I have elevated ALT and AST

[Mei8839]

I am a chronic Hep-B carrier, having got it from my mother. I have been managed and monitored since I found out in the mid 80s when they started testing for Hep B in the country I lived in. My liver function test/ultrasound/CT scans (of late) have always been normal but my last LFT done in late January have returned abnormal results. My ALT had gone up from 35 to 258 and my AST was something like in the region of 200+ as well. My doctor said I have a flare and have referred me for a liver biopsy which I am going for in a couple of days. He said it was to see the progression of my disease and to see if we should start treatment for it. I feel a little discomfort (not pain) on the right side of my body, which is not imagined as I had already started to feel that discomfort even before I went to keep my six monthly appointment with him. My doctor said my liver is slightly swollen and that is consistent with an infection. Apart from these, I am well and feel fine. My last ultrsound scan in July last year was normal, with no trace of lesion and my viral load was about 30,000. I have redone all these tests (except for the ultrasound which I am doing together with the biopsy) and am awaiting results of these. I am very concerned of course and is wondering if anyone would be able to tell me if it is possible for all to go wrong over the last six months. I don't know if my doctor is keeping anything back from me because he does not want to alarm me.  

[stevenNYer]

And this thread may be of interest to you:

http://www.medhelp.org/posts/show/452815

[stevenNYer]

Clevudine is approved in Korea for treatment of HepB.  And current in phase III trials in the US.  So it's not like it's a new drug.  It's proven treatment for HepB.

Clevudine is identical to Telbivudine (Tyzeka) with just a fluor atom attached to the ring (and no, I have no idea what this means ;)

Telbivudine was approved in 2006.  Entecavir in 2005.  Both are quite good I think.  So by trends, the newer meds has been better.

BUT (and here the thing that will make you go with Entecavir...hahahaha) Telbivudine has a higher rate of resistance, similar to Lamivudine (yikes).  So if Clevudine is similiar to Telbivudine, then...well you can make your own guess.  Remember this is coming form a lay person (me) who didn't do so well in biology and chemistry in college.

[Mei8839]

I've just been back from the doctor and have been invited to participate in a clinical trial of Clevudine. No combo treatment in Oz yet. I am inclined to go with Baraclude though. Clevudine is still pretty new, although I do see it in Drug watch in HepB.org and had a look at the website with supporting data for this drug - looks as clear as mud to me. Would anyone one be able to help? Thanks.

[stevenNYer]

Good post by Zelly as usual.

I look in my crystal ball and I see that in the US the first line combo will be:

Entecavir / Tenofovir
or
Emtricitabine / Tenofovir

That's right I'm calling it...haha ;)

[zellyf]

There are people who do not respond to the vaccine...they are actually called non-responders.  Or perhaps the vaccines where somehow administered improperly.  It is possible to live with Hep B carriers and not be exposed.

[cally44]

So with e antigen, it is only good when there is negative if you have the e antibodies?  I belong to the hep b list serve and many pple on there say that the e antibodies doesn't make a difference.  Is it true if u have e  antigen negative that u are most likely precore if u have other than undetectable dna?  What is the difference between precore and core mutant?

Thanks

[Mei8839]

My son has been testing normal so far, v/l about 3000 in August with liver function tests all within their normal limits, also e-antigen negative, e-antibody positive. He doesn't smoke nor drink, but works pretty late into the night as he works as a chef and usually not in bed till after 1:00 am. I was told that the liver is one of the organs in the body that actually rests and detoxes at night, don't know if it is a fact. I have been asking him to consider doing something else but he still enjoys what he is doing and says he is still young and can take a few more years at it.

My daughter who was vaccinated at birth, with booster given at the right ages, etc. and tested antibody positive when she was 7 has been told in test she underwent three weeks ago that she was tested negative for antibodies or antigens, it is like she has never been exposed to the virus. I find this a little difficult to believe but her blood test says that. Our doctor has given her another booster, and asked her to return for another blood test in a couple of months, just to see if her antibodies might show up then, but said he is unlikely to given her another booster if they don't. Do you know if it is possible for her to live with two carriers in her family and not be exposed to Hep-B? She has been vaccinated and I have her vac cert to show for it, but how is it that her blood test shows that she has never been exposed to the virus? Boggles the mind, does anyone have an explanation for this? Thanks.

[zellyf]

I definitely wasn't trying...sometimes I sound flippant w/o even trying.  I haven't been through any therapy yet so I can only offer moral support which, as we know, isn't nothing when you have HepB.

How is your son?

[Mei8839]

Thanks, Zelly. No, if you were trying to be flippant, I missed it, so no worries at all. At this point, I am really interested in learning from anyone who has been "through" the therapy and management part of the disease. I have had it good so far and constant monitoring over the last 20 years have returned stable results and I thought it would always be that. It's ironical that just a year ago, when I started seeing my hepatologist who ran us (both my 24 year old son and I - my mum passed it to me and unfortunately I passed it on to my son) past the the possible landscape of the disease and told us about flares - we have were never been told that in Malaysia - I thought, no, I wouldn't have to worry about that. How quickly life changes. I am now in a steep learning curve and trying to learn all I can. Thanks again.

[zellyf]

I hope that didn't come across as flippant, Mei.  Sometimes, I try to sprinkle in some humor but don't get it right.  I was really glad to get your update but I didn't have anything to add to Steven's excellent posts except for the bit on Tenofovir. Cheers!

[zellyf]

I'm guessing Tenofovir which is not approved for HepB but is used to treat HIV.  However, some doctors will prescribe it for use off-label.  It should get approval this year (2008). I live in the US by the way so things could be different for you.

If I'm wrong then steven can give me a cyber-timeout.

[Mei8839]

Thanks, Steve, for the advice. You said 2 antivirals, if Baraclude was one, what would the second be? I was also told to stay off Lamivudine by someone else because, as you have said, it has a very bad resistance record. Thanks again.

[stevenNYer]

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).

Entecavir is Baraclude and it's an excellent first line.  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.

Obviously your hepatologist appeared to have given you sound advice.  Good luck.  Let us know how it goes.

[Mei8839]

What is combo treatment? I am told that in Australia, the first line oral therapy is Baraclude although my hepatologist has also spoken to me about the possibility of using peglated interferon. But that was before I had my biopsy and his advice then was that we would explore treatment options after he has a better picture with the biopsy results. My GP has now managed to schedule an appointment for me to see another doctor in my own doctor's absence so I thought I should arm myself with a bit more information before I went and saw the new doctor. Thanks.

[stevenNYer]

"you might have confused my post with Mei..."

This is why I suggested all questions unrelated to the original poster be posted as a new thread.  

"and what does it mean by 'the virus is breaking from immuno-control.'?"

If the eSeroconversion is successful, then the eAntibody gains the upper hand and neutralize the eAntigen.  In this case your immune system established immuno-control over the virus.  But the virus is in a constant state of evolution and trying to escape this control.  Once that happens it becomes an active disease again.

[Airwind]

uhmm... i guess there's a mixed up of numbers. it was my first time to post my ALT/AST levels, and i only had 1 test for both so far. that is 500+ for both. you might have confused my post with Mei...

and what does it mean by "the virus is breaking from immuno-control."?

thanks.

[stevenNYer]

How old are you?  

If you are in your 40's, you could probably make a good guess at this point.

You were probably in the inactive phase of the disease before with eAntigen negative, eAntibody positive, low DNA, and normal LFTs.

If you DNA jumped from low to 30,000 (which is a sign of the disease breaking through immuno-control) then to more than 50 million, that is a classic sign 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.

You did good to catch it early.  You caught it in about 6 months and had about 1 flare.  Most don't catch it and let the virus reactivate and do years and years of damage.  That is the difference and that is why carriers need to monitor.

Talk to your doctor.  Good luck.

[Mei8839]

After a grueling and worrying two-week wait, I finally got my results back from my liver biopsy and blood tests. My hepatologist is still away on leave and hadn't called but thankfully, my family doctor managed to get the results sent to her. My ALT level is starting to fall, the second blood test did two weeks after the first gave a reading of 150 ALT, down from 258 and AST of 68, down from 115 (I had thought it was above 200 previously). Other tests did to check liver function have all returned normal readings so my family doctor is quite confident that it was a flare I had experienced, which might be starting to turn around. Again Hep B e antigens negative, e antibody positive. However I am deeply concerned about my viral loading, this time a reading of above 50mil copies/ml, up from 30,000 only six months ago.My biopsy showed no extensive damage/malignancy although there was some damage which was consistent with the flare. My doctor advised that I shouldn't be too alarmed by my results but she will try to get another hepatologist to follow up with me should I feel I cannot wait till my own hepatologist returns at the month end. She thinks I should be starting treatment soon. What do you think or is there too little information to hazard a guess?

[stevenNYer]

You didn't mentioned you were taking lamivudine in earlier post.  When did you start taking lamivudine and when did you stopped?

Can you post up your DNA and ALT with corresponding dates.  Because I am confused by your numbers.  First you indicated your ALT went from 35 to 258, then 500 in the previous post.

Now again, I am NOT a doctor, but my guess is that you either had a bad flare or the virus is breaking from immuno-control.

While it is possible for a chronic infection to clear, it is very unlikely.  

[Airwind]

Hi, it's been a while.. my condition was found out in our office and one of the managers confronted me. since i've been going to my friend-doctor in treating my condition, i was advised to consult our company doctors - anyway, everything's for free as part of our compensation and bebefits. so i went to the company clinic and was referred to a private and well-established hospital for a specialist. i showed my results. at his 1st glance on my lab tests, he said it's chronic. then i handed my AST/ALT results, which are too high (500+). he was then confused since according to him , this level of AST/ALT are only common for Acute infection. he asked me to stop taking lamivudine and take a liver-support medicine. after 2 weeks, i will have to repeat the test to see if i develop the antibodies.. then it could be an Acute infection only.

But I don't get it. If my Hepa Profile clearly says it's Chronic (and my viral Load is 1,200+), how could that be an Acute infection only? Did what the Doctor said about my AST/ALT levels possible?

[zellyf]

Glad you posted.

I can more than understand your anxiety.  Did you ever find out your current viral load? The good thing to remember is that you've been monitoring and so this current activity is new and anything that might be happening is in an early stage.  As CHB carriers we have to expect and anticipate that flares can and probably will happen and its not the end of the world (even if it can feel like it sometimes).  

Best wishes.  

[Mei8839]

I had my liver biopsy done on the 21st. The hospital told me it would not be until the end of next week before I can get some pretty comprehensive finds/diagnosis. The biopsy in itself was quite painless except for the anaesthetic jab they inject into my side before they inserted the needle. What was painful was having to lie on my back for 4 hours afterwards!

Doesn't help that my doctor is going to be away for a month next month, just as my results are coming in as I am pretty worried sick about my results though he has assured me that he will call with my results as soon as he gets it. I guess at this point, it is just a wait and see. I will be back to update lab tests and biopsy results when I know.

[stevenNYer]

It would have been helpful to monitor the viral load to watch for disease reactivation.  Just from your infomation, I think you were in the inactive phase of the disease.  Hopefully it stays that way.  

It must be understood that the virus continues to work to escape immuno-control.  The virus evolves, tinkers to replicate, your immune system adjust to re-establish immuno-control (this battle is the flare).  If the virus gains the upper hand and evolves to the point where your immune system can't re-establish control, then you have a eAntigen negative active disease.  It eventually happens to about 50% of inactive carriers.  In this case your DNA will continue to go up.  In this case, treatment is usually recommended.

I can't emphasis the importance of monitoring.  I get DNA test every 3 months.  And have done so for 2 years (since being diagnosed).  It's important to know what the virus is doing to you have the best chance to counter-attack.  Good luck.

[Mei8839]

Didn't do viral loading till I got to Australia, just the usual LFT together with ultrasound. The first v/l I did was 30k. Blood test results from last week are not back yet. I am 46 yo, previous test results HBeAg non reactive, Anti-HBe reactive, but as I say, this was the results of the blood test I did 6 months ago. I was so traumatised by the news of the flare this time I forgot to ask my doctor for a copy of the test. I will collect it when I go in for my biopsy on Thursday.