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| Year : 2006 | Volume
: 3
| Issue : 1 | Page : 7-10 |
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| Treatment of chronic hepatitis B: A bridge too far |
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Shivaram Prasad Singh, Yogesh Kumar Chawla
Department of Gastroenterology, SCB Medical College, Cuttack 753007, Orissa, India
Click here for correspondence address and email
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How to cite this article:
Singh SP, Chawla YK. Treatment of chronic hepatitis B: A bridge too far. Hep B Annual 2006;3:7-10 |
The present issue of this journal focuses on the two novel antiviral agents now available against hepatitis B virus (HBV) infection and certain special situations in relation to HBV infection which are virtually not touched at all or addressed adequately in most reviews and chapters on the management of chronic hepatitis B (CHB).
Dr. J Fung, Dr. CL Lai and Dr. MF Yuen from Hongkong review Telbivudine the latest weapon in the arsenal against hepatitis B. Telbivudine which is an orally administered nucleoside analog selectively inhibits HBV replication. Telbivudine has demonstrated potent activity against HBV in clinical trials, with good tolerance, lack of mitochondrial toxicity and no dose-limiting side effects. Although the authors stress upon the role of Telbivudine as a promising and upcoming agent for the treatment of CHB, in view of its excellent safety profile and potent antiviral effect, further studies are required to determine its long-term efficacy in the prevention of cirrhosis and its related complications including HCC.
In the second review, Dr. CK Tan from Singapore critically appraises Entecavir, a new guanosine nucleoside analogue with specific activity against HBV DNA polymerase. The review highlights the advantages of Entecavir over lamivudine and adefovir dipivoxil, especially superior efficacy, lack of any major adverse effects and limited potential for resistance. Interestingly, Dr. Tan asserts that Entecavir should be considered a first- or second-line treatment option for the management of HBeAg-positive or -negative nucleoside-naive or lamivudine-refractory CHB patients. However with the limited data available it would be too premature to put all the eggs in one basket; in fact towards the end of the review, Dr. Tan himself speculates on the spectre of appropriate combination therapy being possibly superior to monotherapy.
Dr. CJ Liu and Dr. JH Kao from Taiwan in the chapter on the epidemiology and therapeutic implications of the HBV Genotypes, highlight the differences existing in the clinical and virologic characteristics among different HBV genotypes, and stress the importance of determining HBV genotype in patients with chronic HBV infection to gain more information for etiologic, clinical, and prognostic evaluation. The authors surmise that if responses to a given antiviral agent can be predicted based on HBV genotypes, therapy can then be individualized to spare the cost and adverse effects of ineffective treatment. Finally, they stressed the need to examine in details the molecular and virologic mechanisms accounting for the clinical phenotypes of HBV genotypes.
Dr Anna Liberek and co-workers from Poland address the important issue of managing children with CHB. The role of immune immaturity in perpetuation of HBV infection, its natural history, clinical outcome with its serious long-term consequences, and therapeutic approach in children are reviewed in the paper by the authors. However, the authors conclude that in view of the high incidence of hepatitis B infection, and lack of fully effective treatment of chronic hepatitis and its serious complications, the prevention of the infection by vaccination of the populations at risk becomes especially important.
Dr. PN Wong, Dr. SK Mak, and Dr. AK Wong from Hongkong review the management of chronic hepatitis B infection in patients with end-stage renal disease and dialysis. Chronic hepatitis B virus (HBV) infection is an important issue among dialysis patients. Apart from infection control considerations, chronic HBV infection also poses particular problems to dialysis patients in terms of diagnosis and treatment of hepatic complications, and pre-transplant management. This review summarizes the recent knowledge and understanding regarding the natural history, clinical presentation and outcome of chronic hepatitis infection in uraemic patients, and limitations of various existing diagnostic measures in the management of hepatic complications. In this review, the authors propose an algorithm for approaching this group of patients and discuss the indications of liver biopsy, options of anti-viral therapy and pre-transplant workup in dialysis patients with chronic hepatitis B infection.
These are followed by an exotic review on the oft ignored extrahepatic manifestations of HBV infection by Dr. Michael Shim and Dr. SH Han. Several extrahepatic syndromes including Polyarteritis nodosa (PAN), HBV-associated glomerulonephritis (GN), and a serum-sickness like "arthritis-dermatitis" prodrome are associated with chronic HBV infection, and these syndromes contribute significantly to the morbidity and mortality in these patients. The authors elegantly discuss not only the mechanism of development of these syndromes but also the optimal strategies to be adopted to treat these syndromes.
Next, we have a chapter on management of HBV infection with normal ALT. In this review, Dr. Deepak Amarapurkar from Mumbai emphasizes that although traditionally ALT has been considered a marker for hepatocellular injury, and treatment guidelines often suggest that patients with normal ALT should not be treated, there is a need for a reappraisal of this approach. While summarizing the information available on this subject, Dr. Amarapurkar discusses the implications of ALT levels in CHB, and concludes that treatment of CHB should be base on the HBV DNA levels and histological activity even when ALT is normal.
Finally, there is a chapter by Dr. Gourdas Choudhuri and Dr P Pinayanayagam on the different controversies in the management of hepatitis B. In this review, the authors discuss the problems faced in the management of nucleoside resistant mutants including the current status of "combination therapy". This chapter also throws light on other contentious issues in the field of hepatitis B management including the relevance of anti-HBc screening for blood donors, and the number of doses needed for hepatitis B vaccine: two doses or three doses? Besides, should patients with normal ALT be treated? And is the presence of IgM anti-HBc diagnostic of acute hepatitis B? All these different controversies that arise during care of patients with Hepatitis B are discussed by the authors in this chapter.
However, despite the availability of a potent and effective vaccine against HBV and the development of newer antiviral agents to treat CHB, HBV infection continues to remain a major public health scourge worldwide, especially in the developing world, where the most important factor which comes in the way of preventing and treating HBV infection is not the emergence of mutant strains or resistance but 'poverty'! In the developing countries, most patients with CHB cannot afford Interferon, entecavir and telbivudine, and it is indeed a paradox that all the discourses and deliberations on the efficacy or the lack of it is meaningless to the vast multitude afflicted with this indolent killer. In fact most patients residing in the developing countries cannot even afford the battery of tests including quantitative HBV DNA, HBeAg and anti-HBe assays even once during initial workup of the patients. Nevertheless it is hoped that all countries would be able to provide appropriate immunization to their population at large and make available free or subsidized treatment to CHB patients in the not too distant future.
Correspondence Address:
Shivaram Prasad Singh
Department of Gastroenterology, SCB Medical College, Cuttack 753007, Orissa
India
 Source of Support: None, Conflict of Interest: None  | Check |
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