What is the management approach for a patient with a positive Hepatitis B (HB) core antibody total?

From the Guidelines

Management of a patient with a positive Hepatitis B core antibody total (anti-HBc) requires additional testing to determine their true infection status, and the initial step should be to test for Hepatitis B surface antigen (HBsAg) and Hepatitis B surface antibody (anti-HBs) to distinguish between active infection, resolved infection, or isolated core antibody positivity. According to the most recent and highest quality study 1, the patient's HBV status can be effectively determined by testing for HBsAg, anti-HBc, and anti-HBs. If HBsAg is positive, the patient has active HBV infection and should be evaluated for treatment with antivirals such as entecavir 0.5 mg daily or tenofovir 300 mg daily, particularly if there's evidence of liver inflammation or significant viral load. Some key points to consider in the management of these patients include:

• Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy for the duration of anticancer therapy, as well as for at least 12 months after receipt of the last anticancer therapy 1.
• Patients with past HBV receiving anticancer therapies associated with an established high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem-cell transplantation, should be started on antiviral prophylaxis at the beginning of anticancer therapy and continued on antiviral therapy for at least 12 months after the cessation of anticancer therapy 1.
• If both anti-HBs and anti-HBc are positive with negative HBsAg, this indicates resolved infection with natural immunity, requiring no treatment but periodic monitoring.
• In cases of isolated core antibody positivity (positive anti-HBc with negative HBsAg and anti-HBs), consider HBV DNA testing to rule out occult infection.
• These patients should be monitored, especially if immunosuppression is planned, as viral reactivation can occur.
• The positive anti-HBc result may also represent a false positive or resolved infection with waning immunity, so clinical context is important for interpretation. Regardless of the scenario, patients should be educated about preventing transmission and the importance of follow-up testing.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management Approach for a Patient with a Positive Hepatitis B (HB) Core Antibody Total

• The management approach for a patient with a positive HB core antibody total involves antiviral therapy and liver protection therapy, as seen in a case report where a 30-year-old female patient was treated with entecavir dispersive tablet and glycyrrhizate diamine enteric capsule, resulting in normal liver function and decreased hepatitis B virus-DNA levels 2.
• Serum hepatitis B core antibody (HBcAb) levels can predict HBeAg seroconversion in chronic hepatitis B patients with high viral load treated with nucleos(t)ide analogs, with a baseline HBcAb level >4.375 log10 IU/mL being a satisfactory predictor of HBeAg seroconversion 3.
• Baseline serum hepatitis B core antibody level can also predict HBeAg seroconversion in patients with HBeAg-positive chronic hepatitis B after antiviral treatment, with a higher baseline level of serum anti-HBc being an independent predictor of serological response 4.
• In HBeAg-negative patients with chronic hepatitis B, the association of hepatitis B core antibody level and hepatitis B surface antigen clearance has been studied, and it was found that anti-HBc level at week 12 was an independent predictor of HBsAg clearance and seroconversion 5.
• The American College of Physicians and the Centers for Disease Control and Prevention recommend vaccination, screening, and linkage to care for hepatitis B, including screening for HBV in high-risk persons and providing or referring all patients identified with HBV for posttest counseling and hepatitis B-directed care 6.

Key Considerations

• Antiviral therapy and liver protection therapy are essential components of the management approach for patients with a positive HB core antibody total.
• Serum HBcAb levels can be used to predict HBeAg seroconversion and HBsAg clearance in chronic hepatitis B patients.
• Baseline serum anti-HBc level is an independent predictor of serological response in patients with HBeAg-positive chronic hepatitis B after antiviral treatment.
• Screening for HBV and providing or referring patients for posttest counseling and hepatitis B-directed care are crucial for reducing the burden of chronic hepatitis B virus infection.