Patient, male, 32 years old. He has no family history of hepatitis B. He was found to be a “major triple-positive” carrier since childhood, and has been regularly reviewed without any medication because his liver function has been normal. In the last few years, he was found to have elevated glutamate transaminase, fluctuating between 60 and 120, precise quantification of hepatitis B surface antigen 69801.45 IU/ml, quantification of HBeAg 1500 S/CO, quantification of HBVDNA up to 8 copies, and normal ultrasound and liver fibrosis scan. Considering that the patient occasionally drank alcohol, was overweight and had gallstone cholecystitis, I advised him not to take antiviral therapy for the time being, to stop drinking, to reduce his weight and to take ursodeoxycholic acid for gallstone cholecystitis. Closely observe the situation of ALT changes, and if it is significantly elevated, then consider antiviral therapy, and consider the first choice of long-acting interferon therapy. The patient was later referred by an acquaintance to Beijing for consultation and found a top hepatitis specialist of great repute in China, whose treatment plan was to import entecavir (Boludin) in combination with Peroxin for two years, and then take entecavir monotherapy for two years, for a total of four years. I’m a “not a good” ordinary grassroots doctor, occasionally on behalf of the hospital to participate in some academic meetings, occasionally will speak at the conference, and then respectfully listen to some so-called Jiangxi Province “top experts” review, even if the expert review is wrong, you have to Even if the expert is wrong, you have to smile and nod your head frequently. Is the antiviral program of this “top hepatitis expert” in China reliable? I’m going to be bold enough to “review” it today. First, does this patient have a guideline for antiviral therapy? The patient’s ALT is not high, generally fluctuating between 60 and 120, he is obese, drinks alcohol occasionally, and has gallstone cholecystitis, all of which may cause elevated ALT. All three editions of our hepatitis B guidelines clearly state, “In particular, it is important to caution that other pathogenic infections or other factors such as drugs, alcohol and immunity should be ruled out as causes of ALT elevation before starting treatment”, and with the current increasing number of obese people, the guidelines should actually focus on including steatohepatitis in the differential diagnosis of ALT elevation. This patient had a CT-enhanced scan and liver fibrosis scan with normal results, so it seems a bit hasty to initiate antiviral therapy based on a mild ALT elevation alone and without definitively ruling out fatty liver and cholecystitis as interfering factors. It would have been best if a liver biopsy had been performed prior to treatment. This patient had a viral load of up to 8 times higher, with exceptionally high concentrations of S and E antigens, which are signs that immune tolerance has not been completely broken. So my primary care physician gave a much more reliable treatment: abstain from alcohol, reduce weight, treat gallstone cholecystitis with Eusebio (ursodeoxycholic acid capsules), and closely monitor the status of ALT changes, and if it is significantly elevated, then consider antiviral therapy, which may be considered the preferred long-acting interferon therapy. Even if there are guidelines for antiviral treatment, is this “top hepatitis expert’s” plan reliable? The so-called antiviral therapy is, at the end of the day, a drug therapy, and drug therapy must follow the three basic principles of safety, effectiveness, and economy, which are recognized worldwide, and I don’t think this top hepatitis expert would have a different opinion. Let’s “review” these three points one by one. First of all, what is the safety profile of Peroxin in combination with entecavir for two years? The latest version of our hepatitis B guidelines clearly state that studies have shown that extending PegIFN-a therapy to 2 years can improve response rates, but given the increased adverse effects and economic burden associated with extended therapy, extended therapy is not recommended at this stage from a pharmacoeconomic perspective. Chronic hepatitis B is currently a disease that can be safely and effectively controlled with one pill per day, so is it necessary to take that risk to get the so-called “gold medal”? If the course of interferon is too long, some of the diseases induced are much more difficult and troublesome to treat than chronic hepatitis B. Next, the effectiveness. Our new hepatitis B guidelines are also clear: it is still uncertain whether the combination regimen of synchronized PegIFN–a and NAs can improve the efficacy. The synchronized combination regimen has some advantages over PegIFN–a monotherapy in terms of HBeAg conversion, HBsAg clearance, virologic response and biochemical response at the end of treatment, but it did not significantly improve the durable response rate after drug discontinuation. Another study showed that the addition of entecavir to PegIFN–a did not improve HBeAg seroconversion rates, HBsAg clearance. Will this patient necessarily achieve HBeAg seroconversion with this top expert’s antiviral regimen with two years of combination therapy? I don’t think so! In that case, how can one stop using entecavir alone for another two years? More often than not, I feel that the patient is more like an enrolled patient, an experimental subject for this top hepatitis expert. For medical science to develop, breakthroughs and innovations must be made, and clinical medical trials must be conducted, but on the basis of following objective laws. This patient’s immune tolerance has not been significantly broken and should be observed for now. Even if antiviral therapy is needed, it should be based on the inhibition of viral replication and stable control of liver inflammation, and on this basis, HBeAg seroconversion should be pursued, and finally HBsAg clearance. We should not pull out the seedlings and go beyond the stage of development of things. If this patient needs antiviral therapy, it is best to try long-acting interferon first on the basis of perfecting relevant tests, and then switch to entecavir or tenofovir therapy if it is ineffective or not tolerated. Finally, a word about economics. The patient is spending $6,000 a month on medication alone, which, if combined for two years, is close to $150,000. 150,000, what does that mean for a working family? Has this so-called top hepatitis expert in China ever thought about it?