From the Guidelines
Treatment for acute hepatitis B is generally supportive rather than antiviral, as most immunocompetent adults (95-99%) will clear the infection spontaneously without specific therapy, and only patients with severe acute hepatitis B, characterized by coagulopathy or protracted course, should be treated with nucleos(t)ide analogs (NA) and considered for liver transplantation. The primary goal of treatment in acute hepatitis B is to prevent the risk of acute or subacute liver failure, improve quality of life by shortening the disease-associated symptoms, and lower the risk of chronicity 1. Indications for antiviral treatment in acute hepatitis B include severe or fulminant hepatitis, characterized by coagulopathy (INR >1.5), encephalopathy, or severe jaundice with marked transaminase elevation. Treatment is also indicated in protracted severe acute hepatitis B (symptoms persisting beyond 4 weeks with high viral load), or in patients with risk factors for progression such as older age, immunosuppression, or underlying liver disease.
When treatment is indicated, entecavir 0.5mg daily or tenofovir disoproxil fumarate 300mg daily are preferred options, typically continued for 3-6 months after seroconversion (development of anti-HBs antibodies) or at least 6 months total duration 1. These antivirals work by inhibiting viral replication, potentially preventing progression to fulminant hepatitis and reducing the risk of acute liver failure. All patients with acute hepatitis B should receive close monitoring of liver function tests, coagulation parameters, and clinical status, with hospitalization considered for those with severe disease or complications. The management of acute liver failure and the indication for liver transplantation are discussed in detail in separate guidelines, and early NA treatment does not increase the risk of chronicity, and may even reduce rates of chronicity if initiated within 8 weeks of acute hepatitis B presentation in certain patient populations 1.
Some key points to consider in the treatment of acute hepatitis B include:
- The distinction between true severe acute hepatitis B and reactivation of chronic hepatitis B (CHB) may be difficult and may require liver biopsy 1
- NA treatment is the treatment of choice in both severe acute hepatitis B and reactivation of CHB 1
- The treatment goals in hepatitis B are to decrease the mortality rate and increase the survival rate by alleviating hepatic inflammation and preventing the development of fibrosis, which would ultimately reduce the frequency of progression of hepatitis to liver cirrhosis or hepatocellular carcinoma (HCC) 1
- The ultimate treatment goals in patients with HBeAg-positive hepatitis are normalization of the ALT level, undetectable HBV DNA level, and the clearance or seroconversion of HBsAg and HBeAg 1
From the Research
Acute Hepatitis B Indication for Treatment
- Acute hepatitis B is defined as the discrete onset of symptoms, the presence of jaundice or elevated serum alanine transaminase levels, and test results showing hepatitis B surface antigen and hepatitis B core antigen 2.
- There is no evidence that antiviral treatment is effective for acute hepatitis B 2, 3.
- The vast majority of patients with acute HBV resolve this infection spontaneously, and treatment with an oral anti-HBV agent is not necessary 3.
- However, the use of an oral anti-HBV agent is not unreasonable in a patient who is developing acute liver failure from severe acute HBV 3.
- Treatment is indicated in patients with severe acute hepatitis B, or healthcare workers with viraemia 4.
Treatment Options
- Pegylated interferon alfa-2a, entecavir, and tenofovir are recommended as first-line treatment options for chronic hepatitis B 2.
- Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) are effective antivirals recommended as first-line monotherapies for treatment of chronic hepatitis B (CHB) infection 5.
- TDF and ETV produce a similar treatment response and clinical outcome in patients with severe acute exacerbation of CHB 5.
Patient Selection
- The decision to start treatment should be based on careful patient selection and individualized decisions 4.
- Treatment is generally indicated in chronic hepatitis B patients with HBV DNA >2000 IU/mL, elevated ALT and/or at least moderate histological lesions, while all patients with cirrhosis and detectable HBV DNA should be treated 4.