Should You Start Antiviral Treatment for Hepatitis B with Normal Liver Function?

Q: Should You Start Antiviral Treatment for Hepatitis B with Normal Liver Function?

According to the current expert consensus, if liver function is normal, antiviral medications are only required if cirrhosis or severe liver fibrosis is present along with a viral load exceeding 10,000 copies/ml. <br>The use of antiviral medications is primarily divided into two

Liver function and liver ultrasound are normal, but there was one instance where the viral load exceeded 10,000 copies. Should medication be taken?

Hello Dr.
Hsiao: I am a 53-year-old male.
I was diagnosed as a carrier of Hepatitis B in 1982, and I have been under follow-up for about 28 years until this year (2010).
During this 28-year period, I have undergone liver function blood tests and abdominal ultrasound examinations every six months.
All liver function serum tests, including GOT/AST, GPT/ALT, and AFP, have been normal.
In September 1998, my tests showed HBeAg negative and Anti-HBe positive, indicating the presence of e-antibodies without e-antigen.
The abdominal ultrasound examination showed no abnormalities in the liver.
Recently, my doctor conducted an HBV viral load test: in April 2009, my Hepatitis B viral load was 17,350 copies/ml; in October 2009, it was 3,580 copies/ml.

My question is: some doctors suggest that I consider taking an antiviral medication (such as Entecavir) to achieve clinical cure standards (i.e., HBV-DNA levels below the threshold of <10 IU/ml or <50 copies/ml).
However, other doctors say that as long as my GPT levels are normal, I do not need medication unless I am nearing cirrhosis.
They argue that while medication can reduce the viral load to undetectable levels, once the medication is stopped, the virus will replicate again.
Therefore, if GPT levels are not significantly elevated, taking medication may not be beneficial.

Given my situation with normal liver function, normal abdominal ultrasound, and viral loads fluctuating above and below 10,000 copies, is it necessary for me to take an aggressive approach with oral antiviral medication, or is regular monitoring sufficient?

Mr. Hong, 50~59 year old female. Ask Date: 2010/03/24

Dr. Xiao Jingqin reply Internal Medicine

According to the current expert consensus, if liver function is normal, antiviral medications are only required if cirrhosis or severe liver fibrosis is present along with a viral load exceeding 10,000 copies/ml.
The use of antiviral medications is primarily divided into two different management strategies based on the presence of e-antigen: for e-antigen positive patients, if liver function abnormalities reach twice the upper limit of normal and the viral load is 20,000 IU/ml (approximately 100,000 copies/ml), antiviral therapy can be initiated.
For e-antigen negative patients, who may have mutant viruses, treatment may require a longer duration (currently, there is no consensus on how long treatment should last, and it may require lifelong therapy).
If liver function is abnormal and there are two instances of abnormal results reaching twice the upper limit of normal with a viral load of 2,000 IU/ml (approximately 10,000 copies/ml) over a three-month period, antiviral therapy may be considered.
The probability of achieving viral clearance with oral antiviral medications for hepatitis B is only about 1% (meaning the patient is no longer a carrier), which is similar to the probability of viral clearance in the natural history of hepatitis B.
Additionally, even with antiviral medications like entecavir, there are issues with drug resistance.
Currently, there is no consensus on the use of long-term oral antiviral medications for the prevention of liver cancer.
Given Mr.
Hong's condition, I personally lean towards not recommending treatment.

Reply Date: 2010/03/24

More Info

When it comes to the management of chronic Hepatitis B, particularly in patients with normal liver function, the decision to initiate antiviral therapy can be complex and should be tailored to the individual patient’s circumstances. In your case, you have been a Hepatitis B carrier for many years, with consistently normal liver function tests and no signs of liver damage on ultrasound. Your HBeAg is negative, and you have developed anti-HBe antibodies, which is generally a favorable sign indicating a lower level of viral replication.

The current guidelines for initiating antiviral treatment in chronic Hepatitis B infection typically consider several factors, including liver function, the presence of liver fibrosis or cirrhosis, and the level of HBV DNA. In your situation, the fact that your liver function tests (GOT/AST, GPT/ALT) are normal and that you have no evidence of liver fibrosis or cirrhosis suggests that you may not need to start antiviral therapy at this time.
However, the presence of HBV DNA levels above 10,000 copies/mL can be a point of concern, especially if there are fluctuations in viral load. Some physicians advocate for starting treatment to reduce the viral load to undetectable levels, which can potentially lead to a "functional cure." This approach aims to minimize the risk of future liver damage, even if current liver function is normal.

On the other hand, the argument against starting treatment in the absence of liver inflammation or damage is also valid. The rationale is that if liver function is stable and there are no signs of significant liver disease, the risks and side effects associated with long-term antiviral therapy may outweigh the benefits. Moreover, as you mentioned, stopping antiviral therapy can lead to viral rebound, which complicates management.

In summary, the decision to start antiviral treatment should be made after careful consideration of your overall health, liver function, and personal preferences. Regular monitoring of liver function tests, HBV DNA levels, and liver imaging is essential. If there are any changes in your liver function or if you develop symptoms of liver disease, then it may be time to reconsider the initiation of antiviral therapy.

Additionally, it is crucial to maintain a healthy lifestyle, including a balanced diet, regular exercise, and avoiding alcohol, which can further protect your liver health. Consulting with a hepatologist or a specialist in liver diseases can provide you with a more personalized treatment plan based on the latest clinical guidelines and your specific health status.

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