What is the management for a patient with detected Hepatitis B (HBV) core antibody?

Management of Detected Hepatitis B Core Antibody

Immediately order HBsAg, anti-HBs, and HBV DNA to determine whether the positive hepatitis B core antibody represents chronic infection, resolved infection with immunity, or occult hepatitis B. 1

Initial Diagnostic Workup

The presence of anti-HBc alone cannot distinguish between active, chronic, or resolved infection. 1 Complete the following tests immediately:

• HBsAg (hepatitis B surface antigen) - identifies active infection 1, 2
• Anti-HBs (hepatitis B surface antibody) - indicates immunity from vaccination or resolved infection 1, 2
• HBV DNA (quantitative) - detects viral replication, including occult infection 1, 2

Interpretation and Management Based on Results

If HBsAg Positive (Chronic HBV Infection)

Start antiviral therapy immediately with entecavir 0.5 mg daily, tenofovir disoproxil fumarate, or tenofovir alafenamide if HBV DNA ≥2,000 IU/mL and ALT is elevated. 1

• For patients with cirrhosis, treat immediately with any detectable HBV DNA regardless of ALT levels 1
• Coordinate care with a clinician experienced in HBV management for long-term monitoring 3
• Monitor ALT levels at least monthly for the first 3 months, then every 3 months 3
• Perform baseline ultrasound for HCC screening in all HBsAg-positive persons 20 years and older 3

If HBsAg Negative, Anti-HBc Positive, Anti-HBs Positive (Resolved Infection)

This indicates natural immunity from past infection. 3, 2 Management depends on immunosuppression risk:

• For patients NOT requiring immunosuppression: No antiviral therapy needed; routine monitoring not required 1
• For patients requiring high-risk immunosuppression (anti-CD20 antibodies like rituximab, stem cell transplantation): Start antiviral prophylaxis immediately with entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide 3, 1
• Continue prophylaxis during therapy and for minimum 12 months after completion (18 months for rituximab-based regimens) 3

If HBsAg Negative, Anti-HBc Positive, Anti-HBs Negative (Isolated Core Antibody)

This represents four possible scenarios: resolved infection with waning immunity (most common), false positive, occult chronic infection, or window period of acute infection. 3

Order quantitative HBV DNA immediately to rule out occult infection. 1, 2

• If HBV DNA is detectable: Treat as chronic HBV infection with antiviral therapy 1
• If HBV DNA is undetectable and patient requires high-risk immunosuppression: Start antiviral prophylaxis 3, 1
• If HBV DNA is undetectable and patient requires moderate-risk immunosuppression: Monitor HBsAg and ALT every 3 months during therapy and up to 6 months after; start preemptive antiviral therapy immediately if HBsAg or HBV DNA becomes positive 3
• If HBV DNA is undetectable and no immunosuppression planned: No treatment needed 1

Special Populations Requiring Immediate Prophylaxis

Regardless of HBsAg status, start prophylactic antiviral therapy immediately for anti-HBc positive patients receiving: 3, 1

• Anti-CD20 monoclonal antibodies (rituximab, ofatumumab, etc.)
• Stem cell transplantation
• High-dose corticosteroids (prednisone ≥20 mg/day for ≥4 weeks)
• Anthracyclines (doxorubicin, epirubicin)
• B cell-depleting agents

Preferred antiviral agents: Entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide (avoid lamivudine due to resistance). 3

Additional Essential Management Steps

Screen for Coinfections

• Anti-HCV (hepatitis C) 1
• Anti-HDV if history of injectable drug use 1
• Anti-HIV 1
• Anti-HAV; vaccinate against hepatitis A if negative (coinfection increases mortality 5.6-29 times) 1

Test and Vaccinate Contacts

Test all household and sexual contacts for HBsAg and anti-HBs; vaccinate seronegative contacts immediately. 1

Monitor Renal Function

For patients starting tenofovir or adefovir, assess creatinine clearance, serum phosphorus, urine glucose, and urine protein before initiation and periodically during therapy. 4, 5, 4 Dose adjustment required if creatinine clearance <50 mL/min. 5

Common Pitfalls to Avoid

• Do not delay cancer or immunosuppressive therapy while obtaining HBV testing 3
• Do not use lamivudine monotherapy due to high resistance rates; use entecavir or tenofovir 3
• Do not stop monitoring after immunosuppression ends; continue for at least 6-12 months as reactivation can occur late 3
• Do not assume isolated anti-HBc is always a false positive; occult infection occurs and requires HBV DNA testing 1, 2
• Do not forget to monitor for severe acute exacerbations if antiviral therapy is discontinued; monitor hepatic function closely for at least several months 4, 5, 4