From the Guidelines
Chronic hepatitis B should be monitored and not treated in patients who are in the immune tolerant or inactive carrier phases of the disease, specifically those with normal liver enzymes (ALT) and high viral loads (HBV DNA >1 million IU/mL) with HBeAg positivity, or those with normal ALT, low viral loads (HBV DNA <2000 IU/mL), and HBeAg negativity. These patients should receive regular monitoring every 3-6 months with liver function tests and HBV DNA levels, and annual assessment for hepatocellular carcinoma with ultrasound for those at higher risk (over 40 years, male gender, family history of liver cancer, or cirrhosis) 1. The rationale for observation rather than treatment is that these patients typically have minimal liver inflammation, low risk of disease progression, and treatment would offer little benefit while potentially exposing them to medication side effects and the development of viral resistance 1. Some key points to consider in the management of these patients include:
- HBeAg-positive patients under 30 years of age with persistently normal ALT levels and a high HBV DNA level, without any evidence of liver disease and without a family history of HCC or cirrhosis, do not require immediate liver biopsy or therapy, but should be followed up at least every 3–6 months 1.
- HBeAg-negative patients with persistently normal ALT levels and HBV DNA levels above 2000 but below 20,000 IU/ml, without any evidence of liver disease, do not require immediate liver biopsy or therapy, but should be followed up with ALT determinations every 3 months and HBV DNA every 6–12 months for at least 3 years 1.
- Patients with compensated cirrhosis and detectable HBV DNA must be considered for treatment even if ALT levels are normal 1. If laboratory values change, indicating transition to an immune active phase with elevated liver enzymes and evidence of liver inflammation, treatment should then be considered 1. It is also important to note that current antiviral medications suppress viral replication but rarely achieve complete cure, meaning many patients would require indefinite therapy if started unnecessarily 1. Overall, the management of chronic hepatitis B requires a careful consideration of the individual patient's risk factors, liver disease status, and treatment options, with the goal of improving survival and quality of life by preventing disease progression and HCC development 1.
From the Research
Monitoring of Chronic Hepatitis B (CHB)
CHB should be monitored and not treated in the following cases:
- Patients in the immune tolerance phase, with normal alanine aminotransferase (ALT) and HBV DNA levels 2
- Patients with HBeAg-positive chronic hepatitis B, with serum HBV DNA level < 10^5 copies/mL (20,000 IU/mL) and normal ALT level 2
- Patients with HBeAg-negative chronic hepatitis B, with serum HBV DNA level < 10^4 copies/mL (2,000 IU/mL) and normal ALT level 2
- Patients with persistent normal or mildly elevated ALT levels, without significant hepatic inflammation or fibrosis 3
Key Factors to Consider
When deciding whether to monitor or treat CHB, the following factors should be considered:
- HBV DNA levels: patients with high HBV DNA levels (> 10^5 copies/mL for HBeAg-positive and > 10^4 copies/mL for HBeAg-negative) should be considered for treatment 2, 4
- ALT levels: patients with elevated ALT levels should be considered for treatment 2, 4
- Presence of significant hepatic inflammation or fibrosis: patients with significant hepatic inflammation or fibrosis should be considered for treatment 2, 3
- HBV genotyping: HBV genotyping may be useful in predicting antiviral treatment response 5
Treatment Thresholds
The following treatment thresholds have been suggested: