Guidance
Key priorities for implementation
- Assessment and referral
- Treatment sequence in adults with HBeAg-positive chronic hepatitis B and compensated liver disease
- Treatment sequence in adults with HBeAg-negative chronic hepatitis B and compensated liver disease
- Women who are pregnant or breastfeeding
- Prophylactic treatment during immunosuppressive therapy
Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
Assessment and referral
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Arrange the following tests in primary care for adults who are hepatitis B surface antigen (HBsAg) positive:
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hepatitis B e antigen (HBeAg)/antibody (anti-HBe) status
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HBV DNA level
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lgM antibody to hepatitis B core antigen (anti-HBc lgM)
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hepatitis C virus antibody (anti-HCV)
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hepatitis delta virus antibody (anti-HDV)
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HIV antibody (anti-HIV)
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lgG antibody to hepatitis A virus (anti-HAV)
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additional laboratory tests including alanine aminotransferase (ALT) or aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), serum albumin, total bilirubin, total globulins, full blood count and prothrombin time
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tests for hepatocellular carcinoma (HCC), including hepatic ultrasound and alpha-fetoprotein testing.
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Include the results of the initial tests with the referral (see recommendation 1.2.1 in the section on assessment and referral in primary care).
Treatment sequence in adults with HBeAg-positive chronic hepatitis B and compensated liver disease
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Offer a 48-week course of peginterferon alfa-2a as first-line treatment in adults with HBeAg-positive chronic hepatitis B and compensated liver disease. Avoid use of peginterferon alfa-2a in pregnancy unless the potential benefit outweighs risk. Women of childbearing potential must use effective contraception throughout therapy.
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Offer tenofovir disoproxil as second-line treatment to people who do not undergo HBeAg seroconversion or who relapse (revert to being HBeAg positive following seroconversion) after first-line treatment with peginterferon alfa-2a.
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Offer entecavir as an alternative second-line treatment to people who cannot tolerate tenofovir disoproxil or if it is contraindicated.
Treatment sequence in adults with HBeAg-negative chronic hepatitis B and compensated liver disease
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Offer a 48-week course of peginterferon alfa-2a as first-line treatment in adults with HBeAg-negative chronic hepatitis B and compensated liver disease. Avoid use of peginterferon alfa-2a in pregnancy unless the potential benefit outweighs risk. Women of childbearing potential must use effective contraception throughout therapy.
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Offer entecavir or tenofovir disoproxil as second-line treatment to people with detectable HBV DNA after first-line treatment with peginterferon alfa-2a.
Women who are pregnant or breastfeeding
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Offer tenofovir disoproxil to women with HBV DNA greater than 107 IU/ml in the third trimester to reduce the risk of transmission of HBV to the baby.
In June 2013, this was an off-label use of tenofovir disoproxil. See NICE's information on prescribing medicines.
Prophylactic treatment during immunosuppressive therapy
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In people who are HBsAg positive and have HBV DNA greater than 2000 IU/ml, offer prophylaxis with entecavir or tenofovir disoproxil.
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Start prophylaxis before beginning immunosuppressive therapy and continue for a minimum of 6 months after HBeAg seroconversion and HBV DNA is undetectable.
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In people who are HBsAg positive and have HBV DNA less than 2000 IU/ml, offer prophylaxis:
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consider lamivudine if immunosuppressive therapy is expected to last less than 6 months
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monitor HBV DNA monthly in people treated with lamivudine and change to tenofovir disoproxil if HBV DNA remains detectable after 3 months
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consider entecavir or tenofovir disoproxil if immunosuppressive therapy is expected to last longer than 6 months
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start prophylaxis before beginning immunosuppressive therapy and continue for a minimum of 6 months after stopping immunosuppressive therapy.
In June 2013, this was an off-label use of entecavir, lamivudine and tenofovir disoproxil. See NICE's information on prescribing medicines.
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