Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Viral Hepatitis and Liver Disease

Quick Links
Veterans Crisis Line Badge
My healthevet badge

HBV: Treatment Goals and Medications

for Health Care Providers

Treatment Goals and Medications - Hepatitis B

General goals of HBV treatment

  • To suppress HBV DNA and normalize ALT
  • To achieve loss of HBeAg (if initially HBeAg positive)
  • To achieve loss of HBsAg (this occurs rarely)
  • To reduce the likelihood of cirrhosis and HCC
  • To decrease the morbidity and mortality related to HBV

Carefully review criteria before initiating antiviral treatment for HBV

In general, patients with active HBV (HBV DNA ≥ 2,000 IU/mL if HBeAg-negative and HBV DNA ≥ 20,000 IU/mL if HBeAg-positive, and high ALT or evidence of advanced fibrosis) should be considered for HBV antiviral treatment.

Patients with inactive HBV (HBV DNA < 2,000 IU/mL and low ALT without evidence of advanced fibrosis) may need HBV treatment in certain situations such as if they are immunosuppressed or on treatment for chronic HCV.

Always carefully review the criteria for starting HBV medicationsLink will take you outside the VA website. VA is not responsible for the content of the linked site.
and/or consult an expert before initiating HBV treatment.

General information on HBV medications

There are 6 medications approved for HBV in the United States:

  • 1 is pegylated interferon (subcutaneous injection)
  • 5 are nucleos(t)ide analogs (oral)

The oral medications generally have high safety profiles and are used long-term.

Pegylated interferon has significant side effects but is used for a finite period.

First line (low resistance potential)

Tenofovir alafenamide (TAF, Vemlidy®)

Tenofovir disoproxil fumarate (TDF, Viread®)

Entecavir (ETV, Baraclude®)

Peginterferon (PEG, Pegasys®) - in select patients

Second line (high resistance potential)

Lamivudine (3TC, Epivir-HBV®)

Adefovir (ADV, Hepsera®)

TherapyRouteFood RestrictionsAdverse Reactions Dose Adjust if CrCl < 50 mL/min When to Use
TAFOralNone Pain, depression, rash, high cholesterol, diarrhea, nausea, headache No, but avoid if CrCl < 15 mL/min Treatment naive (1st line)
LAM-, ETV- or ADV-resistant
TDFOralNone Pain, depression, rash, high cholesterol, diarrhea, nausea, headache, bone mineral density loss, nephrotoxic Yes Treatment naive (1st line)
LAM-, ETV- or ADV-resistant
ETVOralTake on an empty stomach, 2 hours before or after a mealHeadache, fatigue, dizziness, nauseaYes Treatment naive (1st line)
ADV- resistant
PEGSub-cutan-eousNoneFlu-like symptoms, fever, chills, headache, fatigue, dizziness, depression, neutropenia, leukopenia, anemia, myalgia, weakness, skeletal painYes Patients with high ALT, low HBV DNA, HBV genotype A or B.
Treat for 48-72 weeks
3TCOralNoneHeadache, fatigue, insomnia, diarrhea, nausea, vomiting, anorexia, rash, pancreatitis, neutropenia, myalgia, neuropathy, musculoskeletal painYes Treatment naive (2nd line)
If 3TC-resistant, switch to or add TDF or TAF, or switch to combination medication TDF/ emtricitabine or TAF/ emtricitabine
ADVOralNoneHeadache, abdominal pain, nausea, weakness, nephrotoxicityYes Treatment naive (2nd line)
If ADV- resistant, switch to or add ETV

Related resources