拉米夫定预防和治疗糖皮质激素诱导的慢性乙型肝炎急性发作

Lamivudine efficacy on the prevention and treatment of hepatitis B virus reactivation induced by glucocorticoid in patients with HBV infection

目的分析慢性乙型肝炎患者因其他疾病经糖皮质激素治疗后的病情活动和应用拉米夫定防治此病情活动的效果。方法选取126例乙型肝炎病毒（HBV）感染并应用糖皮质激素治疗的患者，根据拉米夫定治疗基线时的血清HBV DNA载量和血清丙氨酸转氨酶（ALT）水平，将患者分为3组：血清ALT正常，HBV DNA低于检测下限，39例（A组）；血清ALT正常，HBV DNA≥10^3拷贝／mL，60例（B组）；血清ALT≥2倍正常值上限，HBV DNA≥10^4拷贝／mL，27例（C组）。每3～6个月观察患者血清HBV DNA载量和ALT水平一次，观察12～18个月。结果A组和B组中有47例慢性乙型肝炎患者未用拉米夫定治疗，在随访过程中发生HBV DNA明显升高者29例（61．70％），31例（65．96％）ALT升高，10例（21．28％）发生肝功能失代偿；而接受了拉米夫定治疗的52例患者，随访中仅4例（7．69％）发生病情再活动。C组患者拉米夫定治疗有效率为37．04％（10／27），显著低于在没有肝脏炎症活动时预防性应用拉米夫定的有效率（92．31％）（χ^2=27．82，P〈0．01）。结论糖皮质激素治疗可诱导HBV感染的再激活和加重肝损害。拉米夫定能有效防治糖皮质激素诱导的慢性乙型肝炎急性发作，且预防应用的效果明显优于延期治疗。

Objective To analyse hepatitis B virus（HBV） reactivation induced by glucocorticoid and the efficacy of lamivudine on the prevention and treatment of HBV reactivation in patients with HBV infection after receiving glu- coeorticoid therapy. Methods One hundred and twenty-six patients with HBV infection receiving glucocorticoid treatment were divided into three groups according to serum alanine transaminase （ALT） and HBV DNA levels： 39 patients with normal serum ALT level and negative HBV DNA （group A）, 60 patients with normal serum ALT level and HBV DNA level at ≥10^3 copies/mL（group B）, and 27 patients with ALT ≥two fold of normal value upper limit and HBV DNA level ≥10^4 copies/mL （group C）. Patients with and without lamivudine treatment were followed up by testing serum ALT and HBV DNA every three to six months for 12 - 18 months. Results Forty-seven patients in group A and B did not receive lamivudine treatment, 29 of whom （61.70%） had obvious HBV DNA elevation , 31 （65.96%） with ALT elevation , and 10 （21.28%） with liver function decompensation during glucocorticold treatment follow up; In group A and B patients receiving lamivudine treatment, there were only 4 eases （7. 69%） developed recurrence. The efficacy of lamivudine therapy in group C was only about 37. 04% （10/27）, which was significantly lower than that（92. 31%） in patients without activation of hepatitis B （χ^2 = 27. 82, P〈 0. 01）. Conclusion Glucocorticoid therapy can induce reactivation of HBV infection, recurrence of liver inflammation and decompensation in patients with HBV infection. Lamivudine can efficiently control HBV reactivation induced by glucocorticoid in chronic hepatitis B patients. The efficacy of preventive therapy is obviously better than the delayed therapy.