Year : 2008 | Volume
: 5 | Issue : 1 | Page : 7--11
Management of chronic Hepatitis B: Problems galore
Shivaram Prasad Singh1, Yogesh Kumar Chawla2,
1 Department of Gastroenterology, SCB Medical College, Cuttack 753007, Orissa, India
2 Department of Hepatology, Postgraduate Institute of Medical Education & Research (PGIMER), Sector -12, Chandigarh-160 012, India
Shivaram Prasad Singh
Department of Gastroenterology, SCB Medical College, Cuttack - 753007, Orissa
|How to cite this article:|
Singh SP, Chawla YK. Management of chronic Hepatitis B: Problems galore.Hep B Annual 2008;5:7-11
|How to cite this URL:|
Singh SP, Chawla YK. Management of chronic Hepatitis B: Problems galore. Hep B Annual [serial online] 2008 [cited 2020 Sep 21 ];5:7-11
Available from: http://www.hepatitisbannual.org/text.asp?2008/5/1/7/58802
Despite all the research and advances accomplished in the field of HBV management, hepatitis B virus [HBV] infection continues to be a major health hazard across the globe. Although research on HBV infection over the last few decades has added considerably to our understanding of this infection, especially its diagnosis and treatment, ongoing research continues to generate new knowledge that helps us understand this infection better and produce new molecules that assist us to treat this infection with greater success. This issue of Hepatitis B Annual is another cog in our endeavor to offer our readers authoritative reviews on important and relevant issues related to HBV infection with which they grapple with in their interface with hepatitis B. Besides, in this issue, the section "Hepatitis B: News from the Research World" is carried forward; we intend to continue this section on a regular basis in the future issues of Hepatitis B Annual too.
Flares may occur on and off therapy during chronic HBV infection. In this context, it is essential to understand the interaction between HBV and the host to diagnose the cause of the flare and optimally manage the problem. Dr. Amarapurkar has very succinctly dealt with the significance, pathogenesis and management of these flares in the article "Flares On and Off Therapy During Chronic HBV Infection: Pathogenesis, Significance and Management." He rightly stresses the need to identify flares at the earliest by following up all patients with chronic HBV infection at periodic intervals with liver function tests and HBV DNA levels. The article also highlights the importance of testing and vaccinating for hepatitis A in all patients with chronic HBV infection, and avoiding potentially hepato toxic drugs in these patients. Besides, the author forbids the use of interferon in patients with advanced liver disease to avoid fatal flares. The article also outlines the management of flares occurring with immunosuppressive regimes with concurrent administration of oral antiviral drugs.
Immunosupression due to underlying disease or on account of the drugs used in immunosuppressive or anticancer therapy and in organ transplants can influence the HBV leading to reactivation of the virus and even acceleration of a pre-existing chronic hepatitis. Dr. Alfredo Marzano and his colleagues from Italy in their article "Prophylaxis and Treatment of Hepatitis B in Immunocompromised Patients" lucidly describe how to approach these patients in a judicious manner. The article highlights the importance of evaluation of HBV markers and of liver status at baseline in all subjects starting immunosuppressive therapies, and the appropriate pre-emptive use of antiviral (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies and are judged to be at high risk. Besides, the authors have also laid emphasis on biochemical and HBsAg monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive) to prevent reverse seroconversion. The authors have also outlined the strategy in dealing with the patients undergoing liver transplantation in the setting of HBV infection.
Vaccination against hepatitis B is the most powerful tool to combat the spread of the disease. Dr. Kazimierz Madalinski from Warsaw has scripted the important chapter, "Recent Advances in Hepatitis B Vaccination". In this article, Dr. Madalinski has emphasized the importance of the persistence of anti-HBV cellular immunity for over a decade, and highlighted the importance of this kind of response which may last longer than the detectable antibodies in the defense against the virus. The article has also shed light on the emerging next generation vaccines, including DNA-based and plant-based HBV vaccines, which evoke a lot of hope in the ongoing fight against the virus, especially with regard to the optimism of a comfortable route of administration.
Lamivudine (LMV) was the first nucleoside analog to be marketed for the treatment of patients with chronic HBV. The advent of LMV saw a remarkable improvement in management of patients with chronic hepatitis B, particularly those with advanced liver disease, resulting in substantial reduction in the rates of liver-related complications and mortality. However, hepatologists have had to face high rates of HBV resistance to LMV therapy after prolonged treatment with LMV. Initially ignored, LMV resistance is now recognized to be a significant clinical issue whose management requires specific therapeutic strategies. In fact, drug resistance to antivirals has emerged as a major challenge in the management of chronic hepatitis B today. Drug resistance is considered a natural response to the selective pressure of the antiviral drug, and depends on the viral mutation frequency, intrinsic mutability of the antiviral target site and the magnitude and rate of virus replication. The emergence of resistance to antiviral agents for the treatment of chronic HBV can be associated with exacerbation of hepatitis, hepatic decompensation, reduced HBeAg seroconversion, and worsening of liver disease. Despite the fact that quite a few active oral analogues have been marketed, LMV is still the number one prescribed anti-HBV agent worldwide for the treatment of chronic HBV patients, due to its limited cost, excellent safety and well predicted resistance profile.
In the article: "Management of Lamivudine Resistance: An Overview," Dr. Pietro Lampertico and colleagues from Milan have penned an overview of the problem of LMV resistance quite comprehensively; they have exhaustively reviewed the enormity of the problem, the kinetics of viral resistance and the clinical consequences of this phenomenon. They also outlined the management of this problem with rational approach to selection of appropriate rescue antiviral and rescue strategy to obtain optimal results.
Chronic delta hepatitis represents the most severe form of chronic viral hepatitis and is associated with the most rapid progression of disease among hepato trophic virus infections. In the article, "Chronic Delta Hepatitis: An Overview," Dr. Cihan Yurdaydin from the University of Ankara Medical School, Turkey has comprehensively discussed the epidemiology, pathogenesis, clinical characteristics and treatment of chronic hepatitis D. This article provides the clinicians with much needed guidance in managing patients suffering from chronic hepatitis D. Besides, the article also discusses the novel therapies including novel nucleoside analogues and prenylation inhibitors which are likely to benefit these patients, and the urgent need to develop new treatment strategies for these patients.
Incidentally detected asymptomatic HBsAg positive subjects [IDAHS] constitute a mammoth pool of hepatitis B virus infected population who need to be properly assessed and followed up to minimize morbidity and mortality in them. The article "Incidentally Detected Asymptomatic HBsAg Positive Subjects" by Dr. Vinod Kumar Dixit from Varanasi reviews the literature relating to this subset of HBV patients and attempts to provide a rational guideline to approach and manage them.
Medical students represent a high risk population for HBV infection. Medical students and HCWs all over the world do not practice universal precautions on a routine basis, and there exists the widely prevalent problem of under-reporting of percutaneous and mucocutaneous exposures and a lack of awareness about the disease transmission, its consequences and the importance of adhering to universal precautions at all times. This further compounds the issue of safety of student HCWs. In the article, "An Overview of Hepatitis B Prophylaxis Practices among Medical Students," Swati Chouhan highlights the dismal scenario vis-ΰ-vis awareness about these risks and HBV prophylaxis amongst medical students from a student's perspective and suggests how to tackle the situation to protect the unfortunate medical students from an unwarranted predicament.
Malnutrition is very common in all forms of liver disease. Since malnutrition is an important predictor of complications of liver disease and mortality, early diagnosis of malnutrition is essential to allow appropriate treatment. Dr. Neeraj Saraf in his article: "Nutritional Management of Acute and Chronic Liver Disease" provides an overview of the nutritional management of acute and chronic liver disease, including disease-specific nutritional therapy for special situations like acute liver failure, sepsis, transplantation, and encephalopathy.
Despite all recent advances and the availability of newer antiviral drugs for the treatment of chronic hepatitis B, a plethora of unresolved issues and areas for further study are aptly highlighted in the concluding remarks of the recently updated APASL recommendations for chronic hepatitis B. These include the necessity or justification of HBV genotyping before designing treatment plan, optimal treatment strategy for children with chronic HBV infection, and patients with chronic HDV infection. Other contentious issues are the role of corticosteroid withdrawal, lamivudine pulse therapy and other modes of immuno modulation, optimal combination therapy to enhance efficacy, and the cost-effectiveness of different therapeutic strategies. It is hoped that development of new drugs and new strategies, especially combination or sequential antiviral therapy in the near future would pave the way for further improvement in the outcome of treatment in these patients.