Doctors Explain Which Medical Guidelines They Follow, Or Ignore
There are three sets of hepatitis B treatment guidelines available worldwide (from America, Asia and Europe) and sometimes they agree, and often they conflict.
Confronted with varying treatment recommendations, a team of expert doctors from the University of Michigan Health System in Ann Arbor detailed which they followed when caring for their own patients in the January 2014 issue of the journal of Clinical Gastroenterology and Hepatology.
All three guidelines give guideposts forwhen antiviral treatment should begin—when ALT levels are elevated indicating liver cell damage, or viral load is high, or when a liver biopsy uncovers fibrosis or cirrhosis. But there is much gray area and little consensus about exactly how high viral load or ALT levels should be to trigger treatment, or when to perform a liver biopsy. For example:
American guidelines suggest treatment should start when HBV DNA levels exceed 20,000 IU/mL.
Asian guidelines start treatment when viral load exceeds 20,000 IU/mL for HBeAg-positive patients and 2,000 IU/mL for HBeAg-negative patients.
And, European guidelines recommend a minimum of 2,000 IU/mL to initiate treatment no matter what the patient's HBeAg status is.
医生解释哪些医疗指引他们遵循或忽略
有三套全球现有的乙肝治疗指南（来自美洲，亚洲和欧洲） ，有时他们同意，他们常常会发生冲突。
面对不同的治疗建议，一队来自密歇根大学健康系统在安阿伯详细介绍了大学的专家医生，他们在2014年1月发行的临床胃肠病学和肝脏病学杂志上的照顾自己的病人时，紧随其后。
所有这三个准则为路标forwhen抗病毒治疗应开始 - 当ALT水平升高说明肝细胞损害，或病毒载量高，或当肝活检揭示纤维化或肝硬化。但仍然有很多灰色地带，大约究竟有多高病毒载量或ALT水平应触发治疗，或何时进行肝活检一点共识。例如：
美国指南建议治疗应开始时HBV DNA水平超过20,000 IU /毫升。
亚洲指引开始治疗时病毒载量超过20,000国际单位/毫升的HBeAg阳性患者和2000个国际单位/毫升的HBeAg阴性患者。
而且，欧洲指南建议至少2,000 IU / mL到开始治疗，无论患者的HBeAg状态是什么。
When do these doctors start treatment? When patients have moderate (compensated) cirrhosis, they follow American guidelines but they don't wait for HBV DNA to reach 20,000 IU/mL. They start treating when HBV DNA is much lower (at 2,000 IU/mL) because of the risk of liver cancer in these cirrhotic patients.
In non-cirrhotic patients, they follow American guidelines and start treatment when HBV DNA levels exceed 20,000 IU/mL and ALT levels are greater than twice the upper limits of normal.
For patients in the gray zone, with moderately elevated viral loads and ALT levels, the doctors recommend liver biopsies to determine the true health of their livers, especially if patients are 40 or older.
什么时候这些医生开始治疗？当患者有中度（补偿）肝硬化，他们遵循美国的准则，但他们不等待HBV DNA达到20,000国际单位/毫升。他们开始治疗时，HBV-DNA是因为肝癌在这些肝硬化患者的风险要低得多（在2000国际单位/毫升）。
在非肝硬化患者，他们跟随美国的准则，并开始治疗时，HBV DNA水平超过20,000 IU/ mL和ALT水平高于正常值上限的两倍。
对于患者在灰色地带，具有中度升高病毒载量和ALT水平，医生建议肝活检，以确定他们的肝脏的真正的健康，特别是如果患者是40岁以上。
When do they order a liver biopsy? All guidelines agree that neither treatment nor a biopsy is needed in patients with normal ALT and low viral load. These doctors order a biopsy when patients have slightly elevated ALT levels, especially in patients age 40 or older. (European guidelines recommend a biopsy in these patients once they reach age 30.) Treatment is recommended if moderate to severe inflammation and/or fibrosis is found.
If patients have high viral load, even though their ALT levels are normal (called the immune-tolerant stage), the doctors would not treat or biopsy until the patient reached age 40, when liver damage and cancer risks increase.
他们什么时候订购肝活检？所有指导方针同意本治疗也不活检是必要的，患者ALT正常和低病毒载量。这些医生下令活检时患者有轻微ALT水平升高，尤其是在患者40岁或以上。 （欧洲指南推荐对这些患者进行活检，一旦他们达到30岁。）治疗，建议如果中度至重度炎症和/或纤维化被发现。
如果患者病毒载量高，即使他们的ALT水平正常（称为免疫耐受期），医生不会治疗或活检，直到病人达到了40岁，当肝功能损害和癌症的风险增加。
Do they treat pregnant women with high viral loads to prevent infection of newborns? European and Asian guidelines promote treating women with high viral loads with antivirals to prevent mother-to-child infection. "We defer treatment in women who have plans to be pregnant unless they have active or advanced liver disease," they wrote. "We discuss the benefits and risks of ... antiviral treatment with women who have HBV DNA level(s) greater than (10 million) IU/mL during the second trimester of pregnancy. "We recommend starting antiviral treatment around week 30 if the patient agrees and (we) prefer tenofovir (Viread)…. We stop treatment immediately after delivery and emphasize the importance of monitoring for postpartum flares. We discuss the potential risk of exposing the infant to the antiviral medication if treatment is continued, but we do not advise against breastfeeding."
难道他们对待孕妇高病毒载量，以防止新生儿感染？欧洲和亚洲的指引，促进治疗的妇女高病毒载量与抗病毒药物以防止母亲对孩子的感染。
“我们推迟治疗，谁拥有的计划，除非他们有主动或晚期肝病是孕妇，”他们写道。 “我们讨论的好处和...抗病毒治疗的风险与谁拥有的HBV DNA水平（S）大于（10元）IU/ mL的妊娠孕中期妇女。
“我们建议在开始抗病毒治疗的大约30周，如果病人同意和（我们）更愿意替诺福韦（Viread的）......我们交货后，立即停止治疗，并强调产后耀斑监测的重要性。我们讨论的暴露对婴幼儿的潜在风险抗病毒的药物治疗，如果继续，但我们不建议对母乳喂养。“
How often do these doctors monitor their patients? They monitor patients under age 30 in the immune-tolerant stage every six to 12 months and older patients every three to six months. "We monitor HBeAg-negative patients every three months over a one-year period before determining they are truly in the inactive carrier phase, at which time we decrease monitoring to every 6 to 12 months."
多久这些医生监测患者？他们监测30岁以下的患者在免疫耐受期每6至12个月以上的患者每三至六个月。 “我们监测HBeAg阴性患者每三个月在确定他们是真正的非活动载波相位，届时我们减少监控，每6〜12个月之前的一年时间。
What treatments do these doctors use? Pegylated interferon and the antivirals tenofovir and entecavir are recommended as first treatments by the American guidelines and the doctors follow their recommendations. However, despite their good experience with interferon, fewer than 10% of their patients select interferon. "We are more enthusiastic in recommending interferon to young patients, particularly those who are hesitant to commit to a long duration of treatment and young women who are planning to start a family within the next two to three years," they wrote.
When it comes to antivirals, they believe entecavir and tenofovir are equally effective. "We prefer entecavir in patients who are at increased risk of (kidney damage) such as patients with decompensated cirrhosis, older patients, and patients with hypertension or diabetes. We prefer tenofovir in young women who might become pregnant during the course of treatment," they wrote.
They avoid prescribing lamivudine, telbivudine, and adefovir because of their higher rates of drug resistance. "In addition, we systematically have switched patients from adefovir to tenofovir because tenofovir is more potent. For patients taking lamivudine plus adefovir because of prior lamivudine resistance, we have switched them to tenofovir if they have undetectable HBV DNA levels or to the combination pill Truvada (containing the antiviral emtricitabine plus tenofovir). We have switched most patients taking lamivudine to tenofovir, except for a few who had been on lamivudine for many years with undetectable HBV DNA levels because the risk of antiviral drug resistance in these patients is very low."
做这些医生使用什么治疗方法？聚乙二醇干扰素和抗病毒药物替诺福韦和恩替卡韦被推荐为治疗首先由美国的指引，医生按照他们的建议。然而，尽管他们用干扰素很好的经验，他们的病人不到10％选择干扰素。 “我们是在推荐干扰素对年轻患者，特别是那些谁是犹豫致力于治疗和年轻妇女谁正计划在未来两到三年内组建家庭的时间长更热烈， ”他们写道。
当涉及到抗病毒药物，他们认为恩替卡韦和替诺福韦也同样有效。 “我们喜欢恩替卡韦的病人谁在（肾损害），如失代偿性肝硬化，老年患者，和患者有高血压或糖尿病的风险增加，我们宁愿替诺福韦在年轻女性治疗过程中谁可能怀孕， ”他们写道。
他们避免因处方药耐药的比率较高的拉米夫定，替比夫定和阿德福韦。 “此外，我们系统皆已患者阿德福韦替诺福韦，因为替诺福韦是更有效的。对于服用拉米夫定，因为之前拉米夫定耐药加上阿德福韦的患者，我们皆已他们替诺福韦，如果他们有检测不到HBV DNA水平或组合药片Truvada的（含抗病毒药恩曲他滨加替诺福韦） 。我们已经切换服用拉米夫定替诺福韦大多数患者，除了少数谁已经对拉米夫定多年，检测不到HBV DNA水平，因为在这些患者抗病毒耐药的风险是很低的。 “
When do the doctors stop antiviral treatment? These doctors continue antiviral treatment indefinitely in those who have cirrhosis and in many older patients (older than 60) unless they clear HBsAg.
For HBeAg-positive patients without cirrhosis, the doctors won't stop treatment until 12 months after the patients have achieved HBeAg seroconversion in order to "consolidate" the HBeAg loss.
In HBeAg-negative patients, they stop treatment after HBsAg loss, but this has occurred in only one patient they have treated in the past five years.
"We have, however, discontinued treatment in several patients who can no longer afford or are no longer willing to commit to long-term treatment if they have completed at least five years of treatment with undetectable HBV DNA levels in the past three years," they reported. "Although all patients experienced virologic relapse after treatment was stopped, most patients continue to have low HBV DNA levels and normal ALT levels and have not required resumption of treatment."
"Guidelines provide an evidence-based framework for managing patients; however, management of individual patients must be flexible, taking into account the patient's preference and other medical or psychosocial conditions, evolution in knowledge over time, and the provider's experience," they concluded.
Source: www.natap.org/2014/HBV/011614_01.htm
当你的医生停止抗病毒治疗？这些医生继续抗病毒治疗无限期地在那些谁拥有肝硬化和许多老年患者（ 60岁以上） ，除非他们明确乙肝表面抗原。
对于HBeAg阳性患者无肝硬化，医生不会停止治疗，直到12个月，患者以“巩固”的HBeAg转阴实现HBeAg血清转换后。
在HBeAg阴性患者，他们停止治疗HBsAg消失后，但是这已经发生在他们在过去五年里只处理一个病人。
“我们有，但是，在一些病人谁再也不能或不再愿意承诺长期治疗，如果他们已经完成了至少五年检测不到HBV DNA水平的治疗在过去三年停止治疗， ”他们的报告。 “虽然所有患者经历病毒学复发治疗停止后，多数患者继续有低HBV DNA水平和ALT水平正常，并没有要求恢复治疗。 ”
“指南提供以证据为基础的框架，用于管理病人，但是，个别病人管理必须是灵活的，考虑到病人的偏好和其他医疗或心理状况，演变知识随着时间的推移，与供应商的经验， ”他们的结论。
资料来源： www.natap.org/2014/HBV/011614_01.htm
|
发表于 2014-2-4 17:48
