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*Only for medical professionals to read and refer to the principles of antiviral treatment: one center, two basic points
.
Life is alive, most of the time is spent hesitating, but it often grows in an instant
.
What is the moment that makes you grow? A complicated and difficult case? A brilliant lecture? Or maybe it's a medical column that doesn't care about it? At 19:00 on November 1st, the first issue of "Healer · Heart Road" bloomed dazzlingly.
Thanks to the joint support of 15 media, it set a record of 140,000 views, which not only brought us a taste of China's chronic hepatitis B prevention and control guidelines, anti-virus The development of therapeutic indications has witnessed the years of Professor Wan Mobin from Shanghai Changhai Hospital, Professor Xu Jie from the Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, and Professor Xin Haiguang from Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine
.
China's chronic hepatitis B prevention and control guidelines "previous life and present life" of the indications of antiviral therapy changes.
In 2005, the first "chronic hepatitis B prevention and control guidelines" was officially promulgated.
By 2019, the guidelines have been updated to the fourth edition
.
The progress of the times and the development of science and technology promote the continuous updating of the guidelines, and its treatment focus has also been changed several times, from liver protection treatment → pathogenic treatment → pathogenic treatment + liver protection treatment → expansion of treatment indications
.
Why didn't the previous editions of the guidelines mention the expansion of indications, but did it only reflect the expansion in the 2019 edition? ▎From the perspective of etiology, hepatitis B is a viral disease.
From the perspective of etiology, antiviral therapy is needed when there is a virus.
This is the fundamental way to solve the problem.
The previous guidelines did not relax the indications for antiviral therapy.
It's because the doctors don't have enough weapons
.
▎Drugs are upgraded, and the antiviral efficacy is guaranteed.
In the late 1980s and early 1990s, interferon was used in clinical practice, but the efficacy was limited.
At this time, pathogenic treatment was emphasized and weapons were not enough
.
With the advancement of science and technology, nucleoside (acid) drugs are on the market, and the treatment methods for hepatitis B are relatively more diverse, and the varieties of drugs are also richer.
At this time, the concept of pathogenic treatment can be truly established
.
However, the early antiviral drugs on the market have limited efficacy and are prone to drug resistance.
In order to avoid viral gene mutations, the indications for antiviral therapy need to be controlled more strictly
.
Nowadays, strong and low-resistance nucleoside (acid) drugs such as entecavir, tenofovir, and propofol tenofovir are used in clinical practice, so the indications for antiviral therapy can be relaxed
.
▎Increase in drug availability.
First-line drugs such as Entecavir, Tenofovir, and Propofol Tenofovir have entered medical insurance, and drug prices have been reduced.
Coupled with the support of policies such as volume procurement, the burden of drugs on patients has been greatly reduced
.
▎Development of laboratory medicine The development of laboratory medicine facilitates clinicians to clearly understand the patient's HBV DNA level, and clinicians are more confident and confident about the effects of drug treatment
.
▎The harm of hepatitis B virus infection After infection with hepatitis B virus, although most patients progress slowly, it may affect the prognosis.
Some patients may progress to liver cirrhosis and liver cancer, which will affect the quality of life and life of patients.
Early intervention can be Make patients benefit more
.
▎At the public health level, the disease burden of chronic hepatitis B in China is still heavy.
More people with HBV infection will receive treatment, so that the public can understand that hepatitis B is preventable and curable, and positive guidance can be given to eliminate misunderstandings, which will help 2030 Achievement of the goal of eliminating viral hepatitis
.
What is the essence of the expansion of the treatment indications in the 2019 Chinese Guidelines for the Prevention and Treatment of Chronic Hepatitis B? ▎If the virus is detected, treatment is required.
In the previous guidelines, the virus was detected, but the amount of the virus did not reach a certain standard, and no antiviral treatment was required
.
For example, patients with e antigen-positive have a viral load above 20000IU/mL; patients with e-antigen negative, with a viral load above 2000IU/mL, consider antiviral therapy
.
The new version of the guidelines removes the lower limit of the viral load.
After the virus is detected, the treatment will be comprehensively considered in combination with the ALT level, family history, and age
.
Of course, the method of virus detection emphasized here is an internationally recognized method
.
Internationally recognized methods currently have a lower detection limit of 20IU/mL or even lower, such as 12IU/mL, 10IU/mL
.
▎If the virus is not detected, it is necessary to treat the surface antigen positive.
If the patient has a history of decompensated liver cirrhosis or liver cancer, even if the HBV DNA is negative using a sensitive method, antiviral treatment is also required
.
This is because the patient may have hepatitis B virus reactivation, and during the treatment of liver cancer and liver cirrhosis, if hepatitis B virus reactivation occurs, it will directly threaten the life of the patient
.
▎Treatment for elevated ALT Under the premise of positive HBV DNA, ALT exceeds the upper limit of normal and requires treatment
.
▎If ALT is normal, treatment is required.
If the patient has imaging and histological changes, treatment is required; if the patient has no changes in imaging and histology, but is older than 30 years old and has a family history of liver cirrhosis and liver cancer, treatment is also required
.
[Antiviral therapy principle: one center, two basic points] One center: maximum long-term inhibition of HBV replication, for some patients with suitable conditions, clinical cure should be pursued
.
Two basic points: the drug is strong and low resistance; the price of the drug is low, and the drug is available
.
What is the significance of the expansion of treatment indications in the 2019 Chronic Hepatitis B Prevention and Treatment Guidelines? Early intervention to prevent chronic hepatitis B from progressing to the stage of liver cirrhosis and liver cancer, save patients' lives and improve their quality of life
.
Controlling hepatitis B will promote the entire society at the public health level and help achieve the goal of eliminating viral hepatitis by 2030
.
Improve hepatitis B discrimination, reduce the psychological burden of patients, and deliver the correct voice of diagnosis and treatment
.
Treatment or observation? Clinics often need to consider more.
The first thing that patients need to understand is that the timing of antiviral therapy should be an objective indicator, not a symptom
.
If it is a patient with HBV DNA-positive chronic hepatitis B, the transaminase is elevated, and other causes that cause the transaminase elevation are eliminated, then treatment is needed; if the patient has a high HBV DNA load but normal liver function, the big three positive and young patients are fine.
Observe closely
.
Secondly, clinicians need to communicate more with patients, which can not only understand patients' daily routine, eating habits, family history, etc.
, but also improve patient compliance
.
In the future, where will the guidelines develop? I believe that as antiviral drugs continue to be updated and the efficacy is gradually enhanced, the indications for the treatment of patients with chronic hepatitis B will continue to expand
.
At this stage, it is necessary to distinguish between what is true immune tolerance and what is "false" immune tolerance
.
Immune tolerance stage: chronic HBV carrying state, also known as HBeAg-positive chronic HBV infection
.
The patients in this stage are in the immune tolerance stage, the patient is younger, the quantitative level of HBV DNA (usually >2×107IU/mL) is higher, the serum HBsAg (usually >1×104IU/mL) is higher, HBeAg is positive, but the serum ALT And AST continued to be normal (3 consecutive follow-ups within 1 year, at least 3 months apart each time), and histopathological examination of the liver showed no obvious inflammatory necrosis or fibrosis
.
[Summary of the golden sentence: the first grade, the third grade and the second grade are normal, and they are basically young men] What inspiration and thinking the new crown epidemic has brought us should follow three principles: control the source of infection, cut off the route of transmission, and protect susceptible people
.
For hepatitis B, vaccination allows the source of infection to be controlled and the susceptible population is protected.
Next, it is necessary to pass screening to find as many patients as possible
.
Judging from the current situation, new coronary pneumonia may coexist with humans for a long time.
In this case, infection/hepatology doctors must combine peace and war, taking both into account
.
Difficulties bring experience and experience to people’s wisdom, not forgetting the true nature of the original healer.
It’s dangerous to enter the field of infection/infectious disease.
It is also fortunate to endure loneliness, calm down, study hard, and be a warm, determined, and hopeful healer.
The end of the trial is flowers blooming thousands of miles.
May you set off in a small way and end "Healer · Heart Road" with greatness.
Looking forward to sharing with you the beautiful scenery along the successful journey.
We will see you in the next issue
.
.
Life is alive, most of the time is spent hesitating, but it often grows in an instant
.
What is the moment that makes you grow? A complicated and difficult case? A brilliant lecture? Or maybe it's a medical column that doesn't care about it? At 19:00 on November 1st, the first issue of "Healer · Heart Road" bloomed dazzlingly.
Thanks to the joint support of 15 media, it set a record of 140,000 views, which not only brought us a taste of China's chronic hepatitis B prevention and control guidelines, anti-virus The development of therapeutic indications has witnessed the years of Professor Wan Mobin from Shanghai Changhai Hospital, Professor Xu Jie from the Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, and Professor Xin Haiguang from Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine
.
China's chronic hepatitis B prevention and control guidelines "previous life and present life" of the indications of antiviral therapy changes.
In 2005, the first "chronic hepatitis B prevention and control guidelines" was officially promulgated.
By 2019, the guidelines have been updated to the fourth edition
.
The progress of the times and the development of science and technology promote the continuous updating of the guidelines, and its treatment focus has also been changed several times, from liver protection treatment → pathogenic treatment → pathogenic treatment + liver protection treatment → expansion of treatment indications
.
Why didn't the previous editions of the guidelines mention the expansion of indications, but did it only reflect the expansion in the 2019 edition? ▎From the perspective of etiology, hepatitis B is a viral disease.
From the perspective of etiology, antiviral therapy is needed when there is a virus.
This is the fundamental way to solve the problem.
The previous guidelines did not relax the indications for antiviral therapy.
It's because the doctors don't have enough weapons
.
▎Drugs are upgraded, and the antiviral efficacy is guaranteed.
In the late 1980s and early 1990s, interferon was used in clinical practice, but the efficacy was limited.
At this time, pathogenic treatment was emphasized and weapons were not enough
.
With the advancement of science and technology, nucleoside (acid) drugs are on the market, and the treatment methods for hepatitis B are relatively more diverse, and the varieties of drugs are also richer.
At this time, the concept of pathogenic treatment can be truly established
.
However, the early antiviral drugs on the market have limited efficacy and are prone to drug resistance.
In order to avoid viral gene mutations, the indications for antiviral therapy need to be controlled more strictly
.
Nowadays, strong and low-resistance nucleoside (acid) drugs such as entecavir, tenofovir, and propofol tenofovir are used in clinical practice, so the indications for antiviral therapy can be relaxed
.
▎Increase in drug availability.
First-line drugs such as Entecavir, Tenofovir, and Propofol Tenofovir have entered medical insurance, and drug prices have been reduced.
Coupled with the support of policies such as volume procurement, the burden of drugs on patients has been greatly reduced
.
▎Development of laboratory medicine The development of laboratory medicine facilitates clinicians to clearly understand the patient's HBV DNA level, and clinicians are more confident and confident about the effects of drug treatment
.
▎The harm of hepatitis B virus infection After infection with hepatitis B virus, although most patients progress slowly, it may affect the prognosis.
Some patients may progress to liver cirrhosis and liver cancer, which will affect the quality of life and life of patients.
Early intervention can be Make patients benefit more
.
▎At the public health level, the disease burden of chronic hepatitis B in China is still heavy.
More people with HBV infection will receive treatment, so that the public can understand that hepatitis B is preventable and curable, and positive guidance can be given to eliminate misunderstandings, which will help 2030 Achievement of the goal of eliminating viral hepatitis
.
What is the essence of the expansion of the treatment indications in the 2019 Chinese Guidelines for the Prevention and Treatment of Chronic Hepatitis B? ▎If the virus is detected, treatment is required.
In the previous guidelines, the virus was detected, but the amount of the virus did not reach a certain standard, and no antiviral treatment was required
.
For example, patients with e antigen-positive have a viral load above 20000IU/mL; patients with e-antigen negative, with a viral load above 2000IU/mL, consider antiviral therapy
.
The new version of the guidelines removes the lower limit of the viral load.
After the virus is detected, the treatment will be comprehensively considered in combination with the ALT level, family history, and age
.
Of course, the method of virus detection emphasized here is an internationally recognized method
.
Internationally recognized methods currently have a lower detection limit of 20IU/mL or even lower, such as 12IU/mL, 10IU/mL
.
▎If the virus is not detected, it is necessary to treat the surface antigen positive.
If the patient has a history of decompensated liver cirrhosis or liver cancer, even if the HBV DNA is negative using a sensitive method, antiviral treatment is also required
.
This is because the patient may have hepatitis B virus reactivation, and during the treatment of liver cancer and liver cirrhosis, if hepatitis B virus reactivation occurs, it will directly threaten the life of the patient
.
▎Treatment for elevated ALT Under the premise of positive HBV DNA, ALT exceeds the upper limit of normal and requires treatment
.
▎If ALT is normal, treatment is required.
If the patient has imaging and histological changes, treatment is required; if the patient has no changes in imaging and histology, but is older than 30 years old and has a family history of liver cirrhosis and liver cancer, treatment is also required
.
[Antiviral therapy principle: one center, two basic points] One center: maximum long-term inhibition of HBV replication, for some patients with suitable conditions, clinical cure should be pursued
.
Two basic points: the drug is strong and low resistance; the price of the drug is low, and the drug is available
.
What is the significance of the expansion of treatment indications in the 2019 Chronic Hepatitis B Prevention and Treatment Guidelines? Early intervention to prevent chronic hepatitis B from progressing to the stage of liver cirrhosis and liver cancer, save patients' lives and improve their quality of life
.
Controlling hepatitis B will promote the entire society at the public health level and help achieve the goal of eliminating viral hepatitis by 2030
.
Improve hepatitis B discrimination, reduce the psychological burden of patients, and deliver the correct voice of diagnosis and treatment
.
Treatment or observation? Clinics often need to consider more.
The first thing that patients need to understand is that the timing of antiviral therapy should be an objective indicator, not a symptom
.
If it is a patient with HBV DNA-positive chronic hepatitis B, the transaminase is elevated, and other causes that cause the transaminase elevation are eliminated, then treatment is needed; if the patient has a high HBV DNA load but normal liver function, the big three positive and young patients are fine.
Observe closely
.
Secondly, clinicians need to communicate more with patients, which can not only understand patients' daily routine, eating habits, family history, etc.
, but also improve patient compliance
.
In the future, where will the guidelines develop? I believe that as antiviral drugs continue to be updated and the efficacy is gradually enhanced, the indications for the treatment of patients with chronic hepatitis B will continue to expand
.
At this stage, it is necessary to distinguish between what is true immune tolerance and what is "false" immune tolerance
.
Immune tolerance stage: chronic HBV carrying state, also known as HBeAg-positive chronic HBV infection
.
The patients in this stage are in the immune tolerance stage, the patient is younger, the quantitative level of HBV DNA (usually >2×107IU/mL) is higher, the serum HBsAg (usually >1×104IU/mL) is higher, HBeAg is positive, but the serum ALT And AST continued to be normal (3 consecutive follow-ups within 1 year, at least 3 months apart each time), and histopathological examination of the liver showed no obvious inflammatory necrosis or fibrosis
.
[Summary of the golden sentence: the first grade, the third grade and the second grade are normal, and they are basically young men] What inspiration and thinking the new crown epidemic has brought us should follow three principles: control the source of infection, cut off the route of transmission, and protect susceptible people
.
For hepatitis B, vaccination allows the source of infection to be controlled and the susceptible population is protected.
Next, it is necessary to pass screening to find as many patients as possible
.
Judging from the current situation, new coronary pneumonia may coexist with humans for a long time.
In this case, infection/hepatology doctors must combine peace and war, taking both into account
.
Difficulties bring experience and experience to people’s wisdom, not forgetting the true nature of the original healer.
It’s dangerous to enter the field of infection/infectious disease.
It is also fortunate to endure loneliness, calm down, study hard, and be a warm, determined, and hopeful healer.
The end of the trial is flowers blooming thousands of miles.
May you set off in a small way and end "Healer · Heart Road" with greatness.
Looking forward to sharing with you the beautiful scenery along the successful journey.
We will see you in the next issue
.
