East Asia expert opinion on treatment initiation for chronic hepatitis B

Abstract

Background: Globally, chronic hepatitis B (CHB) is a major public health concern. Timely and effective management can prevent disease progression to cirrhosis and reduce the risk of hepatocellular carcinoma (HCC). Currently, there is no consensus on the clinical management of CHB in East Asia. Aim: To establish an East Asia expert opinion on treatment initiation for CHB based on alanine aminotransferase (ALT) level, hepatitis B virus (HBV) deoxyribonucleic acid (DNA) level, cirrhosis and HCC risk scores. Methods: A meeting was held online with a panel of 10 experts from East Asia to discuss ALT, HBV DNA, cirrhosis and HCC risk scores. Indications for CHB treatment in the latest international guidelines were reviewed. Consensus was summarised to provide recommendations on the initiation of treatment for CHB. Results: Anti-viral therapy is recommended for CHB patients with (a) HBV DNA ≥ 2000 IU/mL and ALT ≥ 1× upper limit of normal (ULN); (b) HBV DNA ≥ 2000 IU/ mL, ALT < 1× ULN and ≥ F2 fibrosis and/or ≥ A2 necroinflammation occurs; (c) cirrhosis and detectable HBV DNA; or (d) HBV DNA ≥ 2000 IU/mL, ALT < 1× ULN and a family history of cirrhosis or HCC, extrahepatic manifestations or age > 40 years. Patients with cirrhosis and/or HCC should be treated regardless of ALT levels if HBV DNA level is detectable. Initiating anti-viral therapy or close monitoring at 3-month intervals is recommended for CHB patients with at least two HCC risk factors. Conclusions: These expert recommendations will contribute to a new standard of daily clinical practice in East Asia.

Secondary prevention of hepatitis B virus‐related hepatocellular carcinoma with current antiviral therapies

“…Indeed, subsequent data from the same cohort showed that patients with HBV DNA levels of >10 7 copies/ml had a significantly lower risk of HCC than those with HBV DNA levels between 10 6 and 10 7 copies/ml. 23,43,44 In accordance, in our recent historical cohort study including 6949 non-cirrhotic patients without significant ALT elevation (<2 × ULN at least for 1 year) regardless of HBeAg positivity, the association between HBV DNA levels and HCC risk was not linear but parabolic, showing the highest HCC risk with moderate serum HBV DNA levels of 5.0-7.0 log 10 IU/ml and lowest HCC risk with HBV DNA level of >8 log 10 IU/ml and ≤4 log 10 IU/ml, regardless of ALT levels. 32 A recently published multicenter historical cohort study also confirmed a low risk of HCC development in untreated non-cirrhotic patients with HBV DNA level >10 7 IU/ml.…”

“…45 According to these results, traditional paradigm of "linear association" between HBV DNA and the risk of HCC may have to be revised to "parabolic association." 44 Serum HBV DNA levels may be changed by interaction between the host and virus during the natural course of CHB. Most of the patients with CHB have very high levels (≥8 log 10 IU/ml) of HBV DNA at the initial phase of the infection.…”

Letter: elevated aspartate aminotransferase and aspartate aminotransferase to alanine aminotransferase ratio predicts poor survival in hepatocellular carcinoma after resection

“…The recent East Asia Consensus 1 and official guideline 2 on treatment initiation for chronic hepatitis B recommend that indications for anti‐viral therapies are mainly related to four factors, namely hepatitis B virus (HBV) deoxyribonucleic acid (DNA), alanine aminotransferase (ALT), cirrhosis, and family history of hepatocellular carcinoma (HCC). Aspartate aminotransferase (AST) is not considered a necessary factor in treatment decision.…”

Letter: elevated aspartate aminotransferase and aspartate aminotransferase to alanine aminotransferase ratio predicts poor survival in hepatocellular carcinoma after resection—Authors' reply

“…We thank Li and colleagues for their letter 1 commenting on our recent expert opinion paper 2 and sharing their observations. They highlighted the potential role of elevated serum aspartate aminotransferase (AST) level in predicting the overall survival of patients who had undergone liver resection for hepatocellular carcinoma, mostly due to chronic hepatitis B.…”

“…A number of generic fibrosis scores such as the AST‐to‐alanine aminotransferase (ALT) ratio, AST‐to‐platelet ratio index (APRI) and the Fibrosis‐4 index include AST as an integral component 3 . In our paper, we recommended the use of APRI and Fibrosis‐4 index to evaluate for significant liver fibrosis and cirrhosis, especially in resource‐limited areas 2 . However, clinicians should exercise caution when interpreting these scores in patients with normal ALT levels and in those on antiviral treatment as false‐negative results are common 4 .…”