What is the recommended treatment for chronic hepatitis?

Treatment of Chronic Hepatitis B

For chronic hepatitis B, the recommended first-line treatments are entecavir or tenofovir due to their high potency and high genetic barrier to resistance. 1, 2

Patient Assessment and Treatment Indications

Treatment decisions should be based on several key factors:

• HBeAg status, HBV DNA levels, ALT levels, and liver disease severity 1
• For HBeAg-positive patients with ALT >2 times normal or moderate/severe hepatitis on biopsy, treatment is recommended 3
• For HBeAg-negative patients, treatment is indicated with HBV DNA ≥10^5 copies/mL and ALT ≥2 times normal or moderate/severe hepatitis on biopsy 3
• Patients with persistently normal or minimally elevated ALT (<2 times normal) should not be initiated on treatment unless liver biopsy shows significant inflammation 3

First-Line Treatment Options

Oral Antiviral Agents

• Entecavir or tenofovir are preferred first-line agents due to their high potency and low resistance rates 1, 4
• Lamivudine (100 mg daily for adults) can be used but has higher resistance rates 3
• Adefovir (10 mg daily) is an alternative option 3

Interferon-Based Therapy

• IFN-α (5 million units daily or 10 MU thrice weekly) for adults 3
• Treatment duration for HBeAg-positive: 16 weeks 3
• Treatment duration for HBeAg-negative: 12 months 3

Treatment Duration

• For HBeAg-positive chronic hepatitis B: minimum 1 year 3
• Continue treatment for 3-6 months after HBeAg seroconversion is confirmed 3
• For HBeAg-negative chronic hepatitis B: longer than 1 year, optimal duration not established 3

Special Populations

Cirrhotic Patients

• Compensated cirrhosis: Entecavir or tenofovir preferred; lamivudine or adefovir are alternatives 3, 1
• Decompensated cirrhosis: Lamivudine treatment; adefovir may be used as alternative with close monitoring of renal function 3
• IFN-α should not be used in patients with decompensated cirrhosis due to risk of hepatic decompensation 3

Children

• Children with elevated ALT >2 times normal for >6 months should be considered for treatment 3
• IFN-α dose: 6 MU/m² thrice weekly (maximum 10 MU) 3
• Lamivudine dose: 3 mg/kg/day (maximum 100 mg/day) 3

HIV Co-infection

• Lamivudine dose: 150 mg twice daily, along with other antiretroviral medications 3
• Tenofovir is preferred in HIV co-infection due to dual activity 5

Management of Treatment Failure

• For lamivudine resistance: Switch to adefovir, especially with worsening liver disease 3
• Patients who failed prior IFN-α therapy may be retreated with lamivudine or adefovir if they meet treatment criteria 3

Monitoring During Treatment

• Regular monitoring of HBV DNA levels, liver function tests, and renal function (especially with adefovir) 6
• Monitor for virologic breakthrough, which may indicate resistance development 6

Common Pitfalls and Caveats

• Severe acute exacerbations of hepatitis can occur when discontinuing anti-hepatitis B therapy; monitor hepatic function closely for several months after discontinuation 5
• Long-term nucleos(t)ide analogue therapy is typically required as cure rates (defined as HBsAg loss) remain low (1-12%) 2
• Adherence to medication is essential for adequate HBV DNA suppression 4
• Patients with inactive HBsAg carrier state (normal ALT, low HBV DNA) do not require antiviral treatment 3
• For patients with cirrhosis who achieve viral suppression, continued surveillance for hepatocellular carcinoma is still required 6