To treat or continue monitoring

[Nubu12]

Dear All,

thanks for this forum and hope everyone is in good spirits! I have received support on this forum before and I was hoping I could check in again.

My spouse got diagnosed with Hep b when she was pregnant a year and half ago and she has sine had blood work done three times here are the latest numbers be we have access to:

HBsAg +
HBsAB - (no immunity to hep b)
AFP TUM Maker 2.5
ULTRASOUND: "Liver is 15.8 cm in size and demonstrates normal homogeneous echogenicity. There is no focal lesion or biliary dilatation.
Impression: No definite sonographic abnormality in appearance of liver
ALT 14
AST 22
ALKALINE PHOS 62
HBV DNA 1400 IU/mL

Previous ALT/AST levels have been persistently normal
Liver biopsy confirms absence of any significant hepatitis
HBV DNA was previously 400 IU/mL

this is the information we have. One would have thought the best prognosis here is Inactive carrier, which the specialists agrees with but he wants to start treatment to bring DNA levels to zero or undetectable.

My questions are:

Is it a realistic goal to treat in order to have undetectable serum HBV DNA, given that this occurs only in less than 1% of chronic carriers?

If HBV is unresolved after a definite period of treatment and she has to continue to be on drugs due to fear of lapse and drug resistance wouldn't this be a poor choice as opposed to vigorous monitoring?

Are DNA levels reliable risk factors for treatment (especially with just two data points) given they widely fluctuate?

What are the benefits of early treatment in the absence of red flags (no elevated ALT/AST, normal ultrasound and biopsy)?

Thanks in advance for your help and God richly bless us all with abundant good health.





  

[stef2011]

it is also good to look at what is going to happen with gcmaf and if a nomrmal nagalase is able to awake our blind immune system, in nov 2011 my nagalase was 2.1 so it is possible i will have normal levels by may 2012 and see if there is any effect on hbsag

[stef2011]

this is the problems you can find:

most liver specialists are not aware on how to judge hbsag quant and its meaning, the most updated, especially researchers, know how to deal with hbsag quant and with interferon combo with tdf, etv and even ltd all the rest just refer to the old guidelines considering inactive carriers like something not to treat while inactive carriers are those with low hbsag with highest chances of clearance (some research from 2009 already showed that interferon with normal alt and hbvdna und has response about 30% hbv clearance)

so in the end you have read all research and make your own decision with the most updated liver specialist you find, the good point is all regimens with interferon combo can be stopped safely and must be stopped if interferon has no response by 24 weeks

eather choice is ok monitor or try to clear and my suggestion is take a close monitoring on hbsag so if decreasing you know where the disease is going while if unstable or increasing you will know eather that it wont clear by itself or even worsen

[Nubu12]

Thanks StephenCastlecrag for your opinion. I was more in your corner before Stef2011 suggested HbsAg clearance. I have read the 2007 and 2009 AASLD practice guideline updates and she is clearly in the inactive carrier stage and caution is recommended for treatment since 1) the body might be fighting if not clearing the virus successfully 2) HbeAg clearance is much lower in inactive carriers with normal ALT levels 3) inactive carriers with low DNA levels and persistently normal ALTs are recommended for monitoring. did I add spouse <40 yrs?

But if new research shows that the probability of HBsAg clearance is increasing with new drugs especially with patients infected as adults or relatively newly infected, I will be eager to have us try that but it might be a wrong move to find out after several years of heavy treatment that surface antigen is uncleared and the only benefit of treatment is DNA levels are undetectable but nonetheless present in the liver. While this is still good for  our health, we could have this monitored and achieved through monitoring and when red flags show (persistently high ALT and DNA levels) we treat as recommended.

We will have the specialists quantify the HBsAg test and ask him follow up clarifications prior to final decision to treat but I feel treatment is such a crucial decision that all options must be weighed heavily.

Please feel free to critique my logic since we are no doctors and are just sharing and learning more about this disease.

Thanks Stef2011 and  StephenCastlecrag for responding I greatly appreciate your time.

[StephenCastlecrag]

I will give you my opinion. What Stef2011 has recommended is a course of treatment that may clear the HbsAg completely.

I don't believe any of the guidelines (AASLD, APASLD, etc) will recommend treatment in your spouse's present conditions. Her ALT is in the healthy range (< 19 for female, < 30 for male) and her hbvdna is low.

You may like to have her HBsAg tested quantitatively if the assay is available. If the result is < 500 iu/mL, as Stef2011 suggested, then she may be on her way to clearing the virus by herself.

All in all, I think monitor every 6 or 12 months is an acceptable option.

I am not a doctor, hope I got it right.

[stef2011]

the tests are always:
fibroscan for fibrosis/liver damage monitoring

hbsag quantity in iu/ml, to see clearance of infected cells and immune control

hbvdna must be und all time, less than 10iu/ml always (this is just a poor test because we can t check it in the liver, and in the liver it is never und until hbsg clearance)

ast/alt, but not very important.abnormal ast/alt when hbvdna is undetactable is the ideal situation, it means immune system is able to detect and clear infected cells and make hbsag go down faster

Us every 6 months is the routine for any carrier for detection of liver cancer on time, this is the only use for US and is must not be used to detect liver damage because sensibility is too poor.if a US detects liver damage it is already too late because it can detect cirrhosis only when very very advanced whiel fibroscan can see all the little stages longer before.
ideally fibroscan should stay less than 7-8kpa because liver cancer risk is increased over than range, cirrhosis risk starts from 11-5kpa and is almost certain after 13kpa

sides effects:
tenofovir: extremely rare sides on kidneys for hbv patients, those who get creatinine increase had kidney damage already before therapy.
there are no tests for kidneys damage so creatinine must be checked before and after tdf, if no change no damage at all

use of tdf on this sequential therapy is so short that no sides are the norm

peginterferon alpha can have many sides, even heavy on some but this is the only way to clear hbv.
interferon lambda has mild sides/no sides and will be available in 2 years so you will probably have this option by then.

[Nubu12]

Thanks stef2011. I appreciate your response. What your response means is that treatment is a viable option given the diagnosis. Whats the level of monitoring, blood work, xrays, altrasound etc during treatment and do you know of the extent of side effects? Thanks once again and best.

[stef2011]

the goal of treatment is not hbvdna und, it is required but it means nothing to hbv infection, the goal is hbsag lowering until undetactable

with hbsag less than 500iu/ml there is no hbv replication even off drugs nd of course hbsag und is hbv clearance

this is achieved only by sequential treatment tenofovir 1-3 years +interfron add on 96weeks
40% cleearance by 48weeks of combo, probably 90% by 96 weeks, 10% failure

if hbsag is not cleared those with low hbsag can go off drugs and have no replication
low hbsag i mean less than 500iu/ml or better those with cccdna less than 5 per cell