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Professor of Medicine
Director of Hepatology
Stanford University School of Medicine
Palo Alto, California
Paul K. Kwo, MD, has disclosed that he has received consulting fees from AbbVie, Conatus, Dova, EdiGene, Eisai, Ferring, Gilead Sciences, Quest, and Surrozen; has received funds for research support from Allergan, Assembly, Gilead Sciences, La Jolla, and HCV-TARGET Registries; and has ownership interest in Durect.
This ClinicalThought features 2 key questions asked by participants during an AASLD 2019 satellite symposium focused on the optimal management of patients with hepatitis B.
How long should patients with chronic hepatitis B be treated with nucleos(t)ide analogues?
Current guidance from the AASLD suggests that, for HBeAg-positive individuals, nucleos(t)ide analogue treatment should be continuous with ongoing HBeAg monitoring.
In the case of documented seroconversion (clearance of HBeAg and production of anti-HBe), the guidance suggests that therapy should be consolidated for at least 1 year before discontinuation. Data show that the durability of HBeAg seroconversion in these patients can be improved with longer duration of therapy; a consolidation period of up to 3 years is associated with lower rates of relapse than 1 year of consolidation, although the precise optimal duration of consolidation is not known. Therefore, an alternative approach in patients who have cleared HBeAg is to continue therapy until HBsAg loss.
For HBeAg-negative individuals, indefinite therapy is currently the recommended approach. Limited data exist regarding discontinuation of therapy in those who are HBeAg negative, and thus, this approach should be limited to centers with specialized expertise in hepatitis B.
What factors would lead to treatment in a patient with immune-tolerant hepatitis B?
The most recent AASLD practice guidance for hepatitis B takes into account some of these gray areas where patients may have elevated HBV DNA levels with ALT levels that are not reaching 2 times the upper limit of normal.
In individuals who are 40 years of age or older or who have significant fibrosis or inflammatory activity, treatment should be initiated.
Because history of liver cancer is a major factor in considering treatment candidacy, regardless of ALT level, I routinely offer treatment to this subset of immune-tolerant individuals. In addition, in patients with immune-tolerant chronic hepatitis B who have a family history of hepatocellular carcinoma (HCC), my practice is to routinely screen these individuals for HCC with ultrasound and alpha-fetoprotein levels every 6 months.
I hope that in the future, we will have therapies that will lead to greater rates of HBsAg clearance. In the meantime, it is important to closely monitor your patients with hepatitis B and initiate therapy when required to prevent complications including cirrhosis or HCC.
What challenges do you encounter in managing patients with hepatitis B? Please answer the polling question on your screen and share your thoughts in the comments box below.