From the Guidelines
The initial appropriate action for a Hepatitis B surface antigen (HBsAg) positive patient with liver cirrhosis is to initiate antiviral therapy with tenofovir, as it is a preferred first-line option due to its high genetic barrier to resistance and favorable safety profile, as recommended by the EASL 2017 clinical practice guidelines on the management of hepatitis B virus infection 1.
The patient should undergo a comprehensive evaluation including HBV DNA viral load testing, liver function tests, complete blood count, and assessment of liver disease severity using scoring systems like Child-Pugh or MELD.
- Antiviral therapy with tenofovir should be initiated promptly to suppress viral replication, reduce inflammation, and prevent further liver damage.
- The patient should undergo screening for hepatocellular carcinoma with ultrasound every 6 months.
- Endoscopic evaluation for esophageal varices should be performed if not previously done.
- Vaccination against hepatitis A should be provided if the patient is not immune.
- Alcohol abstinence must be strongly encouraged, and medications metabolized by the liver should be used cautiously.
This comprehensive approach addresses both the viral infection and complications of cirrhosis, potentially slowing disease progression and improving long-term outcomes, as supported by the guidelines and studies 1.
From the FDA Drug Label
5.1 Severe Acute Exacerbation of Hepatitis B in Individuals with HBV Infection ... If appropriate, anti-hepatitis B therapy may be warranted, especially in individuals with advanced liver disease or cirrhosis, since posttreatment exacerbation of hepatitis may lead to hepatic decompensation and liver failure. The initial appropriate action for a Hepatitis B surface antigen (HBsAg) positive patient with liver cirrhosis is to consider anti-hepatitis B therapy, such as Tenofovir.
- Key consideration: Patients with advanced liver disease or cirrhosis are at risk of hepatic decompensation and liver failure if they discontinue anti-hepatitis B therapy. 2
From the Research
Initial Action for HBsAg Positive Patient with Liver Cirrhosis
- The initial appropriate action for a Hepatitis B surface antigen (HBsAg) positive patient with liver cirrhosis involves antiviral therapy to prevent the development of end-stage liver diseases 3.
- Tenofovir is a preferred antiviral agent for the treatment of chronic hepatitis B in patients with cirrhosis due to its high antiviral potency and high genetic barrier to resistance 3, 4.
- Long-term suppression of HBV can lead to regression of fibrosis and cirrhosis, as shown in a 5-year open-label follow-up study of tenofovir disoproxil fumarate treatment 4.
- Other treatment options, such as interferon-α, may be considered, but its use is contraindicated in patients with decompensated cirrhosis, and evidence for reduced hepatocellular carcinoma (HCC) is currently insufficient 3.
- The choice of initial action may depend on the patient's specific condition, such as the presence of decompensated cirrhosis, and the potential for resistance to certain antiviral agents 5, 6.
Comparison of Treatment Options
- Tenofovir alafenamide (TAF) is a more stable prodrug than tenofovir disoproxil fumarate (TDF), leading to decreased plasma exposure of tenofovir and reduced risk of long-term TDF toxicities, such as nephrotoxicity and decreased bone mineral density (BMD) 7.
- TAF has been shown to be noninferior to TDF at suppressing the HBV viral load in treatment-naive and treatment-experienced patients 7.
- Other antiviral agents, such as lamivudine and adefovir dipivoxil, may be considered, but their use may be limited by the development of resistance or nephrotoxicity 5, 6.