In late December of last year, I tested positive for HBsAg during a routine evaluation. My initial labs showed the following:
HBV DNA: 802 million IU/mL
HBeAg: Reactive
ALT: 120 U/L
Anti-HBs: Reactive
Given these findings, my doctor initiated Truvada therapy immediately without waiting for the typical 6-month window to assess for spontaneous clearance.
Follow-up Results:
After starting treatment:
HBV DNA dropped to 2,100 IU/mL
ALT increased to 389 U/L
AST rose to 90 U/L
Most recent labs (this month):
HBV DNA: Undetectable (<10 IU/mL)
ALT and AST: Returned to normal
I would like clarification on the following:
Was it premature to start Truvada without waiting 6 months to assess if my immune system could have cleared the infection naturally?
What are my current odds of developing long-term complications, such as liver fibrosis, cirrhosis, or hepatocellular carcinoma, given my early high viral load and rapid response to therapy?
Do I qualify to stop Truvada therapy, now that my viral load is undetectable and liver enzymes have normalized?
Hi @Takawa,
Welcome to the community. I don’t think it was premature for your doctor to start you on treatment, given that your results were abnormal, putting you at risk for severe liver damage. Getting them down to normal range is great. You will still be able to clear it, say it’s an acute infection.
To start, it’s great to get your numbers back to a normal range and undetectable levels for your viral load. We don’t know how long you have had this high viral load, so it is hard to say. But having it under control is good for future prognosis. Getting an ultrasound of your liver will be great here. It will tell the health of your liver and whether there is anything or damage to be worried about.
Finally, having an undetectable viral load and normal liver enzymes is not a recommended reason to halt/stop antiviral therapy. Rather, a loss of surface antigen, with undetectable viral load, normal AST/ALT, and liver image, are the tests used to make decisions about whether antivirals should be stopped or not. Please, remain under care, follow your treatment plan (s), and your doctor’s recommendations. Do not stop treatment on your own, as it could cause serious health problems.
Instead, antivirals are used to make sure your liver remains healthy. The heightened ALT levels in your first tests indicate significant liver inflammation, which can be eventually controlled by antiviral treatment. This is consistent with the EASL clinical guidelines.
Acute hepatitis B usually resolves spontaneously in most adults, with HBsAg clearance in over 95% of cases.5 Thus, further improving the HBsAg loss rate through antiviral therapy is unlikely and has not been documented. A randomised, placebo-controlled study in India demonstrated no advantage of lamivudine over placebo in acute hepatitis B.464 Conversely, a study from Asia reported improved clinical outcomes, including reduced mortality, with lamivudine in 80 patients with severe cases, including patients with impaired coagulation.465 A European placebo-controlled study in patients with severe hepatitis without liver failure could not be completed due to insufficient recruitment. However, the available data did not demonstrate any survival or transplant benefit in severe cases (defined as prothrombin time >50%, corresponding to an INR <1.5), although this conclusion is based on a low number of cases.466 A meta-analysis covering different degrees of severity of acute HBV infection concluded that antiviral therapy is not generally recommended for acute HBV infection at present.467
However, case reports and case series suggest that early antiviral NA therapy in patients with fulminant hepatitis B (characterised by signs of liver dysfunction and occurring in 0.1–0.5% of adult cases) significantly reduces the need for transplantation. This is in contrast to historical controls, where 50–80% of untreated patients required transplantation.468–470 Of note, patients with fulminant hepatitis B were underrepresented in the aforementioned meta-analysis.467
It really depends on whether you clear it or not. If you become HBsAg negative within the next few months, the risk of additional complications of fibrosis or liver cancer are negligible.
No, the guidelines recommend that you should remain on antiviral therapy until you have consistent negative HBsAg tests.
Ten months ago, I tested positive for Hepatitis B during a routine clinic check-up. My baseline labs showed HBV DNA of 802 million IU/mL, AST = 38 U/L, ALT = 120 U/L, HBeAg positive, and Anti-HB positive.
I was started on Truvada, which I have been taking to date. In March, I repeated my LFTs — AST was 75.1 U/L and ALT 298.7 U/L, while HBV DNA had dropped to 2,118 IU/mL.
In the June follow-up, both AST and ALT were normal, HBV DNA was undetectable, and Anti-HB remained positive (2.8 titre).
In the last two months, my HBsAg has become negative, but I’m yet to do the remaining tests scheduled for December.
Hi @Takawa , the guidance I have heard is to continue taking your antivirals for a minimum of 6 months after surface antigen becomes negative. After that point, you may be able to talk to your doctor about stopping (but please do not stop unless your doctor says it’s okay to)!