Lege Artis Medicinae

[UP-TO-DATE MANAGEMENT OF CHRONIC HEPATITIS B]

HORVÁTH Gábor

NOVEMBER 10, 2008

Lege Artis Medicinae - 2008;18(11)

[Hepatitis B virus infection is a significant health problem worldwide, as well as in Hungary. The chronic infection is usually symptomless, its most dangerous risks are liver cirrhosis and hepatocellular carcinoma. The latter may occur without development of liver cirrhosis, so it means a potential complication for patients with inactive phase of infection, as well. Criteria of the indication of antiviral treatment have changed in the last years due to the flare of our knowledge about the natural history of the disease. In our days quantitative determination of hepatitis B viral nucleic acid titer is essential for diagnosis. Formerly, a HBsAg positive patient with normal liver enzymes had been regarded as inactive carrier, and antiviral treatment had not been advised. In our days, the phase of the infection and the necessity of the treatment can not be determined without measurement of nucleic acid titer. Liver biopsy and, if inflammation or fibrosis is present, antiviral treatment is indicated, if the nucleic acid titer is >20 000 IU/ml in HBeAg positive, and >2000 IU/ml in HBe negative cases, respectively. Interferon alpha is the gold standard of treatment for chronic B hepatitis. Pegylated interferon alpha-2a is used because of its better pharmacokinetic properties. Oral agents include nucleoside/ nucleotide analogues with rare and mild adverse effects, and they may be given to patients with decompensated liver disease. Their main disadvantages include the development of drug-resistance, and the very low ratio of HBsAg-anti-HBs seroconversion. Recent drugs like adefovir, entecavir and tenofovir have replaced lamivudin, which has been in use for the longest time, because they are more effective and resistance against them is less frequent.]

COMMENTS

0 comments

Further articles in this publication

Lege Artis Medicinae

[DISEASES OF THE EXOCRINE PANCREAS AND DIABETES MELLITUS]

CZAKÓ László

[Exocrine and endocrine pancreas constitutes close anatomical and functional links accordingly, any disease affecting one of these sectors will inevitably affect the other. Acute and chronic pancreatitis, pancreatic surgery, cystic fibrosis and pancreatic cancer are those pancreatic conditions that might cause diabetes mellitus. The development of diabetes greatly influences the prognosis and quality of life of patients with exocrine pancreatic diseases. The lack of glucagon and the impaired absorption of nutrients may cause life-threatening complications, such as hypoglycaemia, and the micro- and macrovascular complications may impair the organ functions. Diabetes mellitus is an independent risk factor of mortality in those with exocrine pancreatic diseases. Pancreatic diabetes is a distinct metabolic and clinical form of diabetes, requires special treatment. Diet and pancreatic enzyme replacement therapy may be sufficient in the early stages. Oral antidiabetic drugs are not recommended. If the diet proves inadequate to reach the glycaemic goals, regular insulin treatment is demanded. There are special impairments of the exocrine function and the pancreatic morphology at diabetic patients that resemble to chronic pancreatitis. Atrophy of the exocrine tissue may caused by the lack of trophic insulin. Hyperglycaemia can activate the stellate cells that lead to pancreatic fibrosis. The microangiopathy and neuropathy, as well as the lack of islet hormone action - responsible for the exocrine pancreas regulation - will cause further damage on the pancreas glandular tissue. In the event of a proven impairment of the pancreatic exocrine function in diabetes mellitus, pancreatic enzyme replacement therapy is recommended. This may improve the nutritional condition and decrease the metabolic instability.]

Lege Artis Medicinae

[One minute ECG]

ZÁMOLYI Károly

Lege Artis Medicinae

[Forty Tablets of Digoxin]

CSAPÓ Gábor

Lege Artis Medicinae

[INCRETIN MIMETICS AND INCRETIN ENHANCERS: NEW THERAPEUTIC TOOLS IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS]

JERMENDY György

[Incretins are hormone-like peptides secreted by specific cells of the small intestine mucosa. Their two main representatives are the glucagon-likepeptide- 1 (GLP-1 and the glucose-dependent insulinotropic peptide, (GIP) the release of which is stimulated by meals. The main action of incretins is to enhance insulin secretion following meals. They are rapidly metabolized in the circulation by the enzyme dipeptidyl peptidase IV (DPP-IV). Patients with type 2 diabetes have markedly impaired incretin-mediated insulin secretion mainly due to decreased secretion of GLP-1. Research in the last years has opened up a new therapeutic option to treat patients with type 2 diabetes. Continuous intravenous use of GLP-1 cannot be widely used in clinical practice; however, GLP-1-mimetics that have an agonist effect on the receptors but are resistant to degradation by DPP-IV have been developed. The GLP-1 agonist xenatide, due to its incretin mimetic property, stimulates postprandial insulin secretion, suppresses glucagon secretion, delays gastric emptying and increases sense of fullness thus resulting in weight reduction. In experimental settings, exenatide has a documented beta-cell protecting property. Its disadvantages include the fact that it can only be administered subcutaneously and that it has a well characterized side effect profile. On the contrary, the DPP-IV inhibiting incretin enhancers (sitagliptin, vildagliptin) can be used orally and are well tolerated. Exenatide, sitagliptin and vildagliptin are the first representatives of incretin mimetics and incretin enhancers. Sitagliptin has been available in Hungary since August, 2008. Their effect to reduce blood glucose and HbA1c should mainly be exploited in combination therapy, preferably with metformin. The availability of incretin mimetics and incretin enhancers will offer new therapeutic options for treating patients with type 2 diabetes. Nevertheless, the final assessment of these new drugs will require long-term experience in the clinical practice.]

Lege Artis Medicinae

[Selective Memory?]

KAHÁN Zsuzsanna

All articles in the issue

Related contents

Lege Artis Medicinae

[TREATMENT APPROACHES OF CHRONIC HEPATITIS B IN HUNGARY]

TORNAI István, NEMESÁNSZKY Elemér

[Today, there are less patients with active chronic hepatitis B requiring treatment than patients with chronic hepatitis C. However, the course and outcome of chronic hepatitis B is usually more severe, therefore, the disease has not lost importance. The most dangerous risks are the development of liver cirrhosis and hepatocellular carcinoma. The disease may present in various forms. Symptom-free carriers only need follow-up and hepatologic care. In the active stages with elevated liver enzymes and high level of viral nucleic acid (either HBeAg negative or positive), however, antiviral treatment is strongly indicated. There are two main forms of treatment. Alfa-interferon-based therapy, which is applied for a defined period of time, has a direct antiviral and immunomodulatory effect, but has several adverse effects. Long-term nucleoside analogue treatment represent the other treatment modality. These drugs are administered orally, have minimal side effects, but after some time resistant mutants may develop. Traditional interferon has recently been replaced by pegylated interferon alfa-2a with much better pharmacokinetic properties. Lamivudine has been in use for the longest time of the nucleoside analogues. Its efficacy is high, but after 3 to 4 years of treatment, resistant mutants appear in about 70% of cases. Of the most recent compounds, adefovir dipivoxil has recently become available in Hungary; it is primarily recommended in cases with lamivudine resistant mutants. There are promising new drugs in the stages of clinical trial; of these, entecavir has already been approved in the United States.]

Lege Artis Medicinae

[OUR EXPERIENCE WITH COMBINED ANTIVIRAL TREATMENT IN PATIENTS WITH CHRONIC HEPATITIS C WITH PERSISTENTLY NORMAL ALANINE AMINOTRANSFERASE LEVELS]

HORVÁTH Gábor, TOLVAJ Gyula, HALÁSZ Tünde, STOTZ Gyula

[INTRODUCTION - Persistently normal alanine aminotransferase levels, which occur in a fraction of patients chronically infected with hepatitis C virus, do not rule out the presence of chronic hepatitis C, even of that with advanced inflammation and fibrosis. Here we report our results of the treatment of these patients. PATIENTS AND METHODS - Patients with histologically confirmed chronic hepatitis C received combined antiviral treatment with pegylated interferon (alfa-2a 1×180 μg/week or alfa-2b 1×1.5 μg/kg/week) and ribavirin (800- 1200 mg/day) for 48-52 weeks. The alanineaminotransferase levels of 21 patients (14 females, 7 males, age: 20-54, mean 38 years) did not reach the upper limit of normal (40 U/l) during the period of observation (≥6 months). There were 19 and 2 cases with hepatitis C virus genotype 1b and 3, respectively. The patients' hepatitis activity index was 3.7 1.75, fibrosis score: 0.9 0.64, baseline viral titer: 1.18 1.12×106 IU/ml, alanine-aminotransferase level: 33.51 7.2 U/l. The last 100 unselected patients with elevated alanine-aminotransferase levels enrolled in treatment for chronic hepatitis C and who were followed for at least 6 months served as the control group with the following parameters: 41 females and 59 males (age: 18- 65, mean: 45.65 years), viral genotypes: 98 and 2 cases of type 1 and 3, respectively, hepatitis activity index: 5.44±4.03, stage: 1.29±1.00, baseline viral titer: 4.13±6.25×106 IU/ml. RESULTS - In the study group, all patients were hepatitis C virus RNA negative at the end of the treatment and with one exception remained so by the end of the 6-month follow-up period (20/21), while the sustained virologic response was 36% in the control group. The pretreatment normal alanine aminotransferase level decreased significantly (15.26 4.9 vs 33.51 7.2 U/l, p<0.001) by the end of the treatment, and remained at this level during the follow-up in all except one relapse case. CONCLUSION - The efficacy of the combined antiviral treatment is high in patients with persistently normal alanine aminotransferase levels, possibly due to the relatively younger age, the higher proportion of females, the lower baseline viral titer, and the less advanced liver disease (lower inflammatory activity and less or absent fibrosis) observed in this group. Combined antiviral treatment is recommended for patients with histologically confirmed chronic hepatitis C with normal alanine aminotransferase levels, even with mild inflammatory activity and minimal or absent fibrosis in the liver tissue. The previous suggestions based on published evidence to revise the upper limit of the normal range of alanine aminotransferase level are supported by the results of this study.]

Hypertension and nephrology

[Association between cyclothymic affective temperament and hypertension]

NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]