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Management of Hepatitis B Infection

Stefan Zeuzem, MD
Program Director
Harry L. A. Janssen, MD, PhD
Milan J. Sonneveld, MD, PhD, MSc
Released: June 17, 2019

Primary Care Essentials

HBV infection predominately affects individuals in sub-Saharan Africa, Southeast Asia, and South America, and primary care providers should screen for HBV in patients with exposure to these high-risk areas when applicable. Symptoms of acute HBV infection include influenza-like symptoms, gastrointestinal symptoms, and fatigue, and when these symptoms subside, darkening of urine, pale stool, and jaundice may be observed. Chronic HBV infection is often asymptomatic until advanced liver damage has occurred. In patients suspected of having HBV infection, primary care providers should look for the presence of HBsAg and IgM anti-HBc in serum,[3] as well as measure ALT levels. Patients who are HBsAg positive should be referred to a specialist for further evaluation.

Treatment is generally not indicated for acute HBV infection because > 95% of patients recover spontaneously,[5] and management is typically supportive, with close monitoring for identification of fulminant hepatitis with liver failure. HBeAg-positive patients with immune-tolerant disease should receive liver function tests every 3-6 months and HBeAg tests every 6-12 months. HBeAg-negative patients with inactive disease (HBV DNA < 2000 IU/mL and normal ALT levels) should be assessed every 3 months during the first year and biannually to annually thereafter; patients with low HBV DNA and HBsAg levels may be monitored less frequently.

HBsAg positivity for > 6 months suggests chronic HBV infection, and it is imperative that these patients see a specialist to receive treatment to reduce the risk of progression to liver disease or HCC. International guidelines from the AASLD,[3] APASL,[9] and EASL[4] recommend treatment for patients with chronic HBV infection based on HBeAg status, serum HBV DNA level, ALT level, and liver biopsy results (Table 1). AASLD and EASL guidelines recommend entecavir, tenofovir AF, or tenofovir DF as first-line nucleos(t)ide analogues because of the lower risk of resistance, but finite peginterferon alfa therapy may be a good option for a subset of patients (Table 3). APASL guidance on chronic HBV infection was last updated at the end of 2015, recommending either entecavir or tenofovir DF as preferred first-line nucleos(t)ide analogues.[9]

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