for Health Care Providers
Treatment Goals and Medications - Hepatitis B
Contents
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 medications
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®)
| Therapy | Route | Food Restrictions | Adverse Reactions | Dose Adjust if CrCl < 50 mL/min | When to Use |
|---|---|---|---|---|---|
| TAF | Oral | None | 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 |
| TDF | Oral | None | Pain, depression, rash, high cholesterol, diarrhea, nausea, headache, bone mineral density loss, nephrotoxic | Yes |
Treatment naive (1st line)
LAM-, ETV- or ADV-resistant |
| ETV | Oral | Take on an empty stomach, 2 hours before or after a meal | Headache, fatigue, dizziness, nausea | Yes |
Treatment naive (1st line)
ADV- resistant |
| PEG | Sub-cutan-eous | None | Flu-like symptoms, fever, chills, headache, fatigue, dizziness, depression, neutropenia, leukopenia, anemia, myalgia, weakness, skeletal pain | Yes |
Patients with high ALT, low HBV DNA, HBV genotype A or B.
Treat for 48-72 weeks |
| 3TC | Oral | None | Headache, fatigue, insomnia, diarrhea, nausea, vomiting, anorexia, rash, pancreatitis, neutropenia, myalgia, neuropathy, musculoskeletal pain | Yes |
Treatment naive (2nd line)
If 3TC-resistant, switch to or add TDF or TAF, or switch to combination medication TDF/ emtricitabine or TAF/ emtricitabine |
| ADV | Oral | None | Headache, abdominal pain, nausea, weakness, nephrotoxicity | Yes |
Treatment naive (2nd line)
If ADV- resistant, switch to or add ETV |
