Navigating Unstable Liver Enzymes: Treatment Dilemmas for Chronic Hepatitis B

Persistent abnormal liver function tests without meeting the criteria for medication intervention?

Hello doctor, I am a carrier of hepatitis B and I am about 40 years old.
For the past 5 to 6 years, I have been regularly undergoing blood tests every three months.
My ALT levels fluctuate and often range between 40 and 80, occasionally exceeding 80, but I have never met the criteria for treatment (ALT > twice the normal value for more than three months).
Since my liver enzymes have not returned to normal but also do not meet the treatment criteria, I have some questions and concerns that I would like to discuss:
1.
The doctors I have encountered seem to be divided into two camps.
One group prescribes liver-protective medications, which help lower my liver enzyme levels, but it seems more like symptomatic treatment rather than addressing the root cause.
Should I continue taking these medications as a form of maintenance?
2.
The other group opposes prescribing liver-protective medications, believing that it is unnecessary.
They prefer to let my liver enzymes reach the treatment threshold (ALT > twice the normal value for more than three months) before starting antiviral treatment for hepatitis B, as they think this is the correct approach.
However, since my enzyme levels have not reached the treatment criteria but are also not normal, I am concerned about the prolonged inflammation of my liver.
Is it appropriate to avoid liver-protective medications (to lower enzyme levels) in this situation?

LUT, 40~49 year old female. Ask Date: 2017/09/21

Dr. Chen Shidian reply Gastroenterology and Hepatology

Hello, this is a strategy mandated by the National Health Insurance Administration.
There is no right or wrong; it depends on the discussion between the physician and the patient.
If there is significant fibrosis, a biopsy may be considered to confirm whether cirrhosis is present, and medication can be applied for.
Otherwise, you may consider paying out of pocket for the medication.
Changhua Hospital cares about your health.
Chen Shidian

Reply Date: 2017/09/21

More Info

Navigating the complexities of chronic hepatitis B (CHB) management, especially when liver enzymes are unstable, can be quite challenging. Your situation, where your alanine aminotransferase (ALT) levels fluctuate between 40 and 80, and occasionally exceed 80, but do not consistently meet the threshold for antiviral treatment, is not uncommon among hepatitis B carriers. Let's break down your concerns and explore the treatment options available.

Understanding Your Condition
Chronic hepatitis B is a viral infection that can lead to liver inflammation, fibrosis, and potentially cirrhosis or liver cancer over time. The liver enzymes, particularly ALT and aspartate aminotransferase (AST), are indicators of liver inflammation. In your case, while your ALT levels are elevated, they have not consistently reached the treatment threshold of being more than twice the normal limit for three consecutive months. This presents a dilemma in terms of treatment.

Treatment Dilemmas
1. Supportive Care vs. Antiviral Therapy:
- Supportive Care: Some physicians advocate for the use of hepatoprotective agents (often referred to as "liver protection" medications) to help stabilize liver function and reduce inflammation. While these medications may help lower liver enzyme levels temporarily, they do not address the underlying viral infection. This approach can be seen as a way to manage symptoms and maintain liver health without initiating antiviral therapy prematurely.

- Antiviral Therapy: On the other hand, some healthcare providers prefer to wait until the ALT levels consistently exceed the treatment threshold before starting antiviral medications like entecavir or tenofovir. This approach is based on the understanding that initiating treatment too early may not be necessary and could lead to unnecessary medication exposure.

2. The Role of Regular Monitoring: Given your fluctuating liver enzyme levels, regular monitoring is crucial. This includes not only checking ALT and AST levels but also assessing for hepatitis B virus (HBV) DNA levels and liver function tests. If your liver enzymes remain elevated but do not meet the treatment criteria, your physician may recommend lifestyle modifications, such as avoiding alcohol and maintaining a healthy diet, to support liver health.

3. Potential Risks of Inaction: While waiting for your liver enzymes to reach the treatment threshold, it is essential to consider the potential risks. Chronic inflammation can lead to liver damage over time, even if the enzymes do not consistently indicate severe disease. Therefore, if your liver remains in a state of inflammation, it may be prudent to discuss with your healthcare provider the possibility of starting antiviral therapy sooner rather than later, especially if there are signs of liver fibrosis or other complications.

Recommendations
- Consultation with a Specialist: If you have not already, consider seeking a consultation with a hepatologist or a gastroenterologist specializing in liver diseases. They can provide a more comprehensive evaluation of your liver health and guide you on the best treatment approach based on the latest clinical guidelines.

- Lifestyle Modifications: Regardless of the treatment path you choose, adopting a liver-friendly lifestyle is crucial. This includes avoiding alcohol, maintaining a balanced diet rich in fruits and vegetables, and engaging in regular physical activity.

- Regular Follow-ups: Continue with your regular follow-ups every three months. If your liver enzymes show a significant increase or if you develop any new symptoms, it may warrant a reevaluation of your treatment plan.

In conclusion, managing chronic hepatitis B with unstable liver enzymes requires a careful balance between monitoring and intervention. Engaging in open discussions with your healthcare providers about the risks and benefits of each treatment option will help you make informed decisions about your health. Remember, the goal is to maintain liver health and prevent long-term complications associated with chronic hepatitis B.

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