213.3 🩺 內科專科考前版

213.3.0.1 1⃣ Taiwan HBV Story

  • Pre-vaccine: 15-20% HBsAg+ (one of highest globally)
  • 1984 universal infant vaccination program launched
  • 2024: < 1% HBsAg+ in vaccinated cohorts
  • Major public health success
  • HCC rates declining
  • Old cohort (born pre-1984) — surveillance + treatment focus
  • 盧醫垫 hint: 慢性 HBV 病人 + 糖 + 老 — HCC surveillance critical, treatment for indications

213.3.0.2 2⃣ HBV Reactivation Algorithm

  • All immunosuppression candidates:
    • HBsAg + Anti-HBc total screening
  • Anti-CD20 + HBsAg- + HBcAb+: antiviral prophylaxis (TAF/TDF/entecavir) × 6-12 mo after treatment completion
  • HBsAg+: continue antiviral throughout + 6-12 mo after
  • Monitor ALT + HBV DNA quarterly

213.3.0.3 3⃣ HBV in Pregnancy

  • Maternal HBsAg+ + high HBV DNA → tenofovir 28 wk gestation
  • Birth-dose vaccine within 12 hr + HBIG
  • Breastfeeding compatible (no transmission risk if proper PEP)
  • Postpartum: continue TDF/TAF or transition; monitor

213.3.0.4 4⃣ HBV Drug Resistance

  • Lamivudine: high resistance (M204V/I)
  • Adefovir: rtN236T mutation
  • Entecavir: high barrier; rare resistance in nucleoside-naive
  • Tenofovir: no clinically significant resistance documented
  • Multi-resistance: switch to alternative; combination rare

213.3.0.5 5⃣ HBV-HIV Co-Infection

  • Single regimen ART with HBV activity:
    • TDF + emtricitabine (or TAF + emtricitabine) + 3rd agent
  • Don’t use HBV agents alone in HIV (selects HIV R)
  • Monitor for IRIS
  • HCC surveillance same

213.3.0.6 6⃣ Hepatitis B Liver Transplant

  • Recurrent HBV historic problem
  • Now controlled with: HBIG + entecavir/TDF lifelong
  • Outcomes excellent
  • HBcAb+ donor: prophylaxis + monitoring

213.3.0.7 7⃣ Membranous Glomerulonephritis + HBV

  • Children primarily
  • HBeAg-driven immune complex
  • Treatment: HBV antiviral + ACEi/ARB
  • Self-resolution with HBeAg seroconversion

213.3.0.8 8⃣ PAN + HBV

  • Adult chronic HBV
  • Necrotizing vasculitis medium vessels
  • Treatment: HBV antiviral + steroid initially + plasmapheresis severe
  • Don’t use long-term steroid alone (worsens HBV)

213.3.0.9 9⃣ HCC Treatment Update 2024

  • Atezolizumab + bevacizumab = first-line advanced HCC (IMbrave150)
  • Lenvatinib alternative
  • TACE + Y-90 for intermediate
  • Resection / transplant / ablation for early
  • HBV antiviral continued throughout

213.3.0.10 10. HBV Cure Trials (2024-2025)

  • Multiple Phase 2-3 trials
  • Bepirovirsen + standard antiviral combination (B-Clear)
  • GSK-836 (siRNA) — bepirovirsen successor
  • VIR-2218 + checkpoint inhibitor
  • Vebicorvir (capsid modulator) combination
  • HepTcell therapeutic vaccine
  • Target: 30%+ functional cure (HBsAg loss) within 5 yr