The improvement of the quality of life and the survival of patients infected with the disease have been established as a fundamental objective; this means avoiding progression to cirrhosis and/or hepatocellular carcinoma or, in the case that cirrhosis is already established, preventing the appearance of decompensation, advanced liver failure or death. This objective can be achieved if the suppression of viral replication and the decrease in DNA levels are achieved until they are undetectable with the current real-time PCR amplification techniques (detection limit of 10-200 IU/ml depending on the techniques used).
The interruption of viral replication is associated with other additional objectives, such as the biochemical response (normalization of transaminases), the serological response (loss of HBeAg and seroconversion in positive HBeAg patients) and histological improvement (decreased necroinflammatory activity).
Can A Person Be Cured of Hepatitis B?
Before any patient diagnosed with chronic hepatitis HBV, the need or not to institute an antiviral treatment must be considered, which requires an adequate evaluation of the patient.
In all cases, a complete serology of HBV is necessary with markers of replication and quantification of viral load, as well as a screening for hepatocarcinoma and the exclusion of other viral infections associated with HBV, such as HCV, HDV and HIV.
The general indications for treatment are established mainly based on three variables: the level of viral replication of HBV (DNA quantification), the level of alteration of transaminases (ALT) and the histological damage observed in the liver biopsy. The main clinical practice guidelines propose to initiate the treatment in those patients who show an active viral replication along with inflammation or significant hepatic fibrosis.
There Are Certain Subgroups Of Populations Where Antiviral Treatment Is Not Indicated:
In those patients who are in the immune-tolerance phase; they are characterized by high levels of viral DNA and normal transaminases.
In all likelihood, the liver biopsy would not show significant histological damage in these cases, which is why it is not indicated. These are young patients, under 30 years of age, who will require further follow-up.
There is also no indication of treatment in patients with occult hepatitis B (HBsAg negative with detectable DNA) or in inactive HBV carriers who have low levels of viral DNA (less than 2000 IU/ml) and normal transaminases. It is important to distinguish the inactive carriers from the negative HBeAg patients, in whom there may also be low DNA levels and prolonged periods without alteration of transaminases, requiring a long-term follow-up with periodic determination of DNA and ALT to be able to characterize them and treat them if they meet the appropriate criteria.
In patients with chronic hepatitis HBV in whom adherence to treatment or clinical follow-up is doubtful or erratic, the antiviral treatment should not be initiated due to the lack of response to it, the risk of resistances and the economic cost.
Available Drugs and Treatment Strategies
Once the indication to initiate an antiviral treatment is established, different factors must be assessed to choose the drug to be used, as well as the most adequate therapeutic strategy. It is necessary to individualize these decisions with each patient, taking into account various factors such as age, associated comorbidities or the possibility of a future pregnancy. The patient should be instructed of the advantages and possible disadvantages of each drug and make them part of the treatment of their disease, since in most cases it will be a prolonged treatment, often undefined, with the consequent risk of resistance and/or side effects, requiring adherence and involvement by the patient.
There are currently 7 approved drugs for the treatment of HBV: interferon (standard and its pegylated form) whose use implies a strategy treatment limited to 48 weeks; and nucleoside analogs that include lamivudine, adefovir, telbivudine, entecavir and tenofovir, and which usually involve prolonged, if not indefinite, treatment.
In the case of Hepatitis B virus, the disappearance of HBsAg and seroconversion to anti-HBs would be the ideal objective. Unfortunately, this goal is achieved in a small proportion of patients with current treatments due to the virological characteristics of Hepatitis B virus.