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hepatitis%20b
HEPATITIS B
Treatment Guideline Chart

Hepatitis B is transmitted through perinatal, percutaneous, sexual, and close person-to-person contact, ie by open cuts and sores.

Human hepatitis B virus belongs to the family of Hepadnaviridae of small, enveloped, primarily hepatotropic DNA viruses. The virus replicates in the host and assembles exclusively in the hepatocytes and virions are released non-cytopathically through the cellular secretory pathway.

Chronic hepatitis B is defined as a chronic necroinflammatory liver disease due to persistent hepatitis B virus infection.

Hepatitis D infection is found only in patients with hepatitis B as it requires the hepatitis B outer coat. It is transmitted through sexual and percutaneous (especially IV drug use) routes.

Hepatitis B and D both have an incubation period of 30-180 days.

Hepatitis%20b 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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