HBeAg | HBV DNA (PCR) | ALT | Treatment strategy |
Patients without cirrhosis* | |||
+ | >20,000 international units/mL | ≤2 x ULN¶ | Treatment is not recommended, because current treatment has low efficacy in inducing HBeAg seroconversion. Treatment may be considered in older patients (>40 years) and in those with family history of HCC. |
Patients should be monitoredΔ and treatment considered if ALT becomes elevated >2 x ULN, liver biopsy shows moderate/severe inflammation or fibrosis◊ (eg, METAVIR score ≥F2), and/or noninvasive testing suggests moderate/severe fibrosis. | |||
+ | >20,000 international units/mL | >2 x ULN¶ | Observe for 3 to 6 months if compensated and treat if no spontaneous HBeAg loss. |
Immediate treatment if severe hepatitis flare (eg, icteric or clinical decompensation). | |||
ETV, TAF, TDF, or PegIFN alfa are preferred for initial therapy.§¥ | |||
End-point of treatment – Seroconversion from HBeAg to anti-HBe.‡ | |||
Duration of therapy: | |||
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– | >2000 international units/mL | >2 x ULN¶ OR 1 to 2 x ULN¶ if liver biopsy shows moderate/severe necroinflammation or significant fibrosis◊ (eg, METAVIR score ≥F2) or non-invasive testing shows significant fibrosis | ETV, TAF, TDF, or PegIFN alfa are preferred for initial therapy.§¥ |
End-point of treatment – HBsAg loss. | |||
Duration of therapy: | |||
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– | ≤2000 international units/mL | ≤ULN¶ | Monitor and treat if HBV DNA and ALT increase as described above. |
Patients with cirrhosis* | |||
+/– | Detectable | Any ALT | Compensated: |
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Decompensated: | |||
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+/– | Undetectable | Any ALT | Compensated: Observe, recheck HBV DNA during follow-up, evaluate for other causes of cirrhosis if HBV DNA remains undetectable. |
Decompensated: Refer for liver transplant, recheck HBV DNA during follow-up, evaluate for other causes of cirrhosis. |
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