Hepatitis B Treatment

Approved Antiviral Therapies in Adult and Children 

Selection Criteria of Agents

• Peginterferon alfa-2a, entecavir, and tenofovir are considered first-line options for patients with serum HBV DNA levels [1]2000IU/mL and elevated ALT levels,
•   Entecavir or tenofovir would be preferred for patients with high levels of serum HBV DNA and/or normalALT levels, because response to interferon-based therapy is low in this population.
• Entecavir should not be administered to CHB patients with lamivudine experience.
• The optimal management of patients who have detectable HBV DNA after 48 weeks of entecavir or tenofovir therapy is unclear.
• Patients with declining serum HBV DNA levels may continue with entecavir or tenofovir because of the rise in rates of virologic response over time and the very low risk of resistance to either drug.

• Patients with partial response to entecavir but HBV DNA <1000 IU/mL after 1 year of therapy often achieve viral suppression by continuing entecavir through at least 2 years total
• Patients with partial response to entecavir and higher residual HBV DNA levelafter 1 year of therapy can be switched to tenofovir monotherapy or tenofovir plus entecavir combination therapy.
• For patients with partial response to entecavir 0.5 mg daily, increasing the dose to 1.0 mg daily does not appear to benefit the likelihood of achievingcomplete viral suppression.
• In cases of suspected tenofovir-associated renal dysfunction and/or osteoporosis/osteomalacia, tenofovir should be discontinued and substituted with an alternate NA with consideration for previous drug resistance

Efficacy of Approved Agents

• Biochemical, serological, virological, and histological endpoints are used to assess the success of therapy (Table 5).
• The best predictor of sustained remission off-treatment is HBsAg loss, but this is infrequently achieved with current therapies
• Currently, there is no high-quality evidence comparing these antiviral agents.
• However, tenofovir is considered a preferred choice, owing to its antiviral potency, the available safety data of use during pregnancy, and concerns for resistance with the other antiviral agents.

Treatment Modification in the Case of a Suboptimal Response

Reference : 

1. https://www.usahealthsystem.com/workfiles/physicians_docs/clinics/digestivehealth/teaching_articles/March%2010%20article%20and%20questions.pdf
2. https://www.aasld.org/sites/default/files/guideline_documents/hep28156.pdf
3. https://www.inpractice.com/Textbooks/Hepatology/ch4_Mgmt_of_Hep_B_Infection/Supporting-Assets/Table-10.aspx