Viral Hepatitis Guideline Update

What I'd like to

emphasize here is that there have been many HPV treatment guidelines, either by region or by society or a combination of the two.

And they've really converged in recent years, as you go up from 2018 to 2025, on trying to simplify the criteria for HPV DNA and ALT.

And you can see that as opposed to the 20,000 cutoff, which I think the ASLD intended to be for HPE-AG positive patients, there's really a trend to make 2,000 the threshold for initiation treatment.

And there remains some controversy, but ALT, twice the upper limit of normal as a threshold for treatment, still reflected in the ASLD guideline.

really is being simplified by many around the world, both officially and in practice, to simply saying that ALT, greater than the upper limit of normal, should be the inflection point.

So we're getting down to 2000 for HPV DNA and upper limit of normal and beyond for ALT.

But there's plenty of controversy left because it's not really that simple.

I have included some text on the right to give you an idea of some of the differences amongst these.

In fact, very few of them are precisely the same.

And that's because human beings who differ from each other are making up these guidelines.

Next slide, please.

The two most recent ones that emerged just this year are from the Asia-Pacific group and from Korea.

And you can see that just as the Chinese guidelines dramatically have reduced the threshold for HPV DNA to detectable rather than even 2000 as a criteria for treatment, at least in some patients.

So they also have ALT simply elevated, but they define their upper limit of normal as a 40.

And we're not gonna get into the intricacies of that, but perhaps that's a bit higher than most of the other societies or groups have proposed.

Independent of ALT, we have risk factors that come into the picture when we talk about these guidelines.

So any liver fibrosis might supplant, for example, the requirement that the ALT be above the upper limit of normal, whatever you choose that to be.

Family history of cirrhosis or HCC, we certainly know that first degree relatives of people who've had HCC are themselves at greater risk if they have hepatitis

B as

well.

And the presence of NAFLD is a very interesting subject.

People are more and more interested in the interaction between hepatic steatosis and hepatitis B.

And it increasingly seems that the natural history of hepatitis C can be adversely affected by the presence of steatotic liver disease.

We're not going to go into that in much more detail tonight.