Análise da assistência à saúde aos pacientes com hepatites virais B e C no estado do Amapá / Analysis of health care to patients with viral hepatitis B and C in the State of Amapá, Brazil

O Amapá é uma região hiperendêmica para hepatites virais B (HB) e C (HC), As Políticas Públicas de Saúde garantem o direito dos pacientes ao acesso universal e gratuito à assistência médica e ao tratamento das HB e HC, Neste sentido, o estudo avaliou a assistência à saúde oferecida aos pacientes com HB e HC, atendidos pelo SUS, no Amapá, Os dados foram coletados junto aos prontuários médicos e comparados com os Protocolos Clínicos e Diretrizes Terapêuticas para HB e HC e com a rede assistencial do SUS, Foram identificados e incluídos no estudo 123 pacientes atendidos no Centro de Referência em Doenças Tropicais, dos quais 43 e 85 pacientes apresentaram diagnóstico de HB e HC, respectivamente (cinco coinfectados com HB e HC), O acompanhamento clínico ambulatorial dos pacientes foi inferior a seis meses (período necessário para diagnóstico conclusivo de infecção crônica) para 53,7% dos pacientes devido ao abandono do tratamento, O exame de aminotransferases não foi solicitado à 37,4% dos pacientes e a biópsia hepática foi realizada por 84% dos pacientes com algum grau de severidade da doença, Dezessete pacientes receberam interferon-alfa peguilado como farmacoterapia inicial, mas a escolha inicial do esquema terapêutico mais potente não é recomendada pois não deixa opções para terapia de resgate em casos de resposta negativa à terapia inicial, A assistência à saúde dos pacientes com HB e HC no estado do Amapá apresenta deficiências, tais como o abandono do tratamento, inclusão e exclusão inadequada de pacientes nos protocolos de tratamento, além da dificuldade de acesso aos exames de diagnóstico e ao monitoramento da doença nos pacientes infectados...

Amapá, a Brazilian state, is a hyper endemic area for hepatitis B (HB) and C (HC). The Public Health Policies ensure the right of patients to free access to health care and treatment of HB and HC. Therefore, in this study it was evaluated the health care offered to patients with HB and HC attended by the Brazilian Unified Health System (SUS) in Amapá. The data were collected from the medical records and compared to the Therapeutic Guidelines and Clinical Protocols for HB and HC and to the healthcare network of the SUS. One hundred and twenty three patients treated at the Reference Center for Tropical Diseases were identified and included in the study, of which 43 and 85 patients were diagnosed with HB and HC, respectively (five co-infected with HB and HC). Clinical follow-up of patients was less than six months (period required for conclusive diagnosis of chronic infection) to 53.7% of patients due to treatment dropout. Examination of aminotransferases was not prompted to 37.4% of patients and liver biopsy was performed for 84% of patients with any degree of severity. Seventeen patients received pegylated alfainterferon as initial pharmacotherapy, however, the initial choice of the most potent regimen is not always indicated because it does not let options for a rescue therapy in case of a negative response to therapy. The healthcare provided to these patients in the Amapá state has deficiencies noted by the abandonment of treatment, diagnostic testing and unrealized monitoring and patients inadequately included or excluded from pharmacotherapy...

Rebrote virológico en el tratamiento de hepatitis B con entecavir: ¿resistencia? / Virological breakthrough in treating hepatitis B with entecavir: It means resistance?

Paciente varón de 45 años natural de Lima, casado con antecedentes de , múltiples parejas sexuales y operado de fimosis, que debuta con eritema nodoso y diagnosticado de hepatitis B crónica en Agosto del 2008, en controles por consultorio se realiza diagnóstico de cirrosis hepática child A y hepatocarcinoma. Inicia tratamiento para la hepatitis B con Entecavir 0,5mg y luego se realiza hepatectomía del segmento V, En Febrero 2009 en controles de imágenes se evidencia recidiva de hepatocarcinoma en el segmento VI (lesión de 14mm) con AFP de 68 ng/dl, se realiza etanolización, con evolución final favorable. Durante el seguimiento no se observa evidencia de recidiva de HCC, continua con Entecavir 0,5 mg /d y en abril 2010, luego de 72 semanas de tratamiento con adecuada adherencia al tratamiento presenta rebrote virológico (carga viral positiva de 646 UI/dl), y se decide agregar a la terapia Tenofovir. Actualmente paciente con buena evolución con última carga viral de Abril del 2012 negativa recibiendo terapia doble para VHB. Reportamos el caso por ser uno de los primeros en nuestro país de resistencia probable a Entecavir y donde se pone de manifiesto la necesidad de examenes complementarios que confirmen dicha sospecha.

A 45 year- old - married man, with several sexual partners, initiated symptoms with nodosum erythema and in August 2008, is diagnosed of chronic hepatitis due to hepatitis B virus (HBV). Later he was diagnosed of Child A cirrhosis and hepatocarcinoma. He began HBV treatment with Entecavir 0,5 mg; then he underwent a V segment hepatectomy. In February 2009 he presented a relapse with a tumor of 14 mm on VI segment with AFP values of 68 ng/dl, so he underwent an ethanolization with good evolution. During the follow up, he has not presented evidence of relapse of hepatocarcinoma and continued with Entecavir 0,5 mg/d. In April 2010, after 72 weeks of therapy with good compliance, the patient presented a virological breakthrough (viral load 646 UI/dl) and Tenofovir was added to his therapy. Nowadays the patient is receiving double therapy for HBV and his last viral load, April 2012, was negative. This could be the first case in our country of a probable resistance to Entecavir; complementary tests are needed in order to rule out this suspicion.