From the Guidelines
The treatment plan for liver disease should prioritize antiviral medications such as entecavir 0.5mg daily or tenofovir 300mg daily for hepatitis B, with the goal of suppressing HBV replication and preventing progression of liver disease to cirrhosis, liver failure, or HCC, as recommended by the most recent study 1. The choice of treatment depends on the specific type and severity of the condition, as well as the presence of liver cirrhosis.
- For patients with HBeAg-positive or -negative CHB and elevated ALT levels, an HBV DNA level of 2000 IU/mL or higher is a reasonable threshold for determining candidates for treatment, according to 2.
- The preferred first-line treatments for CHB are entecavir, tenofovir, and peginterferon alfa-2a, with considerations for efficacy, safety, resistance, and method of administration, as noted in 2.
- Long-term administration of a potent NA with high barrier to resistance is the treatment of choice regardless of the severity of liver disease, with the preferred regimens being ETV, TDF, and TAF, as stated in 1.
- Patients should remain under surveillance for HCC, and the treatment approach should target the underlying cause of liver damage while supporting liver function and preventing further deterioration, as the liver has remarkable regenerative capacity when the injurious agent is removed. Key considerations in treatment planning include:
- Monitoring ALT levels every 3 months for naïve patients treated with TDF, ETV, ADV, LDT, or LAM, as recommended in 1.
- Withdrawing NA therapy after HBsAg loss following either HBs seroconversion or at least 12 months of a post–HBsAg clearance consolidation period, or after treatment for at least 2 years with undetectable HBV DNA documented on 3 separate occasions, as suggested in 1.
From the FDA Drug Label
In a small randomized, double-blind, active-controlled trial (0108), subjects with CHB and decompensated liver disease received treatment with tenofovir disoproxil fumarate or other antiviral drugs for up to 48 weeks The overall incidence of on-treatment ALT flares (defined as serum ALT greater than 2 × baseline and greater than 10 × ULN, with or without associated symptoms) was similar between tenofovir disoproxil fumarate (2. 6%) and HEPSERA (2%) In the treatment of chronic hepatitis B, the optimal duration of treatment is unknown.
The treatment plan for liver disease may include tenofovir disoproxil fumarate. Key points to consider are:
- ALT flares may occur, but the incidence is similar to other treatments
- Decompensated liver disease requires careful management, and tenofovir disoproxil fumarate may be used for up to 48 weeks
- The optimal duration of treatment is unknown, and the relationship between response and long-term prevention of outcomes is not established [3] [4]
From the Research
Treatment Plan for Liver Disease
The treatment plan for liver disease depends on the underlying cause and severity of the disease.
- For patients with alcohol-associated liver disease, abstinence from alcohol is crucial, and corticosteroid therapy may be associated with improved survival in select patients with severe alcoholic hepatitis 5.
- Liver transplantation may be considered in patients with decompensated cirrhosis who do not respond to medical therapy, and in patients with severe alcoholic hepatitis who do not respond to medical therapy 5, 6.
- For patients with chronic liver disease, comprehensive care includes general education, counseling, and harm reduction practices, as well as monitoring for cirrhosis and management of its complications 7.
- Patients with hepatitis C virus (HCV) infection and alcohol consumption should be screened for excessive ethanol intake, and patients starting treatment for HCV infection should be advised to stop or reduce alcohol consumption 8.
- Modern antiviral therapy for chronic hepatitis B and C has been shown to improve clinical outcomes, including decreased rates of liver decompensation, hospitalization, and mortality, as well as improved quality of life 9.
Indications for Liver Transplantation
Liver transplantation may be indicated for patients with:
- Acute liver failure
- End-stage chronic liver disease
- Primary hepatic cancers
- Inborn metabolic disorders
- Unresectable hilar cholangiocarcinoma
- Patients over 65 years with a favorable comorbidity profile 6
Evaluation for Liver Transplantation
The evaluation process for liver transplantation includes:
- Assessment of the patient's overall health and comorbidities
- Evaluation of the patient's liver disease and its severity
- Consideration of the patient's social and psychological factors
- Discussion of the risks and benefits of liver transplantation 6