1Division of Hepatology, University of Miami School of Medicine, Miami, Florida. Electronic address: email@example.com.
2Liver Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
3Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California.
4Toronto Centre for Liver Diseases, University Health Network, Toronto, Canada.
5Department of Medicine, The Mount Sinai Medical Center, New York, New York.
6Division of Gastroenterology, University of California, San Francisco, San Francisco, California.
7Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York.
Chronic hepatitis B (CHB) continues to be an important public health problem worldwide, including in the United States. An algorithm for managing CHB was developed by a panel of United States hepatologists in 2004 and subsequently updated in 2006 and 2008. Since 2008, additional data on long-term safety and efficacy of licensed therapies have become available and have better defined therapeutic options for CHB. The evidence indicates that potent antiviral therapy can lead to regression of extensive fibrosis or even cirrhosis, thus potentially altering the natural history of CHB. In addition, appropriate choice of antiviral agent can minimize the risk of resistance. This updated algorithm for managing CHB is based primarily on evidence from the scientific literature. Where data were lacking, the panel relied on clinical experience and consensus expert opinion. The primary aim of antiviral therapy for CHB is durable suppression of serum hepatitis B virus (HBV) DNA to low or undetectable levels. CHB patients who have HBV DNA >2,000 IU/mL, elevated alanine aminotransferase (ALT), and any degree of fibrosis should receive antiviral therapy regardless of their hepatitis B e antigen (HBeAg) status. CHB patients with HBV DNA >2,000 IU/mL and elevated ALT but no evidence of fibrosis may also be considered for antiviral therapy. Approved antiviral therapies for CHB are interferon alfa-2b, peginterferon alfa-2a, lamivudine, adefovir, entecavir, telbivudine, and tenofovir, although the preferred first-line treatment choices are peginterferon alfa-2a, entecavir, and tenofovir. In determining choice of therapy, considerations include efficacy, safety, rate of resistance, method of administration, duration, and cost.