Module 9 Treatment Of Chronic Hbv And Monitoring Of Patients On Treatment
The goal of treating chronic HBV is to prevent disease progression and induce disease regression to minimize liver damage and its complications .
The current approved treatments for HBV are interferon injections or oral nucleoside/nucleotide analogues . As oral antivirals are excreted by the kidney, dose adjustments are required in renal failure.
Not all patients with chronic HBV infection need to be treated. The decision to treat depends on several factors including age, serial ALT and HBV DNA levels, and severity of liver disease. Co-infection, particularly with HIV and HCV, needs to be considered when deciding on which medications to use.
Treatment should be initiated by a hepatologist or other physician with experience in the management of viral hepatitis.
The duration of therapy depends on the type of treatment. Interferon is used for up to 48 weeks oral antiviral medication is used indefinitely or until the treatment endpoint is achieved . Note: Treatment cannot be stopped in organ transplant recipients or infected individuals who require immunosuppressive therapy for another disorder.
All patients being treated for chronic HBV require laboratory monitoring of HBV DNA levels and liver biochemistry every 3 – 6 months. This is necessary both to assess response to treatment and to permit early detection of resistance to antiviral therapy.
Low Response Rates And Nonresponders
Low vaccination response rates have been associated with obesity, smoking, immunosuppression, and advanced age. Approximately 25-50% of persons who initially do not have a vaccine response will show a response to 1 additional vaccine dose, and 50-75% of individuals will have a response to a second 3-dose series.
It is recommended that testing for anti-HBs be obtained 4-12 weeks following vaccination. Revaccinate nonresponders, with another series of 3-dose hepatitis B vaccine. Consider delaying revaccination for several months after initiation of antiretroviral therapy in patients with CD4 counts below 200 cells/mm3 or those with symptomatic HIV disease. The delay in these individuals is an attempt to maximize the antibody response to the vaccine.
Do not defer vaccination in pregnant patients or patients who are unlikely to achieve an increased CD4 count. Individuals at increased risk of severe complications due to HBV infection include those unlikely to achieve CD4 counts of 200 cells/mm3 or above after antiretroviral therapy and HIV-infected pregnant women.
A combined hepatitis A virus /HBV vaccine is licensed in many countries and offers the advantage of protection against both of these viruses at the same time. The vaccine seems to be safe, although some questions exist regarding neurologic complications.
Approach To Test Selection
The choice of tests should be based on patient history and clinical presentation.
Screening to detect infection or determine immune statusFootnote § in asymptomatic patients at risk of acute or chronic infection:
- HBsAg, anti-HBs
- anti-HBc IgM in case of recent known or suspected exposure
Baseline screening to assess need for PEP :Footnote **
- HBsAg, anti-HBs
Screening in patients with defined clinical conditions:
- HBsAg at first prenatal visit or at delivery if there is no documented result on file
Pre-immunization screening of high-risk population:Footnote §
- HBsAg, anti-HBs
Post-immunization screeningFootnote § for those with ongoing exposure or risk of exposure :
Testing to confirm diagnosis in patients with clinical or laboratory findings consistent with acute hepatitis:
- HBsAg, anti-HCV, anti-HAV IgM
If these are negative, test for:
- HEV, HCV-RNA
- Consider other infectious causes or non-infectious causes
- Footnote §
Refer to the Canadian Immunization Guide or to your provincial/territorial guidelines for a discussion of pre- and post-immunization testing for HBV serologic markers.
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Factors Used To Determine Whether To Initiate Treatment
Because of inability to eradicate HBV and the potentially long if not indefinite duration of therapy , treatment is not universally indicated for everyone with chronic HBV, but rather reserved for those who are thought most likely to benefit from the standpoint of disease modification. Conceptually, the clearest indications for treatment are when extensive liver fibrosis has occurred and/or when there is active HBV DNA replication causing ongoing significant hepatic inflammation. The decision to treat persons with chronic HBV therefore typically incorporates the following three factors: cirrhosis status, evidence of hepatic inflammation, as measured by alanine aminotransferase levels or liver biopsy, and ongoing HBV replication as indicated by serum HBV DNA levels. Some guidelines incorporate the HBeAg status as another parameter to consider in deciding whether to initiate HBV treatment.
Who Are Hepatitis B Carriers
Hepatitis B carriers are people who have the hepatitis B virus in their blood, even though they dont feel sick. Between 6% and 10% of those people whove been infected with the virus will become carriers and can infect others without knowing it. There are over 250 million people in the world who are carriers of HBV, with about 10% to 15% of the total located in India. Children are at the highest risk of becoming carriers. About 9 in 10 babies infected at birth become HBV carriers, and about half of children who are infected between birth and age 5 carry the virus. A blood test can tell you if you are a hepatitis B carrier.
For Adults At High Risk Of Exposure
Adults who have not received the hepatitis B vaccine series should be immunized when they have an increased risk of exposure. Job, travel, health condition, or lifestyle all may increase a person’s risk of contracting hepatitis B.
People who live or work where there is risk of exposure include:
- Health care and public safety workers who are likely to be exposed to blood or blood products.
- Clients and staff of institutions or residential settings with known or potential HBV carriers.
- People planning extended travel to China, Southeast Asia, Africa, and other areas where hepatitis B infection is high.
People who have health conditions that put them at high risk for exposure or a severe infection include:
- People who have a severe kidney disease that requires them to have their blood filtered through a machine .
- People who have chronic liver disease.
- People who have hemophilia and other conditions in which they need to have blood products on an ongoing basis.
- People who had a stem cell transplant.
People whose lifestyle puts them at high risk for exposure include:
- People who inject illegal drugs.
- Men who have sex with men.
- People who have had more than one sex partner in the past 6 months or who have a history of sexually transmitted infection.
- Household contacts and sex partners of hepatitis B carriers.
- Prison inmates.
What Should You Know About Hepatitis B Before You Travel
Hepatitis B is quite common in China and other Asian countries, where as many as 1 in 12 people have the virus, though many dont know it. Before traveling to those places, you should make sure youve been vaccinated against the virus.
In addition to getting the vaccine, you can take these additional precautions to reduce your risk of contracting the virus:
- Refrain from taking illegal drugs.
- Always use latex or polyurethane condoms during sex.
- Make sure new, sterile needles are used during all piercings, tattoos and acupuncture sessions.
- Avoid direct contact with blood and bodily fluids.
- Know the HBV status of all your sexual partners.
- Ask your doctor about possible vaccination before you travel to a place where hepatitis B is common.
A note from Cleveland Clinic
Hepatitis B is a liver disease that can cause serious damage to your health. One reason that is dangerous is that it can easily go undetected for years while damaging your liver. Talk with your healthcare provider about being tested for hepatitis B if you have any reason to believe that you were not vaccinated or if you have engaged in risky behavior. If you do test positive, follow the directions from your healthcare provider so that you can live a longer, healthier and happier life.
Last reviewed by a Cleveland Clinic medical professional on 07/09/2020.
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From Person To Person
Blood and other bodily fluids, such as semen and vaginal secretions, contain the virus in infected people. The main ways in which people in the UK become infected include the following:
- Having unprotected sex with an infected person. Even having oral sex can transmit hepatitis B.
- From infected blood. You only need a tiny amount of infected blood to come into contact with a cut or wound on your body to allow the virus to enter your bloodstream, multiply and cause infection. For example:
- Sharing needles and/or any injecting equipment to inject drugs. Even a tiny amount of blood left on a needle from an infected person is enough to cause spread to others.
- Some people who had a blood transfusion or another blood product several years ago were infected with hepatitis B. Now, all blood donated in the UK is checked for the hepatitis B virus . So, the risk of getting hepatitis B from a blood transfusion in the UK is now very small.
- From ‘needlestick’ accidents where the needle was used on an infected person.
- There is a small risk of contracting the virus from sharing toothbrushes, razors and other such items which may be contaminated with blood. The virus can actually live outside the body for more than one week.
- From using equipment which is not sterile for dental work, medical procedures, tattooing, body piercing, etc.
- A bite from an infected person, or if their blood spills on to a wound on your skin, or on to your eyes or into your mouth.
Can Hepatitis B Be Prevented
The hepatitis B vaccine is one of the best ways to control the disease. It is safe, effective and widely available. More than one billion doses of the vaccine have been administered globally since 1982. The World Health Organization says the vaccine is 98-100% effective in guarding against the virus. Newborns should be vaccinated.
The disease has also been more widely prevented thanks to:
- Widespread global adoption of safe blood-handling practices. WHO says 97% of the blood donated around the world is now screened for HBV and other diseases.
- Safer blood injection practices, using clean needles.
- Safe-sex practices.
You can help prevent hepatitis B infections by:
- Practicing safe sex .
- Never sharing personal care items like toothbrushes or razors.
- Getting tattoos or piercings only at shops that employ safe hygiene practices.
- Not sharing needles to use drugs.
- Asking your healthcare provider for blood tests to determine if you have HBV or if you are immune.
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Module 3 Interpretation Of Hbv Diagnostic Test Results
This table describes 6 possible interpretations of diagnostic test results and subsequent recommended actions for clinicians.
In the first scenario of this table, a patient should be considered to be susceptible to hepatitis B when: hepatitis B surface antigen results are negative hepatitis B surface antibody results are negative total hepatitis B core antibody results are negative and the IgM marker of the hepatitis B core antibody is not available/or not done.
It’s noted that approximately 5 percent to 10 percent of people will not respond to vaccine or else do not produce protective levels of antibody post-vaccination .
The recommended action when a patient is considered to be susceptible to hepatitis B is to vaccinate.
In the second scenario of this table, a patient should be considered to be immune to hepatitis B due to vaccination when: hepatitis B surface antigen results are negative hepatitis B surface antibody results are positive total hepatitis B core antibody results are negative and the IgM marker of the hepatitis B core antibody is not available/or not done. Regarding the hepatitis B surface antibody, clinicians are reminded that about 5 percent to 10 percent of people will not respond to the vaccine or else do not produce a protective level of antibody post-vaccination . Note that in immune individuals, levels of hepatitis B surface antibody may decline over time and become undetectable.
What Is Involved In A Liver Transplant
A liver transplant is considered necessary when the liver is damaged and cannot function or in some cases of liver cancer. Your liver is very important. It is responsible for many functions related to making sure that your body stays healthy and is able to digest foods.
You may be eligible for a transplant if you have chronic hepatitis B infection or some of the diseases that may result from it, including liver cancer and cirrhosis. You will have to complete testing and be evaluated before being approved for a transplant. It is likely that you will be placed on a waiting list while an appropriate organ is found.
Donated livers come from two types of donors: living and deceased. Because the liver can regenerate, it is possible to use part of a liver for transplant. The remaining sections in both the donor and the receiver will grow into livers of adequate size.
People who get liver transplants must take anti-rejection drugs for the rest of their lives. These drugs make you more susceptible to infection. However, liver transplants have become more successful over time and continue to improve.
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Is There A Cure For Chronic Hepatitis B
Currently, there is no complete cure for hepatitis B. But when managed properly, those living with the virus can expect to live a normal life. Maintaining a healthy diet and avoiding alcoholic beverages and tobacco products are crucial components in managing the disease.
You should also visit a doctor familiar with hepatitis B at least annuallythough twice a year might be best to monitor your liver through blood tests and medical imaging. As with most diseases, detecting it early leads to a better outcome. If youre exposed to the virus, you should get an antibody injection within 12 hours of exposure.
Herbal Remedies For Hepatitis
According to Ayurveda, it comes under yakrit roga. Pitta dosha is much more aggravated in comparison to other two doshas.
Planet Ayurveda offers best combination of effective herbal remedies such as Liver Care Pack for ayurvedic treatment of Hepatitis-b. These herbal remedies are prepared from using best quality herbs and strictly follow the principles of Ayurveda. All these herbal remedies of Planet Ayurveda are 100 percent pure, natural and vegetarian. These are free from chemicals, additives and preservatives. These remedies are safe to use as these are free from side effects.
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How Do I Treat My Hepatitis B
Not every patient with chronic hepatitis B needs to be on medication. Although there is no cure for hepatitis B, there are effective treatments that can reduce the risk of liver disease. However, if your ALT level is elevated , antiviral medication may be appropriate. There are currently 7 FDA-approved drugs to treat chronic HBV infection . Talk to your doctor about whether you are good candidate for drug therapy and make sure you discuss treatment rationale, options, side effects, and risks associated with each treatment.
Additionally, if you are chronically infected with hepatitis B and are starting cancer chemotherapy, you should be on HBV treatment to protect against potential flare-up of the hepatitis B infection and risk of liver failure.
What Are The Types Of Hepatitis B
There are two types of hepatitis B infection: acute and chronic.
An acute infection happens at the beginning, when you first get infected with hepatitis B. Many people are able to clear it from their bodies and recover. In fact, this is true of about 4 in 5 adults who are infected.
If you are not able to clear the infection within six months or longer, you have chronic hepatitis B. It is chronic hepatitis B that leads to inflammation and the serious, and possibly fatal, illnesses of cirrhosis of the liver and liver cancer. Treatment can slow disease progress, reduce the chance of liver cancer and increase your chances of surviving.
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Who Is At Risk For Hepatitis B
Anyone can get hepatitis B, but the risk is higher in
- Infants born to mothers who have hepatitis B
- People who inject drugs or share needles, syringes, and other types of drug equipment
- Sex partners of people with hepatitis B, especially if they are not using latex or polyurethane condoms during sex
- Men who have sex with men
- People who live with someone who has hepatitis B, especially if they use the same razor, toothbrush, or nail clippers
- Health care and public-safety workers who are exposed to blood on the job
If you have chronic hepatitis B, you may not have symptoms until complications develop. This could be decades after you were infected. For this reason, hepatitis B screening is important, even if you have no symptoms. Screening means that you are tested for a disease even though you don’t have symptoms. If you are at high risk, your health care provider may suggest screening.
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