How Is Hepatitis B Managed in a Patient With Acute Intermittent Porphyria?

David Bernstein, MD


December 28, 2009


What is the appropriate treatment for a patient with acute intermittent porphyria and hepatitis B (e-antigen negative) with a normal alanine transaminase and a hepatitis B virus viral load of 45,000 copies/mL (log 4.56)?

Response from David Bernstein, MD
Chief, Digestive Disease Institute, North Shore University Hospital-Long Island Jewish Medical Center, Manhasset, New York; Associate Professor of Medicine, New York University School of Medicine, New York, NY

Acute intermittent porphyria has not been associated with hepatitis B. Therefore, the question regarding treating the aforementioned patient centers on the patient's hepatitis B status. The patient described previously has a pre-core mutant with normal liver enzymes and detectable virus.

The first decision point is to determine whether this patient has cirrhosis. If the patient is cirrhotic, as evidenced by thrombocytopenia and splenomegaly or other signs of portal hypertension, I would recommend initiating hepatitis B therapy with an oral agent. Pegylated interferon is not to be used in patients with hepatitis B and cirrhosis.

If the patient does not have obvious cirrhosis, then I would recommend following the guidelines published by Keeffe and colleagues.[1] These guidelines recommend either monitoring the alanine transaminase and hepatitis B virus -DNA periodically or performing a liver biopsy to evaluate for underlying fibrosis and initiating treatment if the biopsy reveals significant fibrosis.

I will usually observe these patients for a 6-month period of time, and if the parameters remain unchanged, I proceed with a liver biopsy.