W. Ray Kim, MD Associate Professor of Medicine Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine Rochester, Minnesota Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B This program is supported by educational grants from

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clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Program Faculty Program Director Yun-Fan Liaw, MD Professor of Medicine Department of Medicine Senior Advisor Liver Research Unit Chang Gung University Taipei, Taiwan Program Faculty W. Ray Kim, MD Associate Professor of Medicine Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine Rochester, Minnesota

Introduction

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Outline: ALT and HBV  ALT-ology 101  Use of ALT in evaluation of patients with chronic hepatitis B  Impact of ALT on long-term outcome of patients with chronic hepatitis B  ALT in management decisions in chronic hepatitis B  ALT in monitoring of patients receiving anti-HBV therapy

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B L-alanine PyruvateL-glutamine α-ketoglutarate ALT vitB6 Biochemistry of ALT  Gluconeogenesis  Amino acid metabolism  Liver ALT > 3000 x serum ALT: marker of hepatic necroinflammation Bergmeyer HU, et al. Clin Chem. 1978;24:58-73.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Demographic Determinants of ALT  Patient age and sex affect ALT levels  Average ALT levels increase from childhood to ~ 40 years of age –Greater increases seen in males vs females  ALT levels are ~ 30% higher in males 40 years of age than in males 25 years of age  After 40 years of age, ALT levels again decline –More pronounced in males vs females Dufour DR, et al. Clin Chem. 2000;46:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Demographic Determinants of ALT (cont’d)  Predictors of elevated ALT (> 43 IU/L) from NHANES database evaluated (N = 6823) –Elevated ALT more common in men vs women (OR: 3.3; 95% CI: ), and related to age ( P for trend <.001) ≥ 70 Age (Yrs) WomenMen Prevalence of Elevated ALT (%) Ioannou GN, et al. Am J Gastroenterol. 2006;101:76-82.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Relationship Between Sex, BMI, and ALT  1033 blood donors with negative viral serology  Suggested upper limit of normal Relationship Between ALT and Clinical Factors VariableRegression CoefficientP Value Older age Male0.118<.01 Higher BMI0.177<.01 Smoker ALT, IU/LBMI < 23BMI ≥ 23 Females3245 Males4366 Piton A, et al. Hepatology.1998;27:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Determining the Definition of Normal ALT Values  Statistical definition –Standard practice to define normal lab values –Middle 95% of healthy subjects –Abnormal: > 97.5th percentile –Influenced by reference population  Biological definition –Risk of developing disease or complication –Cholesterol, glucose –Abnormal ALT: level associated with disease –Requires standardization of laboratory assays

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Updated Limits for Determining Normal ALT  9221 first-time blood donor candidates  74% suitable donors after exclusion of anemia, seizure, sexual and other risk –57% determined to be ‘low risk’ for liver disease –Negative viral serology –BMI < 25 –Normal serum cholesterol, triglycerides, and glucose levels –Absence of concurrent medication use  Updated healthy ALT ranges determined from the group of low-risk individuals –Males: 30 IU/L –Females: 19 IU/L Prati D, et al. Ann Intern Med. 2002;137:1-10.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Low-Level Increases in ALT Predict NAFLD  Cohort of 5237 healthy men without diagnosed NAFLD and with ALT < 35 IU/L and γ-glutamyltransferase < 40 IU/L –984 new cases of NAFLD reported during 13,276.6 person-years of follow-up over 4 years  ALT increases within reference intervals predicted incidence of NAFLD (P <.001) –ALT < 16 IU/L: HR* = 1.00 –ALT IU/L: HR* = 1.53 (95% CI: ) –ALT IU/L: HR* = 1.66 (95% CI: ) –ALT IU/L: HR* = 1.62 (95% CI: ) –ALT IU/L: HR* = 2.21 (95% CI: ) *Adjusted for age, weight change, fasting serum glucose, log e triglyceride, HDL cholesterol, BMI, systolic blood pressure, smoking, exercise, and alcohol intake, HOMA-IR, CRP, incident diabetes. Chang Y, et al. Clin Chem. 2007;53:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Disadvantages of Using a Lower ALT ULN Cutoff  Unnecessary testing and consultation  Unclear health consequence –eg, NAFLD with minimally elevated ALT  Rejection of blood donors  Anxiety  Medico-legal Kaplan MM. Ann Intern Med. 2002;137:49-51.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Biologic Definition of Normal ALT  Cohort study of 142,055 health insurance participants –Aged years –Baseline ALT measured –Follow-up through 2000 –Death certificates used to determine timing of death and cause of death –Limitation: hepatitis B diagnosis unknown Kim HC, et al. BMJ. 2004;328:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B ALT and Subsequent Mortality in Men Relative Risk of Mortality ALT (IU/L) < ≥ 100 All cause Liver Kim HC, et al. BMJ. 2004;328:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B ALT and Subsequent Mortality in Women Kim HC, et al. BMJ. 2004;328: Relative Risk of Mortality ALT (IU/L) < ≥ All cause Liver

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Serum aminotransferase activity and mortality risk in a United States community. Lee TH, et al. Copyright © Hepatology. 2008;47: Used with permission of John Wiley & Sons, Inc. ALT and Mortality in Olmsted County Cohort  Adults from Olmsted County, Minnesota, who came to Mayo Clinic in 1995 included (N = 6823) –Followed from January 1995 to April 2006 Women Men Relative Risk of Death ALT (IU/L)

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Phases of Chronic Hepatitis B HBeAg positive HBV DNA  ALT < ULN Immune tolerance HBeAg positive HBV DNA  ALT > ULN HBeAg positive chronic hepatitis HBeAg negative HBV DNA ↓↓ ALT < ULN Inactive carrier HBeAg negative HBV DNA  ALT > ULN HBeAg negative chronic hepatitis Treat Monitor Precore mutation HBeAg seroconversion Adapted with permission. Pungapong S. Mayo Clin Proc. 2007;82(8):

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Phases of Chronic Hepatitis B HBeAg StatusALT NormalALT Abnormal HBeAg positiveImmune-tolerant ( HBV DNA ↑↑↑) HBeAg-positive hepatitis (HBV DNA ↑↑) HBeAg negative (anti-HBe positive) Inactive carrier (HBV DNA negative to ↑) HBeAg-negative hepatitis (HBV DNA ↑) Pungpapong S. Mayo Clin Proc. 2007;82:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Relationship Between ALT and Necroinflammation in Viral Hepatitis Reddy A. DDW Abstract S1755. METAVIR Activity Index ≥ 2 (%) ALT (IU/L) Hepatitis BHepatitis C ≤ > n =

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Correlation Between ALT and Histology in HBeAg-Positive Patients Inflammation* *Knodell necroinflammatory score ≥ 7. † Ishak fibrosis score ≥ 4. Fibrosis † Terrault N. DDW Abstract 94. ALT (x ULN) < 2 2-5> 5 Proportion of Patients (%) ALT (x ULN) < 2 2-5> n = n =

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Terrault N. DDW Abstract *Knodell necroinflammatory score ≥ 7. † Ishak fibrosis score ≥ 4. Inflammation*Fibrosis † ALT (x ULN) < 2 2-5> 5 Proportion of Patients (%) ALT (x ULN) < 2 2-5> n = n = Correlation Between ALT and Histology in HBeAg-Negative Patients

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Use of Updated Normal ALT in Hepatitis B Patients  HBV patients with near-normal ALT values may have –Abnormal liver histology –Increased risk of mortality from liver disease, especially in those older than 40 years of age  Decisions on whether to liver biopsy should take into account –The new suggested upper limits of normal for ALT –Age –HBeAg status –HBV DNA levels –Other clinical features suggestive of chronic liver disease Lok A, et al. Hepatology. 2007;45:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Elevated HBV DNA, Significant Fibrosis Found in Patients With Normal ALT  1387 asymptomatic HBsAg-positive patients with ≥ 1-year follow-up –189 with persistently normal ALT (PNALT)* included in analysis (HBeAg-: 116)  21% of HBeAg-negative patients with PNALT and HBV DNA < 5 log copies/mL had HAI ≥ 3 and/or fibrosis stage ≥ 2 Kumar M, et al. Gastroenterology. 2008;134: *≥ 3 ALT values in the previous 1 year prior to baseline liver biopsy that were all ≤ 40 IU/L and remained so until the start of treatment or the last follow-up HBV DNA ≥ 5 log copies/mLHistologic Fibrosis Stage ≥ 2 HBeAg positive HBeAg negative Patients (%)

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Relationship Between FibroTest Score and Fibrosis Stage in Hepatitis B 11% of ≥ F2 52% of < F2 18% of ≥ F2 1% of < F2 Reprinted from Journal of Hepatology, Vol 39, Myers R, et al. Prediction of liver histological lesions with biochemical markers in patients with chronic hepatitis, Pages , Copyright 2003, with permission from Elsevier. FibroTest Fibrosis stage Donors

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Spontaneous ALT Increases in Asymp- tomatic HBV Patients With Normal ALT  HBeAg-negative, anti-HBe–positive patients with normal ALT (< 40 IU/L) followed (N = 217)  43 patients developed spontaneous ALT flares* during person-years of follow-up –Annual rate of spontaneous ALT flare: 4.3% –Cumulative probability of ALT flare –Year 5: 10.8%– Year 10: 47.3%  Probability of an ALT flare correlated with following baseline factors –30 years of age or older at presentation (OR = 5.31; 95% CI: ; P =.008) –Male sex (OR = 4.54; 95% CI: ; P =.05) –Presence of precore mutation (OR = 10.99; 95% CI: ; P <.001)  If tested every 3 months, 90% of flares would be identified *Defined as ALT > 2 x ULN and HBV DNA levels ≥ 10 5 copies/mL or 100-fold increase in HBV DNA from previous measure. Kumar M, et al. Gastroenterology. In press.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B A Profile of HBeAg-Negative Chronic Hepatitis B  Monitoring ALT and HBV DNA levels at Years 1 and 2 would not reveal the fluctuating nature of these parameters in this patient Hepatitis B e antigen-negative chronic hepatitis B. Hadziyannis SJ, et al. Hepatology. 2001;34: Copyright © Reproduced with permission of John Wiley & Sons, Inc. HBV DNA ALT HBV DNA (copies/mL) ALT (IU/L) Yrs x x x x x

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B AASLD Guidelines on HCC Surveillance  Indication for HCC surveillance in chronic hepatitis B patients –Asian males ≥ 40 years –Asian females ≥ 50 years –All cirrhotic hepatitis B carriers –Family history of HCC –Blacks > 20 years of age  For non-cirrhotic hepatitis B carriers not listed above –Risk varies depending on severity of the underlying liver disease, current and past hepatic inflammatory activity –Patients with high HBV DNA, ongoing hepatic inflammatory activity remain at risk for HCC Bruix J, et al. Hepatology Nov;42(5):

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B The REVEAL Study: ALT as a Risk Factor for HCC  Large, long-term cohort study to determine risk of cirrhosis and HCC  ALT ≥ 45 IU/L at study entry was a risk factor for HCC  HBV DNA levels were the strongest predictor of HCC Chen CJ, et al. JAMA. 2006;295: *Per 100,000 person-years. Risk of HCC Subjects, n (%) HCC Incidence Rate* HR (95% CI) P Value ALT, IU/L < (94) ≥ (6) ( )<.01 HBV DNA, copies/mL < (24) (32) ( ) ,000-99, (18) ( )< , , (9) ( )<.01 ≥ 1 million627 (17) ( )<.01

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Risk of CirrhosisMultivariable HR All (N = 3582)HBeAg Negative (n = 3037) ALT, IU/L  < (ref)  ≥ * 1.6 HBV DNA, copies/mL  < (ref)   10,000-99,9992.5*2.4*  100, ,9995.6*5.4*  ≥ 1 million6.5*6.7* Iloeje UH, et al. Gastroenterol. 2006;130: *P <.05, adjusted for age, sex, cigarette smoking, alcohol consumption, and HBeAg status. The REVEAL Study: ALT as a Risk Factor for Cirrhosis

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B ALT and Spontaneous HBeAg Seroconversion  Spontaneous seroclearance within 18 months in > 60% of patients with ALT > 5 x ULN Follow-up (months) x ≤ 1 x ULN x ULN x ULN x ULN x ULN x ULN > 25.0 x ULN x x Spontaneous HBeAg Clearance (%) x x x Reprinted from Journal of Gastroenterology and Hepatology, Vol 12, Liaw YF, et al. Current therapeutic trends in therapy for chronic viral hepatitis. Pages S346-S353, Copyright 1997, with permission from John Wiley & Sons, Inc.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B ALT and Spontaneous HBeAg Seroconversion  HBeAg and HBV DNA loss significantly associated with degree of ALT flare in patients with high-level HBV DNA at baseline (≥ 100 pg/mL)  In patients with low-level HBV DNA at baseline (< 100 pg/mL) severe flares were not predictive of a virologic response ULN defined as 43 IU/L. Compared with no flare group: *P =.03; † P =.04; ‡ P =.002; § P =.01 Nair S, et al. Hepatology. 2001;34: ResponseALT No FlareMild (2-4 x ULN) Moderate (4-8 x ULN) Severe (≥ 8 x ULN) HBV DNA loss92536*50 ‡ HBeAg loss71729 † 36 §

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B AASLD Guidelines: Management of HBeAg-Positive Patients ALT LevelsTreatment/Monitoring Guidelines ALT < 1 x ULN  Monitor ALT every 6 mos  Monitor HBeAg every 12 mos ALT 1-2 x ULN  Monitor ALT every 3 mos  Monitor HBeAg every 6 mos  Biopsy if elevations are persistent or aged older than 40 yrs  Treat if moderate/severe inflammation or > septal fibrosis ALT > 2 x ULN  Monitor ALT, HBeAg every 1-3 mos  Treat if elevations are persistent ± biopsy  Immediate treatment if jaundice or decompensated Lok A, et al. Hepatology. 2007;45:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B AASLD Guidelines: Management of HBeAg-Negative Patients CharacteristicsTreatment/Monitoring Guidelines ALT ≥ 2 x ULN and HBV DNA ≥ 20,000 IU/mL  Treat ± biopsy ALT 1-2 x ULN and HBV DNA ,000 IU/mL  Monitor ALT and HBV DNA every 3 mos  Biopsy if persistent elevations  Treat if moderate/severe inflammation or > septal fibrosis ALT < 1 x ULN and HBV DNA < 2000 IU/mL  Monitor ALT every 3 months x 3, then every 6-12 mos if ALT still within normal limits Lok A, et al. Hepatology. 2007;45:

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B AASLD Guideline vs US Algorithm AASLD 2007Keeffe Algorithm 2006 ActionHBeAg PositiveHBeAg NegativeHBeAg PositiveHBeAg Negative Monitor; do not treat ALT normal ALT intermittently up to 2 x ULN Aged younger than 40 yrs ALT normal HBV DNA < 2000 IU/mL ALT normal* HBV DNA < 20,000 IU/mL ALT normal HBV DNA < 2000 IU/mL Consider treatment Biopsy shows significant disease ALT 1-2 x ULN HBV DNA > 2000 IU/mL Biopsy shows significant disease ALT normal HBV DNA > 20,000 IU/mL ALT normal HBV DNA ≥ 2000 IU/mL Biopsy shows significant disease TreatALT > 2 x ULN HBV DNA > 20,000 IU/mL ALT elevated HBV DNA > 20,000 IU/mL ALT elevated HBV DNA ≥ 2000 IU/mL Lok A, et al. Hepatology. 2007;45: Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6: *ULN defined as 30 IU/L for men and 19 IU/L for women.

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Chen CJ, et al. JAMA. 2006;295: Relationship Between Baseline HBV DNA and HCC Incidence: HBeAg Negative and Normal ALT at Entry (n = 2966) HBV DNA at Baseline (copies/mL) Incidence of HCC in HBeAg Negative Patients With Normal ALT Cumulative Incidence of HCC at Year 13 Follow-up (%) < , ,999 ≥ 100,

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Antiviral Treatment of HBeAg-Negative Patients With Normal ALT  Reduction (elimination) of risk of cirrhosis  Reduction of HCC risk  Unknown safety of long-term treatment  Possibility of antiviral resistance  Cost

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B HBeAg Seroconversion Rates According to Baseline ALT Levels Lau GK, et al. NEJM. 2005;26: Lok A. DDW Abstract M934. Marcellin P, et al. J Hepatol. 2002;36(S1): Baseline ALT (x ULN) ADVLAMETVPegIFN HBeAg Seroconversion (%) < 22-5> 5

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Lau GK, et al. N Engl J Med. 2005;352: Marcellin P, et al. N Engl J Med. 2004;351: ALT Normalization at Week 48 of PegIFN, LAM, or PegIFN + LAM HBeAg PositiveHBeAg Negative PegIFN PegIFN + LAM LAM Proportion of Patients (%) PegIFN PegIFN + LAM LAM n = 271 n = 272n = 177n = 179n = 181

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Relationship Between On-Therapy ALT Flare and HBeAg Seroconversion Maximum ALT During Treatment (x ULN*) HBeAg Seroconversion (%) PegIFNPegIFN + LAMLAM ≤ 5> 5-10> Lau GK, et al. N Engl J Med. 2005;352: *ULN defined as 30 IU/L.

Summary and Conclusions

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Summary and Conclusions: ALT as an Indicator of Liver Inflammation  The good –Reasonably specific for hepatocellular destruction –Correlate with mortality –Familiar, widely available –Inexpensive  The not-so-good –Imperfect correlation with necroinflammation –Poor correlation with fibrosis –Uncertainty about what is normal

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Summary and Conclusions: Use of ALT in Hepatitis B  Correlate of natural history –HBeAg seroconversion, cirrhosis, HCC  Guide in management –ALT abnormal: antiviral therapy –ALT normal: monitoring –Uncertain: biopsy  Predictor of treatment response –Pretreatment –On-treatment flare (IFN)  Treatment endpoint

clinicaloptions.com/hep Clinical Utility of ALT in Diagnosis and Management of Chronic Hepatitis B Recommendations for Using ALT in Hepatitis B Patients  Be aware of limitations  One of the factors, along with HBV DNA and histology, to take into account in management decisions  Individualized management: include patient preference

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