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Hepsera or Entecavir?
Jul 28, 2006

A little background first. The followings are the timelines of my Hep B infection.

Apr, 2001 - Diagnosed with chronic Hep B at age 39 (I am an Asian male) - Never know when was infected

Apr, 2001 to Jun, 2003 - No treatment but monitored every three months - DNA level fluctuated in the range of 1.2M to 300M copies/ml. ALT fluctuated from as low as 39 to as high as 539 - Ultra Sound scans were normal - HBeAg+ and HBeAg- initially but in Dec, 2002 spontaneously reversed to HBeAg- and HBeAB+ and DNA still positive (a typical case of pre-core mutant)

June, 2003 to Jun, 2005 - Start taking Hepsera - ALT had been normalized since 5 weeks after medication - DNA had become undetectable since around Nov, 2003

Jun, 2005 to May, 2006 - Treatment Stopped and monitored every month - ALT was normal during the entire period - DNA relapsed and fluctuated but never exceeded 500,000 copies/ml.

But the last two labs (June and July) indicated that ALT levels had elevated to 187 and 286. DNA was about 330,000 copies/ml

Questions: 1. Should I resume medication? 2. If yes, Hepsera or Entecavir? Given the fact that I had responded to Hepsera very well, it may be a logical choice. Entecavir is more potent and has a better renal and resistance profile than Hepsera. But I am not sure how the Hepsera/stop/relapse/Entecavir sequence would play out in regard to resistance. This is important as I may have to take this drug for a long time 3. Am I considered as nucleoside-nave as Ive never taken LVD but just ADV? 4. Are you aware of a test called QLSS (Quantitative Live Spleen Scan) which measures the fuctional tissues of the liver I did this test before stopping ADV as my doctor wanted to make sure that I was not cirrhotic. The result was normal.

I really appreciate and value your advice. Thanks.

Response from Dr. McGovern

Thank you for your excellent questions.

Yes you have hepatitis B e antigen negative infection (hepatitis B e antigen negative with viremia).

You responded well to hepsera (adefovir) and would probably respond well again if you are treated.

I personally would want to get a liver biospy to see if you have significant disease since the QLSS looks okay.

The reason I would like to know about your disease was cited by you -you need long-term chronic administration of therapy - or you will have a relapse of viremia. This puts you at risk for resistance.

Right now I feel that many new drugs are emerging - yet I think the field of hepatitis B treatment is evolving. We are still learning about whether monotherapy or combination therapy is best. In patients like you who need long-term therapy, I would prefer to wait to see what happens over the next year or two - if your biopsy shows that it is safe to wait. We may learn that combination therapy is best for viral suppression and to delay resistance. Right now it is unclear.

That is why I would want to stage your disease with a biopsy.



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