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Hepatology

Monitoring and managing viral load key to treating hepatitis B patients

09/01/2006

UCLA liver disease experts recommend that physicians be highly vigilant for cases of hepatitis B, particularly among high-risk groups. These include patients from countries of high hepatitis B prevalence – especially in Asia – and those with family members with hepatitis B infection. Other high-risk groups include injectable drug users, those with multiple sexual partners, men who engage in same-sex intercourse, and dialysis patients. Physicians should screen these patients with a hepatitis B surface antigen test.

After a hepatitis B diagnosis has been made, patients should be closely monitored. Recent research supports the view that viral load is the best predictor of whether a hepatitis B patient will progress to cirrhosis or liver cancer. Even if the viral load is low, patients should be seen at least every six months to monitor viral load and screen for liver cancer. The screening should consist of an abdominal ultrasound, preferably with a serum alpha fetoprotein test.

The old notion that asymptomatic patients could be “healthy carriers” has been discredited with the more recent understanding that the disease can progress even after a period of inactivity. Unlike other liver disease patients, the hepatitis B patient is always at risk of developing liver cancer – even without first developing cirrhosis.

Hepatitis B treatment

Which hepatitis B patients should be treated for the disease and which treatments physicians should prescribe is often difficult to determine. Patients with an elevated viral load should be considered for treatment, even if their alanine transaminase (ALT) level is normal. A liver biopsy can also help determine which patients should be treated.

Until about five years ago, only two drugs were FDA-approved for treating hepatitis B – standard interferon alpha 2b and lamivudine (Epivir). Newer FDA-approved drugs include adefovir dipivoxil (Hepsera), entecavir (Baraclude), and the newer pegylated interferon alpha 2a.

Lamivudine, adefovir and entecavir are oral medications that belong to a class known as nucleoside/nucleotide analogs, which mimic naturally occurring DNA. They infiltrate the viral polymerase and interfere with viral replication to decrease the viral load. The two interferons are injectable drugs that, despite potentially higher costs and possible side effects, can also be effective in decreasing the viral load. Long-term epidemiological data supports the idea that by decreasing the viral load, these medications can decrease the risk to patients of progressing to cirrhosis or liver cancer.

Additional treatments in clinical trial

One of the problems encountered in treating hepatitis B is that patients can develop resistance to individual drugs. Medications are often used in combination to combat this tendency, though it is also important that new drugs continue to be developed to offer potent new treatments for hepatitis B. Two new nucleos(t)ide analogs that are currently under clinical investigation are telbivudine – which has finished Phase III trials and is awaiting FDA approval – and tenofovir, which is currently in a Phase II trial at UCLA among other centers.

Patients who fail to respond to available therapies can be referred to UCLA, where they will always have access to the latest investigational therapies and the highest standards in evidence-based care.

Cirrhosis and liver cancer

For patients whose hepatitis B has progressed to advanced cirrhosis or liver cancer, the only definitive treatment option is consideration for a liver transplant. Patients with cirrhosis who have had gastrointestinal bleeding, liver confusion, or ascites and patients who have developed liver cancer should immediately be referred for a transplantation evaluation. These patients can also benefit from a careful reevaluation of their hepatitis B treatment as they are particularly susceptible to the deleterious effects of drug toxicity as well as the potential viral flares that can result from drug resistance.

Patient referral

To refer a patient, call the numbers below. Patients with high viral loads may be candidates for treatment as part of a clinical trial; please call for more information.

(310) 206-6705 Physician Consultation
(310) 794-7788 Patient Appointments

Participating physicians

The following physicians participate in treating hepatitis B patients at UCLA Medical Center.

Francisco Durazo, M.D.

Steven Han, M.D.

Sammy Saab, M.D.





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