HBeA阳性初治优化治疗幻灯片.ppt

* * * * * * * * The natural history of HBV infection varies according to the age of acquisition of the infection, mode of transmission and ethnic background Acquisition in infancy Three phases of HBV replication: 1. Immunotolerant phase (replicative phase) - high levels of HBV DNA indicate active viral replication - usually HBeAg-positive - no ALT elevation 2. Immune clearance phase - cycles of liver inflammation and repair - transient elevations in ALT and corresponding fluctuations in HBV DNA - eventual conversion from e-antigen to e-antibody and loss of HBV DNA in most people,  but this occurs with an on-going cycle of inflammation and liver disease - 10% chance of developing chronic hepatitis or cirrhosis during this phase - anti-viral treatment most effective during this phase 3. Residual integrative phase - normal ALT, negative e-antigen, positive e-antibody and positive / negative HBV DNA (replication can still occur but at very low levels) - 30% chance of underlying cirrhosis 4. Hepatocellular carcinoma (HCC) - patients with HBV cirrhosis are at risk of developing HCC - risk is estimated at 25% after 15 years of cirrhosis Adult acquisition - 2–6 month incubation period, followed by an episode of acute hepatitis (may be subclinical) - greater than 90% chance of clearing the virus following this - 5–10% chance of chronic HBV infection - may develop chronic hepatitis, cirrhosis and hepatocellular carcinoma Reference 1. Digestive Health Foundation. Hepatitis B: new tests, new treatments, new recommendations. 2nd ed. Sydney: Gastroenterological Society of Australia, 2000. * * * * * * 优化治疗是一个连续的过程，初治患者的贺普丁优化治疗方案可通过基线评估：低病毒载量载量者可选择贺普丁单药治疗，治疗至24周时评估早期应答，如果是完全应答，及HBV DNA阴转，继续贺普丁单药治疗可获得良好疗效。如果24周HBV DNA仍为阳性，则联合应用无交叉耐药药物治疗，如加用ADV优化治疗。对于基线高病毒载量或肝硬化的患者，则可选择贺普丁+ADV初始联合，以提高疗效和降低远期的耐药发生。 * * * * * * * 相较而言，联合治疗是否会增加不良反应的发生率呢？回答这个问题不能仅凭机理去推断，大量关于联合治疗的临床试验提示，无论是在一般不良反应、严重不良反应，还是在大家较关心的血清肌酐、肾小球滤过率等肾脏指标方面，联合治疗都与单药治疗或基线值相比无显著差异。 2011年