A hepatitis B expert is calling for a paradigm shift in hepatitis B treatment toward treating everyone with the disease instead of relying on guidelines with complicated eligibility requirements and tests that only specialists feel comfortable interpreting.
Speaking at the IDWeek 2023 meeting in Boston on Thursday, Su Wang, M.D., M.P.H., said expanding treatment is justified partly by evidence that hepatitis B infections are associated with more than just liver disease and a greater risk of hepatocellular carcinoma, the most common type of liver cancer. She cited research showing that hepatitis C is associated with an elevated risk for stomach, colorectal and pancreatic cancer and that persistent infection can lead to “T cell exhaustion” and a diminished immune response.
Wang acknowledged some of the drawbacks of liberalizing treatment, including overtreatment and logistical and cost burden on patients. She said, though, that she finds the arguments against making treatment more common “extremely paternalistic” and that offering more people would elevate patient role in decision making instead of relying on eligibility algorithms as gatekeepers.
“The patient community wants to be part of this. There are many people who don’t want to take these medicines, of course, but there are many who do but have been offered and have been told they have nothing to worry about,” she said
Wang is medical director of the viral hepatitis programs and Center for Asian Health at the Cooperman Barnabas Medical Center in Livingston, New Jersey; past-president of the World Hepatitis Allianceand a senior advisor to the Hepatitis B Foundation.
Multiple groups have guidelines that set the thresholds for who should be treated for hepatitis B. Evidence of cirrhosis is a strong indication to treatment. In the absence of cirrhosis, most of the guidelines map out decision trees that include measurements of presence of the virus (antigen and DNA) and of liver inflammation (alanine aminotransferase (ALT) levels). Current treatments are not curative but they can effectively suppress infection. Oral antivirals are the preferred choice for initial treatment. Among the choices are Baraclude (entecavir), Vemlidy (tenofovir alafenamide) and Viread (tenofovir disoproxil fumarate).
Wang presented data from research published in the American Journal of Managed Care in 2020 that showed that 36% of those with hepatitis B received hepatitis B-directed care. The more tests required for eligibility for treatment, the less likely patients were to be treated, she said. On another slide, Wang presented data from a 2021 Journal of Hepatology that showed that just 65% of patients eligible for treatment under American Association for the Study of Liver Disease guidelines were treated.
Wang said some groups have simplified treatment guidelines. For example, the Hepatitis B Online website maintained by the University of Washington has a guidance for primary care provider that boils eligibility down to measurements of hepatitis B virus DNA and an abnormal ALT levels and dropping any threshold for the measurement of hepatitis B virus antigens.
Wang mentioned several knock-on effects from liberalizing treatment. Simplified eligibility would open up the care of people with hepatitis B to nonspecialists: “We know the stark reality of is that the vast majority of people with hepatitis B in the world do not have access to a specialist.” Wang said broadening treatment would also mean that fewer people with hepatitis B infections would resort to herbal treatments and supplemental.
Although she acknowledged the risk of overtreatment, Wang said that occurs with other diseases, such as hyperlipidemia.
