Deciding on treatment and liver biopsy

Dear Thomas

What about bone density if you are going through with entacavir or tenofovir that is why I’m asking to you after my biopsy Dr will start treatment currently viral load 54000 IU/mL detected.

Hi @Nisarr, thanks for raising your concerns which many people share with you about the long-term use of antivirals. These issues have been talked about by the Hep B Foundation here:

In short, bone loss is not associated with Entecavir at all.

With Tenofovir there is a very low risk of bone loss, mostly in people already at risk of lower bone density (female, being older, smoking, and lower body mass or low levels of vitamin D.). Your doctor should be monitoring your bone, vitamin D, and blood calcium levels if there is a risk of bone loss. This also generally occurs fairly slowly, so you have time to act before it is a big problem if you are being monitored. You can also do things to prevent this if you are at risk (e.g. vitamin D and/or calcium tablets).

@Joan_Block has some experience in this and maybe she can share her insights.


Dear @ThomasTu, thank you for all the information that you have shared. It’s help.

And thanks for setting up this forum and community. At least I won’t feel that I am the only person who need to go through this alone, and I find support from this community.

I felt blessed to be part of this community. Thanks again for the invaluable feedback and information.



Hi Nisarr, I agree entirely with Thomas about the difference between entecavir and tenofovir. Entecavir is not known to cause bone loss. Tenofovir is know to cause bone loss, but again as Thomas pointed out already, there are specific risk factors. Not sure what you’re gender is, but men generally have heavier bones than women so aren’t at great risk. As a petite, 62 year old Asian woman, I had to switch from tenofovir to TAF since I was losing too much bone density. Since switching to TAF, my bone loss has actually reversed so I’m pretty happy. But as Thomas already explained, entecavir is not known to affect bone mineral density. Hope this helps. Always, Joan

1 Like

Dear Thomas
I have had done extra test 2 days ago
HbsAg 7596.0 positive (26.04.21)
HbsAg 4005.86 pozitive ( 16.04.2018) very close in 2019 as well.
HbsAg 5044 pozitive ( 19.12.2013)
HBeAg negative (27.04.21)all other years.
HBV DNA (PCR)Quantitative 5.698IU/ ml( 15.02.2021)
Kreatinin 0.74 mg/dL
ULTRASOUND liver size normal…
In two weeks time will go Fibroscan examination.
If Fibroscan will show normal…should I still do licer biopsy ? I am good candidate to start antiviral treatment?
Genotype test is not available here in Turkey…should be send to overseas .Is genotype test is important in my case?
I dont want to miss my treatment now …suffer later cirrhosis or liver cancer .
I have no problem with food digestive and general health issues.
Thank you very much .
Regards Askul

Dear Askul,

Thanks for following up. I assume that the HBV DNA levels are log values. Your ALTs are in a normal range so no active liver damage now, but you don’t know about the past liver damage until the fibroscan.

I would wait until your fibroscan results before making a decision. I don’t know if a core biopsy is really necessary, but will tell you for sure if there is small amounts of liver damage. The current guidelines suggest only if there is liver damage should you start treatment.

The most common choice is to get blood tests every 6 months to monitor your ALT levels (a marker for liver damage). If they go up then you should consider treatment.

I hope this gives you more information about your choices.


1 Like

Hi everyone

Good evening, my name is nancy and I’m from Nigeria
I’ have been having burning sensation on the right side of my abdomen. I Have done my LFt and ultra sound and my liver seems to be ok

I was told it ulcer that causing the pain so I have been taking ulcer drugs but this pain and itching won’t go away

I’m scared
I have been hearing about itching liver
Does anyone thing that’s what happening to me
How can I tell if I have a itching liver

Dear @Oluchi, thanks for sharing your experience. I think it is difficult to know what else may be going on because there can be so many causes of itching and pain. I think you’ve done the right thing with ruling out many liver-based possibilities with the LFTs and ultrasound.

I would return to your doctor to say that the ulcer medication is not working and there should be more investigation into other possible causes.


Hi Oluchi, I agree with Thomas that it would be good to return to your doctor to let him or her know that the ulcer medication is not working. In regards to what you’re referring to as an “itchy liver,” I assume you mean that your body feels itchy, that you’re scratching parts of your body. Folks like us living with hep b can sometimes feel more itchy than others. The question is how itchy? And when does your itchiness require medical intervention?

The medical term for itchy skin is “pruritis” and one theory is that those living with a chronic liver disease such as hep b can have increased levels of bile salts, which collect under the skin causing one to feel itchy. [2015 Pubmed article]
Although itchy skin doesn’t necessarily mean you have worsening liver disease, if it’s affecting your quality of life then by all means you should see a healthcare provider who can provide advice (or topical creams) to reduce the sensation of itchiness.

Not sure if this helps, but maybe others have ideas or thoughts to share? Always, Joan

Hi everyone thanks for your all information which you shared here to improve patients life better then better… I’m having problem since March 2021 of very bad smelly farting regular approx 100 times in a day… I don’t know that is reasonable to discuss or not.

1 Like

Hi @nisarr, it sounds like you may have a digestive issue because passing gas (or farting) is often due to food getting clogged in your digestive system. This could be due to lack of exercise, not enough water or fluids, not enough fiber (e.g. fruits and vegetables) to help move the digested food through your colon, etc. Have you changed any of your medications or even your diet? It might be useful to speak with your health care provider about possible causes for this problem because something is changing your normal gastrointestinal systems!! Others may have ideas as well. Thanks for sharing. Always, Joan

@Thomus Tu. Thank you very much for the advisory role on Hepatitis B.
I was diagnosed with Hepb in 2013 but could be having from birth.
I am not any medication.
Last result showed;
1- Mild liver fibrosis Metavir 2.
2- Viral Load is 20IU/ML.
3- HBSAG is more than 1000.
4- Hbeag is negative.
5- AFP is 12 and down from 15.

I recently developed
1-pain in the lower side of the right rib cage.
2-Pain on the shoulder blades.
3-Red rashes that comes and goes.
4-Confusion and unstable decisions.
5- Yellow/red urine specially in the morning when I wake up but goes with water drinking.
6- Itching of the body. This is for 6 years.

Doctor decided to treat me and later on changed his mind and said I don’t need treatment now.
My question is
1- What could be the reason of the Doctor deciding to not treat me?
2- If I start treatment, would the CONFUSION go away?. Would the pain under the rib cages go away?
3- which is the best antiviral tablet for new comer in treatment of hbv.
Please your advise of your experience in this ?

1 Like

Dear @Wadani1,

Thanks for your questions:

  1. The reason your doctor may not be treating you is that your viral load is very low already. The argument is: the antivirals only work suppressing the virus replication and if the virus is already being suppressed by your body then there is no benefit.
  2. It is impossible to know this because there may be no connection between Hep B and these symptoms at all. We have talked about the pain in the right side in other threads (Upper right quadrant pain; Titling feet and pain on the righ shoulder blade; and Deciding when to start treatment). It is worthwhile to investigate other reasons for why you are feeling these symptoms.
  3. This is really up to your personal health situation and country. Your doctor will be in the best position to tell you this.

Hope this helps,

I use to get these little red bumps whenever I got hot or sweaty. Always carried allergy meds with me. Changed my diet and exercised regularly and have not got red itchy bumps for a while.

Just change your diet and exercise a bum it and see if your symptoms go away

Hi @ThomasTu, @Joan_Block, @john.tavis:

I finally found a new physician in my new hometown in the U.S. She was trained at Johns Hopkins University so I kind of have high expectations. :grinning:

My first appointment is Monday, Sept 27. Thankfully, this is also my first six months evaluation since my March 2021 diagnosis after donating blood. I guess at this point it’s not about confirming chronic HepB but monitoring it. The theory from my former provider and gastro is that it appears I may have contracted at birth given a few factors we discussed.

I recently learned that my daughter was vaccinated/immunized at birth with 3 doses. But I have no memory of this or memory of her pediatrician explaining it. But I feel so relieved that she was vaccinated/immunized.

All my blood work was fine; enzymes were fine; viral load was below 300; ultrasound was deemed “unremarkable” for liver, kidneys, stomach, and pancreas; and colonoscopy was fine. All resulted in no treatment.

I will share with the doctor concerns about discomfort (not pain) and the tingling (pins and needle sensation) basically throughout my whole body and very sharp pain across my right foot mostly. In fact, it seems closer I get to appointment day, the “weirder” my body feels.

Here are my questions:

  1. Can you still get liver damage with a low viral load?
  2. How likely is it that I could have some liver damage just 2-3 months after getting “unremarkable” ultrasound results?
  3. I read somewhere on internet that medication can, in some cases, reverse/heal scarring. Is this accurate based on your research and knowledge?
  4. Have either of you had “yellowish” skin on feet? I am not even sure I am seeing what I think I see. I think my body and brain are manipulating my visual impressions of my skin if that makes sense.

Finally, you answer so many questions for others, but how are you doing and coping?

As always, THANK YOU!


Great to hear, @hopefulone! Your results sound like the best you could hope for!

Thanks for your concern; I’m going OK, though still adapting to this ever-changing world and still trying to get work done :slight_smile: .

To answer your questions:

  1. People with a lower viral load are less likely to get liver damage, but it is still possible.
  2. Given your other results, it is very low probability that you’d have any significant liver damage in that time.
  3. Based on clinical trials, yes, it is correct that the majority of people on antiviral medications stop progressing in their liver damage and in the long-term the damage does reverse.
  4. I have never experienced this.

Hope this helps,

1 Like

I agree that even with low loads you can probably still get liver damage from hepatitis b. I also read that people with hepatitis b also got liver cancer without any cirrhosis or any major indicators to show liver cancer was forming.

That’s why I guess monitoring is important. Sadly liver cancer is very deadly and survival rate of 5 years is like 0-15%.


I agree with @Neptune. Regular monitoring by a knowledgeable health care provider is necessary to ensure that IF any problems arise (e.g. liver cancer) they are caught early when intervention is most beneficial. For many of us currently on oral antivirals, the risk of progressing to liver cancer is reduced, but not eliminated. That’s why we all still need to be monitored at least once a year if not more frequently, depending on one’s situation and recommendation of one’s health care provider. I have to admit that every time I go to see my liver specialist, I always wonder, “is this going to be the visit where I learn bad news?” I don’t suffer from anxiety, but there’s always little voice that asks the question. So even though I’ve been diagnosed with HBV for more than 30 years and seeing doctors that long, the question never goes away. Always, Joan

I agree with Joan. I get screened 2times a year. Blood and ultra sound. Everytime I check the results it’s like is it this time.

It’s like dodging the bullet 2x a year. Will I be in the 15-40% who will get liver cancer or hep b becoming serious? Will I be the 60% who won’t.

I guess it’s all just by random luck and gods will. Just get major anxiety after my screening and probably always will


Hi everyone. Met with my new health provider two days ago to establish a new patient relationship. I was diagnosed March 2021 so I’m at the first six month check-up for the blood monitoring. I need to get the blood work done but “passed” the first screening which is the physical examination of the abdomen area and listening to chest, throat, and back area with stethoscope. She said no mass was detected in liver area and did not hear any fluid commonly associated with cirrhosis. No jaundice. No other symptoms. I am grateful!

She stated that my back pain is coming from a mass of tight muscles in the middle of my back and suggested physical therapy. I used to workout more frequently and intensely in my old town including planks and other exercises that put strain on back, so maybe it’s catching up since my routine has slowed down.

But I still feel a bit stressed because I am listening to my body and what I’m feeling. We shall see what the blood tests say and then 6 month ultrasound in January.

Yes, it does feel like every 6 months the stress levels rise because of the impending news. Well, I hope God blesses me with good news for decades and decades to come AND the anxiety just may have to be the small price to pay.

But nothing about the visit worried my doctor so that must count for something. She agreed with the sentiments of my previous doctor that all things considered I am medically boring. I’ll take that.

I continue to take 3 mile walks, do light exercise, eat well, have faith, and think positive. Wishing everyone love, support, courage, and strength.