Hepatitis%20b Treatment
Principles of Therapy
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
- 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 first-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