Should I Start Medication for High Hepatitis B Viral Load Despite Normal Liver Function?

Liver function and liver ultrasound are normal, but the viral load exceeds 100 million copies. Should medication be taken?

Hello Doctor: I am a carrier of hepatitis B, 42 years old, and I have regular follow-up examinations every three months for liver function, fetal protein, and abdominal ultrasound.
All my test results have been normal.
However, during a self-paid viral load test last year, it was found to be over 100 million IU/ml.
I have heard that a higher viral load increases the risk of cancer, but since my liver function is normal, the effectiveness of medication may not be good, and I am concerned that prolonged use could lead to drug resistance.
However, due to the high viral load, I am very worried about the risk of acute hepatitis and liver cancer.
It is difficult to make a decision in this dilemma, so I kindly ask for your advice on whether I should consider self-paying for medication.
Thank you.

Mr. Yu, 40~49 year old female. Ask Date: 2017/06/22

Dr. Hong Yuanbin reply Internal Medicine

Hello, in cases where liver function is normal, the treatment effect of hepatitis B medications is indeed not very effective.
Therefore, it is still recommended in clinical practice to use them when liver function is abnormal, as the results are better.
Regarding concerns about the occurrence of fulminant hepatitis and liver cancer, it is advisable to regularly monitor liver enzymes, liver function, alpha-fetoprotein, and abdominal ultrasound.
If all results are normal, there is no need for excessive worry.
Thank you for your question.

Reply Date: 2017/06/22

More Info

When considering whether to start antiviral medication for hepatitis B despite having normal liver function, several factors must be taken into account. Your situation is quite common among hepatitis B carriers, and it is essential to weigh the risks and benefits of initiating treatment.

Firstly, it is important to understand that a high viral load, such as the one you mentioned (over 100 million IU/ml), is indeed associated with an increased risk of liver complications, including acute exacerbations and hepatocellular carcinoma (liver cancer). The relationship between viral load and cancer risk is well-documented; higher levels of hepatitis B virus (HBV) can lead to more significant liver inflammation and damage over time, potentially resulting in cirrhosis and cancer.

However, the decision to start antiviral therapy is not solely based on viral load. Current guidelines recommend initiating treatment in specific scenarios, even when liver function tests are normal. For individuals with high HBV DNA levels, particularly those exceeding 20,000 IU/ml (or 2,000 IU/ml in certain contexts), treatment is often recommended if there are additional risk factors, such as older age, family history of liver disease, or evidence of liver fibrosis.

In your case, while your liver function tests are normal, the high viral load raises concerns. The fear of developing acute liver failure or hepatocellular carcinoma is valid, especially given your age and the significant viral replication. Antiviral medications, such as tenofovir or entecavir, are effective in reducing viral load and can help prevent liver damage over time.
Regarding your concerns about the effectiveness of treatment when liver function is normal, it is important to note that antiviral therapy can still be beneficial. Studies have shown that starting treatment at high viral loads can lead to a decrease in viral replication, which may prevent future liver damage and complications. Additionally, the risk of developing drug resistance is generally low with first-line therapies like tenofovir and entecavir, especially when adherence to the medication regimen is maintained.

You also mentioned the potential for long-term treatment and the fear of developing drug resistance. While it is true that antiviral therapy for hepatitis B is often long-term, the benefits of controlling the virus and reducing the risk of liver-related complications typically outweigh the risks associated with prolonged treatment. Regular monitoring of liver function and viral load can help manage any potential issues that arise during treatment.

In summary, given your high viral load and the associated risks, it would be prudent to discuss the option of starting antiviral therapy with your healthcare provider. They can help you evaluate your specific situation, including any additional risk factors you may have, and guide you in making an informed decision. Regular follow-ups and monitoring will be crucial in managing your condition effectively. Ultimately, the goal is to minimize the risk of liver damage and ensure your long-term health.

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