HEPATITIS B AN UPDATE ON TREATMENT

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HEPATITIS B AN UPDATE ON TREATMENT
www.drsarma.in

• Dr. R V S N Sarma
• MD MSc (Canada) FIMSA
• Consultant Physician and
• Cardio Metabolic Specialist

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Who should be treated ?

• When to treat in HBV course ?
• What is the treatment ?

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Goal of Antiviral Therapy

• 1. Sustained suppression of HBV replication
• Decrease in serum HBV DNA to lt105 copies/ml
• Seroconversion HBeAg to anti-HBe HBsAg to
  anti-HBs
• 2. Remission of liver disease Normalization of
  serum ALT levels
• Decreased necro-inflammation in liver
• Improvement in clinical outcome Decreased risks
  of developing cirrhosis, liver failure and HCC
• Increased survival

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For whom therapy is indicated

• Patients who have
• Acute liver failure due to HBV
• ALT of gt2 x UNL and or HBV DNA gt 20,000 IU/ml
• Cirrhosis and clinical complications
• Cirrhosis or advanced fibrosis HBV DNA in serum
• Reactivation of Chronic HBV after chemotherapy or
  immuno-suppression
• Infants born to women who are HBsAg-positive
• The immune-active phase who do not have advanced
  fibrosis or cirrhosis

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For whom therapy is not indicated

• Patients with
• Chronic hepatitis B in the immune-tolerant phase
  (with high levels of serum HBV DNA but normal
  serum ALT levels or little activity on liver
  biopsy)
• Patients in the inactive carrier or low
  replicative phase (with low levels of or no
  detectable HBV DNA in serum and normal serum
  ALT levels)
• Patients who have latent HBV infection (HBV DNA
  without HBsAg)

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Predictors of Response to Antivirals

• High baseline ALT level
• Low Baseline HBV DNA level
• Mild-to-moderate histological activity
• Mild to Moderate stage Liver Dysfunction
• Genotype of the HBV (AgtBgtCgtD)
• Baseline HBeAg positivity (wild virus)
• Genetic barrier to resistance - Lamivudine,
  Telbivudine and to a lesser degree, Adefovir

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Predictors of HCC, Cirrhosis after CHBV

• Persistently elevated HBV DNA
• Persistently elevated ALT (SGPT)
• HBV genotype C infection
• Male Gender, Older age
• Family history of HCC
• Co-infection with HCV or HIV or HDV

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Chronology of Drugs for HBV
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AASLD Rx. Guidelines
HBeAg Status HBV DNA IU/ml ALT level x UNL Recommendation
Positive gt 20,000 ? 2 times Do not treat
Positive gt 20,000 gt 2 times Peg Inf, Adefovir, Entacavir
Negative gt 20,000 gt 2 times Peg Inf, Adefovir, Entacavir
Negative gt 2,000 1 to 2 times Liver Bx. for Rx. decision
Negative ? 2,000 ? 1 time Observe
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Standard Threrapy for HBV
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HBV Drugs - Dosage
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Comparison of Oral Antivirals
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Medications and Cautions
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Treatment Algorithm HBeAg ve
HBV DNA, ALT HBV Serology panel
Obtain Baseline tests
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Treatment Algorithm HBeAg -ve
HBV DNA, ALT HBV Serology panel
Obtain Baseline tests
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Adverse Effects

• Endocrine
• Hypothyroidism
• Hyperthyroidism
• Dermatologic
• Rash, Dry skin, Pruritus
• Thinning of Hair
• Gastrointestinal
• Anorexia, Nausea, Weight loss

• Systemic
• Fever (low grade), Fatigue
• Myalgia and or Arthralgia
• Mood Disturbances
• Depression
• Irritability, Insomnia
• Hematologic
• Neutropenia, Anemia
• Thrombocytopenia

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Response to Antiviral Treatment
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Response at 1 Year of Rx.
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Clinical Cure Rates
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Seroconversion Rates
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Clearance of HBV DNA
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Peg Interferon v/s Interferon
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HBeAg Status and HBV DNA Clearance
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HBeAg Status and HBV DNA Clearance
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Tenofovir v/s Adefovir
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Entacavir v/s Lamivudine
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Telbivudine v/s Lamivudine
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Combined Treatment Regimen
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Drug Resistance Profile
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Relapses after Antiviral Rx.
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Incidence of HCC
105 copies/ml (20,000 IU/ml)
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Newer Approaches

• Emtricitabine
• Clevudine (l-FMAU)
• Therapeutic vaccines

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Thank You All