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Dr. Afdhal: These data, with the prolonged suppression for 96 weeks, are a good indication for the use of adefovir therapy in this patient. When the choices of therapy were discussed with the patient, we were happy and he was happy to go on adefovir. Would anybody disagree with that choice in this particular precore mutant patient?
Dr. Schiff: No. I tried to point that out, when you were talking about e-antigen negatives. They notoriously relapse and, therefore, you are talking long-term treatment. You are going to get suppression of viral replication and a very low chance for escape. If you use lamivudine, the chance for escape -- particularly over the period you show, of 3 years -- is probably going to be over 50%.
Dr. Afdhal: He completely agreed with me.
Dr. Dieterich: Yes, but he would have treated him 6 months earlier.
Dr. Schiff: Absolutely, I would have been way ahead. He never would have relapsed in the first place.
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Dr. Afdhal: When we look at his response to therapy over the period that we followed him -- which is now 6 months on therapy -- this particular patient has had a good reduction in viral load, almost a 4 log10 decrease in viral load. That has been associated with a reduction in his transaminases, although these have not yet normalized, and his viral load is not yet below the limit of detection. Obviously, with the knowledge that we have, the continued therapy can cause continued suppression of both inflammation and viremia. This patient will continue on therapy indefinitely, until we achieve these results.
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Dr. Afdhal: This case shows that one needs to be able to have effective viral suppression for a long period, particularly in patients who are precore mutants. This is actually possible with all the agents we have to choose from -- probably optimally, at the moment, with adefovir -- and is associated with improvements in both ALT and histology.
Dr. Keeffe: Let me ask, how did the liver biopsy help you?
Dr. Afdhal: Not very much. We would have treated him without the liver biopsy. There is a saying, "If you only have one tool, you'll use it a lot." A carpenter likes the hammer and nails; a hepatologist likes to stick in needles. If he had gone to somebody else, maybe he would not have gotten that liver biopsy.
Dr. Keeffe: I take Dr. Schiff's point. The patient had elevated enzymes; you saw him, they were down; you see him the next time, they are up again. It really looks like this is a precore mutant. Whether he has stage 1 disease or stage 2 disease, you probably want to suppress that infection.
Dr. Schiff: It would make a difference if you biopsied him when you first saw him, and he had cirrhosis. You would unquestionably have started him on treatment and not risked a flare, because when they flare, they can sometimes flare with jaundice -- but those are the cirrhotic patients.
Dr. Dieterich: Do you think it would make a difference in your hepatocellular carcinoma (HCC) screening too? If he had cirrhosis, of course, that is a 1/1.
Dr. Schiff: With HBV, I would screen anyway -- a male like this, I would definitely screen.
Dr. Afdhal: One of the things that we do sometimes, even in clinical practice, is to rebiopsy these patients if we are trying to make a decision about stopping treatment. Sometimes, we do stop to see if the patient is able to have a durable response even though you stop treatment.
Dr. Keeffe: The other thing we do not have in HBV that we have in hepatitis C virus (HCV) infection, although not everybody agrees, is this criteria of an urgency for therapy. That is, if you do a biopsy and you are stage 0 or stage 1, there is no urgency for therapy in HCV infection; you can defer. We do not have the same mindset in HBV. Would you agree?
Dr. Afdhal: Yes. There is enough evidence to suggest that the natural history of HBV infection is somewhat more aggressive and that we are a little more aggressive in treating patients with HBV than with HCV infection.
Dr. Schiff: Are you routinely testing all HBV patients for a delta? It would be so unlikely in an Asian, but we used to do that routinely in every HBV patient.
Dr. Afdhal: We are testing people whom we consider high risk, such as intravenous drug users who have flares of hepatitis. We are testing people who come in with subfulminant or even fulminant liver failure. But, we are not testing for it in the routine patient where there are other obvious risk factors, such as in this patient.
Dr. Keeffe: The prevalence rate is low in the Asian-American population.
花猫和猫朋友们加油啊...这个好翻译...过几天上病例2. 
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楼主: wwqm
发表于 2005-8-11 22:11
