Hepatitis B virus: Difference between revisions
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==Background== |
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===Microbiology=== |
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== Investigations == |
== Investigations == |
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* [[Hepatitis B serology]] |
* [[Hepatitis B serology]] |
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== Management == |
== Management == |
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=== Acute === |
=== Acute === |
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* Supportive care |
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=== Chronic === |
=== Chronic === |
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* HBsAg present ≥6 months |
* HBsAg present ≥6 months |
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* HBV-DNA is variable |
* HBV-DNA is variable |
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* ALT can be normal or elevated |
* ALT can be normal or elevated |
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* Liver boipsy shows chronic hepatitis and variable necroinflammation or fibrosis |
* Liver boipsy shows chronic hepatitis and variable necroinflammation or fibrosis |
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=== Immune-active === |
=== Immune-active === |
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* HBsAg present ≥6 months and HBeAg either positive or negative |
* HBsAg present ≥6 months and HBeAg either positive or negative |
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* Intermittently or persistently elevated ALT and AST |
* Intermittently or persistently elevated ALT and AST |
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==== Indications for treatment ==== |
==== Indications for treatment ==== |
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* ALT ≥2x ULN or evidence of significant histologic disease, AND |
* ALT ≥2x ULN or evidence of significant histologic disease, AND |
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* Elevated HBV DNA |
* Elevated HBV DNA |
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=== Immune-tolerant === |
=== Immune-tolerant === |
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* HBsAg present for ≥6 months and HBeAg positive |
* HBsAg present for ≥6 months and HBeAg positive |
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* HBV DNA typically over 1 million |
* HBV DNA typically over 1 million |
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==== Indications for treatment ==== |
==== Indications for treatment ==== |
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* Adults >40 years, AND |
* Adults >40 years, AND |
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* ALT rises above 2x ULN (i.e. becomes immune-active), OR |
* ALT rises above 2x ULN (i.e. becomes immune-active), OR |
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==== Surveillance ==== |
==== Surveillance ==== |
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* Monitor at 3 to 6 month intervals, more frequently as ALT levels rise, consider treatment if >2x ULN/ |
* Monitor at 3 to 6 month intervals, more frequently as ALT levels rise, consider treatment if >2x ULN/ |
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=== Treatment Regimens === |
=== Treatment Regimens === |
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* One of pegylated-interferon (48 weeks), tenofovir (until 12 months post-HBeAg conversion), or entecavir (until 12 months post-HBeAg conversion) |
* One of pegylated-interferon (48 weeks), tenofovir (until 12 months post-HBeAg conversion), or entecavir (until 12 months post-HBeAg conversion) |
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** Peg-IFN contraindicated in autoimmune disorders, uncontrolled psychiatric disease, cyptopenia, severe cardiac disease, uncontrolled seizures, and decompensated cirrhosis |
** Peg-IFN contraindicated in autoimmune disorders, uncontrolled psychiatric disease, cyptopenia, severe cardiac disease, uncontrolled seizures, and decompensated cirrhosis |
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=== Inactive chronic hepatitis B === |
=== Inactive chronic hepatitis B === |
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* Defined by HBeAg-negative, anti-HBeAb-positive, normal ALT, and HBV DNA <2000 IU/mL |
* Defined by HBeAg-negative, anti-HBeAb-positive, normal ALT, and HBV DNA <2000 IU/mL |
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* Monitor ALT q3mo for 1 year, then q6-12mo |
* Monitor ALT q3mo for 1 year, then q6-12mo |
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=== HCC screening === |
=== HCC screening === |
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* Screen if HBsAg-positive with cirrhosis, or HBsAg-positive at higher risk (Asian men >40yrs, black men >40yrs, Asian women >50yrs, family history, HDV coinfection) |
* Screen if HBsAg-positive with cirrhosis, or HBsAg-positive at higher risk (Asian men >40yrs, black men >40yrs, Asian women >50yrs, family history, HDV coinfection) |
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* First-line is ultrasound every 6 months |
* First-line is ultrasound every 6 months |
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=== Prophylaxis in Immunosuppression === |
=== Prophylaxis in Immunosuppression === |
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* Concern especially with chronic steroids and rituximab |
* Concern especially with chronic steroids and rituximab |
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* Can have the following effects |
* Can have the following effects |
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* Prophylaxis with lamivudine until 6 months after chemotherapy |
* Prophylaxis with lamivudine until 6 months after chemotherapy |
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== |
== Further Reading == |
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* [https://doi.org/10.1002/hep.29800 Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance] |
* [https://doi.org/10.1002/hep.29800 Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance] |
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Revision as of 18:07, 20 June 2020
Background
Microbiology
- Reverse-transcription double-stranded DNA (RT-dsDNA) virus
Investigations
Management
Acute
- Supportive care
Chronic
- HBsAg present ≥6 months
- HBV-DNA is variable
- Can be HBeAg positive or negative, with generally higher HBV DNA levels in HBeAg-positive patients
- ALT can be normal or elevated
- Liver boipsy shows chronic hepatitis and variable necroinflammation or fibrosis
Immune-active
- HBsAg present ≥6 months and HBeAg either positive or negative
- Intermittently or persistently elevated ALT and AST
Indications for treatment
- ALT ≥2x ULN or evidence of significant histologic disease, AND
- Elevated HBV DNA
- > 2000 IU/mL if HBeAg negative
- > 20,000 IU/mL if HBeAg positive
Immune-tolerant
- HBsAg present for ≥6 months and HBeAg positive
- HBV DNA typically over 1 million
- Normal or minimally-elevated ALT and AST
- That is, high viral load but normal ALT
Indications for treatment
- Adults >40 years, AND
- ALT rises above 2x ULN (i.e. becomes immune-active), OR
- Liver biopsy showing significant necroinflammation or fibrosis
Surveillance
- Monitor at 3 to 6 month intervals, more frequently as ALT levels rise, consider treatment if >2x ULN/
Treatment Regimens
- One of pegylated-interferon (48 weeks), tenofovir (until 12 months post-HBeAg conversion), or entecavir (until 12 months post-HBeAg conversion)
- Peg-IFN contraindicated in autoimmune disorders, uncontrolled psychiatric disease, cyptopenia, severe cardiac disease, uncontrolled seizures, and decompensated cirrhosis
- Peg-IFN preferred in lamivudine resistance
- Tenofovir is safe in pregnancy
- Duration depends on what stage is being treated
- HBeAg positive and HBV DNA >20,000 and ALT >2 ULN
- Peg-IFN for 48 weeks
- Tenofovir or entecavir for at least 12 months after HBeAg seroconversion (Ag to Ab)
- HBeAg negative and HBV DNA > 2000 and ALT >2x ULN (or biopsy shows necroinflammation or fibrosis, or non-invasive testing shows fibrosis)
- Peg-IGN for 1 year
- Tenofovir or entecavir for many years, possibly indefinitely
- HBeAg positive and HBV DNA >20,000 and ALT >2 ULN
- Continue HCC surveillance regardless of treatment
Inactive chronic hepatitis B
- Defined by HBeAg-negative, anti-HBeAb-positive, normal ALT, and HBV DNA <2000 IU/mL
- Monitor ALT q3mo for 1 year, then q6-12mo
- If ALT rises, check HBV-DNA and HBsAg for activity
HCC screening
- Screen if HBsAg-positive with cirrhosis, or HBsAg-positive at higher risk (Asian men >40yrs, black men >40yrs, Asian women >50yrs, family history, HDV coinfection)
- First-line is ultrasound every 6 months
- Second-line is AFP levels every 6 months
Prophylaxis in Immunosuppression
- Concern especially with chronic steroids and rituximab
- Can have the following effects
- Asymptomatic HBV DNA and ALT
- Hepatic failure
- Death
- If ≥7.5mg/d should be screened
- HBsAg +/- HBcAb if they're adding a second agent (rituximab, TNF-alpha inhibitors, or other)
- Refer to Hepatology or Infectious Diseases
- Prophylaxis with lamivudine until 6 months after chemotherapy
Further Reading
References
- ^ Mustafa Sunbul. Hepatitis B virus genotypes: Global distribution and clinical importance. World Journal of Gastroenterology. 2014;20(18):5427. doi:10.3748/wjg.v20.i18.5427.
- ^ Carla S. Coffin, Scott K. Fung, Fernando Alvarez, Curtis L. Cooper, Karen E. Doucette, Claire Fournier, Erin Kelly, Hin Hin Ko, Mang M Ma, Steven R Martin, Carla Osiowy, Alnoor Ramji, Edward Tam, Jean Pierre Villeneuve. Management of Hepatitis B Virus Infection: 2018 Guidelines from the Canadian Association for the Study of Liver Disease and Association of Medical Microbiology and Infectious Disease Canada. Canadian Liver Journal. 2018;1(4):156-217. doi:10.3138/canlivj.2018-0008.
