Treatment of chronic hepatitis B: virological and pharmacological aspects

Tenofovir is a nucleotidic analog inhibitor used in monotherapy as first line treatment of chronic Hepatitis B virus (HBV) infection. This drug requires a two-step phosphorylation by cellular kinases. The active triphosphate form inhibits viral DNA polymerase. Tenofovir has a very low oral bioavailability following oral administration. Hence, its oral administration requires the use of prodrugs: tenofovir disoproxil fumararate (TDF) or tenofovir alafenamide (TAF). TAF demonstrated a lower kidney and bone toxicity than TDF. TAF and TDF treatments allow prevention of chronic hepatitis B complications, which are cirrhosis and hepatocellular carcinoma. Prevention of these complications requires a virological response to the treatment, defined as undetectable HBV DNA. TDF and TAF are associated with virological response rates from 64 to 94 % after one year of treatment. This rate depends on HBV viral load at diagnostic, HBe antigen status, mutations in the HBV polymerase gene (Pol/RT) and patient compliance to the treatment. Tenofovir has a high genetic barrier and resistance mutations to this drug have not yet been described. However, mutations rt181T/V and/or rtN236T have been associated with reduced susceptibility to TDF/TAF in vitro and delayed response in vivo. Recently described mutations CYEI and rtA194T have been associated with reduced susceptibility to TDF/TAF in vitro without any change in viral response in vivo. Patient compliance can be improved using cognitive behavioral therapy, supporter interventions and use of short message service. Finally, some genetic polymorphisms in MRP(multidrug resistance-associated protein)-2 and MRP4 efflux transporters could be associated with TDF toxicity and virological response to TDF or TAF. In the perspective of functional HBV cure, TDF and TAF are likely to be still used, in association with new class of antivirals. For this reason, it is important to further characterize the pharmacological and virological factors associated with partial virological response to tenofovir.