Hepatitis%20b Treatment

Hepatitis D

• Aim of treatment is to eradicate or to achieve long-term suppression of both hepatitis D virus and hepatitis B virus
• Supportive care
• Consider hospitalization if there is vomiting, dehydration, signs of hepatic decompensation
• Screen for other sexually-transmitted diseases in cases of sexually-acquired hepatitis or if otherwise appropriate
• Consider expert referral

Acute Hepatitis B

• Main goal of treatment is to prevent the risk of acute or subacute hepatic failure
  
  • Other relevant goal of treatment is to improve the quality of life by shortening disease duration associated with symptoms as well as the risk of chronicity
• Supportive care
  • Treatment with antivirals is generally not recommended
• Consider hospitalization if there is vomiting, dehydration, signs of hepatic decompensation
  • Consider treatment with nucleoside or nucleotide analogues in severe acute hepatitis

Chronic Hepatitis B

• Vaccination against hepatitis B for non-immune patients
• Periodic screening for hepatocellular carcinoma in high-risk carriers
  
  • HCC may have a long asymptomatic stage lasting 2 years or longer
  • Carriers of HBV at high risk for developing HCC include Asian men >40 years, Asian women >50 years, patients with cirrhosis, coinfected with HCV, with HBV genotype C, with HDV infection, persistent HBV DNA >2000 IU/mL, or those with family history of HCC in 1st-degree relative
  • Screening methods are ultrasound with or without alpha-fetoprotein (AFP) determination every 6 months
• Liver biopsy
  • Purposes are to assess the degree of liver damage, to rule out other causes of liver disease and to help predict prognosis
  • Recommended for chronic hepatitis B patients who are candidates for antiviral therapy

Patients For Whom Treatment is Not Recommended

• Without clinical evidence of cirrhosis, with persistently normal alanine aminotransferase (PNALT), HBV DNA <2,000 IU/mL, regardless of HBeAg status or age

Patients For Whom Treatment is Recommended

• Evidence of compensated or decompensated cirrhosis regardless of HBeAg status or HBV DNA or ALT levels
• Without clinical evidence of cirrhosis but with persistently abnormal ALT, HBV DNA >20,000 IU/mL, regardless of HBeAg status
• Chronic HBV severe reactivation

Goals of Treatment

• Continued viral suppression is necessary to reduce or prevent hepatic disease and disease progression
• Primary goal of treatment is to permanently suppress HBV or to eliminate it
  
  • Short-term goals are to sustain suppression of HBV DNA, ALT normalization, to prevent decompensation and to decrease hepatic necroinflammation and fibrosis during and after therapy
  • Long-term goals of therapy are to avoid hepatic decompensation, reduce or prevent progression to cirrhosis and/or HCC and to prolong survival

• Endpoints used to assess response:
  
  • Biochemical response: Normalization of serum ALT
  • Virological response: HBV DNA <104 copies/mL and sustained seroconversion from HBeAg to anti-HBe
  • Histological response: Decrease in histology activity compared to pretreatment liver biopsy or a reduction of at least 1 point in fibrosis by Metavir staging
  • Complete response: Fulfill criteria of biochemical and virological response and loss of HBsAg

Considerations Prior to Initiation of Treatment

• Age of patient
• Severity of liver disease
• Likelihood of response
• Potential adverse events and complications
• HBeAg-positive patients with elevated ALT levels and compensated liver disease should be observed for 3-6 months for spontaneous seroconversion from HBeAg to anti-HBe prior to initiation of treatment
• Choice of therapy will depend on availability, cost of medication, necessary number of clinic visits, expected duration of treatment and patient/clinician preference

Other Considerations in Pharmacological Therapy

• There is no evidence that combination therapy of 2 direct antiviral agents results in better viral suppression compared to single agent
• Antiviral therapy does not remove the risk of hepatocellular carcinoma and thus hepatocellular carcinoma surveillance must continue 
• In treating concurrent infections such as hepatitis C virus, hepatitis D virus and HIV infection, it is important to identify the dominant virus as this will determine the therapeutic regimen
  
  • Concurrent hepatitis C infection may be treated with same antiviral therapy for HCV monoinfection