Current treatment indications and strategies in chronic hepatitis B virus infection

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http://www.wjgnet.com/1007-9327/abstract_en.asp?f=6902 & v=14

World J Gastroenterol 2008 December;14(45):6902-6910

Current treatment indications and strategies in chronic hepatitis B virus

infection

Papatheodoridis GV, Manolakopoulos S, Archimandritis AJ.

2nd Department of Internal Medicine, Athens University Medical School,

Hippokration General Hospital of Athens, 114 Vas. Sophias Ave, Athens 11527,

Greece. gepapath@...

The optimal approach to the management of several marginal cases with chronic

hepatitis B virus (HBV) infection is controversial. Serum HBV DNA and

aminotransferase levels, and the degree of necroinflammation and fibrosis

determine the therapeutic decisions. All patients with elevated aminotransferase

(> twice the upper limit of normal) and serum HBV DNA above 20000 IU/mL should

be treated. Liver biopsy is important for therapeutic decisions in cases with

mild aminotransferase elevations and serum HBV DNA below 20000 IU/mL. Chronic

HBV patients who do not receive treatment should be followed for life. There are

seven agents licensed for chronic hepatitis B: standard and pegylated

interferon-alpha, lamivudine, adefovir, entecavir, telbivudine and tenofovir.

One-year courses with pegylated interferon-alpha induce sustained off-therapy

remission in 30%-32% of patients with HBeAg-positive chronic hepatitis B and in

a smaller proportion of patients with HBeAg-negative chronic hepatitis B. Oral

antivirals achieve initial on-therapy responses in the majority of patients, but

are intended as long-term therapies. Viral suppression has favourable effects on

patients' outcome and modifies the natural course of the disease. Viral

resistance, however, is the major drawback of long-term oral antiviral therapy.

Lamivudine monotherapy is associated with the highest and entecavir monotherapy

with the lowest resistance rate so far. There has been no resistance to

tenofovir, but after only 18 mo of treatment to date. The optimal first-line

anti-HBV therapy with the best long-term cost/benefit ratio remains unclear. If

oral antiviral agents are used, compliance should always be ascertained and HBV

DNA levels should be regularly tested.