慢性乙型肝炎患者停用长期核苷类似疗法的挑战

StephenW

Challenges With Stopping Long-term Nucleos(t)ide Analogue Therapy in Patients With Chronic Hepatitis B
K. Seng Liem
Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
Adam J. Gehring
Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
Jordan J. Feld
Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
McLaughlin-Rotman Centre for Global Health, Toronto, Ontario, Canada
Harry L.A. Janssen
Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
The treatment goals for patients with chronic hepatitis B include improving quality of life and decreasing the risk of liver disease-related complications. These aims can be achieved with nucleos(t)ide analogue (NUC) therapy, which largely prevents liver failure, decreases the risk of hepatocellular carcinoma, and has excellent safety data.1,2 Yet low rates of on-therapy functional cure (hepatitis B surface antigen [HBsAg] loss), which is regarded as the optimal end point to withdraw therapy, preclude many patients from stopping therapy. Additionally, other concerns of long-term therapy such as adherence, side effects, and, particularly, costs, spurred a worldwide scientific debate on NUC discontinuation before patients reach functional cure.

Although all major chronic hepatitis B guidelines have included recommendations on NUC withdrawal, these considerations are based on limited evidence and may underestimate sequelae of clinically significant flares.3, 4, 5 Recommendations differ on which patients can discontinue NUC treatment, when to restart treatment and what the optimal duration of consolidation therapy is. Some reasons for the lack of consensus are economical or practical, but arguably less scientific given the limited data available. Could the guidelines have concluded too prematurely that patients can stop NUC therapy?

StephenW

慢性乙型肝炎患者停用长期核苷类似疗法的挑战
森·林
多伦多肝病中心，多伦多总医院，大学健康网，多伦多，加拿大安大略省
鹿特丹伊拉斯姆斯大学医学中心消化内科和肝病科，荷兰鹿特丹
亚当·杰林
多伦多肝病中心，多伦多总医院，大学健康网，多伦多，加拿大安大略省
乔丹·J·费尔德
多伦多肝病中心，多伦多总医院，大学健康网，多伦多，加拿大安大略省
McLaughlin-Rotman全球卫生中心，加拿大安大略省多伦多
哈里·詹森
多伦多肝病中心，多伦多总医院，大学健康网，多伦多，加拿大安大略省
慢性乙型肝炎患者的治疗目标包括改善生活质量并降低与肝病相关并发症的风险。这些目标可通过核苷酸类似物（NUC）治疗来实现，该疗法可大大预防肝衰竭，降低肝细胞癌的风险并具有出色的安全性数据1,2。 B表面抗原[HBsAg]丢失）被认为是退出治疗的最佳终点，这使许多患者无法停止治疗。此外，长期治疗的其他问题，如依从性，副作用，尤其是成本，也引起了全世界对在患者达到功能性治愈之前停用NUC的科学争论。

尽管所有主要的慢性乙型肝炎指南均已建议戒断NUC，但这些考虑都是基于有限的证据，可能会低估临床上明显发作的后遗症。 3、4、5条建议对哪些患者可以停止NUC治疗，何时重新开始治疗以及巩固治疗的最佳持续时间有所不同。缺乏共识的一些原因在经济上或实践上都是可行的，但鉴于可用的数据有限，可以说科学性较低。指南是否过早得出结论，患者可以停止NUC治疗？

StephenW

https://www.gastrojournal.org/article/S0016-5085(19)41872-6/fulltext