engleski

Hepatitis B – new clinical and treatment approach

Although an effective preventive HBV vaccine exists for over 30 years, chronic hepatitis B virus (HBV) infection currently affects 240 million people worldwide. While the prevalence is decreasing in highly endemic countries that had implemented vaccination programs, epidemiology is changing in Europe mainly due to the high prevalence rates in migrants and refugees. Patients with chronic HBV infection are at increased risk of progression to cirrhosis and hepatocellular carcinoma (HCC). Currently, there is no cure for HBV infection ; therefore the goal of antiviral treatment is to improve survival and quality of life by preventing disease progression and HCC development. These are achieved through long-term suppression of HBV replication that is associated with alanine aminotransferases normalization (ALT) and decrease in hepatic necroinflammation and fibrosis. The decision to treat is complex and must be individualized. Three criteria are used to assess the need for therapy: serum ALT level, HBV DNA viraemia and the severity of liver disease assessed by biopsy or non-invasive markers. The treatment should be started in patients with: (1) HBV DNA >2, 000 IU/ml with elevated ALT and/or at least moderate necroinflammation or fibrosis ; (2) HBV DNA >20, 000 IU/ml and ALT >2xULN regardless of the degree of fibrosis ; (3) in all cirrhotic patients with detectable HBV DNA ; (4) HBeAg positive infection (high viraemia, persistently normal ALT) may be treated if older than 30 years ; (5) patients with family history of HCC or cirrhosis and extrahepatic manifestations. Additional indications include the prevention of mother to child transmission and preventionm of HBV reactivation in patients requiring immunosuppression or chemotherapy. The recommended first line agents for treatment are peginterferon alpha, entecavir and tenofovir. Current therapy, however rarely leads to HBsAg loss and lifelong therapy is often required. New antivirals that target distinct steps of the HBV life cycle including entry, assembly and/or release inhibitors, cccDNA inhibitors and transcription clearance, or immunemodulators (TLR7 inhibitors) hopefully would lead to functional cure.

Hepatitis B, treatment

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