1. STDs
2. Hep B
3. Treatment

Hepatitis B Treatment Singapore | Shim Clinic

Hepatitis B Treatment is available, and is usually done in collaboration with a hepatologist

• Nucleoside analog reverse transcriptase inhibitors
  • Lamivudine (Epivir) – 40% resistance by 2 years. Also used to treat HIV
  • Telbivudine (Tyzeka)
  • Entecavir (Baraclude)
• Nucleotide analog reverse transcriptase inhibitors
  • Adefovir (Hepsera)
  • Tenofovir (Viread) – Also used to treat HIV

TREATMENT

Patients should be advised to avoid unprotected sexual intercourse until they have become non-infectious or their partners have been successfully vaccinated [III,B]. Hepatitis B is a notifiable disease. Screen for other STIs in cases thought to have been sexually acquired or if otherwise appropriate.

General counselling:

• No donation of blood, sperm, milk, organs
• No sharing of toothbrushes, shavers
• Household contacts, sexual partners to be immunized if negative HBsAg, anti-HBs and anti-HBc
• Pregnant carrier – inform O&G
• Healthy diet, avoid regular alcohol
• Steroids and immunosuppressive agents can aggravate latent infection
• Clean blood spills with bleach/detergents Note:

Hepatitis B virus transmission is not transmissible through:

• Sharing of utensils, food or kissing as part of social greetings
• Participating in all activities including contact sports and social interaction with others (e.g. in schools, day care centres) [IV, D]

Acute Hepatitis – as for hepatitis A.

Chronic Hepatitis B Infection

Management of patients with chronic hepatitis B should be tailored according to the clinical state of liver disease (compensated versus decompensated liver disease) as well as virologic and biochemical (i.e. the liver function test, in particular the serum transaminase levels) status.

1. For patients with HBsAg positive > 6 months and well compensated liver disease:
   1. HBeAg–positive hepatitis B virus infection and:
      1. ALT < Upper limit of normal (ULN): no pharmacotherapy needed. Monitor ALT at least 6 monthly and HBeAg at least 12 monthly
      2. ALT 1-2 X ULN: monitor ALT 3 to 6 monthly and HBeAg 6 monthly. Refer to specialist if persistent evidence of early deterioration of liver function or age >40. Consider liver biopsy and treatment if biopsy shows significant liver damage
      3. ALT > 2X ULN: repeat ALT and HBeAg within 1 to 3 months. Refer to specialist if persistent. Treat immediately upon evidence of hepatic decompensation
   2. HBeAg–negative hepatitis B virus infection and:
      1. ALT < ULN: Monitor ALT 3 months later. If still normal, monitor ALT every 6 to 12 monthly
      2. ALT 1-2X ULN: Monitor ALT 3 to 6 monthly. Refer to specialist if persistent, evidence of early deterioration of liver function or age > 40. If HBV DNA is > 2000 IU/ml, consider liver biopsy and treat if biopsy shows significant liver damage
      3. ALT > 2X ULN: repeat ALT within 1 to 3 months. Refer to specialist if persistent. If HBV DNA > 2000 IU/ml, consider treatment if persistent. Note that common conditions, such as fatty liver and commonly consumed drugs may be confounding factors giving rise to mild to moderate elevation of serum transaminases
2. For patients with decompensated hepatitis B virus–related cirrhosis: Refer to gastroenterologist or hepatologist for management [IV, D].

Surveillance of patients with chronic hepatitis B should be carried out regularly; frequency of surveillance will depend on the risk profile, which should be determined before the start of the surveillance programme (see below):

1. Baseline assessment to stratify risk
   1. check serum ALT, AST, bilirubin, albumin, prothrombin time, alpha- fetoprotein, HBsAg, HBeAg, anti HBe and HBV DNA
   2. liver imaging
2. Periodic reassessment is necessary
   Frequency of surveillance is dependent on patients’ risk profile:
   1. Low-risk group (patients who have seroconverted and have a nonreplicative hepatitis B virus infection): 6 monthly serum ALT and bilirubin – if abnormal, HBV DNA should be checked
   2. Medium-risk group (patients with replicative HBV infection who are beyond the immuno-tolerant window; chronic hepatitis B not on treatment; chronic hepatitis B which is resistant to treatment; patients who are expected to tolerate exacerbation of hepatitis B poorly, e.g. patients with liver cirrhosis): 4-6 monthly serum ALT and bilirubin assessment – if abnormal, HBV DNA should be checked
   3. High-risk group (patients who are subjected to immunosuppressive treatment either during immunosuppressive treatment or on withdrawal of immunosuppressive treatment with agents such as steroids, cytotoxics, monoclonal antibodies with imunomodulatory activity; patients withdrawn from nucleoside/tide analogue treatment for prior chronic hepatitis B; demonstrating resistance to their ongoing nucleoside/tide analogue treatment for their prior chronic hepatitis B; having reduced liver mass, e.g. post-hepatic resection): 2-4 monthly serum ALT, bilirubin, HBV DNA, appropriate to each set of circumstances. If abnormal the specialist will have to decide on further appropriate management [GPP]

Most patients in medium risk group and all patients in high risk group should be referred for management by a specialist.

Treatment of Chronic Hepatitis B Infection

• Treatment should normally be given in collaboration with a hepatologist or physician experienced in the management of liver disease [IV, C]. The decision to treat depends on pattern of disease, HBV DNA level, and presence or absence of significant necroinflammation and hepatic fibrosis. A HBV DNA level of ≥ 4 log IU/ml is generally considered as significant and treatment should be considered
• Patients should be considered for therapy with lamivudine, adefovir, tenofovir, telbivudine, entecavir (or combinations of nucleos(t)ide analogues) or pegylated interferon [Ib, A]. Additional treatments that may soon be licensed in HBV monoinfection include emtricitabine (FTC) [Ib,A], clevudine [II,B] and valtorcitabine [III,C]. Treatment responders have long term benefits in terms of reduced liver damage and decreased risk of liver cancer
• All patients should have an HIV test prior to starting HBV therapy because of different treatment strategies required and the significant risk of antiretroviral resistant HIV developing if lamivudine, tenofovir or entecavir are used as monotherapy [Ib,A]
• Lamivudine, emtricitabine and tenofovir will suppress hepatitis B viral replication during therapy of HIV, and may delay liver damage if given as part of triple antiretroviral therapy [Ib, A]
• Lamivudine and emtricitabine should only be given to HIV+ patients in combination with tenofovir as part of HAART because of the rapid high rate of resistance that occurs to these drugs if given as the only HBV active agent [Ib,A]
• Entecavir should not be used in HIV+ patients without adequately suppressed HIV as it causes the M184V (lamivudine/emtricitabine) resistant mutation
• Adefovir or telbivudine can be used alone in HIV+ patients [II,B]
• Active surveillance of cirrhotic patients for Hepatocellular carcinoma (HCC) leads to earlier detection and better treatment outcomes

Pregnancy and Breastfeeding

• Vertical transmission of infection occurs in 90% of pregnancies where the mother is HBeAg +ve and in about 10% of HBsAg +ve, HBeAg -ve mothers. More than 90% of infected infants become chronic carriers
• Infants born to infectious mothers are vaccinated from birth, usually in combination with Hepatitis B specific Immunoglobulin 200 i.u. i.m. [Ia, A]. This reduces vertical transmission by 90%
• There is some evidence that treating the mother in the last month of pregnancy with lamivudine may further reduce the transmission rate if she is highly infectious [III, C], but this needs to be further substantiated
• Infected mothers should continue to breast feed as there is no additional risk of transmission [II, B]

Hepatitis B treatment:

• Telbivudine (Tyzeka®)
• Entecavir (Baraclude®)
• Lamivudine (Epivir®)
• Tenofovir disoproxil fumarate (Viread®)
• Adefovir (Hepsera®)

References

• Hepatitis B treatment @ Wikipedia