Hepatitis%20b Management

Management

Monitoring

During Therapy

Monitor ALT, HBeAg, anti-HBe, and/or HBV DNA at least every 3-6 months; HBsAg every 6-12 months
Monitor renal function (eg creatinine, phosphate) if Tenofovir, Entecavir, or Adefovir is used
Monitor for adverse effects (ie CBC, TSH) if Interferons are used
Monitor blood phosphorus levels and renal function every 6-12 months if Tenofovir disoproxil fumarate is used
May perform enhanced CT scan and MRI for early detection of HCC, abdominal ultrasound and AFP every 6months for cirrhosis-free patients and every 3 month for patients with cirrhosis, during treatment with nucleos(t)ide analogue therapy

End of Therapy

Induction of long-term viral suppression is the main endpoint of treatment
Monitor ALT and HBV markers (including HBV DNA) to detect relapse every 3-6 months for the 1st year then every 6-12 months
- For patients with cirrhosis, may monitor monthly for the 1st 6 months then every 3 months
May monitor every 6 months in patients who responded to therapy
Further monitoring of HBV DNA every 3-6 months in non-responders is recommended to recognize delayed response and to plan retreatment if required
Monitor for hepatocellular carcinoma in high-risk patients every 6-12 months using ultrasound and alpha-fetoprotein; may perform enhanced CT scan and MRI for early detection

Viral Resistance

Testing for viral resistance may be done in patients who have undergone treatment, those with persistent viremia despite nucleos(t)ide analogue therapy, or those who had virological breakthrough (a 10-fold increase from nadir in serum HBV DNA during therapy after an initial virological response) while on therapy

Chronic Hepatitis B Patients who are Not Treated but Need Continuous Monitoring

Include patients age <30 years without cirrhosis, with persistently normal alanine transaminase (PNALT), HBV DNA >20,000 IU/mL, and HBeAg-negative patients age <30 years without cirrhosis, ALT levels intermittently abnormal, HBV DNA between 2000 and 20,000 IU/mL
Monitor ALT every 3 months for the 1st year, then every 6-12 months thereafter
- HBV DNA testing should be done if ALT and AST levels are elevated, and interval for ALT monitoring should be reduced

Prevention

Prevention and Post-exposure Prophylaxis of Hepatitis B

Patient Group for Whom Prevention or Post-exposure Prophylaxis is Recommended	Recommended Prevention or Post-exposure Prophylaxis Regimen
Prevention
Unvaccinated medically-stable infants, children, adolescents and adults Premature infants with immediate risk of HBV infection Unvaccinated persons who attend STD clinics, including pregnant women Persons with any of the following sexual risk factors: History of STD and HIV, multiple sex partners, sex with an injection drug user, sexual partner of HBsAg-positive individuals, MSM, victims of sexual assault Illegal IV drug users Household members, sex partners and drug-sharing partners of a person with chronic HBV infection¹ Residents or staff of facilities for developmentally disabled individuals Persons on hemodialysis, are receiving clotting factor concentrates, who have occupational exposure to blood, or are needing immunosuppressive therapy Healthcare personnel in treatment facilities Inmates of correctional facilities Patients with diabetes mellitus, HCV infection, chronic liver disease, HIV infection Travelers to places with endemic HBV infection (≥2% HBsAg prevalence) Individuals seeking protection from HBV infection	Hepatitis B Vaccine
Post-exposure Prophylaxis
Unvaccinated or nonimmune sex partners of persons with acute hepatitis B	Administer hepatitis B immune globulin (HBIg) and begin hepatitis B vaccination series (if not contraindicated) within 14 days after the most recent sexual contact For individuals or healthcare personnel with percutaneous or mucous membrane exposure² to blood or body fluids from patients with HBV, HBIg is recommended if unvaccinated, unresponsive to previous vaccination or with unknown response to immunization

¹Vaccination of household contacts (especially children and adolescents) of persons with acute HBV infection is also encouraged. Consider postvaccination testing (anti-HBs) for sex partners of persons with chronic HBV infection. Those found to be antibody negative should receive a second, complete, vaccination series.
²Skin and wound sites exposed to blood or body fluids with HBV infection should be washed with soap and water immediately following contact; exposed mucous membranes should be flushed with water

Revaccination is recommended for infants born to HBsAg-positive mothers, healthcare practitioners, hemodialysis patients and immunocompromised individuals when anti-HBs is <10 mIU/mL
Postvaccination serologic testing is recommended only for infants born to HBsAg-positive mothers, healthcare practitioners, hemodialysis patients, immunocompromised individuals (eg HIV-positive patients, stem-cell transplant recipients, cancer patients receiving chemotherapy), and sex partners of HBsAg-positive individuals

Prevention of Hepatitis D

Vaccination and safety measures against HBV infection are the best protection against HDV infection
- Immunization does not apply to patients already positive for HBV infection

Follow Up

Acute Hepatitis B

Monitor patient to ensure that fulminant liver failure does not develop
Monitor liver function tests (LFT) every 1-4 weeks until normal; ALT every 3-6 months if patient did not meet criteria for treatment
Repeat serologic testing 6 months after infection to rule out development of chronic hepatitis

HBeAg-positive Chronic HBV Infection (Immune-tolerant)

ALT every 3-6 months and HBeAg every 6-12 months
If ALT is 1-2x ULN, recheck ALT every 1-3 months and HBeAg every 6 months
If ALT is >2x ULN x 3-6 months, or has concerns for hepatic decompensation
- Consider treatment
If ALT is persistently elevated, age is >40 years and/or with family history of hepatocellular carcinoma
- Consider treatment if with moderate to severe inflammation or significant fibrosis on liver biopsy and/or noninvasive testing
Screen for hepatocellular carcinoma in relevant populations

HBeAg-negative Chronic HBV Infection (Inactive Carrier)

ALT every 3 months for 1 year; every 6-12 months if persistently normal
If ALT is 1-2x ULN,
- Check serum HBV DNA level and exclude other causes of liver disease
- Monitor ALT and HBV DNA levels every 3 months
If ALT is >2x ULN, consider treatment if HBV DNA >2000 IU/mL
If ALT remains elevated or HBV DNA is persistently ≥2000 IU/mL, consider treatment if with moderate to severe inflammation or significant fibrosis on liver biopsy and/or noninvasive testing
Screen for hepatocellular carcinoma in relevant populations

HBsAg-negative (Occult HBV Infection)

Check HBV DNA and LFT every 1-3 months until at least 12 months after the last cycle of immunosuppressive therapy if HBV DNA is not detectable in the serum

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