Thai Hepatitis B C guideline 2552 by Patama Gomutbutra

ISBN 978-974-225-231-1 ß«π≈‘¢ ‘∑∏‘Ï æ‘¡æå§√—Èß∑’Ë 1 ¡‘∂ÿπ“¬π 2553

®”π«πÀπâ“ 40 Àπâ“

®”π«πæ‘¡æå 4,000 ‡≈à¡

®—¥æ‘¡æå ‚¥¬ ¡“§¡‚√§µ—∫ (ª√–‡∑»‰∑¬) 32/23 Õ“§“√´‘‚π-‰∑¬ ™—Èπ 14 ‚´π´’ ¬Ÿπ‘µ‡Õ ∂. ÿ¢ÿ¡«‘∑ 21 ‡¢µ«—≤π“ °√ÿß‡∑æœ 10110 ‚∑√. 02-261-2428 ‚∑√ “√ 02-261-2429 ‡«Á∫‰´µå †www.liversocietythailand.org

§≥–°√√¡°“√∫√‘À“√ ¡“§¡œ «“√–ªï∫√‘À“√ 2552-2553 π“¬° ¡“§¡ æ≈.µ.πæ.Õπÿ™‘µ ®Ÿ±–æÿ∑∏‘ Õÿªπ“¬° æ≠.«‚√™“ ¡À“™—¬ ‡≈¢“∏‘°“√·≈–ªØ‘§¡ πæ.∏’√– æ‘√—™«‘ ÿ∑∏‘Ï ‡À√—≠≠‘° æ≠. ÿæ√ µ√’æß…å°√ÿ≥“ ª√–∏“πΩÉ“¬«‘™“°“√·≈–°“√»÷°…“µàÕ‡π◊ËÕß πæ.∑«’»—°¥‘Ï ·∑π«—π¥’ ª√–∏“πΩÉ“¬«‘®—¬ æ≠.Õ“¿— ≥’ ‚ ¿≥ ƒ…Øå ÿ¢ ª√–∏“πΩÉ“¬«“√ “√ πæ.¥√.ªî¬–«—≤πå ‚°¡≈¡‘»√å

Chronic Hepatitis B and C 2009

ª√–∏“πΩÉ“¬®√‘¬∏√√¡ æ≠.«—≤π“ ÿ¢’‰æ»“≈‡®√‘≠ ª√–∏“πΩÉ“¬‡ß‘πÕÕ¡ πæ.‡µ‘¡™—¬ ‰™¬πÿ«—µ‘ ª√–∏“πΩÉ“¬ª√–™“ —¡æ—π∏å æ≠.»‘«–æ√ ‰™¬πÿ«—µ‘ π“¬∑–‡∫’¬π πæ.¥√.¬ß¬ÿ∑∏ »‘√‘«—≤πÕ—°…√ °√√¡°“√°≈“ß πæ.»µ«√√… ∑Õß «— ¥‘Ï ∑’Ëª√÷°…“ æ≠.™ÿµ‘¡“ ª√–¡Ÿ≈ ‘π∑√—æ¬å

§≥–°√√¡°“√ª√—∫ª√ÿß·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ‰«√— µ—∫Õ—°‡ ∫∫’·≈–´’‡√◊ÈÕ√—ß„πª√–‡∑»‰∑¬ ªï 2552 πæ.§¡ —πµå πæ.®√Ÿ≠ πÕ.πæ.™‘π«—µ√å æ≠.™ÿµ‘¡“ πæ.‡µ‘¡™—¬ πæ.∂πÕ¡ πæ.∑«’»—°¥‘Ï πæ.∏’√π—π∑å πæ.∏’√– πæ.π‘æ—∑∏å πæ.¥√.ªî¬–«—≤πå πæ.¥√.¬ß¬ÿ∑∏ æ≠.«—≤π“ æ≠.«‚√™“

‡≈‘»§Ÿæ‘π‘® ™“ «— ¥‘Ï ÿ∑∏‘«π“ ª√–¡Ÿ≈ ‘π∑√—æ¬å ‰™¬πÿ«—µ‘ ®‘« ◊∫æß…å ·∑π«—π¥’ √√æ®‘µ æ‘√™— «‘ ∑ÿ ∏‘Ï ’¡“¢®√ ‚°¡≈¡‘»√å »‘√‘«—≤πÕ—°…√ ÿ¢’‰æ»“≈‡®√‘≠ ¡À“™—¬

æ≠.«√πÿ™ πæ.»µ«√√… πæ.»√—≥¬å æ≠.»‘«–æ√ πæ. °ÿ≈ πæ. ¬“¡ æ≠. ÿæ√ æ≠. ÿ¿—∑»√’ πæ.‡ ° ‘µ æ≈.µ.πæ.Õπÿ™‘µ æ≠.Õ¿‘≠≠“ æ≠.Õ“¿— ≥’ πæ.‡Õ°«’√å πæ.‚ÕÃ“√

®ß»√’ «— ¥‘Ï ∑Õß «— ¥‘Ï «√√≥¿“ π’ ‰™¬πÿ«—µ‘ ‡≈Á°»√’ °ÿ≈ »‘√‘π∏√ªí≠≠“ µ√’æß…å°√ÿ≥“ ‡»√…∞ ‘π∏ÿå ‚Õ ∂“°ÿ≈ ®Ÿ±–æÿ∑∏‘ ≈’√æ—π∏å ‚ ¿≥ ƒ…Øå ÿ¢ »√’ª√‘«≤ ÿ ‘ «‘«—≤π“™à“ß

Chronic Hepatitis B and C 2009

§”π” ∂â“‡√“¡’¬“∑’Ë “¡“√∂√—°…“‚√§‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß‰¥âÀ“¬∑ÿ°√“¬ „π√“§“∑’Ë‡ªìπ∑’Ë ¬Õ¡√—∫‰¥â·≈–‰¡à¡’º≈¢â“ß‡§’¬ß°Á§ß‰¡à®”‡ªìπµâÕß¡’·π«∑“ß (Guideline) „π°“√√—°…“ºŸâªÉ«¬ ‰«√— µ—∫Õ—°‡ ∫∫’ ·µà‡π◊ËÕß®“° 25% ¢ÕßºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫∫’ ·≈– 10% ¢ÕßºŸâªÉ«¬ ‰«√— µ—∫Õ—°‡ ∫´’ ‡∑à“π—πÈ ∑’®Ë –‡ ’¬™’«µ‘ ‡æ√“–‚√§µ—∫ ‡æ√“–©–π—πÈ ¥â«¬ª√– ‘∑∏‘¿“æ¬“∑’¡Ë Õ’ ¬Ÿà µ≈Õ¥®π√“§“¬“·≈–°“√¥◊ÕÈ ¬“∑’‡Ë ªìπ¢âÕæ‘®“√≥“ ®÷ß®”‡ªìπµâÕß¡’·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸªâ «É ¬ ‰«√— µ—∫Õ—°‡ ∫∫’·≈–‰«√— µ—∫Õ—°‡ ∫´’ ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß ºŸâªÉ«¬∑’Ë‡∫‘°¬“À√◊Õ‰¡à ‰¥â‡ ’¬ ‡ß‘π‡Õß ‡æ◊ËÕ∑”„Àâ°“√√—°…“‡ªìπ‰ª„π·π«∑“ß‡¥’¬«°—π ·≈–‡°‘¥ª√–‚¬™πå Ÿß ÿ¥µàÕ∑ÿ°ΩÉ“¬ ‡À¡“– ¡°—∫‡»√…∞“π–¢Õßª√–‡∑» ¡“§¡‚√§µ—∫ (ª√–‡∑»‰∑¬) ‰¥â®—¥ª√–™ÿ¡·π«∑“ß°“√√—°…“‚√§‰«√— µ—∫Õ—°‡ ∫∫’ ·≈–‚√§‰«√— µ—∫Õ—°‡ ∫´’ ‡¡◊ÕË «—π∑’Ë 12 ‘ßÀ“§¡ 2552 ‚¥¬¡’º∑Ÿâ √ß§ÿ≥«ÿ≤®‘ “°‚√ß‡√’¬π·æ∑¬å ·æ∑¬å∑’Ë¥Ÿ·≈ºŸâªÉ«¬„π à«π¿Ÿ¡‘¿“§ ®÷ß‰¥â·π«∑“ß©∫—∫π’È´÷Ëß‡ªìπ©∫—∫∑’Ë 3 ·≈â« ·π«∑“ß∑’®Ë ¥— ∑”¢÷πÈ ‡ªìπ‡æ’¬ß·π«∑“ß ”À√—∫·æ∑¬å„π°“√√—°…“ºŸªâ «É ¬ ‚¥¬‰¡à “¡“√∂ „™âÕâ“ßÕ‘ß∑“ß°ÆÀ¡“¬‰¥â ‡π◊ËÕß®“°°“√ªØ‘∫—µ‘µâÕßª√—∫µ“¡ ∂“π°“√≥å ¡“§¡‚√§µ—∫ (ª√–‡∑»‰∑¬) À«—ß«à“¢âÕ¡Ÿ≈∑—π ¡—¬∑’Ë∑”„Àâ¡’°“√‡ª≈’Ë¬π·ª≈ß°“√ √—°…“‰ª®–°àÕ„Àâ‡°‘¥ª√–‚¬™πå∑—Èß·æ∑¬å·≈–ºŸâªÉ«¬„π°“√√—°…“‚√§µ—∫Õ—°‡ ∫®“°‰«√— µ—∫ Õ—°‡ ∫∫’·≈–´’

æ≈.µ.πæ.Õπÿ™‘µ ®Ÿ±–æÿ∑∏‘ π“¬° ¡“§¡‚√§µ—∫ (ª√–‡∑»‰∑¬)

Chronic Hepatitis B and C 2009

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß „πª√–‡∑»‰∑¬ ªï 2552 Thailand Consensus Recommendations for Management of Chronic Hepatitis B 2009

°“√ª√–‡¡‘πºŸâªÉ«¬∑’Ëµ√«®æ∫«à“¡’ HBsAg ‡ªìπ∫«° 1. µ√«®‡≈◊Õ¥ª√–‡¡‘π¥Ÿ¿“«– HBeAg ·≈– HBeAb 2. µ√«® serum ALT ∂â“§à“Õ¬Ÿà „π√–¥—∫‡°≥±åª°µ‘„Àâµ‘¥µ“¡ serum ALT ∑ÿ° 3-6 ‡¥◊Õπ 3. „π°√≥’∑’Ë HBeAg ‡ªìπ≈∫ ·µàºŸâªÉ«¬¡’ serum ALT º‘¥ª°µ‘ À√◊Õ ¡’ªí®®—¬‡ ’Ë¬ß µàÕ°“√‡°‘¥‚√§µ—∫ ‡™àπ ºŸâ™“¬Õ“¬ÿ¡“°°«à“ 40 ªï ¡’ª√–«—µ‘µ—∫·¢Áß·≈–¡–‡√Áßµ—∫ „π§√Õ∫§√—« µ√«®√à“ß°“¬æ∫ chronic liver stigmata §à“ ALT Õ¬Ÿà„π‡°≥±å ¡“°°«à“§√÷ßË ¢Õß§à“ª°µ‘ Õ—≈µ√“´“«¥å¡≈’ °— …≥–º‘¥ª°µ‘¢Õßµ—∫ §«√µ√«®¥Ÿª√‘¡“≥ serum HBV DNA √à«¡¥â«¬

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß∑’Ë§«√‰¥â√—∫°“√√—°…“ ºŸâ∑’Ë ¡§«√‰¥â√—∫°“√√—°…“ ‰¥â·°àºŸâªÉ«¬∑’Ë¡’≈—°…≥–¥—ßµàÕ‰ªπ’È 1. HBsAg ∫«°„π‡≈◊Õ¥‰¡àµË”°«à“ 6 ‡¥◊Õπ 2. ¡’À≈—°∞“π∑’Ë∫àß«à“¡’ active HBV viral replication §◊Õ a. HBeAg ‡ªìπ∫«° À√◊Õ HBV DNA ¡“°°«à“À√◊Õ‡∑à“°—∫ 20,000 IU/ml b. HBeAg ‡ªìπ≈∫ ·≈–¡’ HBV DNA ¡“°°«à“À√◊Õ‡∑à“°—∫ 2,000 IU/ml 3. √–¥—∫ serum ALT ¡“°°«à“À√◊Õ‡∑à“°—∫ 1.5 upper limit of normal (ULN) Õ¬à“ßπâÕ¬ 2 §√—ÈßÀà“ß°—π‰¡àπâÕ¬°«à“ 3 ‡¥◊Õπ (¬°‡«âπ„π°√≥’ºŸâªÉ«¬¡’À≈—°∞“π «à“¡’µ∫— ·¢ÁßÀ√◊Õ impending decompensation æ‘®“√≥“„Àâ°“√√—°…“∂÷ß·¡â®–¡’ ALT ª°µ‘ À√◊Õ‰¡à®”‡ªìπµâÕß√ÕÀà“ß°—π‡°‘π 3 ‡¥◊Õπ)

Chronic Hepatitis B and C 2009

4. §«√¡’°“√µ√«®æ¬“∏‘ ¿“æ¢Õßµ—∫„π°√≥’∑’ËºŸâªÉ«¬¡’§à“ ALT πâÕ¬°«à“ 2 ‡∑à“ ¢Õß§à“ª°µ‘‚¥¬∑’Ë ‰¡à¡≈’ °— …≥–∑“ß§≈’π°‘ À√◊Õ√—ß ’«∑‘ ¬“«à“¡’µ∫— ·¢ÁßÀ√◊ÕºŸªâ «É ¬∑’Ë ‰¡à “¡“√∂µ—¥ “‡Àµÿ¢Õßµ—∫Õ—°‡ ∫Õ◊πË √à«¡¥â«¬‡æ◊ÕË ¬◊π¬—π«à“ “‡Àµÿ¢Õß°“√‡æ‘¡Ë ¢Õß serum aminotransferase ‡ªìπ®“°‰«√— µ—∫Õ—°‡ ∫∫’ ·≈–¡’≈—°…≥–∑“ß æ¬“∏‘«‘∑¬“∫àß™’È«à“¡’°“√Õ—°‡ ∫≈ÿ°≈“¡¢Õß‡π◊ÈÕµ—∫Õ—π‡π◊ËÕß¡“®“°‰«√— µ—∫Õ—°‡ ∫ ™π‘¥∫’ ´÷Ëß§«√¡’ HAI necroinflammatory score ¡“°°«à“À√◊Õ‡∑à“°—∫ 3 À√◊Õ ¡’ significant fibrosis (equivalent Metavir score ¡“°°«à“À√◊Õ‡∑à“°—∫ 2) 5. §«√µ√«® HCV Ab ·≈– HIV Ab °àÕπ‰¥â√—∫°“√√—°…“∑ÿ°√“¬ 6. µâÕß‰¡à¡’ ‚√§Õ◊Ëπ∑’Ë‡ªìπ “‡ÀµÿÀ≈—°¢Õßµ—∫Õ—°‡ ∫ „π°√≥’∑’ËºŸâªÉ«¬ chronic hepatitis B infection ∑’Ë¬—ß‰¡à¡’¢âÕ∫àß™’È „π°“√√—°…“ À√◊Õ ‡ªìπ inactive chronic hepatitis B infection ‰¡à ¡§«√„Àâ¬“µâ“π‰«√— ·µà§«√‰¥â√—∫°“√ µ‘¥µ“¡ ALT ‡ªìπ√–¬–Ê ∑ÿ° 3-6 ‡¥◊Õπ °àÕπ„Àâ°“√√—°…“ºŸâªÉ«¬ chronic hepatitis B §«√ ‰¥â√—∫°“√ª√–‡¡‘π·≈–°“√·π–π”Õ¬à“ß≈–‡Õ’¬¥ ´÷Ëß√«¡∂÷ß¿“«–¢Õß‚√§ ‚√§√à«¡ ¢âÕ®”°—¥ À√◊Õ¢âÕÀâ“¡„π°“√„™â¬“ °“√ªØ‘∫—µ‘µ—« §à“„™â®à“¬„π°“√√—°…“·≈–°“√µ‘¥µ“¡√–¬–¬“« (III)

°“√√—°…“∑’Ë‡À¡“– ¡ ë ºŸâªÉ«¬ compensated chronic hepatitis B ∑’Ë¡’ HBeAg ‡ªìπ∫«° “¡“√∂ ‡≈◊Õ°„™â¬“‰¥â∑°ÿ ¢π“π¢÷πÈ °—∫ªí®®—¬¢Õß‰«√— ∫’ ªí®®—¬∑“ßºŸªâ «É ¬ ·≈–√–¬–¢Õß‚√§ ·æ∑¬å§«√Õ∏‘∫“¬ „ÀâºŸâªÉ«¬∑√“∫∂÷ßª√–‚¬™πå·≈–¢âÕ®”°—¥¢Õß¬“·µà≈–™π‘¥ ‡æ◊ËÕ„ÀâºŸâªÉ«¬¡’ ‚Õ°“ √à«¡µ—¥ ‘π„®„π°“√‡≈◊Õ°™π‘¥°“√√—°…“ ¬“∑’Ë„™â√—°…“‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß„πªí®®ÿ∫—π¡’¥—ßµàÕ‰ªπ’È - Conventional interferon α ¢π“¥ 5-10 MU ©’¥‡¢â“™—Èπ„µâº‘«Àπ—ß 3 §√—ÈßµàÕ —ª¥“Àåπ“π 6 ‡¥◊Õπ - Pegylated interferon α ¢π“¥ 180 mcg „π°√≥’ Pegylated interferon α -2a À√◊Õ 1.5 mcg/kg „π°√≥’ Pegylated interferon α -2b ©’¥‡¢â“™—Èπ „µâº‘«Àπ—ß —ª¥“Àå≈–§√—Èß π“π 12 ‡¥◊Õπ {¢âÕ¡Ÿ≈°“√√—°…“¥â«¬ Pegylated interferon α ∑—Èß 2a ·≈– 2b ‡ªìπ‡«≈“ 6 ‡¥◊Õπ ¬—ß‰¡à‡æ’¬ßæÕ §«√√Õ¥Ÿº≈ °“√»÷°…“«‘®—¬∑’Ë‡ª√’¬∫‡∑’¬∫√–¬–‡«≈“ 6 ‡¥◊Õπ °—∫ 12 ‡¥◊Õπ (NEPTUNE STUDY) ´÷Ëß®–∑√“∫º≈¿“¬„πµâπªï æ.». 2553} - Lamivudine 100-150 mg √—∫ª√–∑“π«—π≈–§√—Èß 6

Chronic Hepatitis B and C 2009

- Adefovir dipivoxil 10 mg √—∫ª√–∑“π«—π≈–§√—Èß - Entecavir 0.5 mg √—∫ª√–∑“π«—π≈–§√—Èß µÕπ∑âÕß«à“ß Õ¬à“ßπâÕ¬ 2 ™—Ë«‚¡ß °àÕπ·≈–À≈—ßÕ“À“√ - Telbivudine 600 mg √—∫ª√–∑“π«—π≈–§√—Èß - Tenofovir# 300 mg √—∫ª√–∑“π«—π≈–§√—Èß #

ªí®®ÿ∫—π¬—ß‰¡à¡’®”Àπà“¬„π¢âÕ∫àß™’È¢Õß°“√√—°…“‚√§‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß„π ª√–‡∑»‰∑¬ „Àâæ‘®“√≥“ª√—∫¢π“¥¬“ °√≥’∑’ËºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õß‰µ∫°æ√àÕß (¥Ÿµ“√“ß°“√ ª√—∫¬“) µ“√“ß∑’Ë 1 °“√ª√—∫¢π“¥¬“ Lamivudine Creatinine clearance First dose of (ml/min) Lamivudine 30 ≤ CrCl < 50 100 mg 15 ≤ CrCl < 30 100 mg 5 ≤ CrCl < 15 35 mg CrCl < 5 35 mg

Maintenance dose once daily 50 mg 25 mg 15 mg 10 mg

„πºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß∑’Ë ‰¥â√—∫°“√øÕ°‚≈À‘µ„Àâ Lamivudine 100 ¡‘≈≈‘°√—¡ —ª¥“Àå≈– §√—ÈßÀ≈—ß°“√øÕ°‚≈À‘µ µ“√“ß∑’Ë 2 °“√ª√—∫¢π“¥¬“ Adefovir Creatinine clearance Hemodialysis (ml/min) patients* 20-49 10-19 Recommended Dose 10 mg 10 mg 10 mg every 7 days and Dosing Interval every 48 every 72 following dialysis hours hours * Dosing recommendation derived in study where high flux dialysis was conducted three times a week Chronic Hepatitis B and C 2009

µ“√“ß∑’Ë 3 °“√ª√—∫¢π“¥¬“ Entecavir CrCI (ml/min) ≥ 50 30 to <50

10 to <30

<10 Hemodialysis* or CAPD

Usual Dose (0.5 mg) 0.5 mg once daily 0.25 mg once daily or 0.5 mg every 48 hours 0.15 mg once daily or 0.5 mg every 72 hours 0.05 mg once daily or 0.5 mg every week after dialysis

Lamivudine Refractory (1 mg) 1 mg once daily 0.5 mg once daily or 1 mg every 48 hours 0.3 mg once daily or 1 mg every 72 hours 0.1 mg once daily or 1 mg every week after dialysis

*Administer after hemodialysis µ“√“ß∑’Ë 4 ¢π“¥¬“ Telbivudine Creatinine clearance (ml/min) ≥ 50 30-49 < 30 (not requiring dialysis) ESRD* * End stage renal disease

Dose of Telbivudine 600 mg once daily 600 mg once every 48 hours 600 mg once every 72 hours 600 mg once every 96 hours

„π°√≥’∑’ËºŸâªÉ«¬¡’¢âÕ®”°—¥‡√◊ËÕß§à“„™â®à“¬À√◊ÕµâÕß‰¥â√—∫¬“∑’Ë¡’ Low genetic barrier ‡™àπ Lamivudine À√◊Õ Telbivudine ¡’¢âÕ·π–π”„π°“√‡≈◊Õ°√—°…“ºŸâªÉ«¬‡æ◊ËÕ„Àâ ‰¥âº≈„π °“√√—°…“¥’·≈–≈¥°“√¥◊ÈÕ¬“¥—ßµàÕ‰ªπ’È 1. ºŸâªÉ«¬∑’Ë¡’ HBeAg ‡ªìπ∫«° ·≈–¡’ HBV DNA πâÕ¬°«à“ 8 logs IU/ml ·≈– ALT ¡“°°«à“ 2x ULN ®–¡’º≈µàÕ°“√√—°…“¥’·≈–‚Õ°“ ¥◊ÈÕ¬“≈¥≈ßÕ¬à“ß™—¥‡®π 8

Chronic Hepatitis B and C 2009

2. §«√µ√«® HBV DNA ∑ÿ° 6 ‡¥◊Õπ ∂â“¬—ßµ√«®æ∫ HBV DNA ¡“°°«à“ 60 IU/ml ∑’Ë 6 ‡¥◊Õπ À≈—ß‡√‘Ë¡√—°…“ æ‘®“√≥“‡æ‘Ë¡¬“∑’Ë‡ªìπ non cross-resistant drugs ‡™àπ Adefovir À√◊Õ Tenofovir ë ºŸâªÉ«¬ compensated chronic hepatitis B ∑’Ë¡’ HBeAg ‡ªìπ≈∫ “¡“√∂ ‡≈◊Õ°„™â¬“‰¥â∑°ÿ ¢π“π¢÷πÈ °—∫ªí®®—¬¢Õß‰«√— ∫’ ªí®®—¬∑“ßºŸªâ «É ¬ ·≈–√–¬–¢Õß‚√§ ·æ∑¬å§«√Õ∏‘∫“¬„ÀâºŸâªÉ«¬∑√“∫∂÷ßª√–‚¬™πå·≈–¢âÕ®”°—¥¢Õß¬“·µà≈–™π‘¥‡æ◊ËÕ „ÀâºŸâªÉ«¬¡’ ‚Õ°“ √à«¡µ—¥ ‘π„®„π°“√‡≈◊Õ°™π‘¥°“√√—°…“ ¬“∑’Ë „™â√—°…“‰«√— µ—∫ Õ—°‡ ∫∫’‡√◊ÈÕ√—ß„πªí®®ÿ∫—π¡’¥—ßµàÕ‰ªπ’È - Conventional interferon α ¢π“¥ 5-10 MU ©’¥‡¢â“™—Èπ„µâº‘«Àπ—ß 3 §√—Èß µàÕ —ª¥“Àåπ“π 12 ‡¥◊Õπ - Pegylated interferon α ¢π“¥ 180 mcg „π°√≥’ Pegylated interferon α -2a À√◊Õ 1.5 mcg/kg „π°√≥’ Pegylated interferon α -2b ©’¥‡¢â“ ™—Èπ„µâº‘«Àπ—ß —ª¥“Àå≈–§√—Èßπ“π 12 ‡¥◊Õπ - Lamivudine 100-150 mg √—∫ª√–∑“π«—π≈–§√—Èß Õ¬à“ßπâÕ¬ 12 ‡¥◊Õπ - Adefovir dipivoxil 10 mg √—∫ª√–∑“π«—π≈–§√—Èß Õ¬à“ßπâÕ¬ 12 ‡¥◊Õπ - Entecavir 0.5 mg √—∫ª√–∑“π«—π≈–§√—Èß µÕπ∑âÕß«à“ß Õ¬à“ßπâÕ¬ 2 ™—Ë«‚¡ß °àÕπ·≈–À≈—ßÕ“À“√ Õ¬à“ßπâÕ¬ 12 ‡¥◊Õπ - Telbivudine 600 mg √—∫ª√–∑“π«—π≈–§√—Èß Õ¬à“ßπâÕ¬ 12 ‡¥◊Õπ - Tenofovir# 300 mg √—∫ª√–∑“π«—π≈–§√—Èß Õ¬à“ßπâÕ¬ 12 ‡¥◊Õπ #

ªí®®ÿ∫—π¬—ß‰¡à¡’®”Àπà“¬„π¢âÕ∫àß™’È¢Õß°“√√—°…“‚√§‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß„π ª√–‡∑»‰∑¬ „π°√≥’∑’ËºŸâªÉ«¬¡’¢âÕ®”°—¥‡√◊ËÕß§à“„™â®à“¬À√◊ÕµâÕß‰¥â√—∫¬“∑’Ë¡’ Low genetic barrier ‡™àπ Lamivudine, Telbivudine ¡’¢âÕ·π–π”„π°“√‡≈◊Õ°√—°…“ºŸâªÉ«¬‡æ◊ËÕ„Àâ‰¥â º≈„π°“√√—°…“¥’·≈–≈¥°“√¥◊ÈÕ¬“¥—ßµàÕ‰ªπ’È 1. ºŸâªÉ«¬∑’Ë¡’ HBeAg ‡ªìπ≈∫ ·≈–¡’ HBV DNA πâÕ¬°«à“ 6 logs IU/ml ®–¡’º≈ µàÕ°“√√—°…“¥’·≈–‚Õ°“ ¥◊ÈÕ¬“≈¥≈ßÕ¬à“ß™—¥‡®π Chronic Hepatitis B and C 2009

2. §«√µ√«® HBV DNA ∑ÿ° 6 ‡¥◊Õπ ∂â“¬—ßµ√«®æ∫ HBV DNA ¡“°°«à“ 60 IU/ml ∑’Ë 6 ‡¥◊ Õ π À≈— ß ‡√‘Ë ¡ √— ° …“ Õ“®æ‘ ® “√≥“‡æ‘Ë ¡ ¬“∑’Ë ‡ ªì π non cross-resistant drugs ‡™àπ Adefovir À√◊Õ Tenofovir „π°√≥’∑’Ë‡√‘Ë¡¥â«¬ low resistant drugs ‡™àπ Lamivudine, Telbuvudine ë „πºŸâªÉ«¬∑’Ë¡’ hepatic decompensation À√◊Õ¡’§«“¡°—ß«≈«à“®–‡°‘¥ decompensation §«√‡√‘Ë¡¥â«¬ Lamivudine, Telbivudine, Entecavir ·≈–§«√µ√«® HBV DNA ∑ÿ° 6 ‡¥◊Õπ ‡π◊ÕË ß®“°¡’√“¬ß“π Nucleoside analogues Õ“®∑”„Àâ‡°‘¥ Mitochondrial toxicity ‰¥â„πºŸªâ «É ¬∑’¡Ë ’ hepatic decompensation ´÷ßË ‡ªìπ class toxicity ¢Õß¬“„π°≈ÿ¡à Entecavir, Lamivudine, Telbivudine ¥—ßπ—πÈ §«√µ‘¥µ“¡ Õ“°“√·≈–‡ΩÑ“√–«—ß°“√‡°‘¥ mitochondrial toxicity „πºŸâªÉ«¬∑’Ë ‰¥â√—∫¬“°≈ÿà¡π’È

°“√µ‘¥µ“¡ºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√√—°…“ ¢≥–√—°…“ºŸâªÉ«¬§«√‰¥â√—∫°“√µ√«®√–¥—∫ ALT Õ¬à“ßπâÕ¬∑ÿ° 3 ‡¥◊Õπ ·≈– HBeAg, HBV DNA Õ¬à“ßπâÕ¬∑ÿ°Ê 6 ‡¥◊Õπ „πºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√√—°…“¥â«¬ Interferon À√◊Õ Pegylated interferon §«√‰¥â√—∫°“√µ√«®∑ÿ° 2 —ª¥“Àå„π™à«ß 1-2 ‡¥◊Õπ·√° À≈—ß®“° π—Èπ∑ÿ° 4-6 —ª¥“Àå ®π ‘Èπ ÿ¥°“√√—°…“‡æ◊ËÕ¥ŸÕ“°“√¢â“ß‡§’¬ß∑’Ë‡°‘¥®“°°“√„™â¬“´÷Ëß√«¡∂÷ß °“√µ√«®π—∫‡¡Á¥‡≈◊Õ¥ (complete blood count; CBC) °“√µ√«®°“√∑”ß“π¢Õß thyroid ·≈–Õ“°“√¢â“ß‡§’¬ßÕ◊ËπÊ „πºŸâªÉ«¬∑’Ë ‰¥â√—∫ Adefovir À√◊Õ Tenofovir §«√µ√«®°“√∑”ß“π ¢Õß‰µ·≈–√–¥—∫øÕ øÕ√— „π‡≈◊Õ¥√à«¡¥â«¬ ë ¿“¬À≈—ß ‘Èπ ÿ¥°“√√—°…“§«√‰¥â√—∫°“√µ‘¥µ“¡‡™àπ‡¥’¬«°—∫¢≥–„Àâ°“√√—°…“´÷Ëß √«¡∂÷ß°“√µ√«® ALT ∑ÿ° 3 ‡¥◊Õπ·≈– HBeAg/Anti HBe („π°√≥’∑º’Ë ªŸâ «É ¬ HBeAg ‡ªìπ∫«°), HBV DNA Õ¬à“ßπâÕ¬∑ÿ°Ê 6 ‡¥◊Õπ „πºŸâªÉ«¬∑’Ë°“√√—°…“‰¥âº≈¥’§◊Õ À≈—ßÀ¬ÿ¥°“√√—°…“·≈â«Õ¬à“ßπâÕ¬ 6 ‡¥◊Õπ¬—ß¡’√–¥—∫ ALT ª°µ‘·≈–¡’√–¥—∫ HBV DNA µË”°«à“ 2,000 IU/ml ·≈–§«√µ‘¥µ“¡µàÕ∑ÿ° 6 ‡¥◊Õπ ë „πºŸâªÉ«¬∑’Ë relapse À√◊Õ‰¡à ‰¥âº≈®“°°“√√—°…“§«√µ‘¥µ“¡∑ÿ° 3-6 ‡¥◊Õπ

Chronic Hepatitis B and C 2009

‡¡◊ËÕ„¥§«√À¬ÿ¥¬“ ë „πºŸâªÉ«¬∑’Ë ‰¥â√—∫ Interferon §«√„Àâ¬“‡ªìπ‡«≈“ 6 ‡¥◊Õπ „πºŸâªÉ«¬ HBeAg ‡ªìπ ∫«° ”À√—∫ºŸâªÉ«¬ HBeAg ‡ªìπ≈∫ §«√‰¥â√—∫¬“Õ¬à“ßπâÕ¬ 1 ªï ë ”À√—∫ Pegylated interferon „πºŸâªÉ«¬ HBeAg ‡ªìπ∫«° §«√‰¥â√—∫°“√√—°…“ 6-12 ‡¥◊Õπ ”À√—∫ºŸâªÉ«¬ HBeAg ‡ªìπ≈∫ §«√‰¥â√—∫°“√√—°…“ 1 ªï ë ”À√—∫ºŸªâ «É ¬∑’Ë ‰¥â√∫— ¬“ Lamivudine, Telbivudine, Tenofovir, Adefovir dipivoxil À√◊Õ Entecavir §«√‰¥â√—∫¬“µàÕ‡π◊ËÕßÕ¬à“ßπâÕ¬ 1 ªï ë ºŸâªÉ«¬∑’Ë HBeAg ‡ªìπ∫«° À“°æ∫«à“¡’ HBeAg seroconversion ‚¥¬µ√«®æ∫ HBeAg seroconversion √à«¡°—∫ µ√«® HBV DNA πâÕ¬°«à“ 400 copies/ml (60 IU/ml) Õ¬à“ßπâÕ¬ 2 §√—Èß Àà“ß°—πÕ¬à“ßπâÕ¬ 6 ‡¥◊Õπ “¡“√∂æ‘®“√≥“ À¬ÿ¥¬“À≈—ß®“°‰¥â¬“µàÕ‡π◊ËÕßÕ’°Õ¬à“ßπâÕ¬ 6-12 ‡¥◊Õπ ë ”À√—∫„πºŸªâ «É ¬∑’Ë HBeAg ‡ªìπ≈∫ µâÕß‰¥â√∫— °“√√—°…“√–¬–¬“«®π°«à“¡’ HBsAg clearance À√◊Õ Õ“®æ‘®“√≥“À¬ÿ¥¬“‰¥âÀ≈—ß®“°µ√«®‰¡àæ∫ HBV DNA 3 §√—Èß ·µà≈–§√—ÈßÀà“ß°—π‰¡àπâÕ¬°«à“ 6 ‡¥◊Õπ ·µàµâÕß‡ΩÑ“√–«—ß°“√°≈—∫‡ªìπ´È”

°“√¥Ÿ·≈ºŸâªÉ«¬ chronic hepatitis B „π ¿“«–æ‘‡»… ë ºŸªâ «É ¬ HBV „π°√≥’ HIV co-infection À“°‰¡à ‰¥â√∫— °“√√—°…“¥â«¬ antiretroviral agents ·≈–¡’§«“¡®”‡ªìπµâÕß‰¥â√∫— °“√√—°…“ hepatitis B §«√‡√‘¡Ë ¥â«¬ Adefovir dipivoxil À√◊Õ Telbivudine ‡æ◊ËÕªÑÕß°—π°“√‡°‘¥ cross resistance ë ·µà ”À√—∫ºŸâªÉ«¬∑’Ë ‰¥â√—∫ anti-retroviral agents Õ¬Ÿà·≈â«À“°‡ªìπ regimens ∑’Ë¡’ Lamivudine À√◊Õ Tenofovir Õ¬Ÿà·≈â«°Á “¡“√∂§«∫§ÿ¡ hepatitis B ‰¥â¥â«¬ ‡π◊ËÕß®“°°“√√—°…“¡’§«“¡´—∫´âÕπ·≈–Õ“®∑”„ÀâºŸâªÉ«¬¡’Õ“°“√∑√ÿ¥≈ßÀ√◊Õ‡ªìπ Õ—πµ√“¬·°à™’«‘µ‰¥â „π°“√√—°…“·π–π”„Àâ àßµàÕ‰ª¬—ßºŸâ‡™’Ë¬«™“≠ ë „π°√≥’∑’ËºŸâªÉ«¬¡’ CD4 count πâÕ¬°«à“ 200 cells/ml ·≈–¡’ liver cirrhosis ·≈â«§«√„Àâ¬“ 2 ¢π“π°àÕπ ‡™àπ Lamivudine ·≈– Tenofovir æ‘®“√≥“‡æ‘Ë¡ anti-retroviral agents ¢π“π∑’Ë 3 À≈—ß®“° HBV DNA πâÕ¬°«à“ 400 copies/ ml ‡æ◊ËÕªÑÕß°—π°“√‡°‘¥µ—∫Õ—°‡ ∫ µ—∫«“¬ ®“°¿“«– immune reconstitution syndrome Chronic Hepatitis B and C 2009

ë ºŸâªÉ«¬∑’Ë¡’ overt hepatic decompensation À√◊Õ impending hepatic decompensation §«√æ‘®“√≥“‡√‘Ë¡°“√√—°…“¥â«¬ Lamivudine, Telbivudine, Tenofovir, Entecavir ‡æ√“–≈¥ª√‘¡“≥‰«√— ‰¥â‡√Á«·≈–¡’§«“¡ª≈Õ¥¿—¬„π ºŸâªÉ«¬°≈ÿà¡π’È ë °àÕπ„Àâ chemotherapy À√◊Õ immunosuppressive drugs §«√µ√«®°√Õß ºŸªâ «É ¬°àÕπ«à“¡’ HBsAg À√◊Õ‰¡à À“° HBsAg ‡ªìπ∫«° §«√‰¥â√∫— ¬“ Lamivudine ‡æ◊ËÕªÑÕß°—π reactivation ¢Õß hepatitis B ·≈–§«√„Àâ¬“µàÕ‰ªÕ¬à“ßπâÕ¬ 12 —ª¥“ÀåÀ≈—ßÀ¬ÿ¥ immunosuppressive drugs (À“°„π°√≥’∑’Ë¡’¢âÕ∫àß™’È „π°“√√—°…“ chronic hepatitis B „Àâ¬÷¥µ“¡¢âÕ·π–π”¢â“ßµâπ) Õ“®æ‘®“√≥“ „Àâ¬“µàÕ 1 ªï „π°√≥’∑’Ë HBV DNA °àÕπ‡√‘Ë¡ chemotherapy ¡“°°«à“ 2,000 IU/ml ë „πºŸâªÉ«¬∑’Ë ‰¥â√—∫ rituximab À√◊Õ anti CD20 Monoclonal antibody Õ“® æ‘®“√≥“„Àâ Lamivudine ‡ªìπ‡«≈“ 1 ªï À≈—ß ‘Èπ ÿ¥°“√©’¥ rituximab ë „πºŸâªÉ«¬∑’Ë‡°‘¥ Lamivudine, Telbivudine À√◊Õ Entecavir resistance §«√ ‡æ‘Ë¡¬“µâ“π‰«√— „π°≈ÿà¡∑’Ë ‰¡à¡’ cross resistance ‡™àπ Adefovir dipivoxil, Tenofovir À√◊Õ‡ª≈’Ë¬π‡ªìπ Pegylated interferon ë „πºŸâªÉ«¬∑’Ë‡°‘¥ Adefovir resistance §«√‡æ‘Ë¡¬“µâ“π‰«√— „π°≈ÿà¡∑’Ë ‰¡à¡’ cross resistance ‡™àπ Lamivudine, Telbivudine À√◊Õ Entecavir À√◊ÕÕ“® ‡ª≈’Ë¬π°“√√—°…“‡ªìπ Pegylated interferon ë „πºŸâªÉ«¬‡¥Á°Õ“¬ÿ¡“°°«à“ 2 ªï æ‘®“√≥“°“√√—°…“‡™àπ‡¥’¬«°—∫„πºŸâ „À≠à (¬°‡«âπ °√≥’ HBeAg ‡ªìπ≈∫¬—ß‰¡à¡’¢âÕ¡Ÿ≈™—¥‡®π„π°“√°”Àπ¥·π«∑“ß√—°…“) ¬“∑’Ë¡’°“√»÷°…“·≈–‰¥â√—∫°“√¬Õ¡√—∫„Àâ „™â „π‡¥Á° ‰¥â·°à - Lamivudine 3 mg/kg/day ‰¡à‡°‘π 100 mg/day - Adefovir dipivoxil 10 mg „π‡¥Á°∑’ËÕ“¬ÿ¡“°°«à“ 12 ªï, 0.25 mg/kg/day (‰¡à‡°‘π 10 mg) „π‡¥Á°Õ“¬ÿ 7-12 ªï ·≈– „π‡¥Á°Õ“¬ÿ 2-6 ªï - Conventional interferon 5-10 million unit per m2 (¢π“¥¬“ Ÿß ÿ¥‰¡à‡°‘π 10 million unit) 3 §√—ÈßµàÕ —ª¥“Àå 12

Chronic Hepatitis B and C 2009

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß°≈ÿà¡µàÕ‰ªπ’È - ºŸâ™“¬Õ“¬ÿ¡“°°«à“ 40 ªï - ºŸâÀ≠‘ßÕ“¬ÿ¡“°°«à“ 50 ªï - ¡’ª√–«—µ‘¡–‡√Áßµ—∫„π§√Õ∫§√—« ‰¡à®”°—¥Õ“¬ÿ - ºŸâªÉ«¬µ—∫·¢Áß ‰¡à®”°—¥Õ“¬ÿ §«√‰¥â√—∫°“√‡ΩÑ“√–«—ß°“√‡°‘¥¡–‡√Áßµ—∫ (hepatocellular carcinoma) ‚¥¬‰¥â√—∫ °“√µ√«®Õ—≈µ√“´“«¥å ·≈– serum AFP ∑ÿ° 6 ‡¥◊Õπ æ‘®“√≥“„Àâ«—§´’πªÑÕß°—π‰«√— µ—∫Õ—°‡ ∫‡Õ„πºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫∫’‡√◊ÈÕ√—ß∑’Ë ‰¡à‡§¬ µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫‡ÕÀ√◊Õµ√«®‰¡àæ∫«à“¡’¿Ÿ¡‘µâ“π∑“πµàÕ‰«√— µ—∫Õ—°‡ ∫‡Õ‚¥¬‡©æ“– Õ¬à“ß¬‘Ëß „πºŸâªÉ«¬∑’Ë¡’µ—∫·¢Áß

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Chronic Hepatitis B and C 2009

7. Liaw YF, LeungN, Guan R et al. Asian-Pacific consensus statement on the management of chronic hepatitis B: An update. J Gastroenterol Hepatol 2003; 18:239-245. 8. Fattovich G. Natural History of Hepatitis B. J Hepatol 2003; 39:S50-S58. 9. Lok ASF, Lai CL, Wu PC, et al. Spontaneous hepatitis B e antigen to antibody seroconversion and reversion in Chinese patients with chronic hepatitis B virus infection, Gastroenterology 1987;92:1839-1843. 10. Wong DK, Cheung AM, O没Rourke K, et al. Effect of alpha-interferon treatment in patients with hepatitis B e antigen-positive chronic hepatitis B. A meta-analysis, Ann Intern Med. 1993;119 :312-323. 11. Craxi A, Bona DD, Camma C. Interferon-alpha for HBeAg-positive chronic hepatitis B. J Hepatol 2003; 39:S99-S105. 12. Brunetto MR, Oliveri F, Coco B, et al., Outcome of anti-HBe positive chronic hepatitis B in alpha-interferon treated and untreated patients: a long term cohort study, J Hepatol 2002;36 :263-270. 13. Cooksley WGE, Pirathvisuth T, Wang YJ et al., Evidence for the efficacy of Peg-Interferon alpha 2A (40Kd) (Pegasys) in the treatment of HBeAntigen positive chronic hepatitis B and impact of baseline factors [abstract], J Hepatol 2002; 36: 8. 14. Lau G, Piratvisuth T, Luo KX. Et al. Peg-Interferon alpha 2A (40Kd) (Pegasys) monotherapy and in combination with lamivudine is more effective than lamivudine monotherapy in HBsAg-positive chronic hepatitis B: results from a large , multinational study. AASLD 2004, abstract 20. 15. Marcellin P, Lau GK, Bonino F, Farci P, et al Peginterferon alfa-2a alone, lamivudine alone, and the two in combination in patients with HBeAg-negative chronic hepatitis B. N Engl J Med. 2004 16;351(12) :1206-17. 14

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16. Janssen HLA, von Zonneveld M, Senturk H et al. Pegylated interferon alfa-2b alone or in combination with lamivudine for HBeAg-positive chronic hepatitis B: a randomized trial. Lancet 2005; 365:123-129. 17. Chan HL, Leung NW, Hui AY et al. A randomized, controlled trial of combination therapy for chronic hepatitis B: Comparing pegylated interferon-alpha-2b and lamivudine with lamivudine alone. Ann Intern Med. 2005 Feb 15;142:240-50. 18. Lai CL, Chien RN, Leung NW et al., A one-year trial of lamivudine for chronic hepatitis B. Asia Hepatitis Lamivudine Study Group, N Engl J Med 1998;339:61-68. 19. Liaw YF, Leung NW, Chang TT et al., Effects of extended lamivudine therapy in Asian patients with chronic hepatitis B. Asia Hepatitis Lamivudine Study Group, Gastroenterology 2000;119:172-180. 20. Papatheodoridis GV, Dimou E, Laras A et al., Course of virologic breakthroughs under long-term lamivudine in HBeAg- negative precore mutant HBV liver disease, Hepatology 2002;36:219-226. 21. Marcellin P, Goodmann Z, Chang TT, et al., Adefovir Dipivoxil for the treatment of hepatitis B e antigen-positive chronic hepatitis B, N Engl J Med 2003; 348:808-816. 22. Hadziyannis S, Tassopolous N, Heathcote EJ, et al., Adefovir Dipivoxil for the treatment of hepatitis B e antigen-negative chronic hepatitis, N Engl J Med 2003:348:800-807. 23. Yeo W, Chan PK, Ho WM. Et al Lamivudine for the prevention of hepatitis B virus reactivation in hepatitis B s-antigen seropositive cancer patients undergoing cytotoxic chemotherapy. Clin Oncol. 2004 ;22:927-34. 24. Dai MS, Wu PF, Shyu RY, et al. Hepatitis B virus reactivation in breast cancer patients undergoing cytotoxic chemotherapy and the role of

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145. Hsu C, Hsiung C, Su IJ, Hwang WS, Wang MC, Lin SF et al. A revisit for prophylactic lamivudine for chemotherapy-associated hepatitis B reactivation in non-Hodgkin没s lymphoma: a randomized trial. Hepatology 2008;47:844-853.

Chronic Hepatitis B and C 2009

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∫ÿ§§≈¥—ßµàÕ‰ªπ’È¡’§«“¡‡ ’Ë¬ßµàÕ°“√µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ §«√‰¥â√—∫°“√ ∑¥ Õ∫À“‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ - ºŸâ∑’Ë¡’ª√–«—µ‘‰¥â‡≈◊Õ¥À√◊Õ à«πª√–°Õ∫¢Õß‡≈◊Õ¥°àÕπªï æ.».2538 - Intravenous drug use (IVDU) ∂÷ß·¡â«à“∑¥≈Õß„™â‡æ’¬ß§√—Èß‡¥’¬« - ºŸâªÉ«¬µ‘¥‡™◊ÈÕ HIV infection - ºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß∑’Ë ‰¥â√—∫°“√√—°…“¥â«¬ Hemodialysis - ºŸâ∑’Ë¡’ Unexplained abnormal ALT - ºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√ª≈Ÿ°∂à“¬Õ«—¬«–°àÕπªï æ.».2538 - ‡¥Á°∑’Ë‡°‘¥®“°¡“√¥“∑’Ë‡ªìπ‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß - ∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’Ë∂Ÿ°‡¢Á¡µ”®“°ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß - ºŸâ∑’Ë¡’ª√–«—µ‘¡’‡æ» —¡æ—π∏å°—∫ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß

ºŸ∑â ¡’Ë ‡’ ™◊ÕÈ ‰«√— µ—∫Õ—°‡ ∫´’ §«√‰¥â√∫— §”·π–π”„π°“√À≈’°‡≈’¬Ë ß°“√·æ√à‡™◊ÕÈ Ÿºà ÕŸâ π◊Ë

«‘∏°’ “√À≈’°‡≈’¬Ë ß°“√·æ√à‡™◊ÕÈ - ºŸâ∑’Ë¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ ‰¡à§«√∫√‘®“§‡≈◊Õ¥ Õ«—¬«– πÈ”‡™◊ÈÕ À√◊Õ πÈ”Õ ÿ®‘ - ºŸâ∑’Ë¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ §«√À≈’°‡≈’Ë¬ß°“√„™â·ª√ß ’øíπ ·≈–¢Õß¡’§¡√à«¡ °—∫ºŸâÕ◊Ëπ - À¬ÿ¥°“√„™â¬“‡ æµ‘¥ Chronic Hepatitis B and C 2009

- ºŸâ∑’Ë¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ §«√‰¥â√—∫§”·π–π”«à“§«“¡‡ ’Ë¬ß¢Õß°“√µ‘¥µàÕ ∑“ß‡æ» —¡æ—π∏åµË” ®÷ß‰¡à¡’§”·π–π”„ÀâªÑÕß°—π°“√µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫ ´’ ¬°‡«âπ„π°√≥’∑’Ëµ‘¥‡™◊ÈÕ HIV √à«¡¥â«¬ ·µà§«√À≈’°‡≈’Ë¬ß°“√¡’‡æ» —¡æ—π∏å ∑“ß∑«“√Àπ—° 3.

ºŸâªÉ«¬∑’Ë ß —¬«à“¡’ acute À√◊Õ chronic HCV infection §«√‰¥â√—∫°“√∑¥ Õ∫ À“ anti-HCV ·≈– HCV-RNA viral load

°“√∑¥ Õ∫ HCV RNA §«√∑”‡¡◊ËÕºŸâªÉ«¬ - ¡’º≈°“√∑¥ Õ∫ anti-HCV ‡ªìπ∫«° - ¡’·π«‚πâ¡®–„Àâ°“√√—°…“∂â“µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ - ‰¡à “¡“√∂Õ∏‘∫“¬ “‡Àµÿµ—∫Õ—°‡ ∫‰¥â ·≈–¡’º≈°“√∑¥ Õ∫ anti-HCV ‡ªìπ≈∫ ‚¥¬‡©æ“–ºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß À√◊ÕºŸâªÉ«¬ HIV À√◊Õ ºŸâªÉ«¬∑’Ë ‰¥â¬“ °¥¿Ÿ¡§‘ ¡ÿâ °—π

°àÕπ„Àâ°“√√—°…“ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß µâÕß∑”°“√µ√«® genotype ‡æ◊ËÕ «“ß·ºπ„π°“√√—°…“·≈–§“¥§–‡π°“√µÕ∫ πÕß

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß‚¥¬‡©æ“– genotype 1 (À√◊Õ∑’Ë ‰¡à„™à genotype 2, 3) §«√‰¥â√—∫°“√‡®“–™‘Èπ‡π◊ÈÕµ—∫¡“µ√«®‡æ◊ËÕ∑√“∫√–¥—∫ fibrosis ¡“ ª√–°Õ∫°“√µ—¥ ‘π„®„π°“√√—°…“

°“√µ√«®ª√–‡¡‘π fibrosis ¢Õßµ—∫‚¥¬«‘∏Õ’ π◊Ë Ê πÕ°‡Àπ◊Õ®“°°“√‡®“–™‘πÈ ‡π◊ÕÈ µ—∫ ‡™àπ fibroscan À√◊Õ«‘∏’Õ◊ËπÊ Õ“®„™â·∑π‰¥â ·µà§«“¡·¡àπ¬”Õ“®¬—ß‰¡à‡ªìπ∑’Ë ¬Õ¡√—∫‡∑à“æ¬“∏‘ ¿“æ¢Õßµ—∫®“°°“√‡®“–™‘Èπ‡π◊ÈÕµ—∫

°“√µ—¥ ‘π„®„π°“√√—°…“ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß·µà≈–∫ÿ§§≈¢÷ÈπÕ¬Ÿà°—∫ §«“¡√ÿπ·√ß¢Õß‚√§µ—∫ ‚Õ°“ ‡ ’Ë¬ßµàÕ°“√‡°‘¥º≈¢â“ß‡§’¬ß ‚Õ°“ ∑’Ë®–µÕ∫ πÕßµàÕ°“√√—°…“‚√§Õ◊ËπÊ ∑’ËºŸâªÉ«¬¡’Õ¬Ÿà ·≈–§«“¡æ√âÕ¡¢ÕßºŸâªÉ«¬„π°“√√—°…“

°“√√—°…“∑’Ë‡ªìπ¡“µ√∞“π„πªí®®ÿ∫—π¢Õß‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß §◊Õ °“√„™â¬“ √à«¡°—π√–À«à“ß Pegylated interferon alfa ·≈– Ribavirin

10. 32

§«√µ√«®À“ª√‘¡“≥ HCV RNA °àÕπ°“√√—°…“

Chronic Hepatitis B and C 2009

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë ¡§«√‰¥â√—∫°“√√—°…“ §◊Õ - Õ“¬ÿ 18 ªï ¢÷Èπ‰ª (∂â“Õ“¬ÿπâÕ¬°«à“ 18 ªï ¥Ÿ„π¢âÕ§”·π–π”°“√√—°…“„π‡¥Á°) - HCV RNA positive - º≈°“√‡®“–µ—∫æ∫«à“¡’ significant fibrosis (Metavir ¡“°°«à“À√◊Õ‡∑à“°—∫ 2) „π°√≥’∑’Ë‡ªìπ genotype 1, 4, 6 - ‡ªìπ‚√§µ—∫·¢Áß„π√–¬–‡√‘Ë¡µâπ À√◊Õ¡’ Child-Pugh score πâÕ¬°«à“À√◊Õ ‡∑à“°—∫ 10 - ¡’§«“¡‡¢â“„®·≈–æ√âÕ¡∑’Ë®–√—∫°“√√—°…“ - ‰¡à¡’¢âÕÀâ“¡¢Õß°“√√—°…“

¢âÕÀâ“¡¢Õß°“√√—°…“‚√§µ—∫Õ—°‡ ∫‡√◊ÈÕ√—ß®“°‰«√— ´’ ¡’¥—ßπ’È - Õ“¬ÿµË”°«à“ 2 ªï - ¡’ª√–«—µ‘·æâ¬“ Interferon ·≈– Ribavirin - ¿“«–´÷¡‡»√â“√ÿπ·√ß∑’Ë¬—ß§«∫§ÿ¡‰¡à ‰¥â - µ—Èß§√√¿å À√◊Õ‰¡à‡µÁ¡„®∑’Ë®–¬‘π¬Õ¡„π°“√§ÿ¡°”‡π‘¥ - ºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√ºà“µ—¥ª≈Ÿ°∂à“¬Õ«—¬«– (‰µ, À—«„® À√◊Õ ªÕ¥) - ¡’ ‚√§∑’ËÕ“®®–·¬à≈ß∂â“‰¥â√—∫ Interferon ‚¥¬‡©æ“– immune mediated diseases - ¡’ ‚√§ª√–®”µ—«∑’Ë¬—ß§«∫§ÿ¡√—°…“‰¡à ‰¥â¥’ ‡™àπ §«“¡¥—π‚≈À‘µ Ÿß ‡∫“À«“π ‚√§À≈Õ¥‡≈◊Õ¥ ∂ÿß≈¡‚ªÉßæÕß ‚√§∏—¬√Õ¬¥å

°“√√—°…“ºŸâªÉ«¬∑’Ëµ‘¥‡™◊ÈÕ‰«√— ´’ genotype 1 À√◊Õ 4, 6 11.

°“√√—°…“¥â«¬ Pegylated interferon ·≈– Ribavirin §«√«“ß·ºπ ”À√—∫ 48 —ª¥“Àå ‚¥¬¡’¢π“¥¬“¥—ßπ’È

Chronic Hepatitis B and C 2009

- Pegylated interferon alfa-2a 180 µg sc. µàÕ —ª¥“Àå √à«¡°—∫ Ribavirin „π¢π“¥ 1,000 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°πâÕ¬°«à“ 75 °‘‚≈°√—¡ 1,200 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°µ—Èß·µà 75 °‘‚≈°√—¡¢÷Èπ‰ª - Pegylated interferon alfa-2b 1.5 µg/kg sc. µàÕ —ª¥“Àå √à«¡°—∫ Ribavirin „π¢π“¥ 800 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°πâÕ¬°«à“ 65 °‘‚≈°√—¡ 1,000 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°µ—Èß·µà 65 ∂÷ß 85 °‘‚≈°√—¡ 1,200 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°¡“°°«à“ 85 ∂÷ß 105 °‘‚≈°√—¡ 1,400 ¡‘≈≈‘°√—¡ ”À√—∫ºŸâ∑’Ë¡’πÈ”Àπ—°¡“°°«à“ 105 °‘‚≈°√—¡

12.

§«√À¬ÿ¥„Àâ°“√√—°…“„π°√≥’∑º’Ë ªŸâ «É ¬‰¡à ‰¥â√∫— °“√µÕ∫ πÕß (no EVR) §◊Õ¡’ HCV RNA ≈¥≈ßπâÕ¬°«à“ 2 log ∑’Ë —ª¥“Àå∑’Ë 12

13.

ºŸâªÉ«¬∑’Ë ‰¥â partial EVR ( HCV RNA ≈¥≈ß¡“°°«à“ 2 log ·µà¬—ßµ√«®æ∫ HCV RNA ∑’Ë 12 —ª¥“Àå) §«√∑”°“√∑¥ Õ∫„À¡à„π —ª¥“Àå∑’Ë 24 ·≈–∂â“ HCV RNA ¬—ß§ß‡ªìπ∫«° §«√À¬ÿ¥°“√√—°…“

14.

ºŸâªÉ«¬∑’Ë ‰¥â partial EVR ·≈–µ√«®‰¡àæ∫ HCV RNA (À√◊Õ HCV RNA <50 IU/ ml) ∑’Ë 24 —ª¥“Àå Õ“®æ‘®“√≥“¢¬“¬‡«≈“°“√√—°…“ÕÕ°‡ªìπ 72 —ª¥“Àå

15.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë¡’ HCV RNA πâÕ¬°«à“ 400,000 IU/ml °àÕπ °“√√—°…“ ·≈–¡’ HCV RNA πâÕ¬°«à“ 50 IU/ml ∑’Ë 4 —ª¥“ÀåÀ≈—ß°“√√—°…“ “¡“√∂æ‘®“√≥“„Àâ°“√√—°…“ 24 —ª¥“Àå ∂â“ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß¡’º≈ ¢â“ß‡§’¬ß¡“° ∑ÿππâÕ¬ ·≈–‰¡à¡¿’ “«–∑’ÕË “®≈¥ª√– ‘∑∏‘¿“æ¢Õß°“√À“¬ ‡™àπ µ—∫ ·¢Áß Õâ«π ¿“«–¥◊ÈÕÕ‘π´Ÿ≈‘π œ≈œ

16.

ºŸâªÉ«¬∑’Ë√—°…“µàÕ‡π◊ËÕß§√∫ 48-72 —ª¥“Àå §«√µ√«® HCV RNA ∑’Ë¡’§«“¡‰« Ÿß‡¡◊ËÕ ‘Èπ ÿ¥°“√√—°…“ ·≈–À“°º≈µ√«®‡ªìπ≈∫ §«√‰¥â√—∫°“√µ√«® HCV RNA ∑’Ë 24 —ª¥“ÀåÀ≈—ßÀ¬ÿ¥¬“‡æ◊ËÕª√–‡¡‘π SVR

Chronic Hepatitis B and C 2009

Diagram √ÿª¢âÕ 12-16 Genotype 1

°“√√—°…“ºŸâªÉ«¬∑’Ëµ‘¥‡™◊ÈÕ‰«√— ´’ genotype 2 À√◊Õ 3 17.

°“√√—°…“¥â«¬ Pegylated interferon ·≈– Ribavirin ‡ªìπ‡«≈“ 24 —ª¥“Àå ‚¥¬ °“√„Àâ Ribavirin „π¢π“¥¬“ 800-1400 ¡‘≈≈‘°√—¡µàÕ«—π (µ“¡πÈ”Àπ—°)

18.

À≈—ß®“°°“√√—°…“§√∫ 24 —ª¥“Àå·≈â« §«√µ√«® HCV RNA ∑’Ë¡’§«“¡‰« Ÿß ‡¡◊ËÕ ‘Èπ ÿ¥°“√√—°…“ ·≈–∑’Ë 24 —ª¥“ÀåÀ≈—ßÀ¬ÿ¥¬“‡æ◊ËÕª√–‡¡‘π SVR 18.1 ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß Genotype 2, 3 ∑’Ë¡’ HCV RNA πâÕ¬°«à“ 400,000 IU/ml °àÕπ°“√√—°…“ ·≈–¡’ HCV RNA πâÕ¬°«à“ 50 IU/ml À≈—ß√—°…“‰¥â 4 —ª¥“Àå Õ“®æ‘®“√≥“À¬ÿ¥°“√√—°…“∑’Ë 14-16 —ª¥“Àå ∂â“ ºŸâªÉ«¬¡’º≈¢â“ß‡§’¬ß¡“° ∑ÿππâÕ¬ ·≈–‰¡à¡’¿“«–∑’ËÕ“®≈¥ª√– ‘∑∏‘¿“æ ¢Õß°“√À“¬ ‡™àπ µ—∫·¢Áß Õâ«π 18.2 ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß Genotype 2, 3 ∑’Ë ‰¡à ‰¥â RVR À≈—ß√—°…“ ‰¥â 4 —ª¥“Àå Õ“®æ‘®“√≥“¬◊¥√–¬–‡«≈“°“√√—°…“‡ªìπ 48 —ª¥“Àå ‚¥¬ ‡©æ“–„π°√≥’∑’Ë‡ªìπ advanced fibrosis

Retreatment „πºŸâªÉ«¬∑’Ë ‰¡à¡’ SVR À≈—ß°“√√—°…“§√—Èß°àÕπ 19.

„π¢≥–π’¬È ß— ‰¡à·π–π”„Àâ°“√√—°…“„À¡à¥«â ¬ Pegylated interferon ·≈– Ribavirin „πºŸªâ «É ¬∑’Ë‰¡àµÕ∫ πÕßµàÕ°“√√—°…“¥â«¬ Pegylated interferon √à«¡°—∫ Ribavirin ·¡â«à“¡’°“√‡ª≈’Ë¬π™π‘¥¢Õß Pegylated interferon Chronic Hepatitis B and C 2009

20.

§«√æ‘®“√≥“√—°…“„À¡à¥â«¬ Pegylated interferon ·≈– Ribavirin „πºŸâªÉ«¬ nonresponders À√◊Õ relapsers ∑’Ë‡§¬√—°…“¥â«¬ Conventional interferon (± Ribavirin) À√◊Õ¥â«¬ Pegylated interferon monotherapy ‚¥¬‡©æ“– ºŸâªÉ«¬∑’Ë¡’ bridging fibrosis À√◊Õ cirrhosis

21.

‰¡à·π–π” maintenance therapy ¥â«¬ Pegylated interferon „π¢π“¥µË”„π ºŸâªÉ«¬∑’Ë ‰¡àµÕ∫ πÕßµàÕ°“√√—°…“¥â«¬ Pegylated interferon ·≈– Ribavirin

°“√√—°…“„πºŸâªÉ«¬∑’Ë¡’§à“ ALT ª°µ‘ 22.

„πºŸªâ «É ¬∑’¡Ë §’ “à ALT ª°µ‘ °“√µ—¥ ‘π„®‡√‘¡Ë ∑”°“√√—°…“§«√¢÷πÈ Õ¬Ÿ°à ∫— §«“¡√ÿπ·√ß ¢Õß‚√§µ—∫‚¥¬ª√–‡¡‘πæ¬“∏‘ ¿“æ¢Õßµ—∫‚¥¬°“√∑” liver biopsy §«√„Àâ°“√ √—°…“∂â“æ¬“∏‘ ¿“æµ—∫¡’ fibrosis = F2 À√◊Õ F1 ·µà¡’°“√Õ—°‡ ∫¢Õßµ—∫ª“π °≈“ßÀ√◊Õ√ÿπ·√ß °“√√—°…“ºŸªâ «É ¬∑’¡Ë √’ –¥—∫ ALT ª°µ‘ ‰¡à·µ°µà“ß®“°ºŸªâ «É ¬∑—«Ë ‰ª

°“√√—°…“„π‡¥Á° 23.

°“√«‘π‘®©—¬‚√§ ·≈– °“√µ√«®„π‡¥Á°§«√ªØ‘∫—µ‘‡À¡◊Õπ°—∫ºŸâ „À≠à

24.

‰¡à·π–π”°“√µ√«® anti-HCV „π‡¥Á°·√°‡°‘¥∑’·Ë ¡à¡‡’ ™◊ÕÈ ‰«√— µ—∫Õ—°‡ ∫´’ ‡π◊ÕË ß®“° antibody ∑’Ë¡’§à“∫«° Õ“®‡°‘¥®“° anti-HCV ®“°·¡àºà“π¡“¬—ß≈Ÿ° ·π–π”„Àâ µ√«® anti-HCV ‡¡◊ËÕ‡¥Á°¡’Õ“¬ÿ 18 ‡¥◊Õπ¢÷Èπ‰ª

25.

‡¥Á°Õ“¬ÿ 2-17 ªï ∑’Ëµ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’ Õ“®æ‘®“√≥“„Àâ°“√√—°…“‚¥¬„™â ‡°≥±å‡¥’¬«°—∫ºŸâ „À≠à

26.

ºŸâªÉ«¬‡¥Á°§«√‰¥â√—∫°“√√—°…“¥â«¬ Pegylated interferon alpha-2b 1.5 µg/kg À√◊Õ 60 µg/m2 µàÕ —ª¥“Àå √à«¡°—∫ Ribavirin 15 mg/kg ∑ÿ°«—π

°“√√—°…“„πºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ HIV √à«¡¥â«¬

27.

ºŸâªÉ«¬µ‘¥‡™◊ÈÕ HIV ∑ÿ°§π§«√‰¥â√—∫°“√∑¥ Õ∫ Anti-HCV

28.

µ√«® HCV RNA ‡æ◊ËÕ¬◊π¬—π°“√µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’„πºŸâªÉ«¬µ‘¥‡™◊ÈÕ HIV ∑’Ë¡’º≈ anti-HCV ‡ªìπ∫«°

Chronic Hepatitis B and C 2009

29.

§«√µ√«® HCV RNA „πºŸâªÉ«¬∑’Ë¡’¿“«°“√≥å∑”ß“π¢Õßµ—∫º‘¥ª°µ‘ À√◊Õ ß —¬ «à“®–µ‘¥‡™◊ÈÕ‰«√— ´’¥â«¬·¡â«à“ anti-HCV ®–‡ªìπ≈∫

30.

§«√∑”°“√√—°…“‰«√— µ—∫Õ—°‡ ∫´’ „πºŸâªÉ«¬µ‘¥‡™◊ÈÕ HIV √à«¡¥â«¬ ∂â“‚√§µ—∫¡’ ‚Õ°“ ≈ÿ°≈“¡ ‚¥¬æ‘®“√≥“®“°ª√–‚¬™πå·≈–º≈¢â“ß‡§’¬ß¢Õß°“√√—°…“√à«¡°—π ºŸâªÉ«¬∑’Ë ¡§«√æ‘®“√≥“„Àâ°“√√—°…“§«√¡’√–¥—∫ CD4 Õ¬à“ßπâÕ¬ 250 cell/mm3

31.

°“√‡√‘Ë¡µâπ√—°…“‰«√— µ—∫Õ—°‡ ∫´’„πºŸâªÉ«¬ HIV §«√„™â Pegylated interferon alfa √à«¡°—∫ Ribavirin ‡ªìπ‡«≈“ 48 —ª¥“Àå „πª√‘¡“≥¬“‡™àπ‡¥’¬«°—∫ºŸâªÉ«¬ HCV mono-infection „π∑ÿ° “¬æ—π∏ÿå

32.

∂â“‡ªìπ‰ª‰¥âºŸâªÉ«¬§«√‡ª≈’Ë¬π zidovudine (AZT) ·≈– didanosine (ddI) ‰ª „™â¬“ antiretroviral agent ¢π“πÕ◊Ëπ∑’ËÕÕ°ƒ∑∏‘Ï§≈â“¬°—π °àÕπ‡√‘Ë¡∑”°“√√—°…“ ¥â«¬ Ribavirin ‡æ√“– AZT ·≈– ddI ®–∑”„Àâ‡°‘¥¿“«–´’¥¡“°¢÷Èπ

33.

ºŸâªÉ«¬µ‘¥‡™◊ÈÕ HIV ∑’Ë‡ªìπ decompensated liver disease (CTP Class B or C) ‰¡à§«√√—°…“¥â«¬ Pegylated interferon alfa ·≈– Ribavirin

°“√√—°…“‰«√— µ—∫Õ—°‡ ∫´’ „πºŸâªÉ«¬∑’Ë¡’‚√§‰µ 34.

ºŸâªÉ«¬‚√§‰µ‡√◊ÈÕ√—ß∑’Ë√Õ√—∫°“√ª≈Ÿ°∂à“¬‰µ À√◊Õ√Õ√—∫°“√√—°…“ Replacement therapy §«√‰¥â√—∫°“√µ√«®À“‰«√— µ—∫Õ—°‡ ∫´’

35.

°“√µ—¥ ‘π„®‡®“–™‘Èπ‡π◊ÈÕµ—∫¡“µ√«®„πºŸâªÉ«¬‚√§‰µ§«√æ‘®“√≥“‡ªìπ√“¬Ê ¢÷Èπ Õ¬Ÿà °— ∫ §«“¡®”‡ªì π „π°“√√— ° …“·≈–§«√æ‘ ® “√≥“‡ªì π √“¬∫ÿ § §≈‚¥¬¢÷È π °— ∫ ·ºπ°“√√—°…“¢ÕßºŸâªÉ«¬

36.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß·≈–¡’¿“«–∑’Ë¡’°“√∑”ß“π¢Õß‰µ‡ ◊ËÕ¡≈ß‡≈Á°πâÕ¬ (GFR > 60 ml/min) “¡“√∂∑”°“√√—°…“‡À¡◊ÕπºŸâ∑’Ë¡’°“√∑”ß“π¢Õß‰µª°µ‘

37.

ºŸâ∑’Ëµ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë¡’¿“«–‰µ«“¬∑’Ë¬—ß‰¡à ‰¥â√—∫°“√√—°…“¥â«¬ hemodialysis “¡“√∂„Àâ°“√√—°…“‚¥¬°“√≈¥¢π“¥¬“¢Õß∑—Èß Pegylated interferon (alpha-2a, 135 µg/week; alpha-2b, 1 µg/kg/week) ·≈– Ribavirin (200-800 mg/day) ‚¥¬µ‘¥µ“¡º≈·∑√°´âÕπÕ¬à“ß„°≈â™‘¥

Chronic Hepatitis B and C 2009

38.

°“√√—°…“ºŸâ∑’Ëµ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’∑’Ë ‰¥â√—∫°“√√—°…“¥â«¬ hemodialysis Õ“® √—°…“¥â«¬ interferon-alpha (2a À√◊Õ 2b) ª√‘¡“≥¬“ 3 MU t.i.w. À√◊Õ ≈¥ ¢π“¥¬“ Pegylated interferon-2a 135 µg/week or 2b 1 µg/kg/week ‡æ’¬ß¢π“π‡¥’¬« Õ“®æ‘®“√≥“„Àâ Ribavirin ·µàµâÕß„™â „π¢π“¥∑’ËµË”¡“°·≈– µâÕßµ‘¥µ“¡Õ¬à“ß„°≈â™‘¥ ‡æ√“–®–‡°‘¥¿“«–´’¥·≈–º≈¢â“ß‡§’¬ß‰¥â¡“°

39.

‰¡à·π–π”„Àâ°“√√—°…“„πºŸªâ «É ¬∑’µË ¥‘ ‡™◊ÕÈ ‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÕÈ √—ßÀ≈—ß°“√ª≈Ÿ°∂à“¬‰µ ‡æ√“–Õ“®‡°‘¥ graft rejection À√◊Õ graft ∑”ß“πº‘¥ª°µ‘ ¬°‡«âπºŸâªÉ«¬∑’Ë‡°‘¥ fibrosing cholestatic hepatitis

40.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë¡’ cryoglobulinemia ·≈–¡’ mild to moderate proteinuria À√◊Õ‰µ‡ ◊ËÕ¡ “¡“√∂√—°…“¥â«¬ Interferon ¢π“¥¡“µ√∞“π À√◊Õ ≈¥¢π“¥ Pegylated interferon alfa ·≈– Ribavirin

41.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë¡’ cryoglobulinemia ·≈–¡’ proteinuria ¡“°√à«¡°—∫‰µ«“¬√«¥‡√Á« “¡“√∂√—°…“¥â«¬ rituximab, cyclophosphamide √à«¡°—∫ methylprednisolone À√◊Õ plasma exchange ·≈–µ“¡¥â«¬ interferon-based treatment

°“√√—°…“ºŸªâ «É ¬‰«√— ´’∑¡’Ë ’ compensated and decompensated cirrhosis

42.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’∑’Ë¡’µ—∫·¢Áß„π√–¬–‡√‘Ë¡µâπ (CTP class A), “¡“√∂ √—°…“¥â«¬ Pegylated interferon ·≈– Ribavirin ·µà®–µâÕßµ‘¥µ“¡Õ¬à“ß„°≈â ™‘¥ ‡æ◊ËÕ‡ΩÑ“√–«—ßº≈¢â“ß‡§’¬ß

43.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’∑’Ë¡’µ—∫·¢Áß¡“° (CTP ¡“°°«à“ 9) §«√‰¥â√—∫°“√æ‘®“√≥“ °“√ª≈Ÿ°∂à“¬µ—∫

44.

°“√√—°…“¥â«¬ Interferon Õ“®‡√‘Ë¡¥â«¬ª√‘¡“≥¬“µË” ”À√—∫ºŸâªÉ«¬∑’Ëµ—∫·¢Áß¡“° (CTP class B and C) À√◊ÕºŸâªÉ«¬∑’Ë√Õª≈Ÿ°∂à“¬µ—∫ ·µàµâÕß¥Ÿ·≈„°≈â™‘¥‚¥¬ ·æ∑¬åºŸâ‡™’Ë¬«™“≠

45.

Õ“®æ‘®“√≥“„™â Growth factor „π°“√√—°…“ anemia ·≈– leukopenia ‡æ◊ËÕ™à«¬≈¥¿“«–·∑√°´âÕπ¢Õß°“√√—°…“ ·≈–ªÑÕß°—π°“√≈¥¢π“¥¢Õß¬“

Chronic Hepatitis B and C 2009

°“√√—°…“ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’∑’Ë ‰¥â√—∫°“√ª≈Ÿ°∂à“¬Õ«—¬«– 46.

ºŸªâ «É ¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÕÈ √—ß À≈—ßª≈Ÿ°∂à“¬µ—∫ “¡“√∂„Àâ°“√√—°…“¥â«¬ Pegylated interferon ·≈– Ribavirin ∂â“¡’À≈—°∞“π«à“¡’æ¬“∏‘ ¿“æµ—∫∑’Ë√ÿπ·√ß

47.

Pegylated interferon alfa √à«¡°—∫ Ribavirin ‡ªìπ°“√√—°…“ºŸâªÉ«¬µ—∫Õ—°‡ ∫´’ À≈—ß°“√ª≈Ÿ°∂à“¬µ—∫ ‚¥¬§«√‰¥â√—∫°“√µ‘¥µ“¡Õ¬à“ß„°≈â™‘¥

48.

°“√√—°…“¥â«¬ Interferon ‰¡à§«√„™â „πºŸªâ «É ¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÕÈ √—ß∑’ªË ≈Ÿ°∂à“¬À—«„® ªÕ¥ ·≈– ‰µ ¬°‡«âπºŸâªÉ«¬∑’Ë‡°‘¥¿“«– fibrosing cholestatic hepatitis

50.

“¡“√∂√Õ‡«≈“‰¥â 8 ∂÷ß 12 —ª¥“Àå À≈—ß®“°¡’ acute hepatitis C ‡æ√“–Õ“® ¡’ºŸâªÉ«¬∫“ß√“¬À“¬‡Õß‰¥â

51.

°“√√—°…“¥â«¬ Interferon À√◊Õ Pegylated interferon ‡æ’¬ßÕ¬à“ß‡¥’¬«„Àâº≈ °“√√—°…“∑’Ë¥’ ‚¥¬‰¡àµâÕß„™â Ribavirin

52.

·π–π”„Àâ√—°…“‡ªìπ‡«≈“ 12 ∂÷ß 24 —ª¥“Àå Õ“®æ‘®“√≥“√—°…“ 24 —ª¥“Àå„π √“¬∑’Ëµ‘¥‡™◊ÈÕ genotype 1

53.

°“√æ‘®“√≥“„Àâ Ribavirin √à«¡¥â«¬ §«√æ‘®“√≥“‡ªìπ√“¬ Ê

“¡“√∂æ‘®“√≥“√—°…“‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’„πºŸâ∑’Ë¬—ß„™â¬“‡ æµ‘¥Õ¬Ÿà À√◊Õ ºŸâ∑’Ë ‰¥â √—∫°“√√—°…“¥â«¬ methadone maintenance program ∂â“ºŸâªÉ«¬‡µÁ¡„®∑’Ë®– √—°…“·≈–æ∫·æ∑¬åÕ¬à“ß„°≈â™‘¥ ·≈–¬◊π¬—π°“√§ÿ¡°”‡π‘¥

55.

ºŸâ ∑’Ë „ ™â ¬ “‡ æµ‘ ¥ §«√‰¥â √— ∫ °“√„Àâ §”ª√÷ ° …“·≈–ª√–‡¡‘ π ‚¥¬®‘ µ ·æ∑¬å ‡ æ◊Ë Õ ª√–°Õ∫°“√æ‘®“√≥“√—°…“‰«√— µ—∫Õ—°‡ ∫´’

Chronic Hepatitis B and C 2009

°“√√—°…“ºŸâªÉ«¬‰«√— ´’∑’Ë¡’ Psychiatric illnesses 56.

ºŸªâ «É ¬‰«√— µ—∫Õ—°‡ ∫´’ ·≈–¡’§«“¡º‘¥ª°µ‘∑“ß®‘µ„® “¡“√∂∑”°“√√—°…“‰¥â¥«â ¬ Pegylated interferon ·≈– Ribavirin ∂â“Õ“°“√§«“¡º‘¥ª°µ‘∑“ß®‘µ„® “¡“√∂ §«∫§ÿ¡‰¥â ·µà§«√‰¥â√—∫°“√ª√–‡¡‘π·≈–¥Ÿ·≈‚¥¬¡’®‘µ·æ∑¬å√à«¡¥â«¬

°“√¥Ÿ·≈·π–π” 57.

ºŸâ∑’Ë¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë ‰¡à¡’¿Ÿ¡‘µàÕ‰«√— µ—∫Õ—°‡ ∫‡Õ À√◊Õ ∫’ §«√„Àâ «—§´’π‡æ◊ËÕªÑÕß°—π°“√µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫ 2 ™π‘¥π’È

58.

ºŸâ∑’Ë¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß §«√ß¥°“√¥◊Ë¡·Õ≈°ÕŒÕ≈å

59.

ºŸâªÉ«¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÈÕ√—ß∑’Ë¡’ advanced fibrosis À√◊Õ cirrhosis ·¡â«à“‰¥â SVR ®“°°“√√—°…“·≈â« §«√‡ΩÑ“√–«—ß°“√‡°‘¥ HCC µàÕ‰ª

60.

¡’√“¬ß“π§«“¡ —¡æ—π∏å√–À«à“ß°“√≈ÿ°≈“¡¢Õß‚√§„πºŸªâ «É ¬‰«√— µ—∫Õ—°‡ ∫´’‡√◊ÕÈ √—ß ∑’Ë¡’¿“«–Õâ«π ¿“«–¥◊ÈÕ insulin À√◊Õ metabolic syndrome ·≈–°“√¥◊Ë¡ ÿ√“ ¥—ßπ—Èπ®÷ß§«√·π–π”ºŸâªÉ«¬„π°“√ªØ‘∫—µ‘µπ‡æ◊ËÕ≈¥¿“«–À√◊Õªí®®—¬¥—ß°≈à“«´÷Ëß Õ“®∑”„ÀâºŸâªÉ«¬µÕ∫ πÕßµàÕ°“√√—°…“¥’¢÷Èπ À√◊Õ ™à«¬™–≈Õ°“√≈ÿ°≈“¡¢Õß‚√§ „πºŸâªÉ«¬∑’Ë ‰¡àµÕ∫ πÕßµàÕ°“√√—°…“

‡Õ° “√Õâ“ßÕ‘ß

Asian Pacific Association for the Study of the Liver (APASL) Hepatitis C Working Party. Asian Pacific Association for the Study of the Liver consensus statements on the diagnosis, management and treatment of hepatitis C virus infection. Journal of Gastroenterology and Hepatology 2007; 22: 615-633.

Marc G. Ghany, Doris B. Strader, David L. Thomas, and Leonard B. Seeff. AASLD PRACTICE GUIDELINES Diagnosis, Management, and Treatment of Hepatitis C: An Update. Hepatology 2009; 49: 1335-1374.

Chronic Hepatitis B and C 2009