If the transaminases are twice the upper limit of normal, the treatment is more effective During the review process, what are the conditions that need to be alerted and thus may require treatment? Prof. Wei Lai: In the case of elevated transaminases, we will determine whether the elevated transaminases are caused by hepatitis B virus infection. If the elevated transaminases are indeed caused by the hepatitis B virus, then we will determine whether it is caused by a relatively long period of liver inflammation; if this is determined, we will consider whether the liver inflammation at this time can spontaneously clear the virus; if it cannot spontaneously clear the virus, we will give treatment. What does this statement mean? When it is determined that the elevated transaminases are caused by the hepatitis B virus, in this case, the body’s own immune function will attack the hepatitis B virus, and some of these people with stronger immune function can use this time to clear the hepatitis B virus away. Therefore, it is not the case that as soon as the transaminases rise, medication is started immediately. Generally, we will advise the patient to observe for six months, and if the virus cannot be cleared up within six months, then it is time to use the medication. However, if some of you find during the review and monitoring process that there are repeated fluctuations of transaminases every year, and every year the fluctuation of transaminases is caused by the virus, and this time the fluctuation is not necessary to wait for another six months, you need to start treatment immediately. Another condition requires consideration of the level of elevated transaminases, and from current treatment experience, treatment is more effective when transaminases are elevated more than twice the upper limit. Of course, it is not true that if the aminotransferase is less than twice as high, no treatment will be given, but it will be analyzed on a case-by-case basis. As soon as inflammation of the liver is determined to exist, treatment should be given, but the effectiveness of treatment may be affected somewhat. In addition to cirrhosis and immunosuppressive treatment, anti-viral therapy is also required even if the transaminases are not high. However, there are also some special cases where medication should be considered even if the transaminases are not high, and here there are also two cases. One is cirrhosis, and as long as cirrhosis exists, the sooner it is treated, the better, regardless of the level of transaminases; the second is because when certain diseases require the application of immunosuppressive drugs (this case is extremely special), even if there is no liver inflammation and no cirrhosis, antiviral drugs need to be applied early. Because immunosuppressive therapy has the potential to break the balance between autoimmune function and the virus and suppress the autoimmune function, it is important to apply antiviral drugs early to avoid viral activity and reduce the potential liver damage during treatment. What conditions require the application of immunosuppressive drugs? What are the commonly used immunosuppressive drugs? Prof. Wei Lai: First of all, it is important to emphasize that this condition refers to the long-term application of immunosuppressive drugs, while short-term two or three days, a week or a month does not count. So, which diseases require the application of immunosuppressants? Patients with excessively strong immune function or immune dysfunction, such as systemic lupus erythematosus, organ transplantation, bone marrow transplantation, etc. So, what drugs are immunosuppressants? You may not know much about what immunosuppressants are, but it may be clear once I say the name of the drug. The most commonly used drugs are corticosteroids, such as prednisone, as well as cyclophosphamide and some biologics. If you are not sure enough about these issues, just remember one thing, if the surface antigen is positive and at the same time you may need to apply certain drugs for a long time, consult a doctor in the liver disease department first. The best time for treatment: HBV-DNA positive, transaminase increased So, from no treatment to treatment, is the timing better the later or the earlier the treatment? Prof. Wei Lai: This is a very important and at the same time very relevant question. In fact, the timing of treatment needs to be differentiated between different cases. For hepatitis treatment, the right time is the best; but for friends with cirrhosis, the earlier the better. As we all know, there will be a trilogy of hepatitis, cirrhosis and liver cancer after infection with hepatitis B virus, but not all people will have hepatitis, and not all people will have cirrhosis and liver cancer China’s hepatitis B surface antigen carrier rate is 7.18% (due to the promotion of the vaccine, the rate of hepatitis B surface antigen positivity in people under 30 years old has dropped significantly), which means that for every 100 people in China, there may be 7 people are positive for hepatitis B surface antigen, in other words, if you look for 13 people at random, one of them will be positive. But we don’t find that seven or eight out of 100 people will have cirrhosis or liver cancer. In fact, not everyone will develop hepatitis. So, the best time to treat hepatitis is the right time. So, what is the right time? The right time is when the HBV-DNA is positive and the aminotransferase is elevated. Of course, there may be some differences in the choice of drugs depending on the level of transaminases and the amount of virus. However, for patients with cirrhosis, the earlier the treatment, the better, and the long-term application of antiviral drugs will also help the reversal of cirrhosis. Most carriers are safe, a few will have liver inflammation, fibrosis progression To sum up, HBV-DNA carriers, if transaminases or ultrasound tests, etc. are normal do not need treatment, just regular review and wait for the right time, if the test is out of the question should consider treatment, but the earlier the cirrhosis is treated, the better? Prof. Wei Lai: That’s right. But one point needs to be clarified, although HBV-DNA is positive, transaminases are normal people do not treatment, but from the original intention of hepatitis B virus is not part of our body, we hope to remove him, but unfortunately, there is no such drug. Nowadays, the drugs are more effective only for people with elevated transaminases, but they are very ineffective for people who do not have elevated transaminases, and they even cause drug resistance, so we do not advocate using them. For such people, you do not care? In fact, you do not have to worry. According to some studies, if carriers do not have elevated transaminases for up to five or six years, or even 10 years, the majority of people have slow development of liver inflammation and fibrosis, or even no change. However, there will still be a small number of people, around 10-30%, who will experience progression of inflammation and fibrosis, which is the reason for the regular review mentioned earlier.