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Role of PegIFN in HBV
What Is the Role of Peginterferon for HBV Infection?

Released: May 21, 2018

Expiration: May 20, 2019

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In my practice, I discuss peginterferon with every patient with HBV monoinfection, but I recommend it in a small minority only: those with a desire for a shorter duration of therapy.

This is because, unlike oral agents, peginterferon has a high rate of adverse events, and only 20% to 40% of patients will have viral suppression.

However, the advantage of peginterferon over oral therapies is the ability to give a limited duration of therapy, which may be important for select patient groups. These include women who do not want to receive therapy through their childbearing years or people whose life circumstances might change within the next year or so, such as those expecting a change or loss of insurance, or those moving to another country with a different level of healthcare.

I find that other patients with HBV infection who may desire peginterferon include those whose family members were treated with peginterferon and had a good response with limited adverse events.

Peginterferon is also the only option that has been shown to be clinically efficacious for the rare patients who are coinfected with both HBV and HDV. In these patients, the HDV suppresses HBV replication, so the oral agents normally active against HBV are ineffective. However, coinfection with HBV and HDV, sometimes seen in patients of Mediterranean descent and in some people who inject drugs, is uncommon in the United States.

Practical Considerations
If a patient does want to consider treatment with peginterferon, I check the HBV genotype to see if it is genotype A, which has a better response to peginterferon than other genotypes, particularly if the ALT level is relatively high and the HBV DNA level is relatively low. Genotype A HBV is the most common genotype among black patients, and the chance of hepatitis B surface antigen (HBsAg) loss makes me feel that peginterferon is a reasonable choice in patients with this genotype.

By contrast, patients with genotype B or C HBV infection have extremely low response rates, as do patients with low ALT levels and very high HBV DNA levels. In these patients, I feel the potential for adverse events outweighs the very small potential for benefit. Therefore, I do not recommend peginterferon for patients with HBV infection that is genotype B or C.

HBsAg Quantification
In patients who do desire peginterferon for their HBV infection, an important tool is a commercial test to quantify the level of HBsAg, which can give an early indication of the likelihood of response. Those who are going to respond experience a decrease in HBsAg level by Week 12; if this decrease is not seen, therapy can be stopped, and the patient can switch to oral therapy without having to wait until they have completed a full year of peginterferon treatment.

All told, I have treated only 1 patient in the past 5 years with peginterferon: It was a patient who very much wanted to try a short duration of therapy—he was familiar with peginterferon and did not want to take pills. He had genotype B HBV infection, which has an especially low response rate.

As predicted, the virus did not respond, and this patient eventually had to receive oral therapy instead.

In Clinical Care Options decision support tool for first-line HBV therapy, you can see how I and other experts selected among peginterferon and other available treatments for a variety of patient scenarios.

Your Thoughts
How do you counsel patients about peginterferon vs oral therapy for HBV infection? Please contribute your experiences and insight in the comments box.

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For which of the following patients would you be most likely to consider peginterferon-based therapy?
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