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Guideline on prevention and treatment of chronic hepatitis B in China (2005)

2023-03-03 来源:易榕旅网
维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24).'2159—21 73 2159 Guideline GuidelGui eline on prevention and treatment atment of oi chroniehronic hepath ittisis B in China(2005) Chinese Society of Hepatology,Chinese Medical Association and Chinese Society of Infectious Diseases, Chinese Medical Association 厂 hronic hepatitis B is one of the most common \-一,epidemic diseases in China and has become a maior health issue.To help standardize hte prevention。diagnosis, and treatment of chronic hepatitis B.the Guideline on prevention and treatment of chronic hepatitis B(abbr. Guideline)was created by a group of appropriate experts belonging to hte Society of Hepatology and hte Society of Infectious Disease,the Chinese Medical Association according to the principles of evidence—based medicine using the latest clinical research data.The evidence used to formulate the recommendation has been classified into 3 classes and 5 grades,which are indicated by Roman numerals in bI.ac ts.1 一 It should be noted that the Guideline is not mandatory, only aims to offer advice to clinicinas in order to make an appropriate decision in the prevention,diagnosis,and treatment of chronic hepatitis B,and it could not be including all issues in the diagnosis and treatment of chronic hepatitis B.Therefore,facing an individual patient,the clinicians should rely on their own knowledge nad experience to determine the optimal treatment regimen based on fully understanding the best clinical evidence and current available medical resources of this disease,as well as the patient’s medical condition and his willingness. ETIOLOGY Hepatitis B virus(HBV)belongs to the family of hepadnaviruises.Its genome consists of approximately 3200 base pairs with relaxed ckcular and partially d0uble—stranded DNA. After entering the human b0dV,HBVs aRach to the receptors on hepatocyte membranes.Before penetrating into the cytoplasm,the virus envelope is removed.In the hepatocyte cytoplasm.HBVs remove the capsid and release the circular and partially double—stranded DNA into the hepatocyte nucleus.Wiht the help of the host cells’enzymes.the positive—sense strand is elongated w1th negative—sense DNA as the template.After the fissure in hte positive—sense strand is patched,the viral genome is converted into covalently closed circulra DNA(cccDNA) hTe cccDNA is the template for transcribing into various utRNAs using host cells’RNA polymerase.The 3.5 kb mRNA.which includes all of the genetic information,is called the pregenomic RNA.After exporting from the nucleus into the cytoplasm.the pregenomic RNA is used as the template to synthesize the negative sense DNA by viral reverse—transcriptase.Then,the negative strand DNA acts as the template for the synthesis of positive—strand DNA.The new HBV particle is released after the filial partially double—stranded DNA is synthesized and packaged.The filial circular,partially double stranded DNA may also enter into the hepatoceIlular nucleus and form CCCDNA.Due to CCCDNA's long half-life.it is dififcult to totally eliminate itfromtheb0 . ,。 一 hTere are 4 partially overlapped open reading frames:the pre S/S region,the pre C/C region,the P region,and the X region.The pre S/S region encodes the lrage(pre S 1. pre S2,and S),middle(pre S2 and S),and small(S) surface antigens.The Pre C/C region encodes HBeAg and HBcAg.The P region encodes polymerase,while the X region encodes X protein. Mutations in the pre C region and the basic core promoter (BCP1 region may result in an HBeAg—negative mutant. hTe most frequent mutation in the pre C region is the G 1 896A point mutation.which results in terminal codons (TAG、and does not express HBeAg.The most rfequent mutation of the BCP region is the A1762T/G1764A combined point mutation,which reduces the synthesis of HBeAg by selectively suppressing the transcription of pre.C mRNA . hTe mutation on the P gene is mainly in hte POL/RT gene (349—692 aa.rt1—-n3441.The most frequently occurring mutation during lamivudine treatment is YMDD variation. which results in YMDD changing to YIDD(rtM204I)or t0 YVDD(rtM204V).TIlis YMDD variation can be complicated by an rtl 80M mutation.and becomes the predominant resistant variant due to the drug selection pressure. Mutation of the S gene may result in occult HBV infection.wiht negative HBsAg and low levels of replication(usual serum HBV DNA levels<1 copies/m1). Based on the definition of divergence of the whole HBV genome sequence 8%or variance of the S gene sequence 4%,HBV is classiifed into 8 genotypes rfom A Correspondence to:Prof.ZHUANG Hui,Department of Microbiology,Peking University HealtIl Science Center,Beijing 100083,China(Email:zhuangbmu@126.com) 维普资讯 http://www.cqvip.com 2160 to H.The genotype is further divided into subgenotypes. Genotype A has a higher response rate to interferon than genotype D;geno ̄ pe B has a higher response rate to interferon than genotype C.。However,the effects of genotype on treatment response to nucleot(s)ide analogs are stil】unknown. Mutations are often observed in HB V.There is often a group of variants with the predominant mutants (quasispecies)in the host.The clinical signiifcance of this ifnding is still under investigation. HBV is comparatively stable in the environment.It can be deactivated by heating at 65。C for 10 hours,by boiling ofr 10 minutes,or by autoclave.HBV is easily deactivated by chlorine,ethylene oxide,glutaraldehyde, peracetic acid,and iodophom. EPⅡ)EMIoLoGY Although there is a worldwide distribution of HBV infection,the infection rates are quite different in various raeas.It was reported bv WHO that over 350 million people have chronic HBV infection and 2 billion people have been infected by HBV Approximately 1 million HBV patients die annually, such as hepatic decompensation,cirrhosis and hepatocellular carcinoma (Hcc). Ifl China,the HBV prevalence is high.The HBsAg carrier rate among the general population is 9.09%:the rate among the vaccinated population is 4.5l%.and 9.51% among the unvaccinated. The prevalent serotypes of HBV in China rae adrq+and adw2+;while seldom found. ayw3 is found mainly in Xinjinag,Tibet and Inner Mongolia autonomous regions.The prevalent genotypes in China rae C and B.。 HBV is mainly transmitted by transfusion of blood or blood products,perinatal exposure,sexual exposure,and close person-to-person contact involving open cuts of the skin or mucous membranes. Perinatal exposure, particulraly exposure to maternal blood or body fluid during delivery,is the most important factor leading to newborns infected from their HBV-positive mothers(I1. Percutaneous transmission often occurs due to exposure to non—sterilizeddical devices or syringes,invasive . procedures(II一21, …or the intravenous drug usage.Other potential exposures include:tattooing,puncturing, accidental exposure among healthcare workers,and by sharing a razor or tooth brush with HBV-positive persons. hTe infection risk is significantly increased among those who have sexual contacts with HBV-positive pemons(ⅡI), especially those who have multiple sexual partners(I). However,infection risk factor due to the transfusion of blood or blood products has been decreased since strict HBsAg screening of blood dono ̄are performed. HBV is not transmitted by routine contacts,such assharing an office,including computers or stationery; Chin Med J 2007 J20r24J 2J59—2173 shaking hands;hugs;sharing a dormitory;having meals together;and sharing the bathroom without exposure to blood.No evidences are found that insect bites can spread HBV infection. NATURAL HISToRY Chronic hepatitis B infection is defined as the presence of the HBV for more than 6 months after the initialinfection hTe age at the time ofHBV infection is the primary risk factor relating to progression to chronic infection;90%0f those exposed perinatally develop chronic infection(I),“ while 25%-30%of childrenwho are exposed to HBV develop chronic infection.There are 3 phases in the natural history of HBV infection:the immunotolerant phase,the immune clearance phase,and the inactive or . low/non—replication phase.“The immunotolerant phase is characterized by rapid HBV replication,presence of both HBsAg and HBeAg in serum。elevated serum HBV DNA (>10 copies/m1),persistently normal alanine amino— transferase(ALT)leve1.and liver biopsy shows no obvious changes.In the immune clearance phase.HBV DNA is still greater than l(1j copies/m1.but lower than in the imunotolerant phase, with persistently or intermittently elevated serum ALT/AST levels. inflammation and necrosis features by liver biopsy.In the inactive or low/non—replication phase。HBeAg is negative, anti.HBe is positive.HBV DNA in serum is undetectable (by PCR assay)or under the sensitivity of detection,the serum | T levels are normal and less or no inflammation in liver. Only 5%一10%of adolescents and adults develop chronic HBV infection after an acute infection.Usually there is no immunotolerant phase in adolescents and adults.、Ⅳhen they develop active chronic hepatitis B。they have the characteristics of the immune clearance phase which is ofllowed by the inactive or low/non.replication phase,as the patient has relief of liver disease.In the inactive or low/non—replication phase.hepatitis may reoccur with conversion to positive HBeAg.However,if there is a mutation in the precore or core promoter region, HBeAg—negative hepatitis may occur.Recurrence of active chronic hepatitis B can be observed in patients infected during perinatal periodearly,early childhood, adolescent,and adult patients as wel1. hTe rate of developing inactive or low/non—replication statue 5 and 1 0 years later among HBeAg—positive children and adult patients are 50%and 70%.respectively (II一3。II.21.”'J In China.as well as the Asia Paciifc region,the natural history of the inactive or low/non— replication statue has not been fully documented,though there isevidence of recurrence of hepatitis in these 。patients. A prospective study involving 684 chronic hepatitis B patients found that progression to cirrhosis occurs at an annual rate of 2.1%.”A follow—up study of HBeAg.negative chronic hepatitis B patients for an average of 9 years(range 1.0-18.4 years1 showed that the incidence of cirrhosis was 23%and that of HCC was 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24).'2159—21 73 4.4%. ’“The risk factors for cirrhosis include:high viral load;persistent positive HBeAg;high or fluctuating ALT levels;alcohol consumption;and co—infection with HCV HDV,or HⅣ(I). ”HBeAg—positive patients have a higher risk of cirhosis than HBeAg.negative patients (11-2). , 。, 一 一 一 For chronic hepatitis B patients,the annual incidence of decompensated cirrhosis is about 3%. while the cumulative 5一year incidence is about 16%. The 5一year mortality rates in chronic hepatitis B patients without cirrhosis,with compensated cirrhosis and decompensated cirrhosis are 0—2%. 1 4%-20% and 70%-86% respectively.The related risk factors includeage。serum level of albumin,serum level of bilirubin,platelet count. nad splenomegaly.… (II一2)HBeAg seroconversion。 whether spontaneous or after antiviral therapy,conversion to a permanent HBV DNA—negative status, and persistently normal levels are correlated with improved survival(I,II一31.… HBV infection is an important factor for the development Of HCC.The incidence of HCC is significantly increased in patients with both HB sAg..and HBeAg..positive compared to patients wiht HBsAg.positive only(II一21.‘‘ Predictors for the occurrence of HCC in cirrhotic patients are"age,male gender,alcohol abuse,aftatoxin exposure. HCV or HDV co—infection.persistent hepatic inflammation.continued HBeAg—positive and persistently high HBV DNA levels r>1 copies/m1).…In those infected before 6 years of age.about 25%develop cirhosis or HCC in adulthood(II一21. Some HBV related HCC patients have no cirrhosis evidence.A family history of HCC is another predictor of progression to HCC。but。given the same genetic background,a high HBV load is more important wiht respect to HCC development(II.31. PREVENTIoN HBV vaccinatiOn HBV vaccination is the best way to prevent HBV infection.In 1992,HBV vaccination was added to the regulations of the National Immunization Program(NIP) by the Chinese Ministry of Health.At that time,all newborns were to be vaccinated against HB V.howeve ̄ hte parents had to bear the cost.In 2002,HBV vaccination was integrated into the expanded program of immunization.and the vaccine was supplied free of charge,with the parents having to pay only for administration.Since June 1。2o05,HBV vaccination is completely free. The primary HBV vaccine recipients are newborns. Secondary HBV vaccine recipients include infants and high risk populations,such as healthcare workers, personnel who may contact blood,staff who care for babies,organ transplant recipients,recipients of blood or blood products.immunosuppressed persons,those at risk for trauma.family members of HB sAg—positive persons, 216l homosexual gay,individuals who have multiple sexual partners,and injection drug users.The complete immunization schedule consists of 3 shots:vaccination at month 0,1,and 6,after receiving the first dose of vaccine at month 0,the recipients should be administered their 2nd and 3rd doses with an interval of 1 and 6 months .Newborn babies should received their first dose within 24 hours after birth,earlier administering of HBV vaccine will increase the protective efifcacy.In newborns,the vaccine should be injected into the anterolateral muscles of the thighs,while in children and adults,the middle part of the deltoid muscle is appropriate.Newborn and infant should receive 5 gg or 1 0 gg of recombinant yeast hepatitis B vaccine,the dose for adults is 10 gg or 2O LLg. Meanwhile new born and infant should receive 1 0 LLg Of Chinese hamster oocyte(CH0)vaccine and 2O LLg for adults.Eighty—seven point eight percent of infants are prevented from acquiring HBV infection from their mothers by administering HBV vaccine alone(II一31. hTe combined HBIG and HBV vaccine will enhances signiifcantly the blocking effect of HBV transmission rfom mother to newborn.Infants born to mothers who are HB sAg positive should receive hepatitis B immune globulin(HBIG)within 24 hours after bitrh,better within 1 2 hours after delivery for effective postexposure immunoprophylaxis to prevent perinatal HBV infection (II一31. The dose of HBIG should be>100 IU. Meanwhile,the first shot of 1 0 gg of recombinant yeast hepatitis B vaccine or 20 LLg Of CHO hepatitis B vaccine should be inoculated at another site. Alternatively。when the first injection of HBIG and hepatitis B vaccine are given within 1 2 hours after delivery.it can be followed by a second HBIG 1 month later in combination with recombinant yeast 1 O g or CHO vaccine 2O g injected at another site.The interval between the first and second, and between second and third vaccination are 1 month and 6 months separately. 乃ile the second strategy is not as easy to be conduct as the first one,its protective rate is better.A newborn can be breast..fed by an HBsAg.. positive mother after receiving both HBIG and HBV vaccine injected within 12 hours after delivery fIII). Newborns of HBsAg.negative mothers should receive 5 LLg recombinant yeast vaccine or 1 0 g CHO vaccine. Vaccination is necessary for children who have not been vaccinated as newborns.The recommended dose for children is 5 gg recombinant yeast vaccine or 1 O g CH0 vaccine.For adults,the recommended dose is l O g recombinant yeast or 2O g CHO vaccine. For non—responders,the dose and frequency of the injections should be increased.If there is no response after completing the 3一dose series of hepatitis B vaccine, another 3一dose series should be given,and the recipients should be tested for anti—HBs 1—2 months after completing the second 3一dOse series After I.0utine vaccinatiOn,in individuals whO I.espOnd adequately,me pmtectiVe response usually lasts for at least 1 2 years, so periodic anti—HB s testing is not 维普资讯 http://www.cqvip.com

2162 recommended nor are booster doses of vaccine in the general population.However,in high—risk groups, anti—HB s monitoring is useful,and a booster dose of vaccine should be given if anti—HBs is lower than 1 0 mIU/ml fIII). HBV transmission route prevention Use of safe injection techniques,as well as sterilization of dental instruments and endoscopes,are quite important to prevent HBV transmission.Health care workers should follow the standard management’s procedure for prevention of nosocomial transmission,wearing gloves while touching blood,b0dV fluids,and secretions of patients to eliimnate iatrogenic infection.Tools used for hair cutnng, shaving,pedicuring,punctunng, and tattooing should be sterilized after use.Do not share razors and tooth brushes.If the sexual partner is HBsAg—positive.HBV vaccine should be given to this individua1.For individuals with multiple sexual partners. periodic screening for HBsAg and anti—HBs is needed. and condoms should be used during sexual intercourse. For HBsAg—positive pregnant women.in order to reduce hte neonate’s risk of exposure to the mother’s blood. every effort should be made to avoid amniocentesis,to keep the integrity of the placenta,and to shorten the duration of delivery. Prevention after accidental exposure to HB、厂j The following procedures should be ofllowed in the event of accidental exposure.(1)Serologic testing:HBsAg. nati—HBs.and ALT levels should be checked immediately after exposure and rechecked within 3-6 months.(21 Active immunization and postexposure imuno— prophylaxis:There is no need of treatment ofr those who have been vaccinated and have anti—HBs>l 0 mlU/m1. For those who have not been previously vaccinated or have been vaccinated but with anti—HBs<10 mlU/ml or hte anti.HBs level unknown.HBIG 200-400 IU should be iniected imediately after exposrue and.at the same time,HBV vaccine(20 g)should be inoculated at naother site.The 2nd and 3rd doses of vaccine(20 g) should be given 1 and 6 months later. Management of patients and carriers According to the Law for Prevention and Control of Communicable Diseases of the People’s Republic of China,all health care workers have the responsibility to report the case to their local Center for Disease Control fCDC in time when an acute or chronic hepatitis B patient was diagnosed,and the case should be registered either as acute or chronic Hepatitis B.Family members and close contacts of the patient should be advised to be tested for HBsAg. anti—HBc。 and anti—HBs.The individuals with negative for the 3 markers should be vaccinated. Whether an acute or a chronic HBV patient should be hospiatlized is determined by the severiyt of disease.The rooms for HBV patients should be sterilized.All medical equipment and utensils contacted by patients,such as Chin MedJ2007;120(24):2159—2173 needles,surgical instruments,probes,endoscopes,and dental bits,should be sterilized,especially those contaminated by blood. Chronic HBV careers nad HBsAg carriers(referred to in me Guideline under section 5‘Clinical diagnosis’、can continue to have a nOlTllallife as usually healthy people. except that they must not donate blood or work in the particulra occupations specified by law.A11 such individuals require to be followed up. hTe infectivity of chronic hepatitis B patients and careers is based on their HBV DNA level rather than the level of ALT/AST,and bilirubin levels.Follow—up requirements rae referred to in section 2 1(‘Follow—up’)of the Guideline. Clinical diagnosis hTe diagnostic criteria for chronic hepatitis B include a history of hepatitis B or positive HBsAg for at least 6 months and the continuing presence of HBsAg and/or HBV DNA in the serum.The diagnosis of HBV infection is based on serologic markers,virologic markers.1iver function test,biochemical assays。as well as other clinical and supportive findings. ChronichepatitisB (1)HBeAg—posiitve chronic hepatitis B:Patients with serum HBsAg—positive,HBV DNA—positive, and nati—HBe—negative, may also have persistently or intermittently elevated levels or histologic evidence of liver damage. (2)HBeAg—negative chronic hepatitis B:Patients wim serum HBsAg positive。HBV DNA—positive. and persistently HBeAg—negative.The serum anti—HBe may be positive or negative,and they may have persistently or intermittently elevated ALT or histologic evidence of liver damage. Based on the results of biochemical tests and their clinical ifndings,these 2 types of chronic hepatitis B can be classified into mild.moderate。and severe respectively. Cirrhosis caused by hepatitis B Cirrhosis is a sequel of chronic hepatitis B:Both diffuse ifbrosis and pseud0l0bulati0n must be present on pathological examination to make the diagnosis. f 1 1 Compensated cirrhosis:Patients are generally in Child-Pugh class A,with mild fatigue,anorexia,or abdominal distension;they have abnormal nad AST levels without evidence of decompensation.Portal venous hypertensive symptoms,such as hypersplenism and mild esophagogastric varicosity,are present without variceal bleeding,ascites,or hepatic encephalopathy. (2)Decompensated cirhosis:Patients are generally in Child—Pugh class B or C,and esophagogastric variceal 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24):2159—21 73 bleeding,ascites,and hepatic encephalopathy are usually present.Decompensation is indicated by serum albumin <35 g/L,bilirubin>35 txmol/L,elevated ALT and AST levels.and PTA<60%. Patients with compensated and decompensated cirrhosis are further divided into active and the quiescent phase, based on the criteria of the‘Principles of treatment and prevention of viral hepatitis’.2O01. Carrier (1)Chronic HBV carrier:The patients are characterized by being serum HBsAg—positive,HBV DNA—positive, nad either HBeAg—positive or anti—HBe—positive.Thev have persistently normal ALT and AST levels at least 3 times over a l—year period and normal liver histology documented.Liver biopsy is recommended for HBV DNA—positive individuals to confirm the diagnosis and to guide treatment. (2)Inactive HBsAg cariter:The patients rae characterized by being serum HBsAg—positive,HBeAg-negative,and either anti—HBe positive or negative.The HBV DNA is undetectable(PCR、or is under hte sensitivity of detection hTe serum ALT levels have been documented to be normal at least 3 times in a l—year period.The Knodell hepatitis activation index(HAI)is<4,or minimal damage is documented using other semi—quantitative scoring systems ofr liver biopsy specimens. Occult chronic hepatitis B In these patients.there are clinical manifestations of chronic hepatiits B wiht serum HBsAg negative,but HBV DNA is positive in the serum and/or liver tissue.In some patients, serum anti—HBs, anti—HBe, and/or nati—HBc may be positive.About 20%occult chronic hepatitis B patients are characterized by HBV DNA positive and other serologic testing negative.The diagnosis is established after ruling out other(viral or non—vira1)causes of liver damage. LABoRAToRY TESTS Biochemical tests ALTandAST Generally,serum ALT and AST levels reflect the extent of hepatocellular damage and are most frequently used to assess liver function. Bilirubin hTe serum bilirubin level is associated with the extent of hepatocellulra necrosis.Elevated serum bilirubin levels should be differentiated from cholestasis that can occur both within and outside the liver.Serum bilirubin rises markedly and keeps rising in patients with liver failure. hTe total serum biliurbin is often greater than 10xULN (the upper liimt of norma1)and the daily increment is greater than 1 xULN.Sometimes,the bilirubin diverges rfom hte aminotransferase levels. 2163 Prothrombin time f PT1 and prothrombin time activity percentage rP ) PT is an indicator of blood coagulation factor synthesis. frr.usually reported as m.is an important predictor of disease progression and prognosis.PTA level that continues to drop below 40%over a short period of time is one of the most important diagnosis criteria of liver failure.P1 A falling below 20%is a marker for unfavorable prognosis.INR(international normalized ratio,INR)is also used;an increased INR has the same predictive value as a decreased m. Cholinesterase(ChE) Cholinesterase is an index of hte liver’s synthetic function nad is used to evaluate disease progression. Serum album Serum albumin is another index of synthetic liver ufnction.In patients with chronic hepatitis B,cirrhosis, and hepatic decompensation, serum albumin may decrease and globulin may increase.The ratio of serum albumin to globulin also may decrease. Alpha&toprotein lAFP1 is used for HCC screening A significantly elevated is a predictor of HCC but can be observed after massive hepatocyte necrosis.An increase of AFP level also occurs as the result of hepatocyte regeneration after massive hepatocyte necrosis and is used to predict patient prognosis.The increment level and duration of AFP elevation,the pattern of fluctuation,and the relationship between the trends of AFP and aminotransferase should be correlated with clinical manifestations and imaging ifndings. Serological detectioils of HBV Serological markers of HBV consist of HBsAg,anti—HBs, HBeAg,anti—HBe,anti—HBc,and anti—HBc IgM.Enzyme immunoassay (EIA), radioimunoassay (RIA), imcrosome enzyme imunoassay(MEIA). and chemiluminescence are common approach to detect these markers.HBsAg positive means that HBV infection is present.Patients who are positive for the protective natibody,anti—HBs,have immunity against HBV Thus, individuals who have recovered from chronic hepatitis B nad those who have been vaccinated against HBV are nati—HBs—positive.HBsAg seroconversion is defined as hte loss of HBsAg and the presence of anti—HBs.A positive HBeAg is the result of HBV replication and implies infectivity. Anti—HBe represents low HBV replication,except for mutation of the precore region. Loss of HBeAg and tlle presence of anti—HBe are referred to as HBeAg seroconversion.During acute hepatitis,a positive anti一}IE}c IgM indicates HBV replication.110tal Anti—HBc is associated wiht nati—HBc IgG and it remains positive after HBV infection.whether or not the HBV infection clears. To determine whether the patient is coinfected with HDV, HDAg,anti—HDV,anti—HDV IgM,and HDV RNA 维普资讯 http://www.cqvip.com

2164 testings are needed Tests of HBV DNA,genotype,and mutants33m Quantitative and qualitative tests ofHBV DNA These tests indicate the virus’s replicative activity.Thev are used to diagnose chronic HBV infection,monitor serum HBV DNA levels.and monitor the response to antiviral therapy. HBVgenotyping test Genotyping tests include:(1)genotypic speciifc primer PCR,(2)restirction fragment length polymorphism (RFLP),(3)INNO—LiPA,(4)PCR hybridization ELISA. and(5)gene sequencing.Now no HBV typing kit is authorized by State FbOd and Drug Administration.China (SFDA). 一 Detection of resistant mutants hTe usual tests for detection of resistant mutants include: (1)sequencing analysis of polymerase gene,(2)RFLP,(3) quantitative fluorescent real time PCR,(4)Inno—LiPA, etc. DIAGNoSTIC IM_AGING Ultrasound,computed tomography(CT),and magnetic resonance imaging(MRI)of the liver,gallbladder,and spleen are used to screen for HCC and in the differential diagnosis and monitoring of the progression of chronic hepatitis B. PATHoLoGY The histological characteristics of chronic hepatitis B include visible inflammation in the portal triad.The infiltrating cells are predominantly lymphocytes.with few plasmocytes and macrophages.The aggregation of the infiammatory cells usually results in the expansion of the portal triad and the destruction of the interface.which is referred to as interface hepatitis or piecemeal necrosis, and is the characteristic change seen in active chronic hepatitis B. With the progression of hepatitis. hepatocellular degeneration and necrosis within the lobules worsens.Necrosis and interface hepatitis may result in an excessive deposition of collagen in the liver and fibroseparation formation.Cirrhosis occurs once chronic hepatitis B patients develop Dseudolobules. hTe expression of HBsAg and HBcAg in hepatocytes can be detected by immunohistochemical assays.Cytoplasmic or membranous type HBsAg and HBcAg expression represent active HBV replication.The inclusion bodv t、,pe and peripheral type of HBsAg expression,as well as the nuclear type of HBcAg expression are evidence of the presence of HBV within hepatocytes. The necrosis grades and fibrosis stages of chronic hepatitis B are listed jn“Principles of Treatment and Prevention of Viral Hepatitis”.2000. Today.to evaluate the severity of necrosis and fibrosis,as well as to monitor therapeutic effects,the Knodell hepatic activity index Chin MedJ 2oo7:j2o(241:2j59.2i73 (HAI)scoring system is more frequently used worldwide than semi—quantitative systems, such as the Ishak, Scheuer,and Chevallier scoring systems. ・ OVERALL OBJECTIVES OF TREATMENT In chronic hepatitis B patients.the overall phiectives of treatment are to maximize sustained suppression and clearance of HBV as well as to relieve necroinflammation and fibrosis.The reduction and prevention of complications, such as hepatic decompensation.cirhosis,and HCC.will improve patients’quality of life and prolong surviva1. The treatment of chronic hepatitis B includes antiviral therapy,immunomodulating,anti—inflammatory,and protective therapy. as well as antifibrosis and symptomatic treatments. Among these modalities, antiviral therapy plays the key role and.therefore.should be used whenever it is indicated and available. GENERAL INDICATIoNS FoR ANTIVIRAL THERAPY3 - Generalindications for antiviral therapy include:f l HBV DNA 1 0 copies/ml( l 0 copies/ml for HBeAg— negative patients);(2)ALT 2×ULN(AI r 1 0×ULN, biliurbin<2xULN for those treated with interferon);r3) ALT<2xULN, but Knodell HAI >4 or necroinflammation on liver biopsy>G2. Patients with indication(1)and either(2)or(3)should receive antiviral therapy.Those who do not meet the criteria should be carefully monitored.If the patient has persistently positive HBV DNA and abnormal ALT levels, then antiviral therapy should be considered. Elevated ALT levels can be caused by drugs.alcoho1.and other factors that should be ruled out.It should be noted that,after stopping drug treatment,ALT levels may return to norma1.In certain patients with cirhosis,the AST level is higher than the level;in these cases.the AST levels should be considered. RESPONSES TO ANTIVIRAL TREATMENT3’・ Responses to antiviral treatment have different categories and various classificatiOns. Category of response Virological response Serum HBV DNA is undetectable(PCR),or is under the sensitivity of detection,or lower than 2 lOglO below the base line. Serological response SerOcOnVersiOn of HBeAg or HBsAg Biochemical response Serum AI /AST level returns to normal 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24).'2159—21 73 Histological response Necroinflammation or fibrosis improves to a certain leve1. Time order of response Initial response This response occurs at the 1 2th week of treatment. End—of-treatment response hTis response occurs at the end of a defined course of therapy. Sustained response hTe response is sustained without relapse for 6 or 1 2 months after stopping therapy. Maintained response HBV DNA continues to be undetectable(PCR)or below the lower limit of detection.or the serum ALT level remains normal on antiviral therapy. Breakthrough hTe HBV DNA level increases or becomes positive again after undetectable while receiving treatment after achieving initial response and the ALT level may be increased or norma1.Sometimes,breakthrough also refers to an increase in the ALT/AST levels.rather than an increase in the HBV DNA level;however.other causes f0r the elevated ALT/AST levels should be ruled out. Relapse Following an end—of-treatment response.the HBV DNA again increases,or becomes positive again after the stopping therapy.Sometimes,relapse refers to elevated ALT/AST levels instead of elevated HBV DNA levels; however,other causes for the elevated ALT and AST levels should be ruled out. Combined response Complete response(CR) After treatment of HBeAg—positive chronic hepatitis B patients、ALT levels return to normal,HBV DNA(PCR) is undetectable,and HBeAg seroconversion occurs.After treatment of HBeAg。negative chronic hepatitis B patients, A【 levels return to norma1.and HBV DNA(PCR1 is undetectable. Partial response(PR) Response is between CR and NR.After treatment of HBeAg—positive chronic hepatitis B patients,ALT levels return to norma1.HBV DNA is<10 copies/rnl,but there is no seroconversion. Non—response(NR) None of the above responses occur INTERFERoN A meta—analysis study found that,in HBeAg—positive patients after 4-6 months of conventional IFN treatment, the proportions of HBV DNA negative patients (hybridization method)in the treated group and the 2165 control group were 37%and 1 7%.respectively.The HBeAg serOcOnversiOn rates were 33% and l 2%. respectively,while the seroconversion rates for HBsAg were 7.8%and 1.8%.respectively.The therapeutic effects are positively correlated to the baseline serum ALT levels and the severity of histological liver iniury.Four randomized, controlled studies of HBeAg。negative patients showed that end—of-treatment response rates ranged from 38%to 90%.However.sustained response rates ranged from 10%-47%(mean 24%1(I1. It was reported that,to achieve better results,conventional IFN therapy will need to be administrated for at least l year (II). 一Some chronic hepatitis B patients treated with conventional IFN(5 MU subcutaneous iniection daily1 developed elevated ALT levels.and a few of them developed iaundice.In chronic hepatitis B patients with compensated cirrhosis treated by conventionaI IFN.the incidence of hepatic decompensation was less than 1% (II).45 一 In a multinational,randomized,controlled trial,HBeAg— positive chronic hepatitis B patients(87%Asian1 were treated with PegIf 、『 .2a(40 kD1 for 48 weeks and ofllowed—up for 24 weeks after off treatment.The HBeAg seroconversion rate was 32%. Using the same regimen.HBV DNA<2x10 copies/ml was found in 43% of HBeAg—negative patients(60%Asian). A phase II clinical trial done in the Asia Pacitic area showed that.in patients treated with PeglFNct一2a(40 kD1.once per week f0r 24 weeks.the HBeAg seroconversion rate was higher than in patients treated with conventional IFN (32%:25%.P<0.051 at the 24th week of off treatment follow—up. After PegIFNct一2b (1 2 kD) given as monotherapy or in combination with lamivudine for 52 weeks,after 26 weeks of off treatment follow.up,the HBeAg seroconversion rates of both groups were 29%.。 PegIFN 。2a(40 kD1 has been approved for the treatment of chronic hepatitis B by SFDA. Chronic hepatitis B patients who relapse after conventional IFN treatment may still respond to conventional IFN (II1. , Other subtypes of conventional interferon ,PegIFN ,and nucleot(s)ide naalogs can also be useful(III). Predicting response to interferon therapy Patients treated with interferon have a better response in the presence of the following:(1 1 elevated ALT level before start of treatment;(21 HBV DNA<2x l 0。 copies/ml;(3)female gender;(4)short course of disease; (51 not mother to infant transmission;(6)having mild liver fibrosis;(7)having good compliance with therapy; (81 no coinfection.Serum HBV DNA and ALT levels before the start of treatment and the patients’gender are the main predictors of successful treatment(II). 。 Early virological response at the 1 2th week also predicts a good therapeutic effect. Monitoring and follow-up of interferon therapy Before the star[of therapy,the following should be 维普资讯 http://www.cqvip.com

2166 obtained:(1)serum ALT,AS T’bilirubin,albumin and renal function tests;(2)routine blood tests,thyroid function tests;blood glucose,and routine urinalysis;f3) HBv markers,such as HBsAg,HBeAg,anti.HBe,and baseline HBV DNA levels;(4)ECG and blood pressure should be monitored in middle—age patients; r51 autoimmune diseases should be ruled out;f6)urinary HCG levels should be measured to rule out pregnancy. During therapy,the following tests should be monitored: (1)routine blood tests,once every 1—2 weeks for the ifrst month,then once per month until cessation of treatment; (2)ALT and AST levels,once per month for 3 months, nad then once every 3 months depending on patient’s situation;(3)virological markers,including HBsAg, HBeAg,anti—HBe,and HBV DNA,once every 3 months; (4)other tests,such as thyroid function,blood glucose, routine urinalysis,once every 3 months.For patients who has abnormal thyroid function at baseline,appropriate therapy should be initiated.and thyroid function should be closely monitored during antivirla therapy;(5)mental StatuS should be evaluated petitdicaHy;treatment should be discontinued and the patient should be closely monitored if there is evidence of depressive disorder or suicida1 ideation. Adverse events and management of interferon therapy Flu—like symptoms Fever,chills,headache,muscle soreness,and fatigue may OCCUE Symptoms can be reheved by co—administration of naalgesic drug or IFN injection before sleep.The lfu—like symptoms will be ohen resolved during the course of rteatment. Temporarybonemarrowdepression Leucopenia(neutropenia) and thrombocytopenia are usually observed.The dose of interferon should be reduced when the neutrophil count is below 1.0x l 07/L nad the platelet count are below 50x l 07/L.Ⅵ en the neutrophil and platelet levels recover,then.1—2 weeks later,the dose should be increased to the previous dose. Tlreatment should be discontinued if the neutrophil count falls below 0.75xl07/L and the platelet count falls below 30x 10 .C—CSF;GM—CSF should be given in cases of severe neutropenla. Mental disorder Symptoms of mental disorders include depression, paranoia,and severe anxiety.Mental status should be evaluated before starting treatment and carefully monitored throughout the course of treatment. Antidepressants are useful to relieve symptoms. Interferon should be discontinued in severely depressed patients. Autoimmune antibodies and autoimmune diseases inducedby IFN Autoimmune antibodies that are induced by interferon include antithyroid antibody,antinuclear antibody,and nati—insulin antibody.The majoriyt of patients are Chin Med J 2007;120(24):2159—2173 asymptomatic.Howeve ̄some patients develop hypothy— roidism/hyperthyroidism,diabetes,thrombocytopenia, psoriasis,leukasmus,rheumatoid arthritis,or SLE—like syndrome.Interferon should be discontinued in severe cases. Dther uncommon adverse events nIclude renal injury,such as interstitial nephritis, nephrotic syndrome, and acute renal failure, cardiovascular complications, such as arrhythmia, ischemic heart disease,and cardiomyopathy,retinopathy, acouesthesia impaction,and interstitial pneumonitis. nIterferon should be discontinued in patients who develop any of these complications. Contraindications for interferon Absolute contraindications for interferon therapy include pregnancy,mental disorders(such as severe depression), uncontrolled epilepsy,alcohol abuse,narcotic abuse, uncontrolled autoimmune disorders,decompensated liver COUnt COUnt Relative contraindications include thyroid disorder, retinopathy,psoriasis,a history of depressive disorder, uncontrolled diabetes,uncontrolled hypertension,and total bilirubin 5 1 pmol/L,especially in patients with elevated indirect bilirubin. NUCLEOT(S)IDE ANALOG THERAPY Lamivudine hTe results of randomized,controlled,clinical trials suggested that HBV DNA levels are suppressed with oral lamivudine at 100 mg per day.As well,the HBeAg seroconversion rate was found to rise during treatment. hTe seroconversion rates at 1。2,3,4,and 5 years of treatment were 16%,17%,23%,28%,and 35%, respectively. The higher the patient’s ALT level was before treatment,the better the HBeAg seroconversion rate.50-60 Long.term lamivudine treatment reduced the incidence of hepatic fibrosis and cirrhosis,in that less inflammation was noted.1,2 A randomized controlled trial showed that lamivudine could decrease the incidence rate Of hepatic decompesation and HCC. nI decompensated cirhosis patients,it was found that both hepatic function nad survival improved.Another study showed that lamivudine had similra therapeutic effects and a good safety profile in pediatirc chronic hepatitis B patients. ’ In liver transplantation patients,it has been found that lamivudine given before transplantation and combined with HBIG post—transplnatation significantly reduced the irsk of reinfection and reduced the dose of HBIG needed. Howeve ̄the proportion of patients with resistance increases with the length of lamivudine treatment.At 1,2, 3,and 4 years of treatment,the proportions of patients who are resistant to lamivudine are 14%,38%,49%,and 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24):2159—21 73 66%,respectively. ,66.6 Therefore.1ong.term use of lamivudine is limited.Some patients who develop resistance maydeteriorate and even develop decompensation.~ ,。Furthermore. after treatment discOntinuatiOn.HBV DNA and serum AI may increase or decompensation may occuE。 Lamivudine is already approved by SFDA to treat compensated adult chronic hepatitis B patients. Adefovir dipivoxil Adefovir dipivoxil.the precursor of adefovir,is converted to adefovir,which has an antiviral effect by hydrolyzation in vivo.Adefovir is an analog of 5’.monophosphate deoxyarabinosyl adenine.Randomized。double bfind。 placebo-controlled clinical trials showed that HBV DNA replication was significantly suppressed by oral adefovir in HBeAg-positive chronic hepatitis B patients. After 1. 2,and 3 years of treatment.the proportions of patients wim HBV DNA undetectable f<1000 copies/m1)were 28%,45%,and 56%.respectively.the rates of HBeAg seroconversion were 1 2%。29%,and 43%.respectively, and the incidence of resistance was 0%.1.6%.and 3.1%, respectively.“For HBeAg.negative Patients.the incidence of resistance after 1。2.and 3 years oftreatment was 0%, 3.O%. and 5.9%一l1.O%. Adefovir dipivoxil is effective in cirrhosis patients,whether compensated or decompensated.who develop resistance to lamivudine. ’ 。 At high doses,renal toxicity。such as a high serum creatinine level and a decreased serum phosphorous level may occuh but 10 mg per day has li ̄le effect on renal function. After 48-96 weeks of 1 0 mg per day treatment, an increment in the serum creatinine of at least 0.5 mg/dl (44.2 mol,L)over baseline was observed in 2%一3%of patients.Therefore,serum creatinine and phosphorous should be monitored during adefovir usage. Adefovir is already approved by SFDA for use in chronic hepatitis B and is indicated for adult compensated chronic hepatitis B,especially those with lamivudine resistance or those in whom long-term treatment is needed. Entecavir Entecavir is an analog of cyclovalerylguanosine.Phase II/III clinical trials suggest that entecavir,given orally at 0.5 mg per day.is more effective than lamivudine in suppressing HBV DNA replication. ’ The data of phase 111 clinical trial showed that the dose of entecavir should be increased to lmg per day for the patient with YNIs 】[)Dmutants to inhibit the HBV replication. The initial incidence of resistance in treated cases to entecavir is 0. However,5.8%of patients wim Y=MDD variations develop resistance to entecavir after 1-year treatment.~ Entecavir is already approved bv SFDA to treat chronic hepatitis B patients. Monitoring and follow—up during nucleot(s)ide naalog treatment Before starting treatment,the following tests should be done:(1)serum ALT,AST,bilirubin,and albumin;(2) HBeAg.anti-HBe。and baseline HBV DNA;(3)routine 2167 blood tests,phosphocreatine kinase,and serum creatinine. Liver biopsies before and after treatment are recommended if possible. To evaluate the results and encourage compliance,the following tests should be periodically monitored.(1、 Biochemical tests should be monitored once per month ofr 3 months and then repeated at least every 3 months。 depending on the degree of improvement.(21 HBV markers,including HBsAg。HBeAg,anti~HBe,and HBV DNA,should be monitored every 3 months.(31 Routine blood tests,phosphocreatine kinase,and serum creatinine should be tested if necessary. Regardless of whether HBeAg is positive or negative prior to treatment,the antiviral agent should be changed if HBV DNA is still present or the reduction is less than 2 logl0 after 1 year of treatment.When switching antiviral agents,a 1-3-month period of overlap with both antiviral agents could be implemented.Discontinuation of treatment is not recommended in patients with cirrhosis and hepatic decompensation. 1]、 仉 oMoDULATD G AGENT THERAPY Immunomodulation plays an important role in chronic hepatitis B treatments.No specific immunity treatment against HBV has yet been identified.Thymic peptide 1 has the potential to enhance nonspecific immunity wim imld adverse effects.Subcutnaeous injection of thymic peptide.1.6 mg twice per week for 6 months.is useful for those patients in whom antiviral therapy is indicated but who refuse or cannot tolerateⅡ and nucleot(s)ide analog therapy. oTHER ANTⅣIRAL AGENTS AND HERBAL DRUGS Kushenin fammothamnine)has been extracted from the ofxtail.1ike sophora herb and developed by a Chinese researcher. Intravenous. intramuscular, and oral preparations are available.Chinese clinical trials have shown that kushenin has the potential to improve the biochemical markers of HBV infection and to suppress HBV DNA.“一 However,the therapeutic effects need to be confirmed by multicenter,randomized,controlled trials. Herbal medicines are widely used in China to treat chronic hepatitis B,but most of them have not been evaluated in randomized.controlled trials.The antiviral effects of herbal medicines need to be further investigated. CoMB ED THERAPY For both HBeAg-positive and negative chronic hepatitis B patients,interferon therapy combined with lamivudine is not recommended.The results of sequential therapy using IFNt ̄and lamivudine are still under investigation. 维普资讯 http://www.cqvip.com 2168 Lamivudine combined with adefovir dipivoxil is not recommended as initial treatment or for patients who are not resistant to lamivudine. A sustained response to the combination of lamivudine and thymic peptide has been reported but still needs confirmation. The therapeutic effects of interferon or lamivudine combined with other medicines(including herbal medicines)need to be confirmed. RECoMMENDATIoNS FoR ANTⅣIRAL TREATMENTS Chronic HBV carrier and inactive HBsAg carrier A liver biopsy should be done in chronic HBV carriers. Antiviral therapy is indicated if the Knodell HAI is>4 or, if on histology.necroinflammation is G2.Treatment is not recommended without evidence of hepatitis or without a biopsy having been done.Treatment is usually unnecessary for inactive HBsAg carriers,but such patients should have appropriate tests(biochemistry, virology. A and imaging) every 3-6 months. Treatment withⅡ or nucleot(s)ide analogs should be started in cases that simultaneously develop >2×ULN and positive HBV DNA(II.21. HBeAg-positive chronic hepatitis B patients Antiviral therapy is indicated in HBeAg-positive chronic hepatitis B patients with HBV DNA l×l 0 copies/ml and A【 >2xULN, Knodell HAI 4, or necroinflammation三G2 with ALT<2xULN.The choice of usingⅡ (AL <l O×ULN)or a nucleot(s)ide analog should be individualized and take into account the patient’s wishes.Patients whose HBV DNA is positive, but is below l×l 0 copies/m1.should be monitored for 3 months.Antiviral therapy should be initiated if HBV DNA remains positive nad ALT rae abnormal(III). Conventional IFN Subcutaneous injection of conventional IFN 0【is given at a dose of 5 MU thrice weekly or every other day for 6 months.If a response is observed,the duration of treatment may be prolonged to 1 year or more(na individualized dosage is preferable)to enhance the effect. Otherwise.if no response is observed,the antiviral agent should be changed. PeglFNa-2a Subcutnaeous injection of PeglFN 0【-2a is given at a dose of 180 lag weekly for 1 year.The dosage is adjusted based on individual tolerance. Lamivudine After 1 year of 100 mg daily oral use,in patients in whom the HBV DNA is undetectable(PCR)or below the lower limit of detection.with a normal ALT level,who have not had HBeAg seroconversion,and who have HBeAg loss, Chin Med J 2007;120(24):2159—2173 but no anti-HBe.treatment should be continued until seroconversion of HBeAg.HBeAg seroconversion,which should be confirmed by 2 tests at an interval of at least 6 months,is the endpoint of treatment;however, biochemical and virologic tests must still be monitored. Adefovir d ivoxil hTe treatment regimen is the same as for lamivudine at a dosage of 1 0 mg—orally daily(II). tecavir hTe treatment regimen is the same as for lamivudine at a dosage of 0.5 mg(1 mg ofr lamivudine-resistant patients) orally daily. HBeAg-negative chronic hepatitis B Antiviral therapy is suggested for HBeAg.negative chronic hepatitis B patients with HBV DNA->1×l0 copies/m1.and AL ->2xULN,or Knodell HAI 4,or G2 necroinflammation with ALT<2xULN.Antiviral therapy should be considered in patients who do not fulnll these criteria but have persistent ALT elevations and positive HBV DNA.Treatment is continued until HBV DNA (PCR1 is undetectable and the ALT level retums to norma1.Since the relapse rate is high in this group, treatment should be given for at least l year.Since long-term treatment is needed,treatments with low incidence of resistance,such as IFN(ALT<l 0xULN), adefovir dipivoxil,and entecavir rae preferred. Conventionat lFN Subcutnaeous or intramusculra injection of conventional IFN 0【5 MU was given thrice weekly or every other day ofr at least 1 year. PeglFNa-2a Subcutnaeous injection of PegIFNa-2a 1 80 lag was given weekly foratleast 1 year. Adefovir d ivoxil Adefovir dipivoxil l 0 mg daily is taken orally for at least l year.If HBV DNA is undetectable(PCR)or below the lower limit of detection and the ALT is normalized in 3 tests(wiht na interval of at least 6 months),treatment can be discontinued(II). Lamivudine Oral use of lamivudine 1 00 mg daily for at least 1 year; the endpoint is the same as for adefovir dipivoxil. tecavir Oral use of entecavir 0.5 mg(1 mg for lamivudine- resistnat patient)daily is continued until the same endpoint as for adefovir dipivoxil is reached. Compensated chronic hepatitis B cirrhosis hTe indication for antiviral treatment in HBeAg-positive patients with compensated hepatitis B cirrhosis is HBV DNA>1 0 copies/ml,while in HBeAg-negative patients; 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24):2159—21 73 the indication of antiviral treatment is HBV DNA 104 copies/ml with normal or elevated ALT levels.The aims of treatment are to delay and to decrease the development of hepatic decompensation and HCC. Oral lamivudine 1 00 mg daily should be used for a long’term course.The optimal duration of hterapy has not been determined. Oral adefovir 10 mg daily should be used for a long.term course.The optimal duration of therapy has not been determined. Interferon treatment should be given with caution due to potential risk of hepatic decompensation.If interferon rteatment is chosen,treatment should be started with a small dose and then gradually increased to the target dose depending on patient tolerance(III). Decompensated chronic hepatitis B cirrhosis nI patients wiht decompensated hepatitis B cirrhosis,the indication for treatment is positive HBV DNA wi山 normal or elevated ALT levels.The aim of treatment is to delay and reduce the need for liver transplantation by suppressing viral replication and improving hepatic function. Antiviral therapy can only delay the development of the disease rather than eliminate it: end—stage cirrhosis is inevitable.Interferon treatment is contraindicated due to its potentia1 risk Of decompensation exacerbation(II). For decompensated cirrhosis patients with active replication and hepatitis,lamivudine can be used to improve liver function.Once started,treatment should not be stopped.Other approved anti—resistant nucleot(s)ide analogs should be added if resistance develops(II一2). Patients receiving chemotherapy and immunosuppressive agents For HBsAg-positive patients receiving chemotherapy or immunosuppressive agents for other diseases,lamivudine 1o0 mg daily should be started 1 week prior to these other 仃eatments even if the HBV DNA is negative and ALT is norma1.The decision to stoP lamivudine treatment should be based on the Patient’s condition after cessation of chemotherapy or immunosuppressive agents(II一2,II一3). Other approved anti.resistant nucleot(s)ide analog should be added if the Patient develops resistance.After cessation of nucleot(s)ide analog仃eatment.the patient should be monitored carefully ofr relapse or deterioration. Liver transplantation patients In HBV.infected patients who are about to receive fiver rtansplantation,treatment with lamivudine 100 mg daily should begin 1_3 months prior to the operation.During hte anhepatic phase.HBIG should be added. Postoperatively.1ong.term of lamivudine and small doses ofHBIG f800 IU daily in the first week followed by 100 IU weekly)should be administered.The dose nad interval 2169 of HBIG treatment should be adjusted according to the anti—HBs level(the anti.HBs trough is usually above 100-150 mIU/ml:a 1eve1 over 500 m/U/ml within 6 months after operation should be obtained)(II,1、.The optimal course of treatment is still under discussion. Other approved anti・resistnat nucleot(s)ide analogs should be added to treat lamivudine resistance. Management under special circumstances Non—response to conventional lFN hTe therapeutic effect of restarting conventionalⅡ Q is poor if no response was observed after a proper treatment course failed(Ⅱ).PeglFNa一2a or nucleot(s)ide analogs could be ed. Intensiifcation therapy This involves initial therapy with conventional I】} daily for 2-3 weeks and then every other day or thrice weekly.There are difering opinions on the efFicacy of this approach.Therefore.intensification therapy is not recommended fIII1. 7 atment after mutations that cause resistance to a nucleot(s)ide analog During lamivudine treatment.breakthroughs may occur due to the development of resistance.Another approved anti—resistnat nucleot(s)ide analog should be added to treat resistance by overlapping the two drugs for about 1-3 months.0therwise,lamivudine should be stopped when HBV DNA is undetectable.Ⅱ Q is another choice when resistance develops if there is no contraindication (III). Treatment ofrelapse after cessation ofnucleot(s)ide analogtherapy Lamivudine treatment can be reinitiated if there was no evidence of resistance before treatment cessation.Other nucleot(s)ide analogs and IFN Q can also be used if there rae no con仃aindjcatiOns. Pediatric patients hTe indications.therapeutic effects. and safety of conventional IFN Q仃eatment in Pediatric chronic hepatitis B patients over 12 years of age are similar to those of adult patients.The dose should be 3-6 MU/m with a maximum of 10 MU/m .The dose and course of lamivudine for adult patients Can also be used in pediatric patients over 1 2 years of age(I1. ANTI.INFLAN 伽IoN AND PRoTECTIoN oF HEP.ATIC FUNCTIoN Necroinflammation and subsequent fibrosis are the pathologic bases for the development of liver cirrhosis. hTe progress of fibrosis is delayed by effectively suppressing inflammation.The active components of glycyrrhizic acid and silybin have been identified as having potential anti—inflammatory,antioxidative,and protective effects on the cell membrane and cell organs. hTeir use improves biochemical markers Of inflammation 维普资讯 http://www.cqvip.com 2170 Chin Med J 2007 12o{24)2159.2173 '.Fig.How chart for chronic hepatiis tB antiviral treatment. (II一2,II一3).Bifendate and bicyclol are used to reduce serum levels of ALT and other aminotransferases. However,the use of anti—inflanunatory drugs and those that protect hepatic function must be considered to be part of combination therapy;they cannot replace antiviral he advaTntages of interferon include a fixed course,a high HBeAg seroconversion rate,sustained effects,and ewer cases of fresistance.The disadvantages of interferon include the need for injections,adverse effects,and it is cOn仃aindicated in hepatic decompensation.On the other hand,the advantages of nucleot(s)ide nalaogs include oral administration,strong suppression of virus,fewer adverse terapy.To threat patients with very high ALT levels and severe necroinflanunation, anti—inflammatory and protective agents are to be added to basic antiviral therapy The use of multiple anti—inflammatory and protective agents is not recommended for fear of causing unnecessary metabolism load to livers and extra adverse effects,and can be used in patients with hepatic decompensation.The disadvantages of nucleot(s)ide analogs include an indefinite course,a low HBeAg seroconversion rate,low sustained effect,development of resistance with long—term use,and patient deterioration after treatment cessation.The decision as to which reatment to use should be made based on tthe clinician’s efiects. ANTⅡ mROSiS THERAPY It has been reported that cirrhosis and fibrosis noted on expertise and clinical experience,as well as the individual condition and wishes of the patient.The guidelines provide the framework for the principles used to liver biopsy are mitigated afterⅡ a or nucleot(s)ide nalogs treatment.Taherefore,antiviral therapy is the basis of ntifaibrotic treatment. determine reattment(Fig.). FoLLoW-UP After treatment is stopped,no maaer what the patient’s According to Chinese traditional medical theories and clinical experience,fibrosis and cirrhosis are due to asthenia of healthY energy and stagnation of blood.Thus, response,ALT,AS T,serum bilirubin(if necessary),HBV markers,and HBV DNA should be followed every 2 months for the first 6 months,and then every 3-6 months fr a totalo of 1 year follow—up.The time interval between tests should be shortened if the patient’S condition changes. In patients with a normal ALT level and negative HBV supplementing Qi,nourishing Yin,and promoting blood flow are helpfu1.As has been reported,many Chinese medical formulae have posiive ttherapeutic effects on liver cirrhosis.However,large,randomized,double—blind, clinical studies that are done under GCP regulations and comply with the principles of evidence—based medicine re needed tao confirm the therapeutic effects of Chinese medical formulae based on liver biopsy results. DNA,HBV DNA,A【工AF and B ulrtasound testing should be done every 6 months.In Patients with a normal level and positive HBV DNA HBV DNA testing is suggested every 3 months.and AFP and B DRUG oPTIoNS AND FLoW CHART oF ANTⅣIRAL THERAPY here aTre two categories of ntai—HBV medicine that are widely accepted,interferon and nucleot(s)ide analogs. ultrasound are suggested every 6 months.A liver biopsy is recommended if possible. n chronIic hepatitis B patients wih cirtrhosis,especially hey each have theiTr own advantages and disadvantages high—isk rpatients(>40 years of age,male,alcohol abuse, 维普资讯 http://www.cqvip.com Chinese Medical Journal 2007;120(24).'2159—21 73 hepatic decompensation,or elevated AFP leve1) AFP and abdominal B ultrasound(CT or MR1 when needed) should be done every 3-6 months to identify early evidence of HCC.Gastroscopy and UGI should be done every l一2 years in cirrhosis patients to identify esophageal fundus varices. REf1三RENCES 1. 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