HBV Treatment Algorithm Summary

A Treatment Algorithm for the Management of Chronic Hepatitis B Infection in the United States
Drs. Emmet B. Keeffe, Douglas T. Dieterich, Steve–Huy, B. Han, Ira M. Jacobson, Paul Martin, Eugene R. Schiff, Hillel Tobias, and Teresa L. Wright

Clinical Gastroenterology and Hepatology February 2004

A panel of U.S. hepatologists developed a comprehensive treatment algorithm for chronic hepatitis B, published in Clinical Gastroententerology and Hepatology (February 2004), which supports the AASLD updated 2004 guidelines. These guidelines were updated in July, 2006.

A summary of the treatment recommendations is offered below. To read the full Treatment Algorithm article, click here.

Summary of Recommendations

The goal of therapy for patients with chronic HBV infection is to prevent the progression of liver disease to cirrhosis and HCC [liver cancer]. Because HBV replication is implicated in the outcome of chronic HBV infection, the primary aim of therapy is durable suppression of serum HBV DNA to the lowest levels possible.
The threshold HBV DNA level for determination of candidates for therapy is =10⁵ copies/mL for patients with HBeAg-positive chronic HBV infection. Patients also should have elevated ALT levels and/or evidence of hepatitis on liver biopsy. A lower serum HBV DNA threshold is needed for patients with HBeAg-negative chronic hepatitis B and those with decompensated cirrhosis.
IFN, lamivudine, and adefovir are all approved as initial therapy for chronic hepatitis B. The issues to consider are efficacy, safety, resistance, method of administration, and cost.
IFN has the advantage of a finite duration of treatment, durable response (in patients who respond), and lack of resistance, but it is expensive to use, has to be administered by injection, and has many side effects.
Lamivudine is well tolerated, with an excellent safety profile and good efficacy, but its long-term use is limited by the development of resistance. Thus, it might be a good choice for patients with high baseline ALT levels with a =50% chance of HBeAg loss with only 1 year of therapy and for patients receiving short-term antiviral prophylaxis during chemotherapy.
Patients requiring therapy for longer than 1 year probably are treated best with adefovir, with its much lower incidence of resistance. Adefovir has similar efficacy to lamivudine and is well tolerated. It has the advantage of a delayed and very low rate of resistance development and therefore is preferred for long-term use. However, its cost is greater than that of lamivudine.
Several areas require further study. Combination therapy may prove to be more effective than monotherapy in suppressing viral replication and may decrease or delay the incidence of drug resistance. Several large studies are under way exploring the use of two nucleoside/nucleotide antivirals or an antiviral plus peginterferon in compensated patients.

*This article was published in the Hepatitis B Foundation’s B Informed Newsletter, Summer 2004.