31. What are the AASLD Treatment Guidelines for hepatitis B?

Now Dr. Anna Lok and Dr. Brian McMahon are good friends of mine I have to tell you, we do a lot of work together. But let me beat up on them a bit. They published the AASLD Guidelines (this stands for the American Association for the Study of Liver Disease) and as I said, this is the more recent reference that just came out in 2004. Here is their suggested guideline. And in the yellow are the ones that I take a little bit of exception to. They said if you have e-Positive and a DNA, and by the way, they just used greater than 10 to the fifth because this was an arbitrarily chosen value for a positive DNA. So they said, if you have the wild type, and the DNA and the ALT are less than two times normal, observe. If you have a patient that has the wild type virus, e-Positive, DNA high, and the ALT is greater than two times the upper limit of normal, so let’s say that’s 150 ALT, observe six months, treat if no sero-conversion. That’s the point I made earlier, I would rather initiate therapy because if the ALT is 150 or 200 or 300, there is active inflammation going on and I don’t know if that patient is going to sero-convert in the next three months or six months, I would rather initiate therapy. And as I said earlier, I think if an ALT is one and a half times normal, I think most people feel that’s good enough to treat. Now what about the e-Negative patients? The DNA is high, they say if the ALT is greater than two-fold, treat. We would all agree with that. But if the ALT is less than two-fold, they say observe. I would disagree with that. I think that e-Negative chronic hepatitis B is a more serious illness and these people ought to be considered for therapy. If there’s cirrhosis, treat, we would all agree with that. But if the DNA is low, observe. Many of us feel that if there is already cirrhosis even if the DNA level is 10 to the third or 10 to the fourth, that’s enough to treat because there has already been severe liver damage.