Treatment of chronic hepatitis B with nucleos(t)ide analogues

Recently antiviral therapies for chronic hepatitis B using nucleos(t)ide analogues have become standard treatment modalities on the basis of several independent guidelines, starting with those of the American Association for the Study of Liver Diseases (AASLD) and other such organizations and bodies, including the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver (APASL), and the Japanese Ministry of Health, Labour and Welfare (MHLW)'s research team. The philosophies underlying such treatment strategies are considered basically equivalent. MHLW's guidelines define subjects for medical intervention to be cases measuring alanine aminotransferase (ALT) ≥31 IU/L, with serological hepatitis B virus (HBV) DNA level ≥5 log copies/mL for hepatitis B e antigen (HBeAg)‐positive cases, and serological HBV DNA level ≥4 log copies/mL for HBeAg‐negative cases. These Japanese guidelines advocate entecavir as the first‐line treatment option for nucleos(t)ide‐naïve patients, and combination treatment of lamivudine and adefovir as the basis of treatment for patients with lamivudine‐ and/or entecavir‐resistant viruses. Of particular note for patients undergoing lamivudine treatment with persistent HBV DNA level < 2.1 log copies/mL is the recommendation of a switch to entecavir. Early detection of drug‐resistant virus is desirable after initiation of nucleos(t)ide analogue treatment, but such a procedure is not uniformly available at all medical institutions. Nevertheless, timely estimation of potential early‐stage drug‐resistant virus development is crucial for getting a head start on treatment. HBV core‐related antigen (HBcrAg) level or HBV DNA level are considered useful markers for the appearance of such drug‐resistant viruses.