[Expert Viewpoint] How to discontinue nucleoside (acid) drugs in patients with successful treatment In recent years, due to the long-term treatment of nucleoside (acid) drugs, some patients do meet the criteria for discontinuation, and the treatment is successful, so they can stop the drugs. How should these patients discontinue their medication? What should be noted during discontinuation? What are the discontinuation criteria for nucleoside (acid) drug therapy For patients with e antigen positive “major triple yang”, test ALT, HBV DNA and e antigen, e antibody after 1 year of treatment, if ALT is normal, HBV DNA is undetectable, and e antigen serological conversion has occurred, then continue to take the drug, every 3 months to 6 months If ALT, HBV DNA and e antigen, e antibody are detected once every 3 months to 6 months, and the above efficacy is maintained for 1 year, the drug can be stopped. If the above efficacy is not achieved, the drug should be continued until the efficacy is achieved. Thus, the total course of treatment must be ≥ 2 years. For e antigen negative “small triplet” patients, after 1 year of treatment, ALT and HBV DNA testing, if the ALT is normal and HBV DNA is not detected, continue to take the drug and maintain the efficacy for 18 months before discontinuing the drug, the total course of treatment must be ≥ 2.5 years. The latest revision (2007) of the American Association for the Study of Liver Diseases “Guidelines for Chronic Hepatitis B” considers that anti-viral drugs for chronic hepatitis B in e antigen-negative patients should be continued until the surface antigen (HBsAg) disappears and then discontinued. How to stop medication if you meet the criteria for discontinuation Some patients think that tapering off or taking every other day before stopping medication will reduce the rebound after discontinuation. This is a wrong approach. Approximately 20% of patients who have met the criteria for discontinuation may rebound after discontinuation. The reason for rebound in these patients is that the hepatitis B virus is not completely suppressed in the body. If we reduce the dose or take the medication on alternate days, the virus is exposed to low levels of medication in the body for a long time, which will definitely lead not only to drug resistance, but also to rebound later. If the drug-resistant virus bounces back and the drug is taken again, it will be ineffective. Therefore, if a patient who has met the criteria for discontinuation decides to discontinue the drug, he or she should discontinue it completely and never reduce the dosage or take it every other day. If there is a rebound, the medication will still be effective if taken again. How to Prevent or Reduce Post-Discontinuation Rebound There are many factors that may affect post-discontinuation rebound. First, post-discontinuation rebound is related to whether or not the discontinuation criteria have been met. About 20% of patients who meet the criteria for discontinuation may rebound after discontinuation, but the rebound rate can be as high as 80% or more for those who do not meet the criteria for discontinuation. Secondly, the rebound after discontinuation is related to the status of e antigen and surface antigen before and after treatment. e antigen-positive “major triple-positive” patients are less likely to rebound the earlier they turn into “minor triple-positive” patients, and the higher the value of e antigen before treatment, the faster it decreases after treatment. The higher the value of e antigen before treatment, the faster it decreases after treatment, the less likely it is to rebound; the lower the quantitative value of surface antigen before treatment, the faster it decreases after treatment, the less likely it is to rebound after stopping the drug; and almost all those who have turned negative surface antigen will not rebound. Thirdly, the rebound after stopping the drug is related to the time of consolidation treatment. e antigen positive “big three yang” patients turn into “small three yang”, the longer the time of consolidation treatment, the smaller the chance of rebound. Therefore, it is best to use imported reagents to test the quantitative values of the five hepatitis B items before and after treatment, observe the changes during treatment, and try to extend the consolidation period as long as possible after reaching the criteria for drug discontinuation, preferably until the surface antigen disappears and then stop the drug. Regardless of the factors associated with rebound after discontinuation, patients need to be monitored after discontinuation. Generally, liver function and HBV DNA are checked once a month after discontinuation, and the most likely rebound time is usually 3 to 6 months after discontinuation. If there is no rebound after 6 months, the frequency of monitoring can be reduced to once every 2-3 months; if there is no rebound after 1 year, it can be determined that the drug has been successfully discontinued, but monitoring is still needed every 6-12 months to be alert to the re-activity of the hepatitis B virus.