Hepatitis B Mutations and Their Treatment Challenges

Q: Hepatitis B Mutations and Their Treatment Challenges

Reply： Hello, initially it was stated that there was no hepatitis B or C, but later it was mentioned that HBV-DNA is positive and it is a mutant strain of the virus. <br>However, shouldn't the hepatitis B surface antigen be positive? I have not encountered such a situation person

Hepatitis B virus mutation diseases

Hello Doctor: In early February, I felt unwell and went to the hospital for liver function tests.
There was no infection with hepatitis B or C.
The results showed liver enzyme levels of GOT 66 and GPT 108, while other liver function tests and ultrasound were normal, except for a positive reaction in the smooth muscle test.
The treatment was as follows: from February to March, I was prescribed a liver protective agent (Polihepar Forte) and a sedative (Ativan), with liver enzymes at GOT 56 and GPT 155.
From March to July, the doctor prescribed steroids (Prednisolone) and a bile acid agent (URSO), with liver enzymes dropping to GOT 37 and GPT 68.
However, while on steroids, I developed acne on my face, chest, and shoulders, and eventually experienced pain in the kidney area.
I have a strong aversion to the side effects of steroids.
The doctor later tested for hepatitis B DNA (HBV-DNA) and found a mutated virus, as I was a carrier of hepatitis B since childhood.
From July to mid-August, I only took the liver protective agent, but liver enzymes rose to GOT 102 and GPT 247.
From mid-August to the end of August, I was prescribed Lamivudine (Zeffix) along with the liver protective agent, but the liver enzymes increased to GOT 120 and GPT 256 instead of decreasing.
I have the following questions for the doctor: 1.
Why did my liver enzymes not decrease while taking Lamivudine (Zeffix), especially since it is an out-of-pocket expense at over a hundred dollars per pill? 2.
My liver enzymes keep rising, and the medication seems ineffective.
Am I at risk of developing cirrhosis or liver cancer? I'm really worried! Does an increase in enzyme levels indicate worsening liver inflammation? 3.
It has been over seven months since February, and my liver enzymes continue to rise.
The doctor mentioned that if Lamivudine does not work, I would need to take a more expensive version of Lamivudine, which is not covered by insurance.
There is no guarantee that the levels will decrease.
Should I consider seeing a traditional Chinese medicine practitioner or changing doctors? 4.
Are the medications for mutated strains of hepatitis B the same as those for regular hepatitis B?

Guozi, 30~39 year old female. Ask Date: 2004/09/11

Dr. Chen Zhiping reply Gastroenterology and Hepatology

Reply: Hello, initially it was stated that there was no hepatitis B or C, but later it was mentioned that HBV-DNA is positive and it is a mutant strain of the virus.
However, shouldn't the hepatitis B surface antigen be positive? I have not encountered such a situation personally, so I cannot make a definitive statement, but generally, mutant strains of the virus are more difficult to treat and may require a longer duration of treatment.

1.
The National Health Insurance (NHI) program for hepatitis B and C has specific criteria for the indication of antiviral therapy for hepatitis B.
If these criteria are not met, treatment would need to be self-paid.
However, if your hepatitis is not caused by hepatitis B, then the use of entecavir (干安能) may not be effective (your hepatitis may be autoimmune hepatitis, as indicated by the positive anti-smooth muscle antibody and response to steroids).
Regarding the cost, each hospital sets its own price, but the NHI price is 92 NTD per tablet.
2.
Theoretically, yes, there is a risk of developing chronic hepatitis, cirrhosis, and even hepatocellular carcinoma over time.
3.
Generally, entecavir is used to treat drug-resistant viruses that cause hepatitis flare-ups and elevated liver enzymes.
Currently, there is another medication available called tenofovir (干適能), which is not yet covered by NHI and is expensive.
However, since your mutant virus did not arise from entecavir treatment, it is advisable to consult with other more experienced liver disease specialists regarding the necessity of this medication.
4.
There are many types of mutant viruses; some are effective against entecavir, but if the mutant virus developed during entecavir treatment, it is usually resistant to entecavir and requires switching to tenofovir.

Best regards, Dr.
Chen Chi-Ping.
Thank you!

Reply Date: 2004/09/11

More Info

Hepatitis B (HBV) is a viral infection that can lead to serious liver complications, including chronic liver disease, cirrhosis, and hepatocellular carcinoma (liver cancer). The management of HBV has evolved significantly over the years, particularly with the advent of antiviral therapies. However, the emergence of HBV mutations poses significant challenges in treatment efficacy and patient outcomes.

Understanding Hepatitis B Mutations
Hepatitis B mutations can occur due to the virus's high replication rate and its ability to undergo genetic changes. These mutations can affect various regions of the virus, including the surface antigens and polymerase gene, leading to changes in the virus's behavior and its response to antiviral medications. For instance, mutations in the "e" antigen (HBeAg) can lead to a situation where patients may test negative for HBeAg while still having active viral replication, complicating the clinical picture.

In your case, the presence of HBV DNA with mutations indicates that the virus may not respond well to standard treatments, such as lamivudine (Zeffix). This is particularly concerning if your liver function tests (GOT and GPT) continue to rise despite treatment, suggesting ongoing liver inflammation and potential progression towards more severe liver disease.

Treatment Challenges
1. Efficacy of Antiviral Medications: The fact that your liver enzymes are not improving with Zeffix raises concerns about the possibility of drug resistance, especially if the virus has mutated. Antiviral medications like Zeffix are designed to suppress viral replication, but if the virus has developed resistance, the treatment may not be effective.
2. Risk of Progression to Cirrhosis or Cancer: Elevated liver enzymes over an extended period can indicate ongoing liver damage. If left untreated or inadequately treated, there is a significant risk of developing cirrhosis and subsequently liver cancer. Regular monitoring of liver function and imaging studies (like ultrasound) are crucial to assess liver health and detect any early signs of complications.

3. Cost and Accessibility of Treatments: The financial burden of antiviral medications can be a significant concern, especially if they are not covered by insurance. If Zeffix is ineffective, your healthcare provider may consider switching to other antiviral agents, such as tenofovir or entecavir, which may have a better efficacy profile against resistant strains of HBV. However, these options may also come with higher costs.

4. Alternative Treatments: While some patients consider traditional Chinese medicine or alternative therapies, it is essential to approach these options with caution. Evidence supporting their efficacy in treating HBV is limited, and they should not replace conventional antiviral therapy. Consulting with a hepatologist or a liver specialist who has experience with HBV mutations is advisable to explore all possible treatment options.

Recommendations
- Regular Monitoring: Continue regular follow-ups with your healthcare provider to monitor liver function tests and HBV DNA levels. This will help assess the effectiveness of any treatment regimen and make timely adjustments as needed.

- Consider a Specialist: If you feel that your current treatment plan is not effective, seeking a second opinion from a hepatologist or a specialist in infectious diseases may provide new insights and treatment options.

- Adherence to Treatment: Ensure adherence to prescribed antiviral therapy, as inconsistent use can lead to resistance and treatment failure.

- Lifestyle Modifications: Maintain a healthy lifestyle, including a balanced diet, regular exercise, and avoiding alcohol, which can exacerbate liver damage.

In conclusion, managing HBV, especially with the presence of mutations, requires a comprehensive approach that includes regular monitoring, potential adjustments in therapy, and collaboration with specialists. Your concerns about liver health are valid, and proactive management is essential to mitigate the risks of severe liver disease.

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