Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.
Clinical Case Scenario : Chronic Hepatitis B HBeAg Negative Dr Yeong Yeh Lee MD, MRCP (UK), MMed May 2007
Case Study <ul><li>45 years old gentleman; married; army officer  </li></ul><ul><li>HBsAg positive > 6/12 in Jan 2003 </li...
<ul><li>Q : What is the significance of HBeAg -ve  CHB? </li></ul>
<ul><li>clinically silent for years </li></ul><ul><li>Severe necroinflammation in >50%, cirrhosis in 25-40% </li></ul><ul>...
<ul><li>Q1 : Would you order a viral load test? </li></ul><ul><li>Q2 : What level of HBV DNA would you start treatment? </...
REVEAL: High HBV Viral Load is associated with increased incidence of HCC Chen CJ, et al.   JAMA 2006; 295:65–73 HBeAg neg...
Haimen City Cohort: HBV  V iral  L oad at  B aseline  is  A ssociated with HCC  M ortality 1.00 0.96 0.92 0.88 0.84 0.80 0...
<ul><li>HBV Quantitative 55,000 copies/ml </li></ul><ul><li>(or 11,000 iu/ml @ 1 iu/ml=5.6 copies/ml) </li></ul><ul><li>Q3...
Updated  US  Treatment Algorithm Patients with Compensated Disease <ul><li>No treatment </li></ul><ul><li>Monitor every 6–...
Liver biopsy : bridging necrosis and fibrosis  Ishak Staging for fibrosis Score 3
Case Study <ul><li>He was started on lamivudine 100mg OD </li></ul><ul><li>After 1 year of treatment, HBV DNA 500 copies/m...
<ul><li>Q4 : Should we continue or stop the lamivudine? If continue for how long? </li></ul><ul><li>Q5 : Besides lamivudin...
FDA Approved Therapies for Chronic Hepatitis B Oct 28, 2006 Idenix/Novartis TYZEKA ™ Telbivudine March 29, 2005 Bristol-My...
HBV DNA suppression: Comparison of treatments at 1 year in naïve patients* Lai CL, et al.  Hepatology 2005; 42(Suppl 1):74...
Case Study <ul><li>He was continued on lamivudine. After 24 months HBV DNA below detectable levels. ALT 20 mmol/l </li></u...
<ul><li>Q6 : What is the cause for his virologic and biochemical breakthrough? </li></ul>
Case Study <ul><li>He was restarted with lamivudine 100mg OD </li></ul><ul><li>6/12 later HBV DNA 18,000 copies/ml </li></...
<ul><li>Q7 : What treatment options for lamivudine resistant YMDD mutation? </li></ul><ul><li>a. switch to adefovir </li><...
Lamivudine-resistant mutations result in reduced treatment efficacy and poorer patient outcomes Adapted from Liaw. Semin L...
 
 
 
Nächste SlideShare
Wird geladen in …5
×

Case Studies: HBeAg Negative Chronic Hepatitis B

8.836 Aufrufe

Veröffentlicht am

Real case studies. Discussion on management for each case based on available evidence at the time.

Veröffentlicht in: Gesundheit & Medizin
  • I'd advise you to use this service: ⇒ www.HelpWriting.net ⇐ The price of your order will depend on the deadline and type of paper (e.g. bachelor, undergraduate etc). The more time you have before the deadline - the less price of the order you will have. Thus, this service offers high-quality essays at the optimal price.
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • You might get some help from ⇒ www.WritePaper.info ⇐ Success and best regards!
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD FULL eBOOK INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookeBOOK Crime, eeBOOK Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD FULL eBOOK INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookeBOOK Crime, eeBOOK Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier
  • DOWNLOAD FULL eBOOK INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. PDF eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... 1.DOWNLOAD FULL. doc eBook here { https://tinyurl.com/y3nhqquc } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookeBOOK Crime, eeBOOK Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Antworten 
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier

Case Studies: HBeAg Negative Chronic Hepatitis B

  1. 1. Clinical Case Scenario : Chronic Hepatitis B HBeAg Negative Dr Yeong Yeh Lee MD, MRCP (UK), MMed May 2007
  2. 2. Case Study <ul><li>45 years old gentleman; married; army officer </li></ul><ul><li>HBsAg positive > 6/12 in Jan 2003 </li></ul><ul><li>Promiscuity, father died of jaundice ?cause </li></ul><ul><li>HBeAg negative; Anti-HBe positive </li></ul><ul><li>ALT 65 mmol/l; repeat 3/12 ALT 70 mmol/l </li></ul><ul><li>Ultrasound normal liver echotexture </li></ul><ul><li>Alpha-fetoprotein (AFP) normal </li></ul><ul><li>Anti-HCV –ve; EIA HIV –ve; </li></ul>
  3. 3. <ul><li>Q : What is the significance of HBeAg -ve CHB? </li></ul>
  4. 4. <ul><li>clinically silent for years </li></ul><ul><li>Severe necroinflammation in >50%, cirrhosis in 25-40% </li></ul><ul><li>Rare spontaneous sustained remission </li></ul><ul><li>Fluctuations in viraemia and ALT </li></ul><ul><li>HBV DNA may be persistently <10 5 copies/mL but yet has significant liver disease </li></ul>
  5. 5. <ul><li>Q1 : Would you order a viral load test? </li></ul><ul><li>Q2 : What level of HBV DNA would you start treatment? </li></ul><ul><li>a. HBV DNA ≥ log 10 4 </li></ul><ul><li>b. HBV DNA ≥ log 10 5 </li></ul><ul><li>c. Any level of HBV DNA </li></ul>
  6. 6. REVEAL: High HBV Viral Load is associated with increased incidence of HCC Chen CJ, et al. JAMA 2006; 295:65–73 HBeAg negative, normal ALT, no liver cirrhosis at entry (n=2,925) .14 .12 .1 .08 .06 .04 .02 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Cumulative incidence of HCC Year of follow-up Baseline HBV DNA Level ≥ 10 6 10 5 –<10 6 10 4 –<10 5 300–10 4 <300
  7. 7. Haimen City Cohort: HBV V iral L oad at B aseline is A ssociated with HCC M ortality 1.00 0.96 0.92 0.88 0.84 0.80 0 1 2 3 4 5 6 7 8 9 10 11 12 Survival distribution function Survival time (Years) HBV DNA >10 5 RR=9.9 (3.2–31.0) HBV DNA >10 3 – <10 5 RR=1.8 (0.5–5.8) HBV DNA <10 3 Chen et al. Am J Gastroenterol 2006; 101:1797-1803
  8. 8. <ul><li>HBV Quantitative 55,000 copies/ml </li></ul><ul><li>(or 11,000 iu/ml @ 1 iu/ml=5.6 copies/ml) </li></ul><ul><li>Q3 : Would you suggest for liver biopsy? </li></ul>
  9. 9. Updated US Treatment Algorithm Patients with Compensated Disease <ul><li>No treatment </li></ul><ul><li>Monitor every 6–12 months </li></ul><ul><li>Monitor ALT, or </li></ul><ul><li>Consider biopsy, since ALT often fluctuates, and treat if significant disease </li></ul><ul><li>Long-term treatment required </li></ul><ul><li>Treat </li></ul><ul><li>Long-term treatment required (oral agents) </li></ul>HBeAg Negative ALT Elevated ALT Normal HBV DNA ≥ 10 4 c/mL HBV DNA <10 4 c/mL Keeffe EB, et al. Clin Gastroenterol Hepatol 2006; 4:936-962
  10. 10. Liver biopsy : bridging necrosis and fibrosis Ishak Staging for fibrosis Score 3
  11. 11. Case Study <ul><li>He was started on lamivudine 100mg OD </li></ul><ul><li>After 1 year of treatment, HBV DNA 500 copies/ml </li></ul><ul><li>ALT 25 mmol/l </li></ul>
  12. 12. <ul><li>Q4 : Should we continue or stop the lamivudine? If continue for how long? </li></ul><ul><li>Q5 : Besides lamivudine, are there any other options? </li></ul>
  13. 13. FDA Approved Therapies for Chronic Hepatitis B Oct 28, 2006 Idenix/Novartis TYZEKA ™ Telbivudine March 29, 2005 Bristol-Myers Squibb BARACLUDE ™ Entecavir May 13, 2005 Hoffmann La-Roche Inc. PEGASYS ® Peginterferon alfa-2a 2002 Gilead Sciences HEPSERA ™ Adefovir dipivoxil 1998 GlaxoSmithKline EPIVIR-HBV ® Lamivudine 1992 Schering Corporation INTRON ® A Interferon alfa-2b, recombinant Date Approved in US Manufacturer Trade Name Generic Name
  14. 14. HBV DNA suppression: Comparison of treatments at 1 year in naïve patients* Lai CL, et al. Hepatology 2005; 42(Suppl 1):748A (abstract LB01); Lau G, et al. NEJM 2005; 352:2882–2695; Chang T-T, et al. NEJM 2006; 354:1000–1010; Lai CL, et al. NEJM 2006; 354:1011–1020; Marcellin P, et al. NEJM 2003; 348:808 – 816; Marcellin P, et al. NEJM 2004; 348:1206 – 1217; Hadziyannis SJ, et al. NEJM 2003;348:800–807 *Collation of currently available data – not from head-to-head studies Peg IFN # Lamivudine* Adefovir # Telbivudine* HBV DNA undetectable (% patients) 36 67 60 0 20 40 60 80 HBeAg(+) HBeAg(-) 0 20 40 60 80 100 72 90 88 *Undetectable <300 copies/mL # Undetectable <400 copies/mL Entecavir* 21 25 63 51
  15. 15. Case Study <ul><li>He was continued on lamivudine. After 24 months HBV DNA below detectable levels. ALT 20 mmol/l </li></ul><ul><li>Lamivudine was then stopped </li></ul><ul><li>Well until 6/12 later (Jun 2005) his ALT 90mmol/l </li></ul><ul><li>Repeat HBV DNA 6,000 copies/ml </li></ul><ul><li>HBeAg -ve </li></ul>
  16. 16. <ul><li>Q6 : What is the cause for his virologic and biochemical breakthrough? </li></ul>
  17. 17. Case Study <ul><li>He was restarted with lamivudine 100mg OD </li></ul><ul><li>6/12 later HBV DNA 18,000 copies/ml </li></ul><ul><li>YMDD mutation found </li></ul><ul><li>Lamivudine was stopped </li></ul>
  18. 18. <ul><li>Q7 : What treatment options for lamivudine resistant YMDD mutation? </li></ul><ul><li>a. switch to adefovir </li></ul><ul><li>b. lamivudine combines with adefovir </li></ul><ul><li>c. switch to entecavir </li></ul><ul><li>d. switch to interferon </li></ul>
  19. 19. Lamivudine-resistant mutations result in reduced treatment efficacy and poorer patient outcomes Adapted from Liaw. Semin Liver Dis 2005; 25:40–47; Liaw et al. N Eng J Med 2004; 351:1521–1531 Wild-type (n = 221) Time after randomisation (months) 0 5 10 15 20 25 0 6 12 18 24 30 36 Percentage of patients with disease progression Placebo (n = 215) 5% 21% M204I/V mutations (n = 209, 49%) 13%

×