From the Guidelines
This patient has chronic hepatitis B infection, as evidenced by the presence of hepatitis B surface antigen (HBsAg) and IgG hepatitis B core antibody (HBcAb), along with the absence of hepatitis B surface antibody (HBsAb), and should be started on first-line antiviral therapy with entecavir 0.5 mg daily or tenofovir disoproxil fumarate 300 mg daily. The elevated liver enzymes (ALT 95 U/L, AST 65 U/L) and jaundice indicate active liver inflammation, which is a concern for morbidity, mortality, and quality of life 1.
Initial Evaluation and Management
The initial evaluation should include additional testing such as HBeAg, anti-HBe, HBV DNA quantification, complete blood count, liver function tests, and liver fibrosis assessment to determine the phase of chronic hepatitis B infection and the level of liver damage 1.
Treatment and Monitoring
Treatment is typically long-term, often lifelong, with regular monitoring of liver enzymes, HBV DNA levels, and renal function every 3-6 months 1. The patient should avoid alcohol, be vaccinated against hepatitis A if not immune, and family members should be screened for HBV and vaccinated if susceptible. Antiviral therapy works by suppressing viral replication, which reduces liver inflammation and decreases the risk of progression to cirrhosis, liver failure, and hepatocellular carcinoma.
Key Considerations
- The patient's serologic profile, including high levels of HBsAg and IgG HBcAb, but absence of HBsAb, is consistent with chronic hepatitis B infection 1.
- The presence of active liver inflammation, as indicated by elevated liver enzymes and jaundice, necessitates prompt initiation of antiviral therapy to reduce the risk of liver damage and complications 1.
- Regular monitoring and follow-up are crucial to adjust treatment as needed and prevent long-term complications 1.
From the Research
Patient Profile
- The patient is a 45-year-old man presenting with jaundice and elevated liver enzymes (alanine aminotransferase: 95 U/L, aspartate aminotransferase: 65 U/L)
- Hepatitis B serological profile shows high levels of HBsAg and IgG HBcAb, but HBsAb is absent, indicating chronic hepatitis B infection
Treatment Options
- According to 2, the goal of antiviral therapy in patients with chronic hepatitis B is to prevent cirrhosis and hepatocellular carcinoma through persistent suppression of HBV replication
- Seven drugs are available for treatment: IFN-alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine, and tenofovir
- Ideal candidates for treatment are hepatitis B e antigen-positive patients with a prolonged phase of immune clearance and hepatitis B e antigen-negative patients with elevated levels of serum HBV DNA, abnormal alanine aminotransferase, and histologic evidence of moderate or severe liver necroinflammation and/or fibrosis
Treatment Goals
- As stated in 3, the goal of new therapies should be to achieve a "functional cure" or an "apparent virological cure", which is defined as stable off-drug suppression of HBV viremia and antigenemia and normalization of ALTs and other laboratory tests
- According to 4, long-term viral suppression is associated with regression of liver fibrosis and reduced risk of hepatocellular carcinoma, and newer agents such as entecavir, tenofovir disoproxil, and tenofovir alafenamide may be associated with a significantly reduced risk of drug resistance
Current Recommendations
- As recommended in 5, moderate-quality evidence supports the effectiveness of antiviral therapy in patients with immune active chronic HBV infection in reducing the risk of cirrhosis, decompensated liver disease, and hepatocellular carcinoma
- Antiviral treatment with either pegylated interferon or a nucleos(t)ide analogue should be offered to patients with chronic HBV infection and liver inflammation, and nucleos(t)ide analogues should be considered as first-line therapy 4