I. The best time for antiviral treatment. After infection with hepatitis B virus, there will be a trilogy of hepatitis, cirrhosis and liver cancer, but not all people will have hepatitis, and not all people will have cirrhosis and liver cancer. For hepatitis, the best time for treatment is the right time. The right time is when the HBV-DNA is positive and the transaminases are elevated. When the transaminases are elevated, we will determine if the elevated transaminases are caused by hepatitis B virus infection. If the elevated aminotransferases are indeed caused by the hepatitis B virus, we will then determine if it is caused by a relatively prolonged period of liver inflammation; if so, we will consider whether the liver inflammation can spontaneously clear the virus at that point; if it does not spontaneously clear the virus, we will give treatment. When it is determined that the elevated transaminases are caused by the hepatitis B virus, 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 are elevated, 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 that the fluctuation of transaminases every year 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 long as inflammation of the liver is established, treatment should be given, but the effectiveness of treatment may be somewhat affected. But in addition, there are also some special cases, when the transaminases do not increase should also consider the use of drugs, 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 transaminase level; 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 earlier. Because immunosuppressive treatment may break the balance between autoimmune function and virus, and suppress the autoimmune function, it is better to apply antiviral drugs early to avoid virus activity and reduce the potential liver damage during treatment. Second, the common drugs used in antiviral therapy. At present, the most important method of treating hepatitis B is antiviral therapy. Chronic hepatitis B and cirrhosis are caused by the hepatitis B virus, and only by removing the cause can we control liver inflammation and cirrhosis. In addition to antiviral therapy, there can be other treatments, called liver protection, enzyme reduction, anti-fibrosis, etc., but the main thing is actually antiviral therapy. Nowadays, there are many antiviral drugs, but actually there are about two main categories: one type of injection and one type of oral. The injectable drug is interferon, and the oral drug is nucleoside analogs, which are a large class of drugs, and there are many kinds of drugs. The mechanism of action of the two types of antiviral drugs is different. Interferon has two main roles: first, it is antiviral, directly resisting and destroying the hepatitis B virus; second, it has an immunomodulatory effect, regulating the body’s own immune function better, so that after stopping the drug, the body’s immune function is restored and can still control the virus. The nucleoside analogues are to inhibit the virus. To use an analogy, the virus is a spring, and the nucleoside analogues are to hold the spring down and play the role of inhibiting the virus. The advantage of interferon is that the course of treatment is fixed, for example, its course is 48 weeks; another advantage is that if the patient is effective on interferon treatment, then it is often effective for a long time, even for life. The disadvantage is that only 30-40% of patients are effective with interferon, and still 60-70% of patients are ineffective with interferon injections; secondly, interferon has more side effects, which can include fever, flu-like symptoms, general aches and pains, and hair loss. The advantages of nucleoside analogs include suppression of the virus very quickly, after taking the drug, maybe 2-4 weeks, or 12 weeks, the hepatitis B virus in the blood is undetectable, the effect is very fast; no injections, convenient to take orally; small side effects, almost no side effects. The disadvantages include a less fixed course of treatment, patients must reach a goal before they can consider stopping the medication, and they cannot stop until they reach this goal; the efficacy is less fixed, easy to relapse after stopping the medication, and difficult to achieve lasting stability. In other words, it takes 48 weeks to play interferon, just like going to college, four years to graduate, regardless of excellent grades, belongs to the academic year system; while using nucleoside analogues belongs to the credit system, must be full of credits to graduate, the specific how long can be full of credits, it varies from person to person. Therefore, these two types of drugs, a course of treatment is fixed, a course of treatment is unpredictable, the specific choice depends on the specific circumstances of the patient Third, the best way to antiviral therapy. If a patient is relatively young and has not yet had children, he is often advised to prefer interferon at this time. This is because, once such a friend is effective with interferon injections, it can be effective for life and has no effect on having children after stopping the drug for a while. In addition, it is true that young people have better results with interferon than those over 40 years of age, which is an advantage of interferon. However, people who are older are not unsuitable for interferon application. If older patients, who have never been treated before, can be treated with interferon first, if conditions allow. If interferon treatment does not work, then switch to a nucleoside analogue. Since interferon has more side effects, older people may be relatively less tolerant. In addition, if nucleoside analogs are used first, it is not known when the therapeutic effect will be achieved and the drug is discontinued, nor is it known how long it needs to be observed. And at this time, some of our patients and friends ask if they can stop using interferon. This is when the answer is more ambiguous. This is because, after the application of nucleoside analogues, the virus has been suppressed and switching back to interferon will not necessarily be effective. So, if we use interferon first, if interferon is effective, we can rest assured; and if interferon is not effective, we will switch to nucleoside analogs, and then we can rest assured that we can apply nucleoside analogs, since interferon has already been used ineffectively anyway, which will be more convenient and easy in the actual process. The application of interferon will be a little better for women than for men. Some nucleoside analogs are relatively safe for pregnancy and gestation, but the safety of some drugs is unknown. Therefore, women who have future fertility requirements can give preference to interferon, and if interferon is effective, they can stop taking it afterwards and have children without worry. The exception is friends with cirrhosis of the liver, which is best not treated with interferon. When slow hepatitis B progresses to cirrhosis, there will be fewer normal cells in the liver. If interferon regulates your immune function, the immune system will attack the hepatitis B cells that contain the virus, and once the attack is too strong, the damage to the liver will be severe. Therefore, if the patient has progressed to the cirrhosis stage, it is less suitable to apply interferon therapy. Fourth, based on the e antigen conversion to determine when to stop the drug. For slow hepatitis B with e antigen positivity, the first year should be treated as required, while after one year, the credits should be evaluated. How to evaluate after one year? First, to determine whether the HBV-DNA turns negative, whether the e antigen disappears, whether the e antibody appears, that is, “major triplet” turns into “minor triplet”, also called “e antigen conversion This is also called “e antigen conversion”. If, after one year, HBV-DNA turns negative, transaminases are normal, and e antigen conversion occurs, we should continue treatment, but at this point we should evaluate the situation after two consecutive six-month periods in the future. The emphasis here is on two consecutive six-month periods, not one year later, which means checking every six months. If the situation remains the same every time (undetectable HBV-DNA, negative e antigen, positive e antibody, normal transaminases), it is time to consider stopping the drug. After stopping the drug, the relapse is related to the length of time after the e antigen switch. When e antigen conversion occurs, the longer you take the medication, the lower the probability of relapse after stopping it. Relapse is also related to age. The younger a person is, the less likely he or she is to relapse after e antigen conversion. Generally speaking, for people over 50 or 60 years old, the probability of relapse after stopping the drug is more than 80%, so for people over 50 years old, we generally do not recommend stopping the drug. For patients with e antigen-negative chronic hepatitis B, also known as “small triple-positive” hepatitis, HBV-DNA positivity and elevated transaminases, credits are also evaluated from one year after treatment. If the hepatitis B virus is negative after one year of treatment, you need to be tested for three consecutive six-month periods (not one and a half years later). If the virus is negative for three consecutive six-month tests, then, at that point, which is two and a half years of treatment, you can consider stopping the medication. Similarly, the relapse rate after discontinuation is also related to the age of the patient and the length of time the patient has been on the drug after meeting the discontinuation criteria. That is, the lower the age, the lower the relapse rate, and the higher the age, the higher the relapse rate; the longer the time on medication after reaching HBV-DNA negativity, the lower the relapse rate. However, if you stop taking the medication after only three and a half months, the chances of relapse are still relatively high. Above we are talking about chronic hepatitis B, but if the patient progresses to cirrhosis, the medication cannot be stopped. The hepatitis B virus is equivalent to a spring, which is held down by the medication, but if the medication is stopped and released, the spring will spring up again. For patients with cirrhosis, if the virus is not brought under control it will bounce back when the medication is suddenly stopped, and at that point, once it relapses, liver failure may occur. Statistics show that the probability of relapse of cirrhosis can reach 50-60% when the medication is stopped, but for a body, it can be 100%. Therefore, cirrhosis cannot be discontinued.