18-11-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[5:08 pm, 18/11/2025] PPM 1: @PPM3 can you share an image of the history written by the intern during my OPD dictation today morning?
@PPM6 I guess you have exam and can't meet her and take a more detailed history today evening?
[5:09 pm, 18/11/2025] PPM 1: The clinical decision making here @PPM5 @PPM4 is if to continue his tenofovir for his chronic hepatitis B and if ordering a HBV DNA test will help to ease that decision
[6.11 pm, 18/11/2025] PPM 4: Of course. This is an excellent and very common clinical dilemma in the management of chronic hepatitis B. The decision to continue or stop tenofovir is nuanced and relies heavily on the results of the HBV DNA test and other clinical parameters.
Here is a structured breakdown of the clinical decision-making to help @PPM5 and @PPM4
### The Short Answer
**Yes, ordering an HBV DNA test is absolutely critical and is the cornerstone of making this decision.** It is not just helpful; it is essential. Continuing tenofovir without knowing the current viral load is practicing blind medicine.
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### Detailed Clinical Decision-Making Framework
The decision is guided by international treatment guidelines (like those from AASLD and EASL). The overarching goal is to prevent progression to cirrhosis, liver failure, and hepatocellular carcinoma (HCC).
#### 1. Why We MUST Check HBV DNA Now
The HBV DNA level tells us several key things:
* **Efficacy of Treatment:** Is the tenofovir effectively suppressing viral replication? The goal is an undetectable or very low HBV DNA (typically <20 IU/mL or <10 IU/mL, depending on the assay).
* **Adherence:** A detectable viral load may indicate issues with medication adherence.
* **Risk of Resistance:** While tenofovir has a high barrier to resistance, checking the DNA helps monitor for this rare possibility.
#### 2. The Two Main Scenarios Based on HBV DNA Result
**Scenario A: HBV DNA is Undetectable or Suppressed (<20 IU/mL)**
This is the desired outcome and indicates the medication is working.
* **Decision: CONTINUE Tenofovir.**
* **Reasoning:** The patient has achieved **virological suppression**. Stopping the drug now would almost certainly lead to **viral relapse** (a sharp increase in HBV DNA and ALT levels), which can be severe and sometimes lead to acute-on-chronic liver failure, especially in patients with advanced fibrosis/cirrhosis.
* **The Concept of "Stopping Rules":** Discontinuation can only be considered in a select group of **HBeAg-negative** patients (like this one, if that is the case) who meet strict criteria:
1. **Confirmed virological suppression** for at least **2-3 years**.
2. **No evidence of cirrhosis** (must be confirmed by a reliable method like FibroScan or liver biopsy).
3. The patient understands the need for close and lifelong monitoring after stopping, as relapse can occur months or even years later.
* **Bottom Line for this Scenario:** Unless the patient clearly meets these "stopping rules," the default is to continue tenofovir indefinitely.
**Scenario B: HBV DNA is Detectable or Elevated**
This is a sign of treatment failure and requires investigation.
* **Decision: INVESTIGATE the cause, but DO NOT stop tenofovir abruptly.**
* **Reasoning:** The goal of therapy has not been met. The priority is to find out why.
* **Differential for Detectable Viremia on Treatment:**
1. **Poor Adherence:** This is the most common cause. A non-judgmental discussion with the patient is crucial.
2. **Suboptimal Virological Response:** The drug may be working, but not powerfully enough. This is less common with tenofovir.
3. **Drug Resistance:** Very rare for tenofovir, but should be considered.
* **Action Plan if DNA is Detectable:**
* **Reinforce adherence.**
* Consider checking for tenofovir resistance mutations.
* **Continue tenofovir** while investigating, as stopping could cause a dangerous flare.
* If adherence is confirmed and viremia persists, the regimen may need to be optimized (e.g., switching to or adding another agent, though options are limited—this is a scenario for a specialist).
#### 3. Other Crucial Tests to Guide the Decision
While the HBV DNA is the most critical, other tests provide essential context:
* **HBeAg / Anti-HBe Status:** Is the patient HBeAg-negative or positive? The "stopping rules" are different and much more permissive for HBeAg-positive patients who undergo seroconversion.
* **ALT (Alaninine Aminotransferase):** Is the liver inflammation controlled? A normal ALT alongside suppressed DNA is the ideal "biochemical response."
* **Liver Fibrosis Assessment:** Does the patient have cirrhosis? **This is a deal-breaker.**
* **If CIRRHOSIS is present: Tenofovir must be continued FOR LIFE, regardless of HBV DNA or HBeAg status.** Stopping in a cirrhotic patient carries an unacceptably high risk of decompensation and death.
* **Alpha-fetoprotein (AFP) & Liver Ultrasound:** Essential for HCC surveillance, which must continue regardless of the decision on tenofovir.
### Summary & Recommended Clinical Pathway
1. **Immediately Order:**
* **Quantitative HBV DNA** (Most important)
* **Liver Function Tests (ALT, AST, Bilirubin, Albumin)**
* **HBeAg / Anti-HBe** (if status is unknown or outdated)
* **Renal Function & Electrolytes** (eGFR, Serum Phosphate - to monitor tenofovir toxicity)
* **AFP and Liver Ultrasound** (for routine HCC surveillance)
2. **Make the Decision Based on Results:**
* **If HBV DNA is suppressed:** Continue tenofovir. Only consider discussing "stopping rules" if the patient is HBeAg-negative, has no cirrhosis, and has been suppressed for >3 years.
* **If HBV DNA is detectable:** Investigate for non-adherence. Reinforce importance of daily dosing. Continue tenofovir. Refer to a hepatologist/GI specialist if the issue is not resolved.
* **If CIRRHOSIS is confirmed:** Continue tenofovir indefinitely, full stop.
**Conclusion for @PPM5 @PPM4:**
**Do not stop tenofovir without first checking the HBV DNA.** The test result will definitively guide your next step. In the vast majority of cases, the correct decision will be to continue the medication to maintain viral suppression and protect the liver from long-term damage.
***
**Disclaimer:** This is for educational purposes and based on international guidelines. The final decision should be made by the treating physician(s) with full access to the patient's clinical history, prior lab results, and current physical condition. Consultation with a gastroenterologist/hepatologist is always recommended for complex cases.
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