Hepatitis B Treatment

Should everyone with hepatitis B be treated?

At the present time, not everyone with hepatitis B should be treated. Hepatitis B infection can be controlled but it still cannot be cured. This is important since control usually means long-term, usually lifelong, therapy. Also, most people with hepatitis B may be fine and not need treatment. So, it is very important to be able to tell which patients are likely to run into trouble with hepatitis B and may benefit from treatment. This has not been so simple to do. In the past, some have been told that they were "healthy carriers" when they actually had active disease. Fortunately, newer tests help us tell which patients are at risk and may benefit from treatment. For a detailed discussion about the natural history of hepatitis B and who should be treated, click here.

What different kinds of treatment are available?

There are two very different treatments currently available for treating patients with hepatitis B.

1. Interferons

Interferons are natural immune substances that are part of the body's defence against viral infections. We think they change the immune balance so the body can control hepatitis B long after interferon therapy has been stopped. However, treatment is only successful in 25% to 30% of the time after 16 to 48 weeks of treatment. It may be possible to predict which patients are more likely to respond to interferon (see below). Standard interferon is given as a needle 3 times a week. The newer pegylated interferons are given once a week.

Good points
  • Defined therapy: Treatment doesn't go longer than 1 year. Younger persons who want to have a family may benefit from treating the hepatitis B and then starting their family.
  • Long-lasting response: when it works, patients may not need further treatment.
  • Effectiveness: Interferon is more effective in younger patients with lower viral load (less than 7-8 log IU/mL). Interferon is also more effective in patients with genotypes A or B rather than genotypes C or D.
Bad points
  • Cost: expensive, $460/week or $22,000 for 48 weeks
    Method: Injections (needles)
  • Side effects: usually mild but still noticable tiredness
  • Decompensated cirrhosis: interferons should not be used in very advanced disease because these drugs may make people very sick even as they are starting to work

2. Oral agents (pills)

There are now several new pills that slow down hepatitis B growth. When taken regularly, the amount of hepatitis B virus (viral load) can be brought down to very low levels where liver disease no longer happens. Unfortunately, liver disease usually re-appears when these drugs are stopped. This means that in most cases, patients using these pills need to take them for the rest of their life.

Good points
  • Method: Pills are easy to take
  • Effective: hepatitis B virus is usually suppressed rapidly
  • Safety: Pills are safe to use in decompensated cirrhosis
Bad points
  • Cost: although not as expensive as interferon, the costs add up over time. Current costs vary from $5 to $51 per day
  • Prolonged (maybe lifelong) therapy: These pills must be taken once a day, every day, for years. It may sound simple, but people forget, lose their pills, cannot afford the pills or just get fed up with taking medications. In general, we think only about 2/3 people are able to take their prescribed cholesterol or blood pressure medications regularly over a long period of time. Just think of how well you do when you are told to take antibiotics for an infection for just one week!
  • Family planning: Patients who want to start a family may not want to be on these medications. Some of these drugs are thought to be safe in pregnancy because they do not cause trouble in animals (Telbivudine, Tenofovir). Other agents have been used safely in a lot of people but have been linked to birth defects in animals (Lamivudine).
  • Drug resistance: the hepatitis B virus might make a small change at just the right place that makes the drug either less effective or not effective at all. Right now, there are two groups of medications that share similar resistance patterns (nucleosides and nucleotides). Resistance to one nucleoside means that all other nucleosides may not work, whereas the nucleotides should still work. Resistance to one nucleotide means that the other nucleotide will not work as well, whereas the nucleosides should still work. This is a very complicated area to deal with. In general, we should try to prevent resistance. An effective way to do this is to not miss any doses of medications. A more effective way is to not use these medications unless they are absolutely necessary.

Nucleosides (approximate cost for 3 months supply from TGH pharmacy in 2008)

  • Lamivudine $444.60
  • Telbivudine $1,777.50
  • Entecavir $2,300.40 for primary treatment; $4,600.80 if prior Lamivudine treatment
  • Emtricitabine (approved for HIV but not hepatitis B)
  • Clevudine (not yet available)

Nucleotides

  • Adefovir $2,300.40
  • Tenofovir $1,699.20

Which drug therapy is right for me?

This is a complicated question as many factors have to be considered. There are good points and bad points to each medication. All these factors must be taken into account when you choose your drug therapy.