Marcellin Patrick, Liang Jake
Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France.
Antivir Ther. 2010;15 Suppl 3:53-9. doi: 10.3851/IMP1624.
In a treatment-naive patient with chronic hepatitis B, a personalized approach allows treatment efficacy to be optimized. Firstly, the selection of good candidates for therapy is crucial. Patients with chronic active hepatitis B--with relatively low levels of HBV DNA replication (<10(9) copies/ml) and relatively high alanine aminotransferase (ALT) levels--are good candidates for therapy. By contrast, patients with chronic hepatitis B in the immunotolerance phase, who have high levels of HBV DNA and persistently normal ALT levels, as well as inactive hepatitis B surface antigen (HBsAg) carriers with low HBV DNA and normal ALT levels do not have an indication for therapy as they are poor responders. Secondly, the characteristics of the patient (for example, gender, age, immune status, general health status and comorbidities), the characteristics of the liver disease (for example, presence of cirrhosis and liver function) and the characteristics of the virus (for example, genotype) are important when assessing the chance of success and when choosing the best therapeutic strategy (nucleoside/nucleotide analogue or interferon). Thirdly, during therapy, the antiviral effect--assessed by decrease in HBV DNA level--allows an individualized response-guided approach. In addition, quantification of HBsAg after 3-6 months of interferon therapy appears to be a good predictor of sustained virological response after treatment and HBsAg clearance. Continuing interferon therapy until week 48 is justified in patients with a significant decrease in HBsAg. Ongoing and future studies will provide useful information regarding prolonging interferon therapy beyond 48 weeks in some patients in order to increase efficacy, and also regarding the role of combination therapy with interferon and potent nucleoside/nucleotide analogues, such as entecavir or tenofovir disoproxil fumarate.
对于初治慢性乙型肝炎患者，个体化治疗方法可优化治疗效果。首先，选择合适的治疗对象至关重要。慢性活动性乙型肝炎患者——乙肝病毒脱氧核糖核酸（HBV DNA）复制水平相对较低（<10⁹拷贝/毫升）且丙氨酸氨基转移酶（ALT）水平相对较高——是治疗的合适对象。相比之下，处于免疫耐受期的慢性乙型肝炎患者，其HBV DNA水平高且ALT水平持续正常，以及HBV DNA水平低且ALT正常的乙肝表面抗原（HBsAg）携带者，由于治疗反应不佳，没有治疗指征。其次，在评估成功几率和选择最佳治疗策略（核苷/核苷酸类似物或干扰素）时，患者的特征（如性别、年龄、免疫状态、总体健康状况和合并症）、肝病特征（如是否存在肝硬化和肝功能）以及病毒特征（如基因型）很重要。第三，在治疗期间，通过HBV DNA水平下降评估的抗病毒效果可采用个体化的反应指导方法。此外，干扰素治疗3 - 6个月后的HBsAg定量似乎是治疗后持续病毒学应答和HBsAg清除的良好预测指标。对于HBsAg显著下降的患者，持续干扰素治疗至48周是合理的。正在进行的和未来的研究将提供有用信息，包括关于在一些患者中将干扰素治疗延长至48周以上以提高疗效，以及关于干扰素与强效核苷/核苷酸类似物（如恩替卡韦或替诺福韦酯）联合治疗的作用。
