From the Guidelines
Hepatitis B treatment should prioritize antiviral medications, with first-line options including entecavir (0.5-1mg daily) or tenofovir (either tenofovir disoproxil fumarate 300mg daily or tenofovir alafenamide 25mg daily), as these have been shown to effectively suppress viral replication and improve patient outcomes 1.
When considering treatment options for Hepatitis B, it's essential to differentiate between acute and chronic infections. For acute hepatitis B, treatment typically focuses on supportive care, as most adults clear the virus naturally. However, for chronic hepatitis B, antiviral medications are the primary treatment option. The goal of treatment is to prevent progression of liver disease, reduce the risk of hepatocellular carcinoma (HCC), and improve quality of life.
Key factors to consider when selecting a treatment include:
- Viral load: Patients with high viral loads (HBV DNA ≥ 2,000 IU/ml) are at increased risk of disease progression and should be prioritized for treatment 1.
- Liver enzyme levels: Elevated ALT levels indicate liver inflammation and damage, and should be monitored regularly during treatment.
- Liver damage assessment: Patients with moderate to severe liver fibrosis or cirrhosis require prompt treatment to prevent further disease progression.
- HBeAg status: Patients with HBeAg-positive chronic hepatitis B may require more aggressive treatment to achieve viral suppression.
Alternative medications, such as lamivudine, adefovir, and telbivudine, are less commonly used due to concerns about resistance development. Pegylated interferon alfa (180mcg weekly for 48 weeks) is another option, but its use is limited by its side effect profile and suitability for only certain patients.
Regular monitoring of liver function, viral load, and potential medication side effects is essential during treatment. This includes:
- Periodical assessments of serum ALT and HBV DNA levels
- Non-invasive markers of liver fibrosis severity
- Regular monitoring for signs of HCC development
By prioritizing antiviral medications and individualizing treatment based on patient-specific factors, healthcare providers can effectively manage chronic hepatitis B and improve patient outcomes. As noted in the EASL 2017 clinical practice guidelines, the long-term administration of a potent nucleos(t)ide analogue with high barrier to resistance, such as entecavir or tenofovir, represents the treatment of choice for most patients with chronic hepatitis B 1.
From the FDA Drug Label
Adefovir Dipivoxil Tablets are indicated for the treatment of chronic hepatitis B in patients 12 years of age and older with evidence of active viral replication and either evidence of persistent elevations in serum aminotransferases (ALT or AST) or histologically active disease
- Treatment Options: Adefovir Dipivoxil Tablets are a treatment option for chronic hepatitis B.
- Patient Population: The treatment is indicated for patients 12 years of age and older with evidence of active viral replication and either evidence of persistent elevations in serum aminotransferases (ALT or AST) or histologically active disease.
- Dosage: The recommended dose is 10 mg, once daily, taken orally, without regard to food 2.
- Key Considerations:
- Monitor hepatic function closely at repeated intervals for at least several months in patients who discontinue Adefovir Dipivoxil Tablets.
- Monitor renal function during therapy for all patients, particularly those with pre-existing or other risks for renal impairment.
- Offer HIV testing to all patients prior to initiating Adefovir Dipivoxil Tablets 2.
From the Research
Hepatitis B Treatment Options
- The goal of antiviral therapy in patients with chronic hepatitis B is to prevent cirrhosis and hepatocellular carcinoma through persistent suppression of HBV replication 3.
- Seven drugs are available for the treatment of chronic hepatitis B: IFN-alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine, and tenofovir 3.
- The choice of treatment should consider the clinical features of patients, antiviral efficacy, risk of resistance, long-term safety profile, method of administration, and cost of therapy 3.
Ideal Candidates for Treatment
- Ideal candidates for treatment are hepatitis B e antigen-positive patients with a prolonged phase of immune clearance and hepatitis B e antigen-negative patients with elevated levels of serum HBV DNA, abnormal alanine aminotransferase, and histologic evidence of moderate or severe liver necroinflammation and/or fibrosis 3.
- Patients with compensated or decompensated cirrhosis should be treated to prevent disease flare and improve liver function, even if alanine aminotransferase levels are normal and/or serum HBV DNA levels are low 3.
Treatment Recommendations
- Antiviral treatment should be initiated in patients with chronic hepatitis B who have a high risk of liver-related morbidity and are likely to respond to treatment 4.
- Treatment should be initiated with one of the recommended first-line therapies: pegylated interferon-α, entecavir, or tenofovir 4.
- Nucleos(t)ide analogues, such as entecavir and tenofovir, may be associated with a significantly reduced risk of drug resistance compared to older agents like lamivudine and adefovir 5.
Comparative Efficacy of Treatment Regimens
- A study comparing the efficacy of tenofovir, entecavir, and a combination of lamivudine and adefovir found that entecavir and tenofovir monotherapies were more effective in reducing HBV-DNA levels than the lamivudine and adefovir combination 6.
- Another study found that entecavir and tenofovir disoproxil fumarate achieved high virologic response rates and low rates of resistance development in 'real-life' settings 7.