Diagnosis

• Provide patient with information re stages of disease, prognosis, transmission, family planning, anti-viral treatment, risk of non adherence
• If HBsAG positive and pregnant refer for treatment in 3rd trimester

Investigation

• If HBsAg (surface antigen) positive) indicates either acute or chronic infection with HBV, then test:
  • HBeAg (e antigen): chronic infection marker and more infective
  • Anti-HBe (e Antibody):either recovered or infected
  • IgM to core antibody: acute infection marker
  • HBV-DNA level
  • Anti-HCV (Hep C antibody)
  • Anti-HIV (HIV antibody)
• LFTs to include: ALP, AST, GGT

Specialist Referral:

• Transient elastography (fibroscan), stiffer = disease
  • >11 kpa offer anti-virals
  • 6-10 kpa: offer biopsy
  • <6 kpa & AST <30 do not offer biopsy nor anti-viral as unlikely to have advanced disease
  • HBV > 20,000 off anti-viral irrespective of transient elastography
• Offer annual re-assessment
• Children / young adults use HBV DNA > 2000, AST > 30 to offer biopsy / anti-virals
• Monitoring:
  • Immune clearance phase (HBeAg positive): ALT every 24 weeks
  • Chronic in-active phase: ALT and HBV-DNA every 48 wks or more frequent if cirrhosis
• Test for hepato-cellular carcinoma (HCC): USS and alpha-Feto protein 6 monthly if severe fibrosis

Management

HBeAg positive treatment & Compensated Liver Disease

• First Line: 48 wk Peginterferon alfa-2a anti-viral
• Stop at 24 wks if DNA level not dropping and switch to second line
• If end point seroconversion of HBeAg to HBeAb not detected (active to carrier status) then:
• Second line: Tenofovir disoproxil or Entecavir
• Review adherence if still significant HBV-DNA > 48 wks

HBeAg positive treatment & Compensated Liver Disease

• As above, but HBeAg sero-conversion not relevant

Children with BC and Compensated Liver Disease

• 48 wk Peginterferon alfa-2a
• Stop at 24 wks if DNA level not dropping and switch to second line: nucleotide analogue

Adults with Decompensated Liver Disease

• First line: Entecavir
• Manage in conjunction with transplant centre

Pregnancy

• If HBV-DNA > 107 offer Tenofovir disoproxil in 3rd trimester to minimise transmission risk
• Continue to monitor post pregnancy for postnatal HBV flares

HCV Co-Infection

• Offer peginterferon alfa and ribavirin

Prophylaxis Treatment During Immunosuppressive Therapy

• If HBsAg and HBV-DNA > 2000 offer entecavir or tenofovir disoproxil

NICE Source: CG165 Hepatitis B (chronic): diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.