"In the next 15 to 20 years, we will be able to cure chronic hepatitis B completely."

Professor Kim Yoon-jun_김윤준, a gastroenterologist at Seoul National University Hospital (SNUH)_{서울대병원}, recently expressed his confidence in treating chronic hepatitis B in a recent interview with Korea Biomedical Review.

Professor Kim declared the full recovery from chronic hepatitis B is a matter of time given the progress of clinical trials of new drugs under way in SNUH and other institutions. In treating chronic hepatitis B, doctors will need to make prescriptions taking these situations into account, Kim said. Patients will be able to join in on the road to complete recovery later only when doctors minimize related complications on bones and kidney, let alone tolerance to drugs, he added. KBR met with Professor Kim to discuss treatment strategies of chronic hepatitis B.

Question: The biggest issue with chronic hepatitis B had long been the tolerance to drugs, but the advents of improved treatments seem to have dissolved most of these problems. Do you also think so?

Answer: That’s right. Tolerance is no longer a big problem. Hepatitis B treatments have proved they can prevent the progression of hepatitis to reduce the risk of liver cirrhosis and cancer. Therefore, it is a worldwide trend people in their 40s or younger start treatment aggressively. Many guidelines also say, “You should start anti-virus treatment even if you don’t show symptoms requiring treatment in a strict sense.”

However, starting treatment in younger age means patients will expose themselves to drugs so much longer. Even if patients start treatment at 50, they will be exposed to drugs more than 20 years (given the average life expectancy). We need to have a treatment strategy that takes these matters into account.

Q: There are many patients in their 60s and 70s in Korea. Do you mean treatment approaches to them should also be different?

A: I mean the selection of drugs should differ from before. In the past, we put the priority on controlling mutant virus because the failure to do so led to hepatocirrhosis. Now that the problem of a mutant virus has all but been solved, it has become more important for us to think about side effects from the prolonged use of these drugs.

Q: Many elderly patients also have illnesses associated with Hepatitis B. How do you treat them?

A: If patients also have high blood pressure, hyperlipidemia or diabetes, we have to pay extra attention as these lead to greater risks of cardiovascular disease or kidney failure. Elderly patients are vulnerable to adverse effects. However, age should not necessarily be the only yardstick judging side effects. Patients under 50 are also exposed to drugs as long as for decades. That is, we need to be cautious about side effects through all age groups

Personally, I expect a cure will come in 15 to 20 years. Doctors’ job is to protect patients until they get a cure. They should treat patients without causing problems in kidneys, hearts, and bones, and use the remedies when they become available.

Q: You sound as if patients get treatment for long without developing tolerance or complications, they will be cured in the future.

A: It's hard to cure the disease completely with the present treatment. However, many treatments are being developed now with about 10 related studies being underway at Seoul National University Hospital alone. Of course, I am not 100 percent sure, but I have high hopes personally. The current progress of hepatitis B treatment research reminds me of 15 years when we were developing hepatitis C treatment. The hepatitis C therapies developed at the time have sharply raised the possibility of complete recovery recently, and hepatitis B treatments seem to be taking a similar path.

Q: Recently, Gillard introduced Vemlidy, which is an upgrade of Viread, by enhancing kidney and bone safety. Do you think the new drug will help in managing side effects?

A: Yes. I think that the patients who are currently taking Viread should switch to Vemlidy. Vemlidy lowered the possibility of kidney toxicity that could occur in Viread theoretically. However, there still are concerns about the upgraded drug regarding the risk of cardiovascular diseases due to the increase of LDL-C and glucose in urine, and about drug interactions.

As patients’ exposure to medicines become longer, it is important to protect blood vessels as well as bones and kidneys. It is too obvious a statement. And that explains why some studies about Vemilidy need to carefully watch the rise of LDL-C and other results. However, I think it is equally undesirable for a medical scientist to make a decision based on results that have yet to be confirmed.

Vemlidy explicitly protects bones and kidneys better than Viread. That is why I recommend all patients switch to Vemlidy.

Q: You said it was a personal opinion. But it is interesting to see how you are so confident of the switch from Viread to Vemlidy. Could you explain why in detail?

A: If you look at the European guidelines, they recommend patients take either Vemlidy or Baraclude if they are over 60 or have kidney or bone problems. However, I think people with hepatitis B who take medication for the first time also ought to either Vemlidy or Baraclude, regardless of age or complications.

This is because young patients who need to take medicine are exposed to drugs longer than elderly patients. In the case of older patients, they should take accompanying diseases and ill effects into account, meaning all patients, old or young, with or without other diseases, have to consider long-term side effects.

Q: What are some things to keep in mind when choosing between Vemlidy or Baraclude?

A: Baraclude is a little more likely to incur virus mutation in comparison to Vemlidy or Viread. Even if the mutation occurs, however, Viread can effectively inhibit it. As noted earlier, at stake is how concerns about CVD will materialize in actual clinical trials.

Also, Baraclude is not desirable for patients exposed to drugs such as Zeffix, Sevbio, and Levovir. Patients who are exposed to these drugs even for weeks have higher chances of generating virus mutation. For these patients, it is recommended that they take either Viread or Vemlidy. However, if patients who are not exposed to the drugs at all use Baraclude, the chance of virus mutation is almost nil.

To sum up, I recommend Baraclude for patients who are not exposed to the drugs mentions above, and Vemlidy for those with bone or kidney problems.

Q: The concerns over Vemlidy’s drug interactions and worries about Vemlidy heightening LDL-C could be eased by Statin. Is that so?

A: I don't think concerns about Vemlidy’s drug interactions are a serious problem. True, I can’t help but pay attention to them as a doctor. Also, all doctors make it a rule to use as little medications as possible. As Vemlidy can generate drug interaction when used with a particular statin (compound Atorvastatin), it would impose quite a burden on patients if they have to use a statin.

Q: Lastly, are there some recommendations or advice you want to give to patients with hepatitis B?

A: Above all, the negative perception about enduring hepatitis B seems to have eased than in the past. When I was a medical resident, it was common to see hospitalized patients with hepatitis soaking the floor with blood. However, the advent of new drugs and vaccines has banished these scenes.

I think it's a breakthrough, but we shouldn't overlook the dangers of hepatitis B. With medications like Baraclude, we can prevent liver cirrhosis by 90 percent and liver cancer by 60 percent. Even though it is possible to prevent these diseases by taking medicine, it is extremely pitiable to see cancer patients visit the hospital because they were not treated properly at the right time.

Also, I have been saying this since 10 years ago, but pregnant women should also take antiviral drugs as well. Drugs were often taken away during pregnancy because of concerns that they could harm the unborn baby. However, if the levels of hepatitis B virus are high, the patient must take antiviral drugs even if they are pregnant. This effectively prevents their children from being infected with hepatitis B virus. It is also the trend of hepatitis B treatment worldwide.