Managing Chronic Hepatitis B: Treatment Decisions and Health Concerns

Q: Managing Chronic Hepatitis B: Treatment Decisions and Health Concerns

Hello： <br>1. <br>For patients with chronic hepatitis B who exhibit significant inflammation or high levels of viral replication, consideration should be given to pharmacological treatment. <br>Treatment options include antiviral medications or interferon. <br>The interferon trea

After three years of taking Baraclude, issues related to hepatitis B treatment?

Hello Dr.
Lin, three years ago I had an acute phase of hepatitis B, with liver enzyme levels exceeding 2000.
An ultrasound showed no tumors.
After taking Baraclude for a month or two, my liver enzymes returned to normal (usually in the low 20s), and the ultrasound was also normal.
To this day, while on Baraclude, my liver enzymes and ultrasound have remained normal, and my viral load DNA is down to single digits or a few tens.
However, my hepatitis B surface antigen has never turned negative.
During my follow-up yesterday, the test results showed that my liver enzymes are normal but slightly higher than before, with one number being 28.
I wonder if this could be related to my recent trip to Europe, where I stayed up later than usual (I usually go to bed by 9 PM in Taiwan) and drank a little alcohol (not much, only on necessary occasions; I don’t drink at all in Taiwan)? Additionally, my attending physician informed me that my Baraclude prescription will reach the limit covered by health insurance (three years) in a month.
He said I need to decide whether to stop the medication to see what happens or to pay out of pocket.
He suggested that since my hepatitis B surface antigen is still positive, I should continue taking it, ideally until it turns negative, but whether it can turn negative is a significant question.
He mentioned that stopping the medication carries a risk of relapse, and I cannot imagine going through the acute hepatitis days from three years ago, so I decided to continue paying out of pocket (I paid over 12,000 NTD for two months of Baraclude).
Money is secondary; I also found online that Baraclude is metabolized by the kidneys, so I asked the doctor if it could harm my kidneys, and he said the risk is very low, so I shouldn’t worry! I would like to know: 1.
If I continue taking the medication but my surface antigen does not turn negative, does that mean I will have to keep taking the medication indefinitely? I have heard about interferon; is this treatment applicable for hepatitis B? Is it considered a more aggressive approach? How do you assess whether your patients should continue or stop their medication? 2.
If I stop the medication, is there any medical statistic on the likelihood of relapse? Will I need to undergo frequent tests and follow-ups? I have also heard that resuming medication after stopping increases the chance of drug resistance! 3.
After my appointment yesterday, I went to a bookstore and looked through some related magazines and books.
I came across the term "coarse" used to describe the liver's surface (scarring after hepatitis).
I recalled that a while ago, after an ultrasound, the doctor mentioned, "It's okay, the surface is a bit coarse." Does "coarse" affect liver function? If the liver is no longer inflamed, will the "coarse" texture disappear? 4.
Additionally, the book mentioned that ultrasound has blind spots and is somewhat dependent on the doctor's experience and skill, and it should be correlated with other blood test data.
The book stated that liver tumors or inflammation may not necessarily cause liver enzyme levels to rise.
I often wonder if I should get a second opinion from another doctor.
5.
Is going to bed early really good for the liver? Honestly, even though I go to bed early every day, my sleep quality is poor; I tend to overthink and end up falling asleep even later.
Thank you! Wishing you health and happiness!

Sean, 20~29 year old female. Ask Date: 2012/08/28

Dr. Lin Minghui reply Gastroenterology and Hepatology

Hello:
1.
For patients with chronic hepatitis B who exhibit significant inflammation or high levels of viral replication, consideration should be given to pharmacological treatment.
Treatment options include antiviral medications or interferon.
The interferon treatment regimen is relatively fixed, lasting about one year with weekly subcutaneous injections.
Some individuals may experience symptoms such as flu-like symptoms, decreased blood cell counts, hair loss, and depression or irritability.
However, if the viral load is excessively high and liver function is severely impaired, interferon treatment is not advisable.
Contraception is recommended during the treatment period.
2.
Currently, oral antiviral medications such as Tenofovir and Entecavir have minimal side effects, strong antiviral effects, and low resistance rates, but they require long-term use.
When can treatment be discontinued? According to current guidelines, (1) for HBeAg-positive patients, it is best to continue treatment until HBeAg seroconversion occurs, followed by an additional 12 months of therapy after HBeAg becomes negative and HBeAb becomes positive; (2) for HBeAg-negative patients, it is recommended to continue treatment until HBV-DNA is undetectable on three separate occasions, with each test spaced six months apart before discontinuation.
Some guidelines suggest continuing treatment until HBsAg becomes negative.
After stopping treatment, there is about a 50% chance of relapse, necessitating follow-up every 3 to 6 months.
3.
In chronic hepatitis, liver fibrosis may occur.
Long-term use of antiviral medications for 3 to 5 years without developing resistance can improve fibrosis.
For hepatitis B carriers, it is recommended to monitor liver function, alpha-fetoprotein levels, and abdominal ultrasound every six months for comprehensive assessment.
If inflammation is detected, the physician will evaluate the need for further treatment.
If alpha-fetoprotein levels are elevated or if abnormalities (such as roughness, nodules, or tumors) are noted on ultrasound, the physician will arrange for additional examinations based on clinical findings.
4.
For hepatitis B patients, it is advisable to maintain liver health by avoiding excessive fatigue, being cautious with medication use, ensuring a balanced and fresh diet, and aiming for early sleep while also paying attention to sleep quality.

Wishing you good health,
Dr.
Lin Ming-Hui, Taoyuan Hospital, Department of Health

Reply Date: 2012/08/28

More Info

Managing chronic Hepatitis B is a complex process that requires careful consideration of treatment options, monitoring of liver function, and lifestyle adjustments. Based on your situation, it seems you have made significant progress since your acute phase three years ago, where your liver enzymes were alarmingly high. The fact that your liver enzymes are now mostly normal and that you have maintained a low viral load is a positive sign. However, the persistence of HBsAg (Hepatitis B surface antigen) indicates that the virus is still present in your body, which raises important questions about your long-term management.

1. Long-term Treatment Decisions: The persistence of HBsAg suggests that you may need to continue antiviral therapy indefinitely. While some patients can achieve HBsAg seroconversion (the loss of HBsAg and the development of antibodies against it), this is not guaranteed. The decision to continue or stop treatment should be based on a thorough discussion with your healthcare provider, weighing the benefits of continued therapy against the risks of potential viral rebound if treatment is stopped. Interferon therapy is another option, but it is typically considered for patients with specific profiles and may not be suitable for everyone. It is generally seen as a more aggressive treatment approach, and its effectiveness can vary.

2. Risk of Viral Rebound: If you decide to stop antiviral therapy, there is indeed a risk of viral rebound. Studies indicate that the risk of hepatitis B reactivation can be significant, especially in patients with a history of high viral loads. Regular monitoring through blood tests is essential if you choose to stop treatment. Your healthcare provider will likely recommend frequent follow-ups to monitor liver function and viral load, typically every few months after stopping therapy.

3. Liver Texture and Function: The term "rough" used to describe your liver surface may indicate some degree of fibrosis or scarring from past inflammation. While this may not directly impact liver function if the inflammation is controlled, it can be a sign of chronic liver damage. If your liver remains free of inflammation, the roughness may stabilize, but it may not completely resolve. Regular imaging and blood tests will help assess the overall health of your liver.

4. Need for Second Opinions: It is entirely reasonable to seek a second opinion, especially if you have concerns about your current treatment plan or diagnosis. Different specialists may have varying approaches to managing chronic Hepatitis B, and a second opinion can provide you with additional insights and reassurance.

5. Lifestyle Factors: Sleep and stress management are crucial for liver health. While early sleep is generally beneficial, the quality of sleep is equally important. Poor sleep can lead to increased stress, which may negatively affect liver health. Consider implementing relaxation techniques, such as mindfulness or cognitive behavioral strategies, to improve your sleep quality.
In summary, your management of chronic Hepatitis B should involve ongoing antiviral therapy, regular monitoring, and lifestyle modifications. It is essential to maintain open communication with your healthcare provider to make informed decisions about your treatment plan. Your proactive approach to understanding your condition and seeking information is commendable, and it will serve you well as you navigate this journey.

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