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Professor of Hepatology
The Liver Unit
Queen Mary University of London
London, United Kingdom
Graham R. Foster, FRCP, PhD: consultant/advisor/speaker: AbbVie, Biogen, Gilead Sciences, GlaxoSmithKline, MSD, uniQure.
Old, in the context of chronic hepatitis B (CHB), does not indicate the very elderly and infirm but instead refers to people older than 40 years of age because a lot of changes occur after this age in patients with CHB. Most healthcare professionals think that patients with CHB who are in their 40s and 50s need a slightly different starting approach because as they age, they may develop numerous comorbidities. Older patients start to experience aches, life gets more challenging, and the number of medications increases progressively. Therefore, when managing patients with CHB who are older, the first question should be, “What else is going on in their life and how will that affect the approach to disease management?”
When to Begin Therapy
When I evaluate patients in their 40s and 50s for CHB treatment, I start considering whether therapy is appropriate. There are patients who certainly require treatment, such as those with high levels of liver transaminases, progressive disease, and high levels of HBV DNA. Conversely, we also have patients who do not require treatment: those with very quiet disease, very low levels of hepatitis surface antigen, undetectable HBV DNA, normal levels of transaminases, and bland histology. Usually, these extremes are straightforward to manage. But for patients who qualify as being in the “gray zone” where the HBV DNA levels are just above 2000 IU/mL and the alanine aminotransferase levels are either marginally elevated or are fluctuating, many healthcare professionals agonize about the right time to begin CHB treatment.
Personally, I think treatment decisions are a little easier to make in the older patient population with CHB. I tend to push toward starting treatment early on because the risks of malignancy and disease progression are higher and the relative contraindications to other things in their lives are much reduced. For example, the risk of malignancy increases substantially for those older than 40 years of age. Therefore, I think we should consider starting therapy for older patients with CHB when they are still in what I call the “light gray zone” rather than waiting for them to move into a more progressive phase.
Factors to Consider Before Starting Antiviral Medication
Most of the drugs currently used to treat hepatitis B have safe drug–drug interaction profiles, and although there are few drug–drug interactions of concern, that should not cause complacency when a patient requires treatment. Generally, people start to take an array of medications as they get older, and we should keep a watch on the other medications the patient is taking. Furthermore, if we are faced with an unfamiliar drug on the patient’s list, we should access the numerous resources available to assess clinically relevant drug–drug interactions. When I come across patients taking drugs that I am unfamiliar with, I always check with the pharmacist, and we perform a quick search online to ensure that I am not missing an important interaction to consider.
As people age, their metabolic and renal function declines and their bone health starts to deteriorate. These are important factors to consider when looking at the therapeutic options in older patients with CHB. Although the currently available first-line drugs have excellent safety profiles, there are still some concerns with certain agents regarding the potential for renal or bone toxicity. It is always good to consider safe medications, including those that are kidney-friendly and bone-friendly, in our older patients with CHB. Moreover, when examining patients with significant liver disease who are at significant risk for osteoporosis, I tend to do a dual x-ray absorptiometry scan before starting therapy, just to get an idea of their baseline bone health. In these patients, it is very important to avoid drugs that pose a risk of increased bone absorption.
Need for Hepatitis B Vaccination
Older patients are just as much at risk of transmitting the infection to their sexual partners and household members (eg, children, grandchildren) as younger people are. Therefore, it is good to protect the rest of the family by ensuring that their hepatitis B vaccinations are up to date and by testing them for hepatitis B.
Monitoring Older Patients With HBV
It is important to assess patients older than 40 or 50 years of age with CHB in the context of their comorbidities and cancer risk. With increasing age, the risks of diabetes, glucose intolerance, and obesity start to rise. Therefore, it is very important to consider cancer screening in the context of the other prevalent promalignant phenotypes. Personally, I am very aggressive about performing liver ultrasounds. I ensure that all of my patients older than 40 years with CHB get an ultrasound and an α-fetoprotein test every 6 months. For patients with CHB and diabetes, I consider doing it even more frequently, and for patients with CHB and obesity-related problems, I consider it necessary to get high quality scans, even if that means performing an MRI scan.
Strategies to Overcome Adherence Issues
When patients are started on medications for hepatitis B, there should be an emphasis on adherence. Older patients often take several different medications; seeing a patient who is taking just one medication is very rare. Therefore, we need to think about ways to ensure that the important hepatitis medicine is incorporated into their daily routine.
For example, we use pill boxes with special compartments, and we get our pharmacists to prepackage tablets labeled by the day, so we can be sure that people with complex drug regimens do not forget their antiviral medication. The beauty of the drugs we use to treat hepatitis B is that they are time agnostic, with most people preferring to take them in the early morning or late evening. Talking to patients about the medications they take, finding out when they take the majority of their pills, and including their hepatitis B drug into that part of their day may help avoid adherence issues.
The other important aspect is to monitor the patient’s response to therapy. The hepatitis B drugs that are currently available are very effective. Therefore, if I see a rise in a patient’s HBV DNA level, I do not think about resistance, but I do think about adherence and begin to have a discussion with the patient.
Our clinical thinking needs to evolve as our patients age. With age comes not just wisdom but also increased numbers of comorbidities and risks of disease complications. In my opinion, older patients with CHB should be more aggressively considered for drug therapy compared with younger people with CHB. Personally, I am much more enthusiastic about starting drug therapy in 40-50 year olds than in the 20 year olds, who may be less likely to be adherent. Furthermore, it is important to use medications that do not cause any drug–drug interactions or influence other ongoing comorbidities. Once drug therapy is started, it is important to monitor continuously and to check adherence by testing HBV DNA levels.
In your clinical practice, what strategies do you use to mitigate HBV medication adherence issues? Join the discussion by posting a comment.