Immune-Active, HBeAg-Negative Chronic Hepatitis B
Some patients develop recurrent viremia after cessation of antiviral therapy. Up to 20% of patients will develop increased levels of HBV DNA with abnormal aminotransferase values after seroconversion with loss of circulating HBeAg. Some may be associated with circulating HBV mutation. Precore and basal core promoter mutations are the most frequent mutations and may be present in both HBeAg-positive and HBeAg-negative disease. There is a greater risk for development of cirrhosis and hepatocellular carcinoma in patients with sustained disease activity.
The AASLD suggests indefinite antiviral therapy for adults with immune-active, HBeAg-negative chronic hepatitis B unless there is a competing rationale for treatment discontinuation. Prolonged antiviral therapies may reduce the risk for viral recurrence. Patients who clear circulating HBsAg can be considered for treatment cessation. Patients who stop treatment should be monitored every 3 months for reactivation of disease, as manifested by ALT elevation, recurrent viremia, or clinical symptoms and signs.
Patients with immune-active, HBeAg-negative chronic hepatitis B who have concomitant cirrhosis should receive indefinite nucleoside/nucleotide therapy. Although such treatment can reduce circulating HBV DNA levels, it may not eliminate viral DNA within hepatocytes or when integrated into the host genome. Long-term antiviral therapy may reduce viremia and the risk for progressive disease or hepatocellular carcinoma.
Treatment in patients with low-level HBV viremia. The AASLD suggests that persons with persistent low-level viremia (< 2000 IU/mL) on entecavir or tenofovir monotherapy continue monotherapy, regardless of ALT level.
The AASLD suggests one of two strategies in persons with a virologic breakthrough on entecavir or tenofovir: Switch to another antiviral monotherapy with a high barrier to resistance, or add a second antiviral drug that lacks cross-resistance. "Viral breakthrough" is defined as a > 1-log increase in HBV DNA compared with the lowest level or a continuing level of circulating HBV DNA > 100 IU/mL while on treatment. This includes patients with persistent viremia after 48 weeks of initial therapy.
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Cite this: Deciding on the Best Treatment in Patients With Various Types of Hepatitis B - Medscape - Apr 19, 2016.