Sa1488.Adherence to AASLD treatment guidelines on treatment initiation among treatment-eligible patients with chronic hepatitis B: experiences from primary care and referral practices (Nguyen VH, et al)
Guidelines from the American Association for the Study of Liver Diseases (AASLD) for treating patients with chronic hepatitis B have changed over time. The authors of this study aimed to assess the rate of optimal evaluation, treatment eligibility and treatment initiation for chronic hepatitis B patients in various practice settings in the United States.
Nguyen et al conducted a retrospective cohort study evaluating 4,130 treatment-naive patients with chronic hepatitis B treated consecutively by a group of community primary care physicians (PCPs) (n=616), community gastroenterologists (n=2,251) and university hepatologists (n=1,263) from January 2002 to December 2016. Eligibility was defined by the AASLD criteria and adjusted based on changes over time in alanine aminotransferase (ALT), hepatitis B e antigen (HBeAg) and hepatitis B virus (HBV) DNA levels. Eligibility was assessed in the first six months of follow-up. Eligible patients were treated if they were on treatment by 12-month follow-up. The follow-up period was up to five years.
By the six-month follow-up, 37% of patients treated by PCPs had all three lab test results, compared with 60% of those treated by GIs and 80% of those treated by hepatologists (P<0.0001). All three groups had low eligibility rates: 13% in the PCP treatment group, 25% in the GI group and 29% in the hepatology group (P<0.0001). Treatment rates were 39% in the PCP group, 56% in the GI group and 58% in the hepatology group (P<0.0001). Male sex (OR, 1.40; 95% CI, 1.09-1.79; P=0.008), referral to hepatologists (OR, 2.58; 95% CI, 1.45-4.59; P=0.001) and having positive HBeAg (OR, 1.87; 95% CI, 1.14-3.05; P=0.013) were the strongest predictors of treatment initiation.
Of the 3,018 patients with chronic hepatitis B who were initially treatment-ineligible, 9% became eligible in the PCP group, 23% in the GI group, and 14% in the hepatology group (P<0.0001). Of these patients, those treated by hepatologists had the highest treatment rate (82%), followed by those treated by GIs (62%) and then PCPs (24%) (P<0.0001). The strongest predictors for treatment initiation were male sex, referral to community GI and having an elevated HBV DNA level.
Dr. Alkhouri: Hepatitis B is a progressive liver disease affecting approximately 1 million Americans. Globally, it is the leading cause of liver cancer, especially in Asian countries. It has different phases, and it may not be clear to nonspecialists who can be treated with antiviral therapy and who can be safely monitored. For example, some patients have immune-tolerant or chronic inactive hepatitis B, which typically are not treated but are monitored closely, while others have immune-active or reactivation of hepatitis B that requires antiviral therapy. Patients’ liver function tests, viral DNA load and HBeAG all have to be monitored frequently, and liver ultrasound must be done to screen for liver cancer.
Deciding on treatment can be tricky. It is different from hepatitis C, for which there is a highly effective treatment that can achieve complete eradication of the virus leading to cure. With hepatitis B, you need to decide who needs to be treated and then frequently monitor to see if the disease has changed phases; this can make it confusing for PCPs, leading to undertreatment.
The study really shows the disparity between care levels. If you are a patient with hepatitis B, you probably should receive an evaluation by a specialist to decide on the need for treatment.