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Start Treatment for Low ALT - PRO
来源：国际肝病作者：Nancy W.Y. Leung发布时间：2009-2-13
文章导读：In summary, there is a strong case for treating CHB patients with low ALT, when there are options of effective and safe therapy. However, it must be emphasized that the recommendation to treat CHB patients with low ALT does not supersede a proper full assessment of the patient. Other factors that should prompt clinician to treat are the male gender, older age group, family history of serious liver disease or hepatocellular carcinoma, high serum HBV DNA levels, histological grading and staging or imaging suggesting coarse liver echo texture or cirrhosis. Nancy W.Y. Leung Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
Serum alanine aminotrans-ferase (ALT) has been used as a surrogate marker for the degree of inflammation in liver diseases. It is a simple, readily available, and cheap blood test that can be repeated serially for monitoring disease progression. It has good correlation with the histological grading and staging of chronic hepatitis B (CHB). In the development of therapy for CHB, the main endpoint was initially targeted at the normalization of abnormal ALT. In recent years, FDA added histological and viral response to ALT normalization as combined endpoints for assessing efficacy of treatment in clinical trials.
Almost all pivotal clinical trials on HBV therapy required raised ALT in the protocol inclusion criteria. Results from these trials formed the backbone for developing HBV consensus and guidelines such as AASLD, EASL, and APASL. This is evidence-based medicine. There is very little published controlled data on therapy for low or normal ALT among CHB patients. However, there are many good reasons to treat patients with low ALT.
1.ALT may fluctuate, some may have recurrent short ALT elevation or even flares. Higher levels are easily missed in usual clinical practice when ALT is monitored at 3 to 6 monthly interval.
2.The “normal” ALT used in different laboratories is above the new suggested normal of 30 IU/L for males and 19 IU/L for females.
3.Many recent research and studies indicate patients with “persistent” low or normal ALT have significant liver diseases that require therapy.
4.A percentage of CHB patients are in immune tolerant stage and have very high viral load but normal ALT. Antiviral therapy is not generally recommended for these patients, especially if they are young. However, many are in their fourth, fifth and even sixth decade of life. Evidence suggests that this prolonged duration of viraemia exposes them to higher risk of fibrosis progression and hepatocelluar carcinoma development.
5.In HBeAg-negative CHB, the ALT may be even more difficult to monitor. These patients are older and despite lower serum HBV DNA, have a higher probability of significant liver disease.
6.In patients with advance fibrosis or cirrhosis, even low rate of disease progression reflected by low ALT level may indicate insidious progression. Withholding therapy in these patients will hasten decompensation and death in short duration.
In summary, there is a strong case for treating CHB patients with low ALT, when there are options of effective and safe therapy. However, it must be emphasized that the recommendation to treat CHB patients with low ALT does not supersede a proper full assessment of the patient. Other factors that should prompt clinician to treat are the male gender, older age group, family history of serious liver disease or hepatocellular carcinoma, high serum HBV DNA levels, histological grading and staging or imaging suggesting coarse liver echo texture or cirrhosis.
http://apasl2009-cn.ihepa.com/16-164-2022.html |
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发表于 2012-7-21 02:56
