From the Guidelines
The next step after a positive Hepatitis B (HBV) surface antigen result is to order a comprehensive panel of hepatitis B serologies and liver function tests, including hepatitis B e antigen (HBeAg), hepatitis B e antibody (anti-HBe), hepatitis B core antibody (anti-HBc), hepatitis B DNA viral load, ALT, AST, bilirubin, albumin, and prothrombin time, as recommended by the most recent guidelines 1. This approach is based on the latest evidence from the Journal of Clinical Oncology, which emphasizes the importance of thorough screening and management for patients with chronic HBV, especially those undergoing anticancer therapy.
Key Components of the Workup
- Hepatitis B serologies: HBeAg, anti-HBe, anti-HBc
- Liver function tests: ALT, AST, bilirubin, albumin, prothrombin time
- Hepatitis B DNA viral load
- Complete blood count and basic metabolic panel
- Liver fibrosis assessment through imaging (FibroScan or ultrasound) or non-invasive markers like FIB-4 or APRI scores ### Importance of Screening for Co-infections Screening for hepatitis A, C, D, and HIV co-infections is crucial, as they can complicate management and affect treatment decisions 2.
Counseling and Prevention
Patients should be counseled about preventing transmission to others through avoiding sharing personal items and using barrier protection during sexual contact. Family members and close contacts should be screened for hepatitis B and vaccinated if susceptible.
Referral to a Specialist
Referral to a hepatologist or infectious disease specialist is recommended for ongoing management, as treatment decisions depend on the phase of infection, viral load, liver function, and fibrosis stage 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps After a Positive Hepatitis B Surface Antigen Result
The next steps after a positive Hepatitis B (HBV) surface antigen result involve a combination of serological, virologic, biochemical, and histologic markers to diagnose chronic HBV infection 3.
- The diagnosis of chronic HBV infection is made using these markers, and the natural history of HBV infection can be divided into four phases: immune tolerance, immune clearance, inactive HBsAg carrier, and reactivation 3.
- Patients in the immune clearance and reactivation phases, with elevated alanine aminotransferase (ALT) and HBV DNA levels, are candidates for antiviral therapy 3.
- The primary goal of therapy for chronic hepatitis B is suppression of viral replication, which has been shown to reduce hepatic necroinflammation and retard progression of hepatic fibrosis 3.
Antiviral Therapy
Antiviral therapy for chronic hepatitis B includes interferon alfa, peginterferon alfa-2a, lamivudine, adefovir, entecavir, and telbivudine 3, 4.
- Tenofovir and entecavir are the most effective antiviral agents for chronic hepatitis B, according to a systematic review and Bayesian meta-analyses 5.
- The choice of antiviral agent and the duration of therapy depend on various factors, including the patient's HBeAg status, HBV DNA level, and ALT level 3, 4.
Monitoring and Follow-up
Patients undergoing antiviral therapy require monitoring every 3 to 6 months to ensure compliance and to test for the development of resistance if an oral agent is used 3.
- Frequent assessment of quantitative serum HBV DNA remains the best approach to early detection of resistance, and antiviral therapy should be modified as soon as resistance is detected 4.
- The presence of at least moderate necroinflammation and the presence of fibrosis on liver biopsy may be useful in supporting the decision to initiate therapy, particularly in patients with normal ALT levels 3.