Hepatitis B: The Basics : How is it treated?
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How is it treated?

People with acute hepatitis B do not require treatment. Getting bed rest, drinking lots of fluids and taking over-the-counter pain relievers (products containing ibuprofen, such as Motrin and Advil, are considered to be safer than products containing acetaminophen, such as Tylenol, in people with acute hepatitis) are usually all that is needed for someone who is experiencing acute hepatitis B symptoms.

Treatment is only recommended for people with chronic hepatitis B, notably those who—based on a person’s age, overall health and the results of the various tests described above—are expected to experience hepatitis B-related illness or death within the next 20 years and are expected to benefit from therapy. The goal of therapy is to prevent cirrhosis, liver failure and liver cancer by reducing HBV viral load and the loss of HBeAg (either with or without detection of anti-HBe) while improving liver enzyme levels.

Deciding when to start therapy, along with which treatments to take, depends on a number of important factors: HBeAg status, HBV viral load, ALT levels, liver biopsy results (if conducted) and a person’s readiness to take medications exactly as prescribed. The American Association for the Study of Liver Diseases (AASLD) maintains some basic guidelines—which were last updated in September 2009—to help patients and their health care providers figure out when to begin treatment and which medications to use:

HBeAg Status

HBV
Viral Load

ALT Level

Treatment Strategy

+

>20,000 IU/mL

< 2 x ULN*

Current treatment options are not likely to be effective

Observe; consider treatment when ALT becomes elevated

Consider biopsy if older than 40 years old, ALT persistently high but normal (e.g., 2 x ULN) or family history of liver cancer

Consider treatment if HBV viral load is >20,000 and biopsy shows moderate/severe inflammation or significant fibrosis

+

>20,000 IU/mL

>2 x ULN

If first visit, observe for 3-6 months—treat if HBeAg remains positive

Consider biopsy before treatment if “compensated” (few or no signs of serious liver disease)

Begin treatment immediately if “icteric” (jaundice) or “decompensated” (signs of serious liver disease)

Interferon-alfa (Roferon A, Intron A), pegylated interferon-alfa (Pegasys, Peg-Intron), lamivudine (Epivir-HBV), adefovir (Hepsera), entecavir (Baraclude), tenofovir (Viread) or telbivudine (Tyzeka) may be used as initial therapy

  • Interferon-alfa (injectable) should be used for 16 weeks
  • Pegylated interferon-alfa (injectable) should be used for 1 year
  • Lamivudine, adefovir, entecavir, tenofovir and telbivudine (oral pills) should be used daily for at least a year

If interferon-alfa isn’t working or you cannot take interferon-alfa, tenofovir plus telbivudine should be used

-

>20,000 IU/mL

>2 x ULN

Interferon-alfa (Roferon A, Intron A), pegylated interferon-alfa (Pegasys, Peg-Intron), lamivudine (Epivir-HBV), adefovir (Hepsera), entecavir (Baraclude), tenofovir (Viread) or telbivudine (Tyzeka) may be used as initial therapy

  • Interferon-alfa (injectable) should be used for 1 year
  • Pegylated interferon-alfa (injectable) should be used for 1 year
  • Lamivudine, adefovir, entecavir, tenofovir and telbivudine (oral pills) should be used for at least a year

Lamivudine and telbivudine not preferred due to high rate of drug resistance

Adefovir not preferred due to weak antiviral activity and high risk of drug resistance after first year

If interferon-alfa isn’t working or you cannot take interferon-alfa, tenofovir plus telbivudine should be used

-

>2,000 IU/mL

1->2 x ULN

Consider liver biopsy and treat if liver biopsy shows moderate/severe inflammation or significant fibrosis

-

< 2,000 IU/mL

< ULN

Observe, treat if HBV or viral load or ALT becomes higher

+/-

Detectable

Cirrhosis

If viral load is above 2,000 IU/mL, treat: Lamivudine (Epivir-HBV), adefovir (Hepsera), entecavir (Baraclude), tenofovir (Viread) or telbivudine (Tyzeka) may be used as initial therapy. Lamivudine and telbivudine not preferred due to high rate of drug resistance; adefovir not preferred due to weak antiviral activity and high risk of drug resistance after the first year.

If viral load is below 2,000, treat if ALT is elevated.

If liver is decompensated, treatment should be coordinated with liver transplant center (lamivudine or telbivudine plus adefovir, tenofovir or entecavir are preferred regimens). Should be referred for liver transplant.

+/-

Undetectable

Cirrhosis

Compensated liver disease: Observe

Decompensated liver disease: Refer for liver transplant

*ULN = upper limit of normal

A few additional words about hepatitis B treatment:

The long-term safety and efficacy of hepatitis B treatment is unknown. Most clinical trials of the available medications lasted one to five years.

  • In choosing which antiviral agent to use as the first-line therapy, consideration should be given to the safety and efficacy of treatment, risks of drug resistance, costs of the treatment (including the medications themselves, monitoring tests and clinic visits), as well as patient and provider preferences, and for women—when and whether they plan to start a family.
  • Although the efficacy of pegylated interferon-alfa is not substantially better than standard interferon, pegylated interferon boasts a more convenient dosing schedule (once weekly versus daily). In addition, patients using either form of interferon should be monitored closely while on treatment.
  • Combining two or more drugs has worked well for hepatitis B and HIV and is considered a logical approach to treating hepatitis B. However, none of the combination regimens tested to date have proved superior to single-agent treatment.

It is also very important that people with chronic hepatitis B take their medications exactly as prescribed. Missing doses can cause HBV to become resistant to HBV medications. Prematurely stopping HBV medications can also cause HBV viral load and liver enzymes to quickly increase, which can damage the liver and cause severe symptoms. This can also happen in people who have HBV that develops resistance to their medications. In turn, for people with chronic hepatitis B who are receiving treatment, it is very important to be monitored frequently and carefully by a health care provider.


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Last Revised: July 15, 2010

This content is written by the Hep editorial team.

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