Chronic HBV -- Anti-viral or Immunomodulatory Therapy?
Chronic HBV -- Anti-viral or Immunomodulatory Therapy?
Background First-line treatment options for chronic hepatitis B (CHB) consist of nucleos(t)ide analogues with a high barrier to resistance (entecavir and tenofovir) or the immunomodulatory agent peginterferon (PEG-IFN). The optimal choice for individual patients remains controversial.
Aim To review treatment options for CHB, with a focus on deciding between prolonged nucleos(t)ide analogue therapy or a finite course of PEG-IFN.
Methods A comprehensive literature search was undertaken.
Results Long-lasting, treatment-maintained suppression of hepatitis B virus (HBV) DNA without resistance is achievable in most patients by entecavir or tenofovir. A sustained off-treatment response is, however, unlikely and long-term therapy must be anticipated. PEG-IFN offers a higher rate of sustained response in a subgroup of patients, but is frequently complicated by side effects. Pre-treatment predictors of response, including HBV genotype, alanine aminotransferase and HBV DNA levels, aid in selecting patients for PEG-IFN therapy. Furthermore, on-treatment markers such as quantitative hepatitis B surface antigen may be applied to identify nonresponders early during the PEG-IFN treatment course, thereby preventing unnecessary treatment.
Conclusions Both nucleos(t)ide analogues and PEG-IFN can be prescribed as first-line treatment options for CHB. However, PEG-IFN should only be considered for patients with a high chance of response based on pre-treatment and on-treatment factors.
Chronic hepatitis B (CHB) remains a major cause of liver disease worldwide. Although the global prevalence has fallen since the introduction of effective vaccination programmes, there are still more than 350 million people who are chronically infected with the hepatitis B virus (HBV). Progression of HBV-related liver disease to cirrhosis, hepatic decompensation and hepatocellular carcinoma (HCC) is estimated to result in 0.5–1.2 million annual deaths.
The immunomodulatory agent interferon (IFN)-alfa has been a mainstay in the treatment of CHB since it was licensed for this indication in the early 1990s. In the last decade, great strides have been made in the treatment of CHB with the introduction of nucleos(t)ide analogues (NA) and pegylated forms of IFN (PEG-IFN). The increasing number of treatment options has added to the complexity of anti-viral therapy for CHB, leading to the development of multiple international practice guidelines in recent years. All of these guidelines support both NA and PEG-IFN as first-line treatment options, but the optimal choice for individual patients remains controversial. This review will focus on deciding between NA and PEG-IFN therapy.
Abstract and Introduction
Abstract
Background First-line treatment options for chronic hepatitis B (CHB) consist of nucleos(t)ide analogues with a high barrier to resistance (entecavir and tenofovir) or the immunomodulatory agent peginterferon (PEG-IFN). The optimal choice for individual patients remains controversial.
Aim To review treatment options for CHB, with a focus on deciding between prolonged nucleos(t)ide analogue therapy or a finite course of PEG-IFN.
Methods A comprehensive literature search was undertaken.
Results Long-lasting, treatment-maintained suppression of hepatitis B virus (HBV) DNA without resistance is achievable in most patients by entecavir or tenofovir. A sustained off-treatment response is, however, unlikely and long-term therapy must be anticipated. PEG-IFN offers a higher rate of sustained response in a subgroup of patients, but is frequently complicated by side effects. Pre-treatment predictors of response, including HBV genotype, alanine aminotransferase and HBV DNA levels, aid in selecting patients for PEG-IFN therapy. Furthermore, on-treatment markers such as quantitative hepatitis B surface antigen may be applied to identify nonresponders early during the PEG-IFN treatment course, thereby preventing unnecessary treatment.
Conclusions Both nucleos(t)ide analogues and PEG-IFN can be prescribed as first-line treatment options for CHB. However, PEG-IFN should only be considered for patients with a high chance of response based on pre-treatment and on-treatment factors.
Introduction
Chronic hepatitis B (CHB) remains a major cause of liver disease worldwide. Although the global prevalence has fallen since the introduction of effective vaccination programmes, there are still more than 350 million people who are chronically infected with the hepatitis B virus (HBV). Progression of HBV-related liver disease to cirrhosis, hepatic decompensation and hepatocellular carcinoma (HCC) is estimated to result in 0.5–1.2 million annual deaths.
The immunomodulatory agent interferon (IFN)-alfa has been a mainstay in the treatment of CHB since it was licensed for this indication in the early 1990s. In the last decade, great strides have been made in the treatment of CHB with the introduction of nucleos(t)ide analogues (NA) and pegylated forms of IFN (PEG-IFN). The increasing number of treatment options has added to the complexity of anti-viral therapy for CHB, leading to the development of multiple international practice guidelines in recent years. All of these guidelines support both NA and PEG-IFN as first-line treatment options, but the optimal choice for individual patients remains controversial. This review will focus on deciding between NA and PEG-IFN therapy.
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