Disease progression of chronic hepatitis B and hepatitis B virus replication significantly correlated. Taiwan REVEAL study confirmed that the load of the hepatitis B virus DNA (HBVDNA) with liver cirrhosis and hepatocellular carcinoma (HCC) was positively correlated. Another study confirmed that the e antigen-positive high-risk factors for primary liver cancer. Therefore, effective suppression of hepatitis B virus replication, HBVDNA sustained suppression (real-time polymerase chain reaction (PCR) method in the detection of less than, the equivalent of 50 to 90 copies / ml) to achieve e antigen seroconversion, may slow disease progression, reduce liver sclerosis, hepatocellular carcinoma, and to extend the life of a patient, to improve the quality of life.
Antiviral therapy of chronic hepatitis B have reached a consensus. What patients need treatment? Which drug treatment? When to stop treatment? Every doctor and patient are most concerned about, the American Society for the Study of Liver Diseases (AASLD), the Asia-Pacific Liver Research Institute (APASL), the European Society of Study of the Liver (EASL) chronic hepatitis B prevention guidelines hot topic.
Which patients need treatment?
Multiple guide's point of view is consistent with the international community, to confirm the diagnosis of chronic hepatitis B, antiviral treatment of the target population; those in patients with immune tolerant phase, activities to carry the state in patients with no need treatment, but regular follow-up . Age> 40 years old is still in the immune tolerance status of patients, patients with HBV DNA and ALT fluctuations, as well as in patients with HCC family history, it is recommended to do liver histological examination. Decide whether the treatment of liver inflammation and fibrosis, liver biopsy suggest that moderate / severe inflammation and / or fibrosis, in need of treatment; for acute liver failure, decompensated cirrhosis, acute exacerbation of chronic hepatitis, decompensated liver sclerosis patients with active replication of HBV DNA to immediate treatment.
Several issues should pay attention to the need for treatment in the assessment of chronic HBV infection, ALT levels, although very important, but not enough to determine which patients are treated subjects, low levels of ALT may also have progressive liver disease should be individualized analysis. Of HBVDNA and liver disease progression threshold is unclear, the low level the HBVDNA also develop into cirrhosis and hepatocellular carcinoma (HCC) risk, comprehensive evaluation of chronic HBV infection, ALT levels should be carried out and the serum HBVDNA the level and age, the treatment of the benefits and risks assessment, is difficult to determine whether to initiate antiviral therapy in patients with liver biopsy should be done.
Our listing of anti-HBV drugs, including two major categories, interferon drugs and nucleos (t), drugs (lamivudine, adefovir dipivoxil, entecavir, telbivudine). Interferon broader role, in addition to antiviral immunomodulatory, and antifibrotic role of the e antigen seroconversion rate in nucleos (t) drugs, suitable for the young, and liver function in decompensated, high ALT the low level of HBVDNA and want to accept short-term course of treated patients, but the poor tolerance of side effects, treatment, regular monitoring under the guidance of experienced specialists. The treatment is generally 48 weeks.
Nucleoside (acid) class of drugs, mainly through inhibition of viral DNA polymerase and reverse transcriptase function HBVDNA in the stronger inhibitory effect of interferon, but the e antigen seroconversion rates are relatively low. Four kinds of nucleos (t) characteristics of drugs, should be based on a reasonable choice of the individual patient by a specialist.
Lamivudine resistance higher rate in the U.S. and Europe, in addition to the need for short-term antiviral used in chemotherapy or pregnancy prevention and treatment of patients, HBV / HIV co-infection is not recommended as first-line treatment. In the Asia-Pacific region including China, lamivudine antiviral faster and stronger, the price is low, security and data integrity of the treatment of various HBV-related disease, is still first-line treatment of anti-HBV therapy.
Adefovir dipivoxil low incidence of cross-resistance with other nucleoside drugs, combination therapy with other nucleoside drugs is a choice of the resistant patients. Antiviral weak and kidney toxicity is the main drawback in Europe and the United States for Nuofu Wei has been gradually replaced by adefovir dipivoxil. Entecavir inhibition HBVDNA role quickly, and the resistance rate of the lowest in the four kinds of nucleos (t) drugs, more suitable for viral load early treatment of people in urgent need of rapid inhibition of the nucleoside lamivudine resistance and select Entecavir, not only the dose should be doubled, but also prone to drug resistance, and therefore not ideal for lamivudine or on behalf of telbivudine resistant.
Inhibit viral effectiveness of telbivudine superior to lamivudine resistance rate was lower than lamivudine, but higher than the ex entecavir and adefovir, cross-resistance with lamivudine (YMDD), the treatment process monitoring of creatine kinase (CK), is not recommended in combination with interferon.
When do you stop treatment?
Nucleos (t) analogue treatment after e antigen seroconversion, should be extended for the treatment of 6 to 12 months to consolidate the curative effect, the party may consider stopping for HBeAg (-) patients did not get the e antigen seroconversion HBeAg (+) patients, patients with cirrhosis (including e antigen seroconversion in patients with cirrhosis of the liver) should be long-term treatment. On combination therapy recommended in the AASLD chronic hepatitis B Guide: nucleos (t) class of drugs in combination therapy for drug-resistant patients and patients with decompensated liver disease.
Marcellin, Professor of the EASL President of the General Assembly in 2009 liver disease in the Asia-Pacific region at the annual meeting: the future will be a joint application of different drugs. But to meet the following: role in HBV DNA replication in different parts; has strong antiviral activity; good security; limited courses of treatment, patients achieved sustained response, peginterferon and potent nucleoside The joint program of the class of drugs deserves further study.
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