Hepatitis B in the Spotlight

In the context of recent developments in the area of antiviral therapy, accurate selection of patients into treatment groups and timely initiation of therapy has become crucial. As infectious diseases practitioners, it is important to use all available tools for identifying those patients which have the potential of responding to the therapeutic options at hand.

Given the fact that hepatitis B virus (HBV) infection is a leading cause of chronic liver disease and of hepatocellular carcinoma, the decision-making process behind the clinical management of the infection needs to take into account all parameters known to play a role in patients’ response to treatment.

Bearing in mind the four stages of disease and given the fact that each patient may respond differently to the presence of the virus, it is vital to choose who to treat, when to start treatment, what to start with and when to stop. It has been postulated that who to treat is no longer an issue, the real question being rather when to switch from watch-and-wait to active therapeutic intervention for each patient.

When talking about therapy in HBV hepatitis, one might automatically think about chronic HBV infection. But what about severe acute hepatitis? Can we spare those initial 6 months watching and waiting only to eventually start therapy for chronic hepatitis? Or should we customize the clinical judgment early to apply a treatment protocol individualized for each patient?

Field literature describes a wide range of options, from lamivudine treatment to entecavir, pegylated interferon and back to the watch-and-wait approach. Which option best suits our patient? This remains an open question. It might be time to learn from the management of HIV infection, where therapy is tailored for each patient.

Looking back at our experience with managing patients with HBV infection, we should focus more on acting in the acute phase of the disease for the symptomatic patients, and treat more actively at that time point in order to limit the integration of HBV into the hepatic cell and the subsequent evolution towards chronic hepatopathy, and as we browse through field literature, we notice some interesting results for these patients.

We should also focus on better vaccination implementing programs and test for response to vaccine in order to minimize the responsive mass for HBV infection, as HBV is a chronic disease with lifelong complications.

‘As for the future, your task is not to foresee it, but to enable it.’-- Antoine de Saint-Exupéry