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 in the section on assessment and referral in primary care).

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

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

  • 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.

    In June 2013, this was an off-label use of tenofovir disoproxil. See NICE's information on prescribing medicines.

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.

    • 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 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 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.

      In June 2013, this was an off-label use of entecavir, lamivudine and tenofovir disoproxil. See NICE's information on prescribing medicines.

  • National Institute for Health and Care Excellence (NICE)