Managing chronic hepatitis B.

Chronic hepatitis B (CHB) is a dynamic disease. Ongoing and consistent monitoring is an essential component of CHB management. It is also critical to remain vigilant about regular screening for liver damage and liver cancer, and to routinely monitor patients on CHB treatment for possible nonadherence or the development of resistance.1

Monitoring CHB patients

Poor monitoring of CHB patients makes determining treatment eligibility more difficult, while suboptimal surveillance predisposes CHB patients to the risks of disease progression, including HCC and its sequelae.2-4

Supporting treatment adherence

Adherence to CHB treatment and regular follow-up visits are essential for optimal patient health.

Assessing comorbidities

People with CHB have a significantly higher prevalence—and risk—of renal disease, and a higher prevalence of cardiovascular, bone, and metabolic diseases than those without CHB.5-7

HCC=hepatocellular carcinoma.

Lifelong monitoring for CHB patients

Many people with CHB receive suboptimal care and are not adequately monitored for ALT and HBV DNA, leaving them at risk for cirrhosis and HCC.2,3

CHB patients who are either never or not routinely monitored for2,a:
ALT
Donut graph showing 22%22%
HBV DNA
Donut graph showing 62%62%
Hepatic Imaging in patients with cirrhosis
Donut graph showing 86%86%
aThis was a multicenter observational study of the Chronic Hepatitis Cohort Study (CHeCS), which included 2338 patients in the US with confirmed CHB.2

Every 3-12 monthsb

AASLD 2018 guidance recommends blood tests to monitor HBeAg, HBV DNA, and ALT levels1

 
HBeAgHBV DNA (IU/mL)ALTRecommended Follow-up
>20,000≥2xULN or significant histologic diseasecTreat patients (immune-active CHB)
>2,000
DetectableCirrhosis, regardless of ALTTreat patients
≤20,000<2xULNConsider treatment based on:
  • Age (>40 years)
  • Family history of cirrhosis or HCC
  • Previous treatment historyd
  • Extrahepatic manifestationse
≤2,000
ALT=alanine aminotransferase; HBeAg=hepatitis B e-antigen; HBV DNA=hepatitis B virus deoxyribonucleic acid.
bAt the clinician’s discretion.
cLiver biopsy/non-invasive testing showing moderate-to-severe necroinflammatory activity on histology and/or significant fibrosis.
dSerologic and virologic benefits of pegylated interferon occur after treatment discontinuation (delayed). Prior exposure to nucleos(t)ide analogs is a risk for drug resistance.
ePresence of extrahepatic manifestations is an indication for treatment, independent of liver disease severity.
CHB patients who never undergo, or receive suboptimal, HCC surveillance3,f:
Donut graph showing 78%78%
Patients without cirrhosis
Donut graph showing 62%62%
Patients with cirrhosis

fThis was a retrospective analysis of 1329 CHB patients from the San Francisco Bay Area (January 1996-July 2013).3

Every 6 months

AASLD and AATA recommend ultrasound ± AFP for HCC surveillance with at-risk patients1

AASLD1
Tests
At-risk populations
  • Ultrasound ± AFP
  • Every 6 months
  1. All HBsAg+ persons with cirrhosis
  2. People with a family history of HCC
  3. People with hepatitis D virus infection
  4. HBsAg+ Asian or African American men >40 years of age
  5. HBsAg+ Asian women >50 years of age
AATA8
Tests
At-risk populations
(Asian Americans)g
  • Ultrasound and AFPh
  • Every 6 months
  1. All HBsAg+ people with chronic hepatitis
  2. People with cirrhosis or family history of HCC
AASLD=American Association for the Study of Liver Diseases; AATA=Asian American Treatment Algorithm; AFP=alpha-fetoprotein; HBsAg=hepatitis B surface antigen.
gConsidered at high risk. Low- to moderate-risk patients such as low replication and immune tolerant should receive surveillance every 6-12 months. Patients who clear HBsAg may still develop HCC, and should continue surveillance.8
hAFP and CT scan or MRI at 3 months for people with elevated AFP or undergoing HCC treatment.
With routine surveillance:
HCC surveillance is recommended for many CHB patients, especially those with cirrhosis1,8

Support patients’ adherence to CHB treatment

Compared with clinical trials, treatment adherence may be lower in clinical practice. Patients may be less motivated, less frequently monitored, and often have to pay a part of their medication costs.10

Discussing treatment adherence with your CHB patients

Engage in an open dialogue with your patients and listen carefully to their concerns. Encouraging your patients to express what is on their minds may help them become more involved in and committed to their chronic hepatitis B treatment plan.

Advise patients to check with you before taking any new medications, over-the-counter medicines, or herbal supplements, and to let you know if they experience any side effects.11

Urge your patients to take their chronic hepatitis B medicine exactly as prescribed. Explain to your patients that they should not stop taking their chronic hepatitis B medicine without first discussing it with you.11

Suggest medication reminder tools, such as a cell phone app, an alarm clock, or a 7-day pill box, for those patients who are prescribed oral antivirals and need help remembering to take them.

Encourage lifestyle changes for liver health, such as avoiding alcohol and smoking and eating a healthy diet low in saturated fats, with plenty of fruits and vegetables.12

Consider the impact of comorbidities on CHB patients

Due to the associations between CHB infection and comorbidities such as kidney- and bone-related conditions, careful evaluation and consideration are needed when managing CHB patients.1

Educational resources for your chronic hepatitis B patients

Information for healthcare professionals

Chronic Hepatitis B Screening & Management Brochure

An overview of the importance of CHB screening and management, including recommendations to simplify management and improve care of chronic hepatitis B patients.
Download the Brochure
AASLD=American Association for the Study of Liver Diseases; ACP=American College of Physicians; CDC=Centers for Disease Control and Prevention; USPSTF=U.S. Preventive Services Task Force.
References:
  • . Terrault N, Lok A, McMahon B, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67(4):1560-1599.
  • Spradling P, Xing J, Rupp, L et al. Infrequent clinical assessment of chronic hepatitis B patients in United States general healthcare settings. Clin Infect Dis. 2016;63:1205-1208.
  • Wang C, Chen V, Vu V, et al. Poor adherence and low persistency rates for hepatocellular carcinoma surveillance in patients with chronic hepatitis B. Medicine (Baltimore). 2016;95:e4744.
  • Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:1-20.
  • Chen YC,et al. 13-year nationwide cohort study of chronic kidney disease risk among treatment-naïve patients with chronic hepatitis B in Taiwan. BMC Nephrology. 2015;16:110.
  • Chen Y, Su Y, Li C, et al. A nationwide cohort study suggests chronic hepatitis B virus infection increases the risk of end-stage renal disease among patients in Taiwan. Kidney Int. 2015;87:1030-1038.
  • Liu A, Le A, Zhang J, et al. Increasing co-morbidities in chronic hepatitis B patients: experience in primary care and referral practices during 2000-2015. Clin Transl Gastroenterol. 2018;9(3):141.
  • Tong M, Pan C, Han S, et al. An expert consensus for the management of chronic hepatitis B in Asian Americans. Aliment Pharmacol Ther. 2018;47(8):1181-1200.
  • Singal A, Pillai A, Tiro J. Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLOS Med. 2014;11:e1001624.
  • Scaglione SJ, Lok ASF. Effectiveness of hepatitis B treatment in clinical practice. Gastroenterology. 2012;142(6):1360-1368.e1.
  • National Institutes of Health. U.S. National Library of Medicine. Hepatitis B. https://medlineplus.gov/ency/article/000279.htm. Last updated October 2, 2019. Accessed October 19, 2019.
  • Hepatitis B Foundation. Adults living with hepatitis B: Healthy Liver Tips. Hepatitis B Foundation website. https://www.hepb.org/treatment-and-management/adults-with-hepatitis-b/healthy-liver-tips. Accessed October 19, 2019.
  • Nguyen M, Lim J, Burak Ozbay A, et al. Advancing age and comorbidity in a US insured population-based cohort of patients with chronic hepatitis B. Hepatology. 2019;69(3):959-973.
  • National Kidney Foundation. Clinical practice guidelines: For chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis. 2002;39(2Suppl 1):S1-S266.
  • Demontiero O, Vidal C, Duque G, et al. Aging and bone loss: new insights for the clinician. Ther Adv Musculoskelet Dis. 2012;4:61-76.
  • Huang Z, Wei H, Cheng C, et al. Low bone mineral density in chronic hepatitis B virus infection: A case-control study. Pak J Med Sci. 2017;33:457-461.