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chronic hepatitis B

see hepatitis B infection Laboratory: - HBeAg in serum - hepatitis B virus DNA* - serum ALT* - HIV1 serology, hepatitis C serology * criteria for treatment (see Management: below) Special laboratory: - screen for heptocellular carcinoma in at risk patients with ultrasound every six months [1]* * screening with serum alpha-fetoprotein insufficient [1] Complications: 1) chronic active hepatitis - persistent HBV viral replication 6 months after exposure 2) cirrhosis - risk factors - older age - longer duration of infection - high hepatitis B virus DNA - long-term alcohol use - HIV or hepatitis C virus coinfection - smoking 3) hepatocellular carcinoma - cirrhosis - HBV genotype C - conversion from HBeAg(-) to HBeAg(+) - male - family history of hepatocellular carcinoma - may develop in the absence of cirrhosis [1] - lipophilic statins (atorvastatin, simvastatin) may reduce (risk 3% vs 8%) [4] Management: - patients in the immune control (inactive) phase generally do not require treatment [1] - treatment indicated for HBeAg(-) patients with - serum ALT > 2-fold upper limit of normal & - hepatitis B virus DNA > 2000 IU/mL - entecavir or tenofovir 1st line for treatment [3] - lamivudine & adefovir no longer 1st line due to lower potency & development of resistance - pegylated interferon (avoid in patients with depression) - most patients will require therapy indefinitely - cure rates are low [3] - bepirovirsen is an antisense oligonucleotide that targets all hepatitis B virus messenger RNAs & decreases levels of hepatitis B viral proteins (investigational) [5]

Related

hepatitis B carrier

Specific

chronic active hepatitis B immune-tolerant chronic hepatitis B

General

hepatitis B infection chronic viral hepatitis

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2021
  2. Lok AS, McMahon BJ Chronic hepatitis B: update 2009. Hepatology. 2009 Sep;50(3):661-2. PMID: 19714720 corresponding NGC AASLD guidelines updated June 2016
  3. Tang LDY, Covert E, Wilson E et al Chronic Hepatitis B Infection. A Review. JAMA. 2018;319(17):1802-1813 PMID: 29715359 https://jamanetwork.com/journals/jama/fullarticle/2679946
  4. Simon TG, Duberg AS, Aleman S et al Lipophilic Statins and Risk for Hepatocellular Carcinoma and Death in Patients With Chronic Viral Hepatitis: Results From a Nationwide Swedish Population. Ann Intern Med. 2019 Aug 20. PMID: 31426090 https://annals.org/aim/article-abstract/2748619/lipophilic-statins-risk-hepatocellular-carcinoma-death-patients-chronic-viral-hepatitis
  5. Yuen M-F et al. Efficacy and safety of bepirovirsen in chronic hepatitis B infection. N Engl J Med 2022 Nov 8; [e-pub]. PMID: 36346079 https://www.nejm.org/doi/10.1056/NEJMoa2210027 - Hoofnagle JH. A modern therapy for an ancient disease. N Engl J Med 2022 Nov 8; [e-pub]. PMID: 36346068 https://www.nejm.org/doi/10.1056/NEJMe2213449