Should a patient with HBV DNA not detected, HBeAg positive, HBeAb negative, and HBcAb positive, and fatty liver with a hemangioma, continue Vemlidy (tenofovir alafenamide)?

Management of HBV Patient with Undetectable HBV DNA, HBeAg+, and Fatty Liver

Yes, this patient should continue Vemlidy (tenofovir alafenamide) therapy despite undetectable HBV DNA, as they remain HBeAg positive without seroconversion. 1, 2

Assessment of Current Virologic Status

• The patient has undetectable HBV DNA but remains HBeAg positive with negative HBeAb, indicating ongoing viral activity despite viral suppression 1
• HBcAb positivity confirms chronic HBV infection rather than acute infection 1
• The presence of fatty liver with a 2.4cm hemangioma in the right hepatic lobe represents comorbid conditions that require monitoring but don't contraindicate continued antiviral therapy 1

Rationale for Continuing Vemlidy

• For HBeAg-positive patients, treatment should continue until HBeAg seroconversion (development of HBeAb) plus at least 6-12 months of consolidation therapy 1, 2
• The American Association for the Study of Liver Diseases recommends that HBeAg-positive patients who fail to lose HBeAg should be treated long-term due to high risk of virologic relapse if therapy is stopped 1
• Tenofovir alafenamide (Vemlidy) is a preferred first-line agent with high potency and low resistance rates 1, 3

Benefits of Continued Therapy

• Continued viral suppression prevents progression to cirrhosis, liver failure, and hepatocellular carcinoma 4
• Long-term tenofovir alafenamide therapy has shown:
  • Sustained viral suppression in >90% of patients 5
  • Improved biochemical parameters with ALT normalization 5
  • Regression of fibrosis and cirrhosis in many patients 4
  • Better renal and bone safety profile compared to tenofovir disoproxil fumarate 3, 5

Risks of Discontinuation

• Discontinuation of anti-hepatitis B therapy, including Vemlidy, may result in severe acute exacerbation of hepatitis B 6
• Without HBeAg seroconversion, the risk of virologic relapse after stopping therapy is very high 1
• Recent evidence suggests early treatment with tenofovir alafenamide reduces the risk of liver-related serious adverse events compared to observation 7

Monitoring Recommendations

• Continue monitoring HBV DNA levels every 3-6 months to confirm continued viral suppression 1
• Monitor HBeAg and HBeAb status to detect potential seroconversion 2
• Regular assessment of liver function tests to evaluate biochemical response 1
• Monitor renal function (serum creatinine, estimated creatinine clearance) and bone health due to potential long-term effects of nucleotide analogues 6, 3
• Follow the fatty liver with periodic ultrasound examinations 1

Important Caveats

• If the patient develops clinically significant decreases in renal function or evidence of Fanconi syndrome, discontinuation of Vemlidy may be warranted 6
• Lactic acidosis and severe hepatomegaly with steatosis have been reported with nucleoside analogues, requiring vigilance for these complications 6
• The 2.4cm hemangioma is likely an incidental finding but should be monitored with routine imaging 1

In conclusion, despite achieving undetectable HBV DNA, this patient should continue Vemlidy therapy until HBeAg seroconversion occurs, followed by a consolidation period of at least 6-12 months. Premature discontinuation risks virologic relapse and hepatitis flares.