Entecavir and tenofovir are the recommended first line antiviral therapies due to their high antiviral potency and low risk of drug resistance. The estimated annual incidence of HCC is significantly reduced among entecavir-treated patients as compared to historic untreated controls in a few studies in Taiwan, Hong Kong and Japan. Most benefit is seen among patients with liver cirrhosis. Complete viral suppression is associated with better HCC prevention. Approximately 20% of entecavir treated patients cannot have complete viral suppression at 3 years. There is no evidence that combination therapy can improve viral suppression among incomplete responders
As antiviral therapy cannot clear cccDNA inside the liver, most patients require long-term antiviral therapy. This poses a challenge to drug adherence and safety, particularly renal and bone safety for tenofovir disoproxil fumarate. The introduction of tenofovir alafenamide is a solution. HBsAg seroclearance is an acceptable timing to stop antiviral therapy, but it rarely develops in Asian patients. HBV DNA suppression alone is an insufficient condition to avoid viral relapse after stopping treatment. Approximately 90% of HBeAg negative patients will have viral relapse and 50% have clinical relapse after stopping antiviral treatment according to the APASL criteria. |
