Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Assessment and referral

  • Arrange the following tests in primary care for adults who are hepatitis B surface antigen (HBsAg) positive:

    • hepatitis B e antigen (HBeAg)/antibody (anti-HBe) status

    • HBV DNA level

    • lgM antibody to hepatitis B core antigen (anti-HBc lgM)

    • hepatitis C virus antibody (anti-HCV)

    • hepatitis delta virus antibody (anti-HDV)

    • HIV antibody (anti-HIV)

    • lgG antibody to hepatitis A virus (anti-HAV)

    • 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

    • tests for hepatocellular carcinoma (HCC), including hepatic ultrasound and alpha-fetoprotein testing.

  • Include the results of the initial tests with the referral (see recommendation 1.2.1).

Treatment sequence in adults with HBeAg-positive chronic hepatitis B and compensated liver disease

  • 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[1].

  • 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.

  • 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

  • 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[1].

  • 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

  • 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[2].

Prophylactic treatment during immunosuppressive therapy

  • In people who are HBsAg positive and have HBV DNA greater than 2000 IU/ml, offer prophylaxis with entecavir or tenofovir disoproxil[3].

    • Start prophylaxis before beginning immunosuppressive therapy and continue for a minimum of 6 months after HBeAg seroconversion and HBV DNA is undetectable.

  • In people who are HBsAg positive and have HBV DNA less than 2000 IU/ml, offer prophylaxis:

    • consider lamivudine[3] if immunosuppressive therapy is expected to last less than 6 months

      • monitor HBV DNA monthly in people treated with lamivudine and change to tenofovir disoproxil if HBV DNA remains detectable after 3 months

    • consider entecavir or tenofovir disoproxil[3] if immunosuppressive therapy is expected to last longer than 6 months

    • start prophylaxis before beginning immunosuppressive therapy and continue for a minimum of 6 months after stopping immunosuppressive therapy.



[1] Avoid use of peginterferon alfa-2a in pregnancy unless the potential benefit outweighs risk. Women of childbearing potential must use effective contraception throughout therapy.

[2] At the time of publication (June 2013), tenofovir disoproxil did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

[3] At the time of publication (June 2013), entecavir, lamivudine and tenofovir disoproxil did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

  • National Institute for Health and Care Excellence (NICE)