Hepatitis-B - Healthcare and Medical News for Atlanta Physicians

Hepatitis B is a blood-borne infection of the hepatocytes in the liver caused by the hepatitis B virus (HBV) which could lead to inflammation of the liver. Many patients with chronic hepatitis B (CHB) do not have any symptoms and thus don’t even know they have the condition. Over many years, chronic infection and inflammation can lead to severe scarring of liver – a condition known as cirrhosis, complications associated with hepatic decompensation, and even liver cancer. Hepatitis B is more common in certain ethnic populations and in those with high-risk behaviors or occupations. It is important for healthcare providers to be familiar with the condition and to offer timely and appropriate screening tests to those who may be at risk of having CHB.

Who Is At Risk for Hepatitis B?

Although anyone can get hepatitis B, these people are at greater risk:

Infants born to mothers with hepatitis B.
People born in certain countries where hepatitis B is common.
People born in the United States not vaccinated as infants whose parent were born in countries with high rates for hepatitis B.
People with hepatitis C.
People who have been incarcerated.
People who inject drugs or share needles, syringes, and other types of drug equipment.
Sex partners of people with hepatitis B.
People who have sexually transmitted infections.
People with HIV infection.
Men who have sex with men.
People who live with someone who has hepatitis B.
Health care and public safety workers exposed to blood on the job.
People on dialysis.

It is estimated that over 2 million individuals in the US and approximately 300 million people worldwide are living with CHB.

Initial Screening Tests for Hepatitis B

The presence of HBsAg establishes the diagnosis of hepatitis B. Chronic versus acute infection is defined by the presence of HBsAg for at least 6 months. HBcAb IgG (total) indicates previous infection with the hepatitis B virus whereas HBsAb indicates immunity, either from prior infection with spontaneous viral clearance, or from successful HBV vaccination.

Follow-up Tests for Patients With Positive HBsAg

Patients with positive HBsAg should then get HBV DNA PCR quantitation (i.e., the viral load), serum ALT level, HBeAg and HBeAb serology. These are factors used in determining whether patients should be treated with antiviral therapy or periodic monitoring.

Patients who are tested positive for CHB should also be tested for HIV, hepatitis A and C. Co-infection with hepatitis B and hepatitis C or HIV, or both increases risk of developing cirrhosis and the associated complications.

Management of Patients With CHB.

Not everyone who has hepatitis B needs to be on antiviral therapy. Patients with chronic in-active hepatitis B (immune-tolerant CHB) and without history of cirrhosis or hepatocellular carcinoma (HCC) do not need antiviral therapy. However, untreated chronic active hepatitis B (immune-active CHB) can lead to silent liver damage and even HCC. The primary goal in treatment of CHB is suppression of viral replication to minimize liver damage and to reduce risk of developing HCC.

Chronic active CHB (immune-active CHB) is defined as elevated ALT and detectable HBV DNA by PCR. Patients with positive HBeAg, HBV DNA PCR >20,000 IU/mL and ALT > 2x NL meets the criteria for starting on antiviral therapy. Patients with negative HBeAg (and usually are with positive HBeAb), HBV DNA PCR >2,000 IU/mL and ALT > 2x NL also meet criteria for antiviral therapy.

Personal history of advanced liver fibrosis or cirrhosis or HCC, family history of first degree relative with cirrhosis or HCC due to CHB, patient’s age (>40 years) and male sex, presence of Basal Core Promoter (BCP) mutation are other important factors that should be considered in determining whether patients should be on antiviral therapy.

It is important for patients with either immune-active or immune-inactive CHB to have a RUQ ultrasound, AFP level, and hepatic function panel test done every 6 months for surveillance of HCC and for routine monitoring of the liver function.

Antiviral Therapy for CHB

There are several preferred initial FDA-approved antiviral therapy for CHB: peg-interferon (peg-IFN), Entercavir, Tenofovir Diproxil Fumurate (TDF) and Tenofovir Alafenamide (TAF). These are first line therapy due to low risk of resistance, safety, and their efficacy.

There are also several other FDA-approved antiviral agents (Lamivudine, Adefovir, and Telbivudine). These agents have higher resistance rates and thus are non-preferred.

Treatment Considerations for Patients Undergoing Immunosuppressive and Cytotoxic Therapy

HBsAg and anti-HBc (total or immunoglobulin G) testing should be performed in all persons before initiation of any immunosuppressive, cytotoxic, or immunomodulatory therapy.
HBsAg-positive, anti-HBc–positive patients should initiate anti-HBV prophylaxis before immunosuppressive or cytotoxic therapy.
HBsAg-negative, anti-HBc–positive patients could be carefully monitored with ALT, HBV DNA, and HBsAg with the intent for on demand therapy, except for patients receiving anti-CD20 antibody therapy (e.g., rituximab) or undergoing stem cell transplantation, for whom anti-HBV prophylaxis is recommended.
When indicated, anti-HBV prophylaxis should be initiated as soon as possible before or, at the latest, simultaneously with the onset of immunosuppressive therapy. Once started, anti-HBV prophylaxis should continue during immunosuppressive therapy and for at least 6 months (or for at least 12 months for patients receiving anti-CD20 therapies) after completion of immunosuppressive therapy.
Anti-HBV drugs with a high resistance barrier (entecavir, TDF, or TAF) should be preferred over low-barrier agents.
For patients being monitored without prophylaxis, HBV-DNA levels should be obtained every 1-3 months. Patients should be monitored for up to 12 months after cessation of anti-HBV therapy.

Treatment Considerations for Women in Pregnancy and Postpartum

All pregnant women should be screened for HBsAg. Pregnant women with CHB should be encouraged to discuss with their obstetrician and/or pediatrician the prevention of mother-to-child transmission. Hepatitis B immune globulin (HBIG) and HBV vaccine should be administered to their newborn <12 hours after being born.
Antiviral therapy in the third trimester is recommended for pregnant women with serum HBV DNA > 200,000 IU/mL to minimize mother-to-child transmission during birth.
Current guidelines recommend that antiviral therapy given for prevention of mother-to-child transmission be discontinued at the time of delivery or up to 4 weeks postpartum.
TDF is the preferred choice owing to its antiviral potency and concerns for resistance with the other antiviral agents.

Treatment Considerations for Patients with co-infection with human immunodeficiency virus (HIV)

All patients with HBV and HIV coinfection should initiate ARVT, regardless of CD4 count. The ARVT regimen should include 2 drugs with activity against HBV. Specifically, the backbone of the ARVT regimen should be TDF or TAF plus lamivudine or emtricitabine.
Patients who are already receiving effective ARVT that does not include a drug with antiviral activity against HBV should have treatment changed to include TDF or TAF with emtricitabine or lamivudine. Alternatively, entecavir is reasonable if patients are receiving a fully suppressive ARVT.
When ARVT regimens are altered, drugs that are effective against HBV should not be discontinued without substituting another drug that has activity against HBV.

Treatment Considerations for Patients with co-infection with hepatitis C virus (HCV)

In HBV-HCV–coinfected patients, the viral activity responsible for liver disease can be determined by measuring HCV-RNA and HBV-DNA levels.
If HCV RNA is detectable, treatment of HCV should be undertaken.
If HBV DNA is detectable, treatment is determined by the HBV DNA and ALT levels, along with other factors as discussed in the prior section.
Importantly, it should be noted that treatment of one virus may lead to changes in the activity of the other virus, and thus monitoring during and after treatment is necessary to assess for viral activity.
In those HBV-HCV–coinfected patients with cirrhosis or those meeting recommended criteria for HBV treatment, HBV antiviral therapy should be started concurrently with HCV antiviral therapy.
There are no known interactions between HBV antivirals (entecavir, TDF, or TAF) and approved HCV direct-acting antiviral (DAA) therapy.

Vaccination

The best way to prevent hepatitis B is by getting vaccinated. The hepatitis B vaccine is safe and effective. Patients need to get all 3 shots in the series to be fully protected. Individuals who have high risk for hepatitis B should get vaccinated against HBV. Patients who have completed the series of vaccination should be checked for HBsAb (qualitative) to confirm immunity.

Patients with CHB should also be vaccinated against the hepatitis A virus (HAV).

References

Terrault NA, Lok AS, McMahon BJ, et al. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance. Hepatology, VOL. 67, NO. 4, 2018

Center for Disease Control and Prevention: https://www.cdc.gov/hepatitis/hbv/bfaq.htm. Assessed January 25, 2024.

Dr. Long B. Nguyen

Dr. Nguyen is a graduate of Syracuse University and holds a master’s degree from the Roswell Park Cancer Institute and graduate school of the University at Buffalo – SUNY. After receiving his degree from the Lake Erie College of Osteopathic Medicine in Pennsylvania, Dr. Nguyen completed his residency and fellowship at the University of Connecticut Health Center School of Medicine. Dr. Nguy-en joined Digestive Care Physicians in 2010 and currently serves as president of the Vietnamese American Healthcare Professionals Association of Georgia. He is Board Certified, Internal Medicine, Gastroenterology and works in the Johns Creek office.