Hepatitis B Management and Treatment

Initial Evaluation and Diagnosis

The American Association for the Study of Liver Diseases recommends beginning with a three-test serological panel (HBsAg, anti-HBc, and anti-HBs) for all adults aged ≥18 years to determine infection status, immunity, and need for further evaluation 1
HBsAg is the primary marker for active infection, with positivity for >6 months defining chronic HBV infection 2
Anti-HBc indicates current or previous HBV exposure, while anti-HBs indicates recovery from infection or successful vaccination 2

Chronic HBV infection is characterized by HBsAg positive, anti-HBc positive, and anti-HBs negative 2
Past infection with immunity is indicated by HBsAg negative, anti-HBc positive, and anti-HBs positive 3, 2
Vaccine-induced immunity is characterized by HBsAg negative, anti-HBc negative, and anti-HBs positive 3, 2

Virological assessment, including HBV DNA quantification, is essential for assessing viral replication and disease activity 2
HBeAg and anti-HBe testing can indicate high or low viral replication 2
Liver function tests, such as ALT/AST, alkaline phosphatase, and GGT, assess liver inflammation and injury 2
Coinfection screening for hepatitis C, D, and HIV is necessary for patients with certain risk factors 2

Patients not on treatment require regular monitoring of ALT and HBV DNA every 3-6 months 4, 1
Patients on antiviral treatment require monitoring of liver function tests, HBV DNA, and HBsAg at regular intervals 5

Clear treatment indications include cirrhosis, high HBV DNA levels, and moderate to severe histological lesions 6, 4
Special populations requiring prophylaxis include those receiving anti-CD20 monoclonal antibody therapy, hematopoietic stem cell transplantation, and CAR-T cell therapy 7, 1

After stopping antiviral therapy, monitor ALT for hepatitis flares and consider long-term antiviral therapy for patients with cirrhosis or high-risk features 7

First-line agents with high genetic barrier to resistance include entecavir and tenofovir alafenamide (TAF) 5
Peginterferon alfa may be considered for finite-duration therapy in compensated disease, but is contraindicated in decompensated cirrhosis 6, 4