EASL 2025 Hepatitis B Guidelines Have Been Published
You are correct—the EASL 2025 clinical practice guidelines for chronic hepatitis B virus infection were published on May 8,2025 1. These represent the most current evidence-based recommendations from the European Association for the Study of the Liver, superseding their 2017 guidelines.
Structure of the 2025 EASL Guidelines
The updated guidelines are organized into ten comprehensive thematic chapters 1:
- Diagnosis and classification of chronic HBV infection
- Treatment goals and endpoints
- Treatment indications based on disease phase and severity
- Treatment options including first-line and alternative therapies
- Hepatocellular carcinoma surveillance strategies
- Management of special populations (pregnancy, children, coinfections)
- HBV reactivation prevention in immunosuppressed patients
- Post-transplant care protocols
- HBV prevention strategies including vaccination
- Future research directions and unresolved clinical questions
Key Updates in Nomenclature
The 2025 guidelines introduce revised terminology for disease phases 2:
- The previously termed "immune-tolerant phase" is now designated as "Phase 1 or HBeAg-positive chronic HBV infection" 2
- This change reflects improved understanding that true immune tolerance may not exist, as this phase is characterized by high HBV DNA integration, clonal hepatocyte expansion, and preserved HBV-specific T cell function until young adulthood 2
Core Treatment Principles from Recent EASL Guidance
While awaiting full publication details of the 2025 guidelines, the most recent EASL recommendations (2017, referenced in the 2025 update) establish these principles 2:
Treatment Indications
All patients with cirrhosis and detectable HBV DNA should receive treatment, regardless of ALT levels 3, 4. For non-cirrhotic patients, treatment is indicated when 3, 4:
- HBV DNA >2,000 IU/mL AND
- Elevated ALT above ULN AND/OR
- At least moderate histological lesions (≥F2 fibrosis or ≥A3 inflammation)
First-Line Treatment Options
Nucleos(t)ide analogues with high genetic barrier to resistance are the treatment of choice 2:
TAF or entecavir should be considered in patients with or at risk for renal dysfunction or bone disease 3. TAF is not recommended in patients with creatinine clearance <15 mL/min or those on dialysis 3.
Monitoring Recommendations
Patients not on treatment require 2:
- ALT determinations at least every 3 months
- HBV DNA every 6-12 months
- Fibrosis assessment every 12 months
During treatment, monitor 2:
- Liver function tests every 3-6 months
- HBV DNA levels every 3-6 months
Treatment Response Definitions
Virological response during NA therapy is defined as undetectable HBV DNA by sensitive PCR assay 2. Sustained off-therapy virological response requires serum HBV DNA <2,000 IU/mL for at least 12 months after therapy ends 2.
Critical Clinical Pitfall
Do not rely solely on traditional laboratory ALT cutoffs to exclude necroinflammation and fibrosis 2. The updated ALT upper limits of normal are 29-33 U/L for males and 19-25 U/L for females, with recommended management thresholds of 35 U/L for males and 25 U/L for females 3. Normal ALT by conventional criteria does not exclude significant liver disease 2.
Special Populations
For pregnant women with HBV DNA >200,000 IU/mL, prophylactic tenofovir DF is recommended beginning at 24-32 weeks of pregnancy to prevent mother-to-child transmission 2.
For patients receiving immunosuppression or chemotherapy, prophylactic antiviral therapy is indicated to prevent HBV reactivation 4.
The full text of the 2025 EASL guidelines will provide additional granular recommendations across all ten thematic areas outlined above 1.