Does a patient with chronic hepatitis B require antiviral treatment with Vemlidy (tenofovir alafenamide)?

Management of Chronic Hepatitis B with HBV DNA 3520 IU/mL

This patient with chronic hepatitis B (HBsAg positive, HBeAb positive, HBcAb total positive, HBV DNA 3520 IU/mL, normal liver ultrasound) should be treated with antiviral therapy such as Vemlidy (tenofovir alafenamide) to prevent disease progression and improve long-term outcomes.

Patient's Virologic Status Assessment

• The patient has HBV DNA level of 3520 IU/mL, which exceeds the treatment threshold of 2000 IU/mL for HBeAg-negative chronic hepatitis B patients 1
• The serologic profile (HBsAg positive, HBeAg negative, HBeAb positive, HBcAb total positive, negative HBcAb IgM) indicates chronic HBeAg-negative hepatitis B infection 1
• The high HBsAg level (1884) suggests ongoing viral activity despite the absence of HBeAg 1

Treatment Indications Based on Guidelines

• The Korean Association for the Study of the Liver (KASL) guidelines recommend treatment for HBeAg-negative CHB patients with HBV DNA ≥2,000 IU/mL plus significant inflammation or fibrosis 1
• For patients with HBV DNA ≥2,000 IU/mL but normal ALT, guidelines suggest consideration of liver biopsy to assess for significant histologic changes 1
• Recent evidence suggests that early antiviral treatment in patients with moderate or high viremia (>4 log10 IU/mL) can prevent serious liver-related adverse events, even with normal or mildly elevated ALT 2

Recommended Treatment Approach

• Monotherapy with tenofovir alafenamide (Vemlidy) is an appropriate first-line option for this patient 1, 3
• Tenofovir alafenamide has demonstrated high antiviral potency similar to tenofovir disoproxil fumarate but with improved safety profile regarding bone and renal toxicity 4, 5
• The recommended dosage is 25 mg once daily with food 6

Benefits of Treatment in This Case

• Long-term viral suppression with potent antiviral agents is the current treatment paradigm aimed at preventing disease progression and improving survival 1
• Treatment can prevent progression to cirrhosis, which is strongly correlated with circulating virus levels 1
• Early treatment has been shown to reduce the risk of liver-related serious adverse events compared to observation in patients with moderate or high viremia 2

Monitoring Recommendations

• Monitor HBV DNA and ALT levels every 3-6 months during therapy 1, 3
• Assess renal function periodically, especially if using tenofovir-based therapy 1, 6
• Monitor for virologic breakthrough, which may indicate development of resistance 1

Important Considerations and Caveats

• Discontinuation of antiviral therapy may result in severe acute exacerbation of hepatitis B, requiring close monitoring if treatment is stopped 6
• Treatment for HBeAg-negative CHB typically requires long-term or indefinite therapy due to high relapse rates after discontinuation 1, 3
• The decision to treat should consider the patient's age, family history of HCC, and other risk factors 1

Alternative Treatment Options

• Entecavir is another first-line option with high potency and low resistance rates 1
• Peginterferon-α could be considered for a finite treatment duration but has more side effects and lower tolerability than oral antivirals 1
• Older agents like lamivudine and telbivudine are not preferred due to high resistance rates 1

In conclusion, based on the patient's HBV DNA level of 3520 IU/mL (exceeding the 2000 IU/mL threshold) and the most recent evidence showing benefits of early treatment in patients with moderate viremia, antiviral therapy with tenofovir alafenamide (Vemlidy) is recommended to prevent disease progression and improve long-term outcomes.