Nucleos(t)ide Analog Can Be Stopped – CON

Nucleos(t)ide Analog Can Be Stopped – CON

Suppression of HBV DNA levels, id eally to undetectable, has been associated with marked histologic improvement of necroinflamation and regression of hepatic fibrosis. Today, Professor, who came from the University of Miami School of Medicine, United States, discussed whether the nucleos(t)ide analog can be stopped. He maintained that the nucleos(t)ide analog can be stopped. Long-term treatment is costly and fraught with compliance problems but the advantages of long term treatment outweigh the risk of discontinuing therapy. HBeAg disappearance followed by seroconversion requires consolidation therapy for at least a year to ensure “durability” of this response after discontinuation of the antiviral therapy. There is a lack of long term data supporting true durability and many of these patients continue to have detectable HBV DNA, albeit low viral levels. Chronic HBeAg negative hepatitis patients notoriously relapse when treatment is stopped even after years of HBV DNA negativity on therapy. In the minority of patients who lose HBsAg, durability of the HBV DNA negativity is undoubtedly more long lasting.

He poined out that if the patient has underlying cirrhosis or is a high risk for hepatocellular carcinoma discontinuation of treatment cannot be justified. Fortunately more recently licensed drugs such as entecavir and tenofovir are very robust and the rate of evolving resistant mutations thus far is very low. Rapid attainment of HBV DNA negativity documented with sensitive assays is much less likely to result in clinically significant viral breakthrough among compliant patients. With periodic follow-up, which must be implemented in all HBV patients, compliance can be established and early recognition of those few with viral resistance accomplished. The primary limitation in long term antiviral therapy for HBV in 2009 is cost. Otherwise the beneficial effects of viral suppression are maximized with long term indefinite antiviral therapy.

Eugene R. Schiff教授主张对部分适合的患者而言，核苷（酸）类似物无需无限期服用。他指出虽然长期治疗能够最大程度的抑制HBV，但长期治疗是非常昂贵的，并存在依从性差的问题。目前慢性乙型肝炎治疗指南要求在出现HBeAg血清转换后仍需坚持至少1年的抗病毒治疗以维持停药后的持久应答。但缺乏数据支持长期治疗停药后的持久应答是确实存在的。一些允许上市的药物如恩替卡韦和替诺夫韦具有很强的疗效并且耐药相关突变率很低。这些药物能够使血清HBV-DNA水平快速转阴，且在适合停药的患者中停药后极少发生临床上有意义的病毒学突破。因此使抗病毒治疗停药成为可能。