, here I go again. My Dr’s notes say I have a Hep B “Viral Load” of 189,000. Is the term “Viral Load” even used when dealing with HBV? What’s weird is the DNA test he basis this on, says only 18900. He has a habit of writing in comma’s on the lab results and I think he put one in the wrong place because where he placed the comma makes the lab test say 180,00. Does that make any since? All I know is that if not for his comma, the test reads 18900 IU/Ml. (At four weeks into tx, my HBV DNA was undetectable.)

I see the Dr. again in 2 weeks. I don’t know if I should question him on this? You know how some Dr’s get when you question their interpretation of test result. And this is the first time for me to see him since before I started tx so I have yet to feel him out. (I have seen his PA during my last 3 visits.)


I think the next big test for my condition will be to see what happens when/if I clear the HCV and start to come off tx. I have a quite a few questions I will ask the Dr. about this scenario during my next visit.

[zellyf]

Ask away! I learn a lot from reading the answers to others' questions and it is so critical to be informed.

Yes, eAg and eAb can both be positive and they can flip back and forth during seroconversion during an epic struggle for control.  

So, you have the basal core promoter mutation.  Sounds scary but about 50% of people go precore or BCP at some times so its really not scary.  The standard for now seems to be to leave it alone until the HBV DNA goes over 2000 IU/ml and or/ALT 2x ULN and/or moderate or significant liver damage on biopsy...usually any 2 of those 3.  You should probably do panels with DNA every 3 months.  At that point, however, you're looking at long term, probably life time, of anti-virals.

[NashPred]

Before I started tx, I was already e-antigen negative and e-antibody positive. So if I understand correctly, that’s a good sign.

Can both eAg and eAb be positive at the same time? I assume that there is a window period when they can while seroconversion is taking place. Is this right?

I am a white American with genotype A. My blood work says “BCP Mutations Detected”.

Thank you very much for your help Zelly. And don’t worry about the co-infection questions. Maybe steven will have a couple of answers on those. I know it’s asking a lot and very difficult to understand, but maybe if I learn enough, I will be able to help others w/ HBV/HCV co-infections on this site.


Sorry for all the questions. Sometimes I feel like a 2 year old with an endless supply of questions and I just have a lot of time on my hands right now as I am unable to work during Interferon/Ribavirin treatment (physical job w/ driving involved). I might as well use my free time to learn about my condition.  I sure don’t feel like doing anything else right now.

Thanks again

[zellyf]

e-antigen can flip flop but tends to remain stable, especially if you have e-antibody.  Studies suggest that induced e-seroconvervsion is somewhat less stable than a natural one.  I'm not sure how significant is the difference.

The trick with e-antigen is that it is a desirable factor to lose it but the virus can still overcome it to do significant damage.  This is called e-antigen negative chronic Hep B.  It happens if you have the markers for the precore mutation of the basal core promoter mutation.  Its common in Asian genotypes.  Do you know your genotype?

Basically, e-antigen negative is great but its not the end of the story.  Careful monitoring for the rest of your life will be important.  

I really can't help you with the co-infection questions.