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©2013 UpToDate ® Print Email Recommendations for treatment of chronic hepatitis B HBeAg HBV DNA (PCR) ALT Treatment strategy + >20,000 int. units/mL ≤2 x ULN Low efficacy with current treatment. Observe, consider treatment when ALT becomes elevated. Consider biopsy in persons >40 years, ALT persistently high normal-2x ULN, or with family history of HCC. Consider treatment if HBV DNA >20,000 int. units/mL and biopsy shows moderate/severe inflammation or significant fibrosis. + >20,000 int. units/mL >2 x ULN Observe for 3 to 6 months and treat if no spontaneous HBeAg loss. Consider liver biopsy prior to treatment if compensated. Immediate treatment if icteric or clinical decompensation. IFNα/pegIFNα, LAM, ADV, ETV, TDF or LdT may be used as initial therapy. ADV not preferred due to weak antiviral activity and high rate of resistance after first year. LAM and LdT not preferred due to high rate of drug resistance. End-point of treatment - Seroconversion from HBeAg to anti-HBe. Duration of therapy: • IFN-α: 16 weeks • PegIFN-α: 48 weeks • LAM/ADV/ETV/LdT/TDF: minimum one year, continue for at least six months after HBeAg seroconversion IFNα nonresponders / contraindications to IFNα→ TDF/ETV. - >2000 int. units/mL >2 x ULN IFN-α / peg IFN-α, LAM, ADV, ETV, TDF or LdT may be used as initial therapy. LAM and LdT not preferred due to high rate of drug resistance. ADV not preferred due to weak antiviral activity and high risk of resistance after first year. End-point of treatment - not defined. Duration of therapy: • IFN-α/pegIFN-α: one year • LAM/ADV/ETV/LdT/TDF: >one year IFNα nonresponders / contraindications to IFN-α→ TDF/ETV. - >2000 int. units/mL 1->2 x ULN Consider liver biopsy and treat if liver biopsy shows moderate/severe necroinflammation or significant fibrosis. - ≤2000 int. units/mL ≤ULN Observe, treat if HBV DNA or ALT becomes higher. +/- Detectable Cirrhosis Compensated: • HBV DNA >2000 int. units/mL - Treat, LAM/ADV/ETV/LdT/TDF may be used as initial therapy. LAM and LdT not preferred due to high rate of drug resistance; ADV not preferred due to weak antiviral activity and high risk of resistance after first year. • HBV DNA <2000 int. units/mL - Consider treatment if ALT elevated. Decompensated: • Coordinate treatment with transplant center, LAM (or LdT) +ADV, TDF, or ETV preferred. Refer for liver transplant. +/- Undetectable Cirrhosis Compensated: Observe. Decompensated: Refer for liver transplant.

• HBV DNA >2000 int. units/mL - Treat, LAM/ADV/ETV/LdT/TDF may be used as initial therapy. LAM and LdT not preferred due to high rate of drug resistance; ADV not preferred due to weak antiviral activity and high risk of resistance after first year. • HBV DNA <2000 int. units/mL - Consider treatment if ALT elevated. Decompensated: • Coordinate treatment with transplant center, LAM (or LdT) +ADV, TDF, or ETV preferred. Refer for liver transplant. +/- Undetectable Cirrhosis Compensated: Observe. Decompensated: Refer for liver transplant. ALT: alanine aminotransferase; ULN: upper limit of normal; IFNα: interferon alpha; pegIFN-α: pegylated IFN-alpha; LAM: lamivudine; ADV: adefovir; ETV: entecavir; LdT: telbivudine; TDF: tenofovir disoproxil fumarate. Reproduced with permission from: Lok ASF, McMahon BJ. Chronic hepatitis B: Update 2009. Hepatology 2009; 50:661. Available online at file://publish.aasld.org/Pages/Default.aspx. Accessed September 8th 2009. Copyright © 2009 American Association for the Study of Liver Diseases.