The Management of Chronic Hepatitis B in Asian Americans

Abstract

Hepatitis B virus (HBV) infection is common with major clinical consequences worldwide. In Asian Americans, the HBsAg carrier rate ranges from 7 to 16%; HBV is the most important cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Patients are first diagnosed at different stages of clinical disease, which is categorized by biochemical and virologic tests. Patients at risk for liver complications should be identified and offered antiviral therapy. The two antiviral agents recommended for first-line treatment of chronic hepatitis B (CHB) are entecavir and tenofovir. The primary goal of therapy is sustained suppression of viral replication to achieve clinical remission, reverse fibrosis, and prevent and reduce progression to end-stage liver disease and HCC. Asian patients with chronic hepatitis, either HBeAg-positive or -negative, with HBV DNA levels >10(4) copies/mL (>2,000 IU/mL) and alanine aminotransferase (ALT) values above normal are candidates for antiviral therapy. HBeAg-negative patients with HBV DNA >10(4) copies/mL (>2,000 IU/mL) and normal ALT levels but who have either serum albumin ≤3.5 g/dL or platelet count ≤130,000 mm(3), basal core promoter mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive antiviral therapy. Considerations for treatment include pregnant women with high viremia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg-positive patients with risk factors, lifelong surveillance for HCC with alpha-fetoprotein testing and abdominal ultrasound examination at 6-month intervals is required. These recommendations are based on a review of relevant literature and the opinion of a panel of Asian American physicians with expertise in hepatitis B treatment.

Access to Care and Optimal Treatment of Chronic Hepatitis B in Asian Americans: An Evolving Agenda

“…The indications for antiviral therapy are generally similar to existing guidelines [14][15][16][17] in the Tong et al [8] set of recommendations for patients with HBeAg-positive or -negative CHB: serum HBV DNA level [2,000 IU/ml and alanine aminotransferase (ALT) levels above the upper limit of normal (ULN), although some guidelines suggest [2 times the ULN for ALT levels [14,16]. For HBeAg-negative patients with a HBV DNA level[2,000 IU/ml and a normal ALT level, liver biopsy is recommended; this recommendation is also generally similar to existing guidelines, with age[35 or 40 years often suggested as a trigger for biopsy.…”

“…Many of these adults are Asian Americans whose cumulative rate of morbidity and mortality from cirrhosis and hepatocellular carcinoma (HCC) is high, based on their infection as neonates or in early childhood [1]. Thus, it is timely that two articles in this issue of Digestive Diseases and Sciences address the challenges of increasing the detection rate of HBV infection in Asian Americans and proposes a consensus recommendation for the treatment of Asian Americans with CHB [7,8].…”

“…The second article in this issue of Digestive Diseases and Sciences by Tong et al [8] proposes guidelines for the treatment of CHB in Asian Americans. This set of recommendations is based on a review of the relevant literature and the expert opinion of a panel of Asian American physicians.…”

“…The first distinction from existing guidelines in the publication by Tong et al [8] is that only entecavir and tenofovir are recommended as first-line treatments, whereas the other guidelines also include peginterferon alfa-2a as a first-line option. This recommendation very likely takes into account the low usage rate of peginterferon alfa-2a in the US.…”

“…For HBeAg-negative patients with a HBV DNA level[2,000 IU/ml and a normal ALT level, liver biopsy is recommended; this recommendation is also generally similar to existing guidelines, with age[35 or 40 years often suggested as a trigger for biopsy. However, for patients in this ''gray zone'' who refuse liver biopsy, Tong et al [8] recommend the use of a ''risk impact scoring system'' that includes age, gender, BCP mutations, HCC in first-degree relatives, and a low serum albumin level or platelet count. Points are allocated to these parameters, and the total point score is used to determine if treatment is indicated.…”