Informed Patient Conference 2006
June 10-11, 2006, Stanford California
HBV Treatment for Children Today
Philip Rosenthal, MD, Medical Director, Pediatric Liver Transplant Program, University of California San Francisco Children’s Hospital
Hepatitis B statistics looks different in children than adults:
- 90% of adults who are infected with HBV will recover
- 90% of infants who infected with HBV will develop chronic infections
- Acute hepatitis B - 4% perinatal, 4% children (1-10 years), and 83% adults
- Chronic hepatitis B – 24% perinatal, 12% children, and 59% adults
Concentration of HBV in Bodily Fluids (see slide)
- High- Blood, serum, and wound exudate
- Moderate - Semen, vaginal fluids, saliva
- Low/Not detectable - Urine, feces, sweat, tears, breast milk
Guidelines for Children with HBV
Although there are no “official” guidelines for children as there are for adults, Dr. Rosenthal is currently serving on a panel to help the Pediatric Gastroenterology Society develop general recommendations. Based on his own experience, Dr. Rosenthal uses the following guidelines, with the caveat that there are situations that may require additional tests:
- History and Physical
- Lab Tests – to assess liver disease (CBC with platelets, hepatitis panel, prothrombin time), and to assess HBV replication (e-antigen, e-antibody, and DNA viral load)
- Tests to rule out other liver diseases (hepatitis C and hepatitis D)
- Liver cancer screening – AFP and ultrasounds; he has seen liver cancer in very young children, so it’s not too early to start screening
- Liver biopsy – to grade and stage liver disease (not routinely performed, though)
Chronic HBV Screening
- If eAg+, DNA > 105, normal ALT – check ALT every 3-6 months
- If ALT > 1-2 x upper normal limits – recheck every 1-3 months
- If eAg+, DNA > 10 5- 1010, and ALT > 2 x upper normal limits – consider liver biopsy and treatment
Approved therapies for children
- Interferon alpha (Intron A) – for eAg positive children (three times a week for 4-6 months); for eAg negative children (three times a week for one year); no drug resistance.
- Lamivudine (Epivir) – for eAg positive children (daily ≥ 1 year); for eAg negative children (daily > 1 year); drug resistance at year 1 is ~ 20% and 70% at year 5.
Interferon alpha is attractive because it is for a short period of time, even though it requires a subcutaneous injection. Most children tolerate the side effects better than adults and there are many tricks to minimize side effects.
Lamivudine is difficult because it requires taking a pill every day for more than a year and drug resistance can develop. Long term use of any drug in children is a thorny issue – what is the potential impact on a child’s future growth and development? With the current oral HBV drugs, what will happen if a 9 year old child develops resistance? What will be his or her treatment options?
There are currently pediatric clinical trials for adefovir dipivoxil (Hepsera) that was already approved for adults. As of now, there are no trials for entecavir (Baraclude) or pegylated interferon (Pegasys).