The European Association for the Study of the Liver (EASL) has issued updated practice guidelines on the management of hepatitis B virus (HBV) infection. The full guideline has been published in the Journal of Hepatology.

HBV “remains a global public health problem” as vaccination policies and migration impact the epidemiology of the disease. The presence of chronic HBV infection increases the likelihood of progression to cirrhosis and hepatocellular carcinoma (HCC), “depending on host and viral factors,” the expert panel explained. 

The updated guidelines include:

  • New definitions of disease phases based on the description of the two main characteristics of chronicity: infection vs. hepatitis
  • Expanded indications for initiating treatment in order to prevent mother-to-child transmission 
  • Recommendations for special populations (e.g., children, extrahepatic disease manifestations, prevention of HBV re-activation)
  • Practical rules for response-guided therapy in patients receiving pegylated interferon for HBV

Regarding therapy, the main goal is to improve survival and quality of life by preventing disease progression and thus HCC development. The main goal with current treatment strategies is the induction of long-term suppression of HBV replication “while HBsAg loss is an optimal endpoint.”  

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All cirrhotic patients with detectable HBV DNA should receive treatment whereas the usual indication for treatment requires patients to have HBV DNA >2,000 IU/mL, elevated ALT and/or at least moderate histological lesions. Other indications for treatment include prevention of mother-to-child transmission among pregnant women with high viremia and prevention of HBV reactivation in patients requiring immunosuppression or chemotherapy

The long-term administration of a strong nucleos(t)ide analogue with high barrier to resistance (eg, entecavir, tenofovir disoproxil, tenofovir alafenamide) is considered the treatment of choice regardless of liver disease severity. Pegylated interferon-alfa may also be considered for patients with mild to moderate chronic hepatitis B. The guidelines generally recommend against combination treatments.

All patients—treated and untreated—should be monitored for treatment response and adherence as well as the risk of progression and development of complications especially HCC. The guidelines also discuss treatment approaches for the future to attain “cure” of disease, including the role of new biomarkers.

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