A recent commentary (KS Liem et al. Gastroenterol 2020; 158: 1185-90) reviews the challenge of stopping nucleos(t)ide (NUC) treatment for chronic hepatitis B viral (HBV) infection.
- NUC therapy “prevents liver failure, decreases the risk of hepatocellular carcinoma, and has excellent safety”
- Yet, there are “low rates of on-therapy functional cure” which is indicated by loss of HBV surface antigen [HBsAg]
- Divergent recommendations: Guidelines “recommend NCU therapy in noncirrhoitic patients can be stopped after >3 years of virologic suppression (EASL), after ≥1 year of undetectable HBV DNA and 2 years of treatment (APASL), or only after achieving HBsAg loss (AASLD)
- “Relapse is highly variable, but is especially dangerous in patients with stage 3 fibrosis or cirrhosis”
- “Hepatic decompensation is relatively rare but is best prevented by continuing NUC therapy in all cirrhotics or those with advanced fibrosis.”
- In a randomized controlled trial in Canada, 72 weeks after NUC discontinuation, “only 33% of pretreatment HBeAg-negative patients had a sustained off-treatment response.”
- “The major guidelines suggest that noncirrhotic pretreatment HBeAg-positive patients can stop NUC therapy after reaching HBeAg seroconversion with undetectable HBV DNA and completing 1-3 years of consolidation therapy…these recommendations are of poor quality.”
- Three issues need to be studied: retreatment criteria in those who stop NUC therapy, biomarkers to distinguish beneficial from detrimental flares, and better criteria for identifying those who are likely to decompensate.
My take: It is hard to argue with the author’s conclusion that “without the tools for proper patient selection, potential benefits of NUC discontinuation do not outweigh limitations of long-term NUC therapy for most patients in clinical practice.” This is due to the safety of NUC therapy and the frequency of relapse when NUC is stopped.
Related blog posts:
- Is Tenofovir the Best Medication for Hepatitis B Infections?
- Why Fewer Children Have Immune-Tolerant Hepatitis B Infection Than Previously
- Preventing Neonatal Hepatitis B Transmission with Tenofovir | gutsandgrowth
- Liver Briefs -September 2019
- Antivirals Reduce Vertical Transmission of Hepatitis B
- More on entecavir and tenofovir | gutsandgrowth
- Extended data with entecavir & annotated HBV management …
- Burden of Hepatitis B and Hepatitis C | gutsandgrowth
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Also: What do you get from a pampered cow? Spoiled milk!