22 Male, High DNA, Fluctuating ALT

[AWholeNewWorld]

Patient Background: Asian Male born in CanadaAge: 22
Transmission: Likely at Birth
Drug Coverage: Private Coverage: Formulary includes Baraclude/Sebvio/Viread
Status: HBeAg Positive

ALT Levels:
Family Doctor ALT Test (June 2007): Elevated (~1.5-2x range)
Family Doctor #2 ALT Test (Nov 2007): Normal Range (High end of range)
Hospital #1 ALT Test (Dec 2007): Normal Range (High end of range)
Hospital #2 ALT Test (Dec 2008): Normal Range (High end of range)

DNA Levels:
Hospital #1 DNA Test (Dec 2007): High but can't recall - Guess is ~ 10^8
Hospital #2 DNA Test (Dec 2008): 250 million


Issue 1: Timing
So the dilemna is when to start antiviral and which to take.  
It "appears" the virus is still in the immunotolerant stage (veriable with biospy if needed) but the raised ALTs earlier is concerning... would that be a signal of potential immunoactivity? If so, not sure what they are normal.

Fluke test? Maybe.. Or possibly different tolerances.

Current Thought: Wait 6 months, redo tests, do biospy.
If all is normal: Keep testing every 6 months. Wait 1-2 years to see if ALT spikes. If not, then start treatment due to high viral levels. Upside: In 1-2 years there should be more Tier-1 Drugs on the market  (Right now it's T1: Baraclude/Viread/Sebivo, With FTC/L-FMAU soon) Downside: Potential damage


Issue 2: Drug Regime
Doctor recommends Baraclude or Viread. I would concur. Through both may be recommended based on high viral levels. Upside: Lower risk of resistance Downside: Lack of FDA trials on the Baraclude/Viread combination may mean unexpected interaction/side-effects.

Current Thought: Go Combo Baraclude/Viread when treatment is needed. It appears current combination studies are progressing on schedule with no substantial reports of issues/discontinuations (through not sure if they report all this). If they have a better combo or even a cocktail by then, go with that.

PS Is 6 months the standard follow-up (even on treatment?). The medical system here covers DNA-PCR every 6 months but I might look into private testing (possibly in the US if not possible from here).

[AWholeNewWorld]

Yup that's the guidelines through if there's no resistance I wonder if it makes sense to lower viral load to "cushion" the immuno-clearance stage.

Theoretically without resistance issues you would think this would be at least as effective as waiting for the catalyst event because the drug would provide the same "boost" to the immune clearance when the time comes...
Gilead claims there's no drug interaction between Tenofovir/Entecavir and so I think it *might* be okay. (http://www.hiv-druginteractions.org/new/InteractionDesc.asp?cmbid=4477)

I heard Clevudine/Levovir (L-FMAU) might be more effective than Entecavir without the associated Baraclude carcinogen rumors. So that might also be worth waiting for... (The study on Levovir/Tenofovir combination should be out by Q4 2010)

[cajim]

With HBeAg(+), treatment recommended by 2007 guideline when ALT > 2xUpper limit and DNA>20000.

22 is a young age, resistance must be seriously considered.

Combination treatment does have more success in dealing with resistance, the other side of the coin is the added drugs, added side effects, added toxins, etc.