Management of Acute Hepatitis B with Elevated LFTs
Most patients with acute hepatitis B do not require antiviral therapy and should be monitored closely for spontaneous resolution, but immediate antiviral treatment with tenofovir or entecavir is mandatory if signs of liver failure develop. 1, 2
Initial Assessment and Risk Stratification
When evaluating acute hepatitis B with elevated AST/ALT, immediately assess for signs of impending liver failure 3, 1:
- Check for coagulopathy: INR >1.5-2.0 or prolonged prothrombin time 1, 3
- Evaluate for hepatic encephalopathy: Any grade of confusion or altered mental status 3
- Look for jaundice and ascites: Clinical signs of hepatic decompensation 3
- Monitor bilirubin levels: Progressive elevation indicates worsening 1
Confirm acute HBV infection with HBsAg positivity and IgM anti-HBc 1.
Treatment Decision Algorithm
For Uncomplicated Acute Hepatitis B (No Liver Failure)
Do not initiate antiviral therapy 1, 2. The vast majority of adults with acute HBV resolve spontaneously and develop long-lasting immunity 2.
Monitoring protocol 1:
- Liver function tests (AST, ALT, bilirubin, albumin) weekly initially
- Coagulation studies (INR/PT) weekly
- Clinical assessment for development of encephalopathy or ascites
For Acute Hepatitis B with Liver Failure
Initiate immediate antiviral therapy if any of the following are present 3:
- ALT ≥5-10 times ULN AND signs of liver failure (jaundice, INR prolongation, ascites, or hepatic encephalopathy) 3
- Progressive coagulopathy with INR >1.5 1
- Any grade of hepatic encephalopathy 3
First-Line Antiviral Therapy
- Tenofovir alafenamide (TAF) 25 mg daily - preferred due to high efficacy and safety 1
- Tenofovir disoproxil fumarate (TDF) - alternative formulation 4
- Entecavir 0.5 mg daily - equally effective option 3, 5
All should be administered on an empty stomach (2 hours after and 2 hours before meals) 5.
Critical Management Considerations
Timing of Antiviral Initiation
The key distinction in acute hepatitis B management is recognizing that treatment failure in severe cases is primarily due to delayed initiation 6. If liver failure is developing, start antivirals immediately without waiting for further deterioration 3, 6.
Liver Transplantation Evaluation
Simultaneously evaluate for emergent liver transplantation in patients with 3:
- High MELD score
- Moderate to severe ascites
- Progressive hepatic encephalopathy
Nucleos(t)ide analogs should be continued as prophylaxis to reduce post-transplant HBV recurrence 6.
Monitoring During Treatment
For patients requiring antiviral therapy 3, 4:
- Liver function tests every 1-3 months initially 3
- HBV DNA by PCR every 1-3 months until undetectable, then every 3-6 months 3, 4
- Monitor for treatment response and clinical improvement
Duration of Therapy
If antiviral therapy is initiated 5:
- Continue until HBsAg loss occurs with or without anti-HBs seroconversion 4
- Followed by at least 12 months of consolidation therapy 4
- The optimal duration is not definitively established 5
Post-Treatment Monitoring
After discontinuation of antiviral therapy (if initiated), monitor closely for at least several months 5:
- Severe acute exacerbations can occur after stopping anti-HBV therapy 5
- Check ALT, AST, and HBV DNA regularly 3
- Reinitiation of therapy may be warranted if exacerbation occurs 5
Common Pitfalls to Avoid
- Do not treat uncomplicated acute hepatitis B - approximately 99% of adults resolve spontaneously without antivirals 2
- Do not delay antiviral therapy when liver failure signs are present - this is the primary cause of treatment failure 6
- Do not use peginterferon-α in acute liver failure or decompensated disease - it is contraindicated due to risk of serious complications 3, 7
- Do not stop monitoring after apparent clinical improvement - late exacerbations can occur 5