Treatment of chronic hepatitis B

Chronic hepatitis B is a problem of great magnitude worldwide. In China, Southeast Asia, and sub-Saharan Africa, where the bulk of carriers reside, the disease is transmitted predominantly perinatally by a carrier mother. Infected newborn babies almost invariably become carriers themselves (presumably because of an ''immature'' immune system) and are at great risk of developing cirrhosis or primary liver cancer. In industrialized countries, the disease is far less prevalent and occurs mainly in adults belonging to special risk groups through percutaneous or sexual contact. Chronic hepatitis B, which is less common in these individuals, presents mainly in those with compromised immune systems. In this review, we summarize briefly the pathogenesis of the carrier state and offer a rationale for treatment. Only limited, well-controlled therapeutic trials have been performed, primarily among Caucasian populations. Among the three primary therapeutic options, corticosteroids, used for their immunosuppressive properties, have proven harmful when administered on their own, whether for extended or abbreviated periods of time. Ara-A and Ara-AMP, potent antiviral agents that inhibit HBV DNA polymerase, are effective in decreasing viral replication in almost half of those treated, but the effect is transient, and the drugs are highly toxic. Best results have been achieved with the interferon, antiviral, and immunomodulatory glycoproteins. Controlled trials with alpha interferon demonstrate a reduction in viral replication in about one third of certain categories of carriers, an effect that seems enhanced by pretreatment with a short course of corticosteroids. The high recurrence rate after treatment withdrawal and the potential for exacerbation of the disease, however, dictates the need to restrict this therapy at present to academic centers with expertise in this area and the availability of sophisticated tests for viral markers.

Duke Scholars

Author Anna Mae Diehl Medicine, Gastroenterology