Challenges and Controversies

I would discuss the option of stopping antiviral therapy with the patient and make a shared decision. Most guidelines agree that in patients who do not have cirrhosis at baseline and who have achieved >12 months of HBeAg seroconversion and HBV DNA undetectability (for initially HBeAg-positive cases), you can consider stopping and monitoring off therapy. But the fact remains that many of these individuals will go on to have hepatitis B viral relapse, and a smaller proportion will have ALT/AST elevation and maybe a hepatitis flare. At this time, there is no clear predictor of who will sustain HBV control and go on to hep B surface antigen (HBsAg) loss and remission. Other than perhaps low quantitative HBsAg levels at baseline. But in the US, this assay is not widely available for clinical decision-making. If the patient is motivated to stop, and understands the importance of regular laboratory monitoring after cessation of therapy, then it is reasonable to proceed but I would not stop without ensuring this mutual understanding.

She has received consolidation therapy with continued entecavir for a year after HBeAg seroconversion. So, it is reasonable for her to want to consider whether she can stop therapy. We know that rebound eventually occurs in the majority of individuals who stop therapy. But, individuals with a quantitative HBsAg <100 IU/ml are less likely to reactivate their hepatitis B than those with higher levels. Thus, I would get a quantitative HBsAg. The lower the level the less likely she is to rebound. I would use this information to discuss the pros and cons of stopping therapy with the patient. If she had cirrhosis, I would not consider stopping since a rebound could lead to fulminant liver failure. But, since she has F0-F1 fibrosis, the risk of serious outcomes from stopping and having a rebound are substantially lower. The APASL guidelines have now incorporated quantitative HBsAg levels into their guidelines for stopping nucleos(t)ide analogues.