Hepatitis B Management
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Direct answer
Tenofovir disoproxil fumarate, tenofovir alafenamide or entecavir — one of these three — is first-line for chronic hepatitis B, and the indication is set by the DNA–ALT–fibrosis triangle rather than by the viral load alone. Treat when HBV DNA exceeds 2000 IU/mL with ALT more than twice the upper limit of normal, or when at least moderate fibrosis (F2) or cirrhosis is present, and treat cirrhotics with any detectable DNA irrespective of ALT. HBeAg-positive patients who seroconvert can stop after a year of consolidation; HBeAg-negative disease usually demands indefinite therapy. Lamivudine survives only in resistance questions — resistance approaches 70 per cent by five years.
What you must remember
- Four phases: immune-tolerant (HBeAg-positive, DNA very high, normal ALT — do not treat), HBeAg-positive chronic hepatitis (treat), inactive carrier (HBeAg-negative, anti-HBe-positive, DNA below 2000 IU/mL, normal ALT — follow up), HBeAg-negative chronic hepatitis from precore mutants (fluctuating ALT — treat).
- Indication rule: DNA above 2000 IU/mL plus ALT over twice normal and/or significant fibrosis; elastography above 9 kPa points to significant fibrosis, above 12 kPa toward cirrhosis.
- Drug pearls: tenofovir alafenamide or entecavir when renal or bone risk exists; monitor creatinine and phosphate on tenofovir disoproxil fumarate; adefovir and lamivudine are rescue-history drugs, not choices.
- End points: undetectable DNA, ALT normalisation, then HBeAg seroconversion to anti-HBe; HBsAg loss is the rare ideal, the "functional cure".
- Perinatal prophylaxis: birth-dose vaccine within 24 hours plus HBIG 0.5 mL intramuscularly for infants of HBeAg-positive mothers, with maternal tenofovir from 28 weeks when HBV DNA exceeds 200,000 IU/mL.
- HCC surveillance: ultrasound with or without alpha-fetoprotein every six months for cirrhotics and for non-cirrhotics with a family history, or Asian men over 40 and women over 50.
- Reactivation: anti-CD20 agents such as rituximab demand prophylaxis in anyone anti-HBc-positive; detectable HBsAg plus any cytotoxic chemotherapy does too.
- Indian programme detail: the National Viral Hepatitis Control Programme, launched in 2018, provides free testing and tenofovir-based treatment — a favourite viva add-on.
How to decide who gets treated
Work through four clinic letters. A 26-year-old pregnant woman, HBeAg-positive, DNA 10 to the power 8 IU/mL, ALT normal: immune-tolerant — no antiviral, but start tenofovir at 28 weeks to protect the fetus. A 42-year-old man, HBeAg-positive, DNA 10 to the power 7, ALT 160 IU/L, elastography 7 kPa: a textbook indication — treat, monitor DNA and ALT at 12-week intervals, aim for seroconversion. A 58-year-old woman, HBeAg-negative, DNA 40,000 IU/mL, ALT oscillating between 80 and 110 IU/L: HBeAg-negative chronic hepatitis — treat, and counsel that this means years, not months. Finally a cirrhotic with DNA 900 IU/mL and normal ALT: treat regardless, because any replication in cirrhosis accelerates decompensation and hepatocellular carcinoma. Each decision turns on the phase, the fibrosis stage and the threshold together — never on one number.
Where students slip
Two errors recur. Candidates treat the immune-tolerant phase — especially young HBeAg-positive women — forgetting that decades of high DNA with normal ALT and minimal fibrosis carry little short-term risk, while therapy needlessly becomes lifelong. The opposite error is trusting a "normal ALT": in HBeAg-negative disease and in older patients, transaminases within the laboratory range can still hide advanced fibrosis, which is why elastography belongs in every work-up. A remembered sequence helps — phase first, fibrosis second, threshold third.
Frequently asked questions
Which patients with chronic hepatitis B should start treatment?
Those with DNA above 2000 IU/mL plus ALT over twice normal, significant fibrosis, cirrhosis with detectable DNA, extrahepatic disease, a family history of hepatocellular carcinoma, or planned immunosuppression.
When can therapy be stopped after HBeAg seroconversion?
After at least 12 months of consolidation with undetectable DNA and normal ALT in HBeAg-positive disease; most HBeAg-negative patients continue therapy indefinitely.
Which nucleos(t)ide analogue suits renal impairment?
Tenofovir alafenamide or entecavir, with entecavir dose-adjusted when creatinine clearance falls; tenofovir disoproxil fumarate requires creatinine and phosphate monitoring.
Which pregnant women need peripartum tenofovir?
Those with HBV DNA above 200,000 IU/mL, started around 28 weeks, alongside the birth-dose vaccine and HBIG for the newborn — breastfeeding is then permitted.
How is hepatitis B reactivation prevented before rituximab?
Screen HBsAg and anti-HBc; give entecavir or tenofovir prophylaxis to HBsAg-positive patients and to anti-HBc-positive patients receiving anti-CD20 therapy, continuing well beyond the last dose.