Sa1488。符合治疗标准的慢性乙型肝炎患者治疗开始的AASLD治疗

StephenW

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.

StephenW

Sa1488。符合治疗标准的慢性乙型肝炎患者治疗开始的AASLD治疗指南：初级保健和转诊实践的经验（Nguyen VH，et al）

美国肝病研究协会（AASLD）治疗慢性乙型肝炎患者的指南随着时间的推移而发生了变化。本研究的作者旨在评估美国各种实践环境中慢性乙型肝炎患者的最佳评估率，治疗资格和治疗启动率。

Nguyen等人进行了一项回顾性队列研究，评估了由一群社区初级保健医生（PCP）（n = 616），社区胃肠病学家（n = 2,251）和大学肝病学家（n = 2,251）连续治疗的4,130例未接受过治疗的慢性乙型肝炎患者。 1,263）从2002年1月至2016年12月。资格由AASLD标准定义，并根据丙氨酸氨基转移酶（ALT），乙型肝炎e抗原（HBeAg）和乙型肝炎病毒（HBV）DNA水平随时间的变化进行调整。在随访的前六个月评估了资格。符合条件的患者如果接受12个月的随访治疗则接受治疗。随访期长达五年。

经过6个月的随访，37％接受PCP治疗的患者有三个实验室检测结果，而接受过GI治疗的患者为60％，肝病专家治疗组为80％（P <0.0001）。所有三组的合格率均较低：PCP治疗组为13％，GI组为25％，肝病组为29％（P <0.0001）。 PCP组的治疗率为39％，GI组为56％，肝病组为58％（P <0.0001）。男性性别（OR，1.40; 95％CI，1.09-1.79; P = 0.008），转诊给肝病学家（OR，2.58; 95％CI，1.45-4.59; P = 0.001）并且HBeAg阳性（OR，1.87; 95 ％CI，1.14-3.05; P = 0.013）是治疗开始的最强预测因子。

在最初治疗不合格的3,018名慢性乙型肝炎患者中，9％符合PCP组，23％符合GI组，14％符合肝病组（P <0.0001）。在这些患者中，肝病专家治疗的患者治疗率最高（82％），其次是GI治疗组（62％）和PCP治疗组（24％）（P <0.0001）。治疗开始的最强预测因素是男性性别，转诊至社区GI并且HBV DNA水平升高。

Alkhouri博士：乙型肝炎是一种进行性肝病，影响了大约100万美国人。在全球范围内，它是导致肝癌的主要原因，特别是在亚洲国家。它有不同的阶段，对于可以接受抗病毒治疗并且可以安全监测的非专科医生可能并不清楚。例如，一些患者具有免疫耐受性或慢性无活性乙型肝炎，其通常未经治疗但是被密切监测，而其他患者具有需要抗病毒治疗的乙型肝炎的免疫活性或再激活。患者的肝功能检查，病毒DNA载量和HBeAG都必须经常监测，必须进行肝脏超声检查以筛查肝癌。

决定治疗可能很棘手。它与丙型肝炎不同，其中有一种非常有效的治疗方法，可以完全根除病毒，从而治愈。对于乙型肝炎，您需要决定谁需要接受治疗，然后经常监测以确定疾病是否已经改变阶段;这可能会使PCP混淆，从而导致治疗不足。

该研究确实显示了护理水平之间的差异。如果您是乙型肝炎患者，您可能应该接受专科医生的评估，以决定是否需要治疗。