Chronic hepatitis B is a challenging problem in the world more so in the south East Asia region. India has intermediate prevalence of hepatitis B. Mostly it is transmitted from mother to child at the time of birth. Even after birth horizontal transmission in the family (with in family members) is quite high. As chronic hepatitis B is usually asymptomatic (without any problems) till adulthood this condition is diagnosed at a later stage i.e. liver failure.
Once chronic hepatitis B is diagnosed it is very difficult to decide on treatment, whether patient requires treatment or not. There are many guidelines but are different slightly in their indications for treatment.
Mainly ASSLD (American association for study of liver diseases) guidelines are followed. In simple terms once patient is diagnosed to have chronic hepatitis B following tests needs to be done.
Quantitative hepatitis B DNA levels
HBe antigen and antibody
Ultrasound abdomen
Liver function test
Serum creatinine
Based on results of these tests one has to decide on treating hepatitis B. In those with HBe Ag +, DNA levels >2000 IU/L, age >30 years and In those with HBeAg negativity, DNA levels>20,000 IU/L antiviral treatment is indicated.
In case of chronic liver disease in ultrasound or in those with decompensated chronic liver disease, treatment is indicated irrespective of e Ag status or DNA level cut-off.
At present best available antiviral for hepatitis B are Entecavir and Tenefovir. Economy mainly determines which is to be started as both have good efficacy and high barrier for resistance. These drugs have minimal side effects, Tenefovir can cause renal tubular defect rarely. It’s advisable to check serum creatinine and calcium once a year in those who are on Tenefovir.
Once patient is on treatment it is advisable to check DNA levels once a year and SGOT and SGPT once in 3 months.
Beyond 40 years of age those with chronic hepatitis B should undergo ultrasound abdomen as a part of hepatocellular carcinoma surveillance.
Once started on antiviral for all practical purpose treatment is to be continued for life long. Except for in specific conditions like in those who attains HBsAg loss can discontinue therapy.
One more important condition where in antiviral to be started irrespective of DNA levels is in those with malignancy planning chemotherapy or in those with diseases requiring long term steroid therapy. In these cases treatment needs to be continued for 6 months after discontinuing chemotherapy or steroid. This is to prevent acute flare which may be even life threatening rarely.
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