MedCompanion

Chronic Hepatitis B

Hepatitis / Viral

Source: IDMP View on spectrum chart →
Patient + scenario modifiers
Patient
Clinical scenario / source

Annotations only — chart still shows the full chemistry of each drug.

1. Clinical Syndrome

Chronic hepatitis B = HBsAg positive ≥6 months. Spectrum: immune-tolerant, HBeAg+ chronic hepatitis, inactive carrier (HBeAg−, low DNA, normal ALT), HBeAg− chronic hepatitis (precore mutant), reactivation, occult HBV (HBsAg− anti-HBc+ low-level DNA). Long-term sequelae: cirrhosis, hepatocellular carcinoma (HCC), liver failure.

Excludes: acute HBV (separate workflow — most adults clear spontaneously; treat severe / fulminant), HBV/HDV co-infection (add anti-HDV testing + bulevirtide in EU), perinatal HBV management (PEP for newborn of HBsAg+ mother).

2. Pathogens

Consider the patient: Phase (immune-tolerant, HBeAg+ active, inactive carrier, HBeAg− active, reactivation), comorbid HCV / HIV / HDV, immunosuppression risk (chemo, biologics, transplant), pregnancy, family history of HCC, alcohol/NASH co-factors.

Consider the case: Treatment eligibility per AASLD (ALT, HBV DNA, fibrosis, immunosuppression), HCC screening (q6mo US ± AFP in cirrhotic + high-risk non-cirrhotic), reactivation prophylaxis (chemo, rituximab, BMT, anti-TNF, high-dose steroids).

Common

    • Hepatitis B Virus

      Sole cause. cccDNA persistence drives chronic infection + reactivation potential.

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • 25 mg · PO daily · PO · Indefinite (until HBsAg loss + 12 months consolidation, rare)
  • 0.5 mg (1 mg if lamivudine-experienced) · PO daily on empty stomach · PO · Indefinite

    Equivalent first-line option. Empty stomach + 2 h before/after meal.

Indefinite for most chronic HBV — endpoint is HBsAg loss (rare, ~3–5% per year) + 12 months consolidation. Inactive carriers + reactivation prophylaxis cases may stop earlier under specialist guidance.**Workhorse therapy.** TAF + entecavir both first-line with high resistance barriers. **Reactivation prophylaxis** in immunosuppression (chemo, biologics, rituximab, BMT, anti-TNF, transplant): start before / at immunosuppression, continue 6–12 months after stopping. **HCC screening q6mo** with US ± AFP for cirrhotic + high-risk non-cirrhotic (Asian men >40, Asian women >50, African >20, family history).

4. Directed Therapy

Initiate treatment per AASLD 2018 if:

  • HBeAg+ chronic hepatitis: ALT >2× ULN + HBV DNA >20,000 (consider treating even at lower ALT if persistent + biopsy/FibroScan shows fibrosis stage 2+)
  • HBeAg− chronic hepatitis: ALT >2× ULN + HBV DNA >2000
  • Cirrhosis (any HBV DNA detectable): always treat — TAF or ETV
  • Decompensated cirrhosis: treat regardless of DNA — TAF preferred over ETV (avoid lactic acidosis class warning more relevant with ETV)
  • Reactivation prophylaxis in immunosuppression
  • Pregnancy with HBV DNA >200,000 at 28–32 weeks
  • HCV co-infection start (HBV reactivation can occur during HCV DAA tx)

Duration: indefinite for most; specialist guidance for HBeAg seroconversion + sustained DNA suppression → potential treatment cessation in select inactive carriers.

HCC screening: q6mo US ± AFP for cirrhosis + high-risk non-cirrhotic (Asian men >40, Asian women >50, Black/African >20, family history of HCC, persistently high ALT + viral load).

HBV/HIV co-infection: ART must include HBV-active drugs (TDF or TAF as backbone); don't treat HBV alone without HIV-active regimen (selects HIV resistance).

HBV/HDV co-infection: peginterferon historically; bulevirtide (EU-approved, FDA pending) newer.

5. Monitoring

On treatment: HBV DNA + ALT q3–6 months; HBeAg status q6–12 months; HBsAg annually (rare loss is endpoint). Bone density + renal function periodically (TAF advantage).

Off treatment / inactive carrier: ALT + HBV DNA q6–12 months for reactivation.

HCC screening: US ± AFP q6mo for cirrhotic + high-risk groups.

Toxicity: TAF — lipid panel, weight; ETV — generally well tolerated; renal function for both.

Pearls

Treat indefinitely for most chronic HBV — endpoint of HBsAg loss is rare. TAF + entecavir are first-line; both have high resistance barriers. Reactivation in immunosuppression is critical to prevent — screen everyone going on chemo, biologics, rituximab. HBV/HCV co-infection: cure HCV first but monitor for HBV reactivation. Pregnancy: TAF at 28–32 weeks if VL >200K + HBIG/vaccine for newborn = >99% transmission prevention. HBV vaccine is universal recommendation (birth dose + 2-dose Heplisav-B for adults). No alcohol + HCC screening q6mo in cirrhotic.

References