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Diease in the News

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Submitted By Morris69
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Disease in the News
Sharon Smith
HCS/245
May 21, 2012
Windy Tanner

Abstract
This article reviews recent developments in the evaluation and treatment of chronic Hepatitis B (CHB) based on articles published between December 2010 and January 2012. The article informs the reader of the natural history, screenings and vaccination, treatment indications and endpoints about Hepatitis B. In this article it gives a breakdown of all the new advances with Hepatitis B. This article will review the new recommendations for screening for Hepatitis B and for first-line antiviral medications to use for treatment. The article also gives information on the updated evidenced-based guidelines for the management of chronic Hepatitis B virus.

Disease in the News
It is estimated that over 350 million persons are infected with chronic Hepatitis B worldwide resulting in 600,000 deaths each year from cirrhosis and hepatocellular carcinoma. As over 90% of infected newborns will develop chronic hepatitis, efforts for eradication have focused on universal vaccination and screening those born in endemic areas. Despite the availability of Hepatitis B virus (HBV) vaccine since 1981, over 4000 cases of acute Hepatitis B virus are still being diagnosed in the United States each year and more than 700,000 have chronic Hepatitis B (CHB). Currently there are seven approved Hepatitis B therapies that can manage 95% of chronic Hepatitis B cases yet 67% of US patients and nearly 90% of European patients are unaware of their infection, highlighting the need for increased awareness and treatment to prevent deaths. (Tujios & Lee, 2012)
The goal of treating Hepatitis B includes antiviral therapy which it will suppress Hepatitis B virus DNA replication and reduce necroinflammatory activity to prevent progression to cirrhosis and hepatocellular carcinoma. In some countries such as the United States and Canada has shown lower disease prevalence, screening, and treating high-risk groups has been shown to be cost-effective and suggests that screening should include immigrants from areas with prevalence less than the currently recommended 2%. Currently there are seven approved therapies including a-2a interferon, pegylated interferon, lamivudine, adefovir, entecavir, telbivudine, and tenofovir. Pegylated interferon, entecavir, and tenofovir monotherapies have the highest efficacy and lowest risk for resistance and are recommended first-line treatment in native patients. Although the development of novel antiviral therapies has been slow, more information becomes available on the three preferred first-line therapies. Pegylated Interferon gives an approximate 30% of HBeAg positive patients that are treated with pegylated interferon will achieve HBeAg seroconversion though current ability to predict an individual's response is limited. Entecavir treatment provides long-term follow-up, studies continue to show that entecavir effectively suppresses HBV DNA incurring very little resistance. In over 100 patients followed for 3 years, 92.1% had undetectable HBV DNA, 43.9% had HBeAg seroconversion, and 92% had normal ALT levels. (Tujios & Lee, 2012) Tenofovir After 3 years of treatment with tenofovir monotherapies, viral suppression with HBV DNA less than 400 copies/ml was achieved in 72% of HBeAg-positive patients and 87% of HBeAg-negative patients with normalization of ALT in 74 and 81%, respectively. (Tujios & Lee, 2012) Tenofovir added to entecavir therapy was studied as a rescue strategy in 57 chronic Hepatitis B patients with multidrug resistance or prior partial response. (Tujios & Lee, 2012)
The natural history of chronic Hepatitis B in Mediterranean and African countries differs from much of Asia due to the predominance of genotypes A, D, and E as well as the more common mode of transmission being horizontal transmission during childhood. Less than a third of those infected during childhood will develop chronic Hepatitis B and most will lose HBeAg rapidly, 14–16% per year. (Tujios & Lee, 2012) The majority of those with elevated ALT levels and histologically active disease are HBeAg negative but are still at risk for cirrhosis and hepatocellular carcinoma. Chronic Hepatitis B is characterized by four phases: immune tolerance with the presence of Hepatitis B e antigen (HBeAg), high Hepatitis B virus DNA with normal alanine aminotransferase (ALT) levels and little liver damage; immune clearance with declining viral loads with elevated ALT levels corresponding to increased hepatic inflammation and fibrosis; an inactive carrier state with loss of HBeAg, low levels of Hepatitis B virus DNA and normal ALT; and reactivation phase with absence of HBeAg but elevated ALT, fluctuating Hepatitis B virus DNA and commonly procure or core promoter mutants. When the virus finally clears, Hepatitis B surface antigen (HBsAg) is absent from serum as in Hepatitis B virus DNA and any residual liver inflammation will be resolved, whereas cirrhosis does not.
The complications of chronic Hepatitis B can now be avoided and reversed with potent antiviral suppression of Hepatitis B virus DNA. For now, treatment is long-term and further studies are needed to discern whether sequential or combination therapy may be superior to current monotherapies for certain patients. Increased awareness should improve screening resulting in more frequent treatment and immunization of at-risk individuals toward eventual chronic Hepatitis B eradication. The article on The New Advances in Chronic Hepatitis B supports the safety and efficacy of potent antivirals with low development of resistance among a variety of patient populations. Increased awareness is needed for screening, treating, and vaccinating at-risk individuals for effective control of chronic Hepatitis B.

References
Tujios, S. R., & Lee, W. M. (2012, May 11). New advances in chronic hepatitis b. Medscape, pp. 3-5.

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