Challenges and Controversies

Most of my hep B patients have been of Asian descent. My understanding of the literature suggests that most patients, especially those of Asian descent, do not achieve a durable off-treatment suppression even when the numbers (as in this case) look encouraging. Also, if cost is one of the issues, an uninsured or under-insured patient should be eligible for patient assistance on tenofovir alafenamide (TAF), making it free. “Under-insured” includes the situation where an insurer “won’t pay for TAF”, but it can be helpful to compose a support letter, especially where patients are at risk for bone/kidney issues anyway. He might then feel better about long-term treatment, given the improved safety profile of TAF. After documenting the discussion of the good possibility of NOT achieving durable suppression, with risk of transmission to others and cirrhosis/hcc, the patient should be supported if he still insists on stopping treatment.

For patients without cirrhosis who are HBeAg negative with viral suppression on a nucleos(t)ide analogue (e.g. TDF, TAF, entecavir) for at least 3 years, you can check quantitative HBsAg levels while the patient is still taking NA to determine how likely they are to attain HBsAg loss 4 years after stopping treatment. Studies show that Caucasian patients are more likely than Asian patients to develop HBsAg loss (41%) 4 years AFTER NA withdrawal if quantitative HBsAg prior to treatment discontinuation is < 1000 IU/mL. For Asians quant HBsAg < 100 (less common) was a predictor of HBsAg loss (33%) 4 years AFTER NA withdrawal. Though it is not necessary to check genotype in these patients, genotypes A and D which are more common genotypes among Caucasians are associated with higher rates of off-NA HBsAg loss (compared to genotypes B, C, and E) despite similar end of NA HBsAg levels. Thus I would decide whether to advise ongoing antiviral therapy vs. trial off therapy depending on this patients race/ethnicity (or genotype, if known) and quant HBsAg levels,