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World J Clin Cases. Aug 26, 2021; 9(24): 6979-6986
Published online Aug 26, 2021. doi: 10.12998/wjcc.v9.i24.6979
Discontinuation of antiviral therapy in chronic hepatitis B patients
Renato Medas, Rodrigo Liberal, Guilherme Macedo
Renato Medas, Rodrigo Liberal, Guilherme Macedo, Department of Gastroenterology and Hepatology, Centro Hospitalar Universitário de São João, Porto 4200-319, Portugal
Author contributions: Medas R and Liberal R developed the concept, planned the manuscript, performed the literature review, and created the first draft; Macedo G performed critical expert review and revision of the manuscript.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Rodrigo Liberal, MD, PhD, Assistant Professor, Senior Lecturer, Department of Gastroenterology and Hepatology, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, Porto 4200-016, Portugal. roliberal@hotmail.com
Received: January 29, 2021
Peer-review started: January 29, 2021
First decision: May 13, 2021
Revised: May 29, 2021
Accepted: July 2, 2021
Article in press: July 2, 2021
Published online: August 26, 2021
Processing time: 207 Days and 1.1 Hours
Abstract

Nucleos(t)ide analogs (NUC) are the first-line therapy for patients with chronic hepatitis B (CHB) recommended by most current guidelines. NUC therapy decreases progression of liver disease, reduces the risk of liver-related complications, and improves the quality of life of patients with CHB. Although indefinite or long-term NUC therapy is usually recommended, this strategy raises several concerns, such as side-effects, adherence, costs, and patient willingness to stop therapy. Recent data showed the feasibility, efficacy, and safety of stopping antiviral therapy in carefully selected CHB patients, leading to its incorporation in international guidelines. Patients who discontinue NUC have a higher likelihood of hepatitis B surface antigen (HBsAg) loss compared to patients who continue on therapy. Recommendations pertaining endpoints allowing safety discontinuation of NUC therapy differ among international guidelines. For hepatitis B e antigen (HBeAg)-positive patients, durable HBeAg seroconversion is considered an acceptable treatment endpoint. For HBeAg-negative patients, some guidelines propose undetectability hepatitis B virus DNA for at least 2 or 3 years, while others consider HBsAg loss as the only acceptable endpoint. CHB patients who stop therapy should remain under strict clinical and laboratorial follow-up protocols to detect and manage relapses in a timely manner. No reliable predictor of relapse has been consistently identified to date, although quantitative HBsAg has been increasingly studied as a reliable biomarker to predict safe NUC discontinuation.

Keywords: Chronic hepatitis B; Finite therapy; Hepatitis B surface antigen loss; Relapse; Retreatment

Core Tip: Recent data support the idea of stopping antiviral therapy in chronic hepatitis B patients. Current guidelines suggest that discontinuation of antiviral therapy may be attempted in non-cirrhotic patients who achieved durable on-therapy virological remission. Available evidence has shown that the paradigm shift from indefinite to finite antiviral therapy in chronic hepatitis B patients is emerging.