What is the management for a patient with positive Hepatitis B (HB) core antibody and Hepatitis B surface antigen?

Management of Positive Hepatitis B Core Antibody and Surface Antigen

Patients with positive hepatitis B surface antigen (HBsAg) and core antibody (anti-HBc) have chronic hepatitis B virus infection and require immediate antiviral therapy to prevent liver damage and viral reactivation. 1

Disease Classification and Assessment

• This serological profile (HBsAg+/anti-HBc+) indicates chronic hepatitis B infection requiring immediate evaluation 1
• Initial assessment should include:
  • HBV DNA viral load testing to determine replication level 2
  • Liver function tests (ALT, AST) to assess inflammation 2
  • HBeAg/anti-HBe status to determine disease phase 2
  • Assessment of liver fibrosis to determine disease severity 2

Treatment Algorithm

First-Line Antiviral Therapy

• Initiate oral antiviral therapy immediately with one of the following high-barrier-to-resistance agents:

  • Entecavir 0.5 mg once daily (1 mg daily if lamivudine-resistant or decompensated liver disease) 3, 1
  • Tenofovir (either disoproxil fumarate or alafenamide) 1, 2

• Avoid lamivudine due to high risk of resistance development 1, 2

Special Situations

• For patients requiring immunosuppressive therapy:

  • Antiviral prophylaxis is strongly recommended regardless of HBV DNA levels 1
  • Continue antiviral therapy throughout immunosuppression and for at least 12 months after completion 1
  • Higher risk with anti-CD20 therapies (e.g., rituximab) or stem cell transplantation 1

• For patients with cancer requiring chemotherapy:

  • Antiviral prophylaxis should be started before or simultaneously with chemotherapy 1
  • Continue for at least 12 months after completing anticancer therapy 1

Treatment Monitoring

• Monitor HBV DNA levels every 3 months until undetectable, then every 6 months 2
• Check liver enzymes (ALT, AST) every 3-6 months 2
• Annual quantitative HBsAg testing to assess for potential HBsAg loss 2
• For patients on immunosuppression, more frequent monitoring may be needed 1

Duration of Therapy

• Long-term (often indefinite) treatment is typically required for chronic HBV infection 2, 3
• Discontinuation of therapy can lead to severe acute exacerbations of hepatitis B 3
• If treatment discontinuation is considered:
  • Monitor hepatic function closely with both clinical and laboratory follow-up for at least several months 3
  • Be prepared to reinitiate therapy if signs of reactivation occur 3

Important Caveats

• HIV testing should be performed before starting HBV treatment, as entecavir is not recommended for HIV/HBV co-infected patients who are not receiving HAART 3
• Renal function should be monitored and dosage adjustments made for patients with creatinine clearance <50 mL/min 3
• Lactic acidosis and severe hepatomegaly with steatosis have been reported with nucleoside analogs; suspend treatment if these are suspected 3
• Fatal reactivation of HBV has been reported in patients who were HBsAg-positive and received chemotherapy without antiviral prophylaxis 4

By following this evidence-based approach, the risk of HBV-related complications including hepatic decompensation, cirrhosis, and hepatocellular carcinoma can be significantly reduced.