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©2013 UpToDate ® Print Email Recommendations for treatment of chronic hepatitis B in adults HBeAg HBV DNA (PCR) ALT Treatment strategy + >20,000 IU/mL ≤2x 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 IU/mL and biopsy shows moderate/severe inflammation or significant fibrosis. + >20,000 IU/mL >2x ULN Observe for 3-6 months and treat if no spontaneous HBeAg loss. Consider liver biopsy prior to treatment if compensated. Immediate treatment if icteric or clinical decompensation. IFNα/peg IFNα, LAM, ADV, ETV or LdT may be used as initial therapy. 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: IFNα: 16 weeks Peg IFNα: 48 weeks LAM/ADV/ETV/LdT: minimum 1 year, continue for at least 6 months after HBeAg seroconversion IFNα non-responders / contraindications to IFNα → ADV/ETV. - >20,000 IU/mL >2x ULN IFNα/peg IFNα, LAM, ADV, ETV or LdT may be used as initial therapy, LAM and LdT not preferred due to high rate of drug resistance. End-point of treatment - not defined. Duration of therapy: IFNα/peg IFNα: 1 year LAM/ADV/ETV/LdT: >1 year IFN-α nonresponders / contraindications to IFN-α → ADV/ETV. - >2,000 IU/mL 1->2x ULN Consider liver biopsy and treat if liver biopsy shows moderate/severe necroinflammation or significant fibrosis. - ≤2,000 IU/mL ≤ULN Observe, treat if HBV DNA or ALT becomes higher. +/- Detectable Cirrhosis Compensated: HBV DNA >2,000 IU/mL - Treat, LAM/ADV/ETV/LdT may be used as initial therapy. LAM and LdT not preferred due to high rate of drug resistance. HBV DNA <2,000 IU/mL - Consider treatment if ALT elevated. Decompensated: Coordinate treatment with transplant center, LAM (or LdT) + ADV 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; peg IFNα: pegylated IFN alpha; LAM: Lamivudine; ADV: Adefovir; ETV: Entecavir; LdT: Telbivudine. Lok, AS, McMahon, BJ. AASLD Practice Guideines: Chronic hepatitis B. Hepatology 2007; 45:507.