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Hepatitis B Community
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Avatar universal

Treatment options

Hi,

My test results:

12/21/06:  HEP B PCR QUANT = 107000 IU/ML
03/19/07:  HEP B DNA, ser/plas, PCR = 100316 IU/ML
02/29/08:  HEP B DNA, ser/plas, PCR = 487165 IU/ML

               ALT       AST
03/19/07:  31         27
10/29/07:  87         49
11/30/07:  123       50
12/31/07:  34         29
02/29/08:  46         36

Questions:  What does the change trend mean?  Should medication treatment start?  What medication to start with?  What dosage?  How long should I prepare to stay on that medication?  What side effects to expect?  What is the monthly cost?  Thank you for your feedback.
190 Responses
181575 tn?1250198786
It means you are sustaining liver cell damage from HepB.

More information is needed to understand your disease status.

How old are you?

When were you infected?

What ethnicity are you?

What is your eAntigen and eAntibody status?

What did your doctor tell you so far?
Avatar universal
Age 48, when infected not sure, ethnicity Asian, eAntigen=HBeAg? if yes =NONREACTIVE, eAntibody not sure, doctor on vacation.  Thanks for your advice.
181575 tn?1250198786
Read the thread started by Mei.  You two have a similiar presentation:

http://www.medhelp.org/posts/show/440703

Since typing the same stuff takes alot of time.  Here's a cut and paste of the relevant points to your presentation:

Sometime prior to Dec 2006, you were probably in the inactive phase of the disease before with eAntigen negative, eAntibody positive, low DNA, and normal LFTs and ALTs.

If you DNA jumped from low to 107,000 IU/ML (which is a sign of the disease breaking through immuno-control) then to 487,165 IU/ML, with elevated ALTs, those are classic signs of a eAntigen negative active disease.  This is a classic sign of the core-promoter mutant strain, which is quite common.  Like 50% of all carriers eventually have this mutation.  This is the re-activation that carriers have to look out for.  If this is you, you should treat.  And start soon, try to cut down the virus' replicating abilities.  Treatment in such cases are long-term.  Consider combo treatment to reduce the risk of resistance.  Lamivudine monotherapy should not be used because of its poor resistance profile.

With a 50 miilion viral load, you could do genotyping now to check for the pre-core or core-promoter mutation.  Ask your doctor for that.  It's probably the core-promoter.

With an eAntigen negative disease, treatment is basically long term.  I think most doctors recommend antivirals because it has minimal side effects and easier to tolerate long term as opposed to Peg Interferon (some on the HepC forum referred to Interferon as doing hard time).

Combo treatment is taking 2 antivirals to cross protect against resistance.  It attacks the virus on 2 fronts to reduce it adaptive abilities.  Important because you may may to take antivirals for the rest of your life.  Always think of the long term.

Discuss the above with your doctor.  Good luck.

And hope you stick around and let us know how you are doing.

181575 tn?1250198786
"With a 50 miilion viral load, you could do genotyping now to check for the pre-core or core-promoter mutation.  Ask your doctor for that.  It's probably the core-promoter. "

Opps, it should be edited for you:

"With 487,165 IU/ML, you could do genotyping now to check for the pre-core or core-promoter mutation.  Ask your doctor for that.  It's probably the core-promoter."

Yes, I am cheating...it takes time to type you know ;)
Avatar universal
Will present your advice to my doctor, will keep you updated.  Many thanks again.
Avatar universal
080318:  Today I saw my doctor who was quite refreshed from rest at home.  He recommended two treatment options, one is injection once a week and the other is baraclude by mouth once daily.  Because the former has side effects that may cause me (the bread earner of my family) to stop working, I immediately chose the latter, which costs $2200 per 90 days.  Would appreciate your sharing your experience if you have used baraclude before.  Thank you.  -cajim
181575 tn?1250198786
Did you ask your MD about the e Antigen / Antibody status, genotyping, etc?

What did your MD say?

"Because the former has side effects that may cause me (the bread earner of my family) to stop working."  -This is why most go with antivirals.

Did you ask about combo antiviral treatment to lower resistance risk?

Do you have insurance for this med?  You may have to take this long term.

And Baraclude is great.  It has a great (low) resistance profile.  I'm taking it now (well not now, it was this morning ;).  No side effects.  Good for the diet too.  You have to take it on an empty stomach (2 hours before or after meal).  So if you take it at night, no more eating right before bed ;)
Avatar universal
Many thanks for your advice and sharing.

My doctor spent more than 30 minutes answering questions from my wife and me:

1.  Genotyping and biopsy can be ordered if I request but the result would not alter the course of treatment.  Genotyping can identify 5 types of something but medicine today does not have a common approach.  Usually one doctor's advice is different that of another's.

2.  I am not sure about my e Antigen / Antibody status but my doctor said my medication requires heavy dosage, 1mg per day.

3.  He advised that Baraclude is more potent than Hepsera and the former does not more easily cause cancer than the latter as a former doctor suggested.  I will ask him about combo treatment by email.

4.  Now I am working and my insurance covers the med with some copay.  The worry is if I become too sick to work, my income stops and the coverage stops too.

You are a wonderful person with a helping heart.  Many thanks.  -cajim
Avatar universal
I would gently insist on knowing your e-antigen/antibody status.  If you are e-positive then the end of treatment is becoming e-negative.  If you are e-negative then the end of treatment is less clear and needs further discussion.
Avatar universal
Doc's reply:  Combo treatments are not FDA approved.
Avatar universal
Combo treatments are part of the arsenal of any doctor who is up to date on the research.  I'm concerned about a doctor who has not bothered to found out your e-antigen status and flatly eschews the idea of combo therapy.
181575 tn?1250198786
I second Zelly's comments.

You posted earlier, "eAntigen=HBeAg? if yes =NONREACTIVE".  Unless you have a truly unique situation, your eAntibody is positive.  Which means you could very well take meds for the rest of your life foe this e- active HepB.  You are 48, so you may need to meds for another 20-30 years or so.  To do so without viral resistance is a tough goal.  This is why resistance issues need to be discussed now.  Say you reach (UND) Undetected DNA on Baraclude, most doctor will not make any changes because you are UND.   They wait to see a rebound in DNA and say "uh-oh", looks like the virus developed resistance to Baraclude.  This will have consequences on your future treatment options...just ask anyone who developed resistance to Lamuvidine.  Resistance is a difficult one way road.

I think it's okay to just go on mono-therapy with Baraclude now since your DNA is still not that high.  But do ask your doctor when is a good time to go with combo.  If the answer is after resistance develops, that's a bad answer.

You don't need FDA approval for combo treatment.  FDA approves the individual meds.  It's up to the doctor to make a clinical decision as to what to treat with.  So personally, I wouldn't accept the answer you got.

Also, I know it's very uncomfortable to challenge your doctor. I've done it and in the end, my doctor thanked me to introducing a new train of thought.   I am on combo treatment with Baraclude and Tenofovir (which is not yet FDA approved for HepB...but it will soon).  Those who know me know that it took alot of work to get my Tenofovir.  Then you ask, hey, isn't that a little dangerous, taking a un-FDA approved drug?  I would say no, because this drug has a nice track record as an FDA approved med for HIV.   Lamivudine, Hepsera, Tenofovir all started out as HIV meds.  Hepsera was scratched for HIV because it needed higher dosage, which wreck havoc on the pts' kidneys.  They reduced the dosage and use the drug for HepB.  So it's not cancer that you have to be concern about with Hepsera.  It's the low antiviral power / resistance profile / and potential to cause kidney problems.

And re: the comment on cancer.  High DNA is correlated to higher risk for liver cancer.  That would be my primary concern.  All meds are tested to see if it causes cancer, so far (to my knowledge) no antivirals are cautioned for any cancer risk.

Re: the genotyping, yes it won't change treatment but the information can't hurt.  Especially all it involves is a drawing a tube or 2 of blood.  It's not like a needle jab into your liver (biopsy).  You have DNA for gentoyping now.  If you start treatment and go UND, you can't do genotyping.  What if they have a new drug that works well with a certain genotype in the future.  The info you get now could help you in the future.
Avatar universal
You play such pillar roles in this forum that not only people like me who you address benefit from your expertise, sharing, and encouragement, but there must be hundreds even thousands who are silently benefiting.  Thank you very much!

1.  My doctor said for me e-antigen is negative. and e-antibody is positive.

2.  As for combo treatment and genotyping, he requested me to see him to discuss them.

3.  zellyf, we are similar in that we have children and spouse.  Do you mind sharing how you protect them but at the same time minimally limit contact with them to express your love for them, especially your spouse?

Merci beaucoup!
Avatar universal
Thank you for your kind words.  steven is the real driving force here, though.

That's good news about your doctor.  A doctor who is willing to talk is a great sign.  

Since you are e-negative you are probably dealing with a mutation...very common.  Steven will have more insight on treatment options.

Everyone in my home has been vaccinated and my children have had titers to prove their immunity.  I am reasonably careful with my blood product if I get a cut. I do not share my razor.  You're not supposed to share nail clippers either or any other personal grooming instruments that might contain traces of blood.  

I don't limit affectionate physical contact with my family at all.  There is no reason to refrain once they have been vaccinated.  Even without vaccination, kissing is not considered a great way to spread the virus.  It is vital that everyone in the home be vaccinated in order to provide everyone with peace of mind.  If your spouse hasn't been vaccinated than protected sex is strongly recommended until she completes the 3 shot series.

Please keep us update!  

181575 tn?1250198786
cajim ( does this mean you are Jim in CA?) :  Read this thread:


http://www.medhelp.org/posts/show/470971

Print the abstract and bring it to your next doctors appointment.  Tell you doctor that one of the investigators is Dr. Keffee.  Dr. Keffee is pretty well known and knows his stuff.

And yes, thanks for the kind words.  As you are on your ways to learn, start treatment, and take care of yourself,  I hope you give back to this community forum as you experience would be very valuable to others.  So I hope you stick around :)
Avatar universal
I'm getting a dead-end on that link.
Avatar universal
Ummmm...nevermind.
181575 tn?1250198786
Zelly:  re: steven is the real driving force here, though.

You are kidding right.  You mean just as much to this forum as I.  I regard you as a personal friend.  You empathy and encouragement mean so much to me and others.  I don't think I would be motivated to stay on if there is nobody to connect with.  As I said before, one day we will look back and say, "we come a long way."
Avatar universal
I'm not kidding! But maybe you just expressed it better than I did.  Knowing that there's someone else invested helps...same with the other regular posters.  Even the Hep C board where I lurk.  If it weren't for knowing that others care too I wouldn't have the same incentive.  And, I wish I had a nickel for everytime I've said, "My friend, steven, at the board...".



Avatar universal
It made me smile reading your dialog and for a moment the Hep B monster shrank.  I feel you two are angels from Heaven.

1.  Which test are the titers that you mentioned related to?

2.  I will bring Dr. Keffee's abstract to my doctor's appointment.

3.  Indeed, I am Jim from California.

Will keep you updated.  Many thanks. -cajim
Avatar universal
The titer is a special blood test drawn after the vaccination series is complete.  It tests the level of immunity (which is more typically a "yes" immune or "no" answer rather than a matter of degrees).  In CA, the children of Hep B moms are required by the Health Dept to have the titers following vaccination.  

In June there is a patient conference in Southern Cal.

I think most people who know me for any length of time would have a good laugh at the idea that I would be called an angel, I have a reputation for crankiness.  I like your version better.
Avatar universal
My children all had the three HepB vaccination shots as they grew up.  Recently because of my change of condition, they had a blood test.  While one showed presence of Hep B antibody, the other did not show antibody.  What does that mean?  We talked to the child's doctor who said the test did not pick up antibody.  We asked if the child should be vaccinated again, the doctor said it would not hurt but it would not be necessary to test the child again after the second 3-shot vaccination because even if the test does not pick up antibody again he will not order another vaccination.  I asked if the test my child had was the one with titers of yes/no to show results, he said yes.  I am confused and worried.  Could you advise how could the second child had 3-shots vaccination yet had absence of antibody?  Many thanks.
Avatar universal
This happened with 2 of my children b/c the doctor waited too long to do the titer and so they showed up as not having the antibody and being "non-responders" the the vaccine.  They re-did the series and then were retested in the recommended time frame and both showed the antibody.

Testing needs to take place about 1 - 2 months after finishing the series because:

"Data show that vaccine-induced hepatitis B surface antibody (anti-HBs) levels might decline over time; however, immune memory (anamnestic anti-HBs response) remains intact indefinitely following immunization. People with declining antibody levels are still protected against clinical illness and chronic disease."

So, chances are the second child is protected but just has no detectable antibodies.  

Its anxiety provoking but odds are good that there is no problem.

I would gently insist on testing after the series b/c if the child is a non-responder that would be good to know.
Avatar universal
Your sharing and educating are so valuable!  Many many thanks!  Will have the second child receive the second series of vaccination to be followed by the blood test.  Merci beaucoup!
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