• Patients who develop abnormal LFTs, cirrhosis and even liver cancer may feel quite well and normal

• Patients who feel unwell due to their hepatitis B may have advanced disease and treatment may be too late for some persons.

Treatment cannot cure Hepatitis B at this point in time. However, it does reduce the risk of cirrhosis of the liver in patients who have an inflamed liver. In those who already have cirrhosis, it reduces the risk of liver cancer and progression or worsening of the liver disease.

The risk of progression to cirrhosis in those with abnormal LFTs ranges from 3% yearly for those with mild to moderate abnormalities to 25% in those with severe and multiple flares. In those that already have cirrhosis, after 3 years of lamivudine, the risk of progression of liver disease was reduced from 21% to 9% and the risk of liver cancer was reduced from 10% to 5%. Consequently there are significant benefits of treatment which not only reduce the complications of hepatitis B liver disease but also likely to improve survival and prolong life. Those that do not seek therapy early or are unfortunate in discovering that they have advanced liver disease will need to have a liver transplant.

What antiviral therapies are available in Singapore?

Injectable therapy

1. Interferon is an injection that is given three times per week, and a course of treatment is 4 to 6 months. Although a number of different forms of interferon are available - interferon alpha 2a (intron A), interferon alpha 2b (Roferon), and consensus interferon. Interferon works by both an anti-viral effect as well as altering the body's immune system. A response to treatment is seen in about 30% of patients. However, it has numerous side effects mainly flu-like symptoms, fever, muscle aches, tiredness, loss of appetite, drop in blood counts, some hair loss, effects on thyroid, worsening of depression, amongst others. A stronger form of the drug is now being tested in hepatitis B patients called pegylated interferon, which can be given once a week.

2. Thymosin alpha-1 is another injectable drug given 2-3 times a week but in contrast to interferon, has virtually no side effects. Its effectiveness, however is unclear with a response rate as low as 12% and as high as 40%. The response of the drug takes place 6-12 months after therapy has been completed.

Tablets

1. Lamivudine is the first oral tablet for Hepatitis B and suppresses the virus in almost all patients, but stopping therapy usually results in return of the virus that can result in a "flare" or severe inflammation of the liver. After 3 years of continuous treatment, about 30-40% of patients "respond" and can stop therapy without fear of a flare. Although the medication is very safe, it tends to lose its effectiveness as the virus becomes more resistant over time - 14% in one year and 50% in 3 years. The development of lamivudine resistant usually indicates a need to change treatment, and adefovir dipovoxil is the only treatment which is universally effective in this situation.

2. Adefovir dipovoxil is the second orally available anti-Hepatitis B drug and is currently the only effective treatment for patients who develop lamivudine resistant mutants. It works in a similar manner to lamivudine by suppressing Hepatitis B virus but the risk of developing mutants resistant to adefovir is extremely low <3% after 3years. There are some concerns about kidney side effects although long term studies have shown this to be <2% over 3 years. The cost of adefovir is about 50% more than lamvidine, hence tends to be reserved for those who fail lamivudine therapy.

In patients who have HBeAg in their blood (HBeAg positive) they need to continue therapy for 6 months after this becomes negative. In those who started therapy when their HBeAg was already negative, there is no agreement on the length of therapy which will be evaluated from time to time with their doctor. Some patients may need to be on indefinite therapy, particularly those who have cirrhosis or have had a liver transplant. Those who are taking medication because they are on chemotherapy or steroids should only need short term therapy, usually a few months (4-6 months) after stopping their chemotherapy or steroids. Treatment will usually need to be individualized with your doctor who will monitor progress and advice you accordingly. You can seek another opinion from any of the liver specialists in our University Digestive Centre. If you are not happy with our advice or recommendation, you can seek further opinions from doctors in private hospitals or other government hospitals. Generally speaking, guidelines on treatment are provided by a number of organizations such as the Singapore Ministry of Health, the European Association of Study of Liver (EASL), and the American Association for Study of Liver Disease (AASLD).

• Firstly, we can refer you to social workers for application of government aid such as Medifund.

• Secondly, currently we have a special Health Services Development Program (HSDP) program for treatment of viral hepatitis at NUH. Patients who need Hepatitis B treatment enjoy an extra 50% subsidy under this program.

• Thirdly, patients can take part in a clinical trial which all treatment, blood tests, and clinic consultations are free.