30. What are the key issues with the current guidelines focused on by the Treatment Algorithm?
The issues that we looked at in putting this
guideline together were that PCR was critically important. Not only in
identifying active disease, but also the rebound, when resistance
occurs. You can’t diagnose resistance if you’re using
a hybridization assay. Some of the labs in the community still use the
hybridization assay. Now how do you know that? It comes back in
picograms/ml rather than in copies/ml, and is much less
sensitive. The ALT, we’ve talked about that. Some of
the guidelines from Dr. Lok and Dr. McMahon say, “don’t treat people
unless the ALT is more than 2 times the upper limit of normal”, we
feel that’s too conservative. And also, what’s a normal ALT? In our
laboratories, normal ALTs are often 40, 45 and sometimes even 60. And
that’s because we have become an obese country, as you know. 23% of
Americans are obese. How do labs get normal values? They survey
people that walk through the door, and then they develop a bell-shaped
curve and do two standard cutoffs and say everything below that is
normal. But the people who walk through the door to
get routine blood tests, some have undiagnosed hepatitis B, or
undiagnosed hepatitis C, a lot drink, and a lot of them are obese. And
so the normal ALT is higher than it really ought to be, we appreciate
that. And biopsy is always challenging, but we
thought we needed to individualize and use selectively when needed to
clarify the diagnosis.
29. Why was the HBV Treatment Algorithm written?
31. What are the AASLD Treatment Guidelines for hepatitis B?