Published online Aug 21, 2022. doi: 10.3748/wjg.v28.i31.4390
Peer-review started: April 22, 2022
First decision: May 9, 2022
Revised: May 22, 2022
Accepted: July 25, 2022
Article in press: July 25, 2022
Published online: August 21, 2022
Processing time: 115 Days and 17.5 Hours
Therapy of hepatitis B virus (HBV) with nucleos(t)ide analogues (NA) can be associated with fibrosis regression. There are both low and high potency agents approved for therapy and access to these therapies maybe variable. There is limited real-world data comparing these agents on their effect to result in fibrosis regression and long term outcomes.
Although high-potency agents are considered the standard of care, there has been variable access to these agents and indeed ongoing use of these agents in 1st world countries to include Canada. It is thus important to provide evidence in outcomes to include fibrosis regression between the high and low potency NA’s. This study may impact the use of these agents in the future, and allow consideration for switching from low to high potency agents if possible.
To assess HBV viral response, biochemical remission, liver fibrosis regression and hepatitis B surface antigen (HBsAg) sero-clearance after treatment with either a 1st or 2nd line NA therapy. These objectives were realized and the future impact would be the consideration of utilizing 1st vs 2nd line NA’s. Further, other outcome measure to include HBsAg loss and development of hepatocellular carcinoma (HCC) may be considered.
We performed a retrospective observational cohort study utilizing a National network in HBV. Novel aspects that allowed this study is the utilization of a National Network which was able to capture differences in NA utilization based on regional differences of reimbursement. The strength of this study lies in the diversity that the Canadian HBV Network provides. The utilization of liver stiffness by transient elastography in a North American cohort for this objective is also unique.
As per differences in utilization, a larger proportion of patients with advanced fibrosis were initiated with tenofovir disoproxil fumarate (TDF) compared to LAM. At the end of the study period there were similar stages of fibrosis between the 2 groups. There was an increased fibrosis regression in those treated with a high potency compared to a low-potency NA. More patients in the TDF group also achieved virological suppression, though alanine amino transferase (ALT) normalization was similar.
In this diverse cohort treatment with low and high potency NA’s achieves high rates of viral suppression, ALT normalization and a large proportion achieve fibrosis regression. The strength of national collaboration within a network is exemplified in this study in particular taking advantages of diversity within an overall similar medical system. These differences within a Network can be a powerful tool to answer research questions and can reduce a number of biases inherent when comparing populations/studies between countries or regions.
The future direction would include potential for long-term outcomes with differential NA usage to include HBsAg loss or seroconversion and any differences in development of HCC albeit in a population with differences in stage of fibrosis at baseline. This study population and Network provides a unique perspective to answer this question.