Drug treatment

Understanding hepatitis B and how it is treated

Chronic hepatitis B is treated with drugs called antivirals. Antiviral drugs work by reducing the amount of virus that is found in the body.

If you have chronic hepatitis B, you or a family member or carer, if appropriate, should be given information about the following before being assessed for drug treatment:

  • how the condition might change over the longer term

  • how well drug treatments might work, and their possible side effects

  • the different types of drug treatment you may be offered

  • the aims of drug treatment and why it may not work in some people

  • how the hepatitis B virus (HBV) is passed from person to person and how it can be prevented.

You may also be advised to have an HIV test before starting drug treatment.

You should be given a written summary describing the treatment you will receive. If you are about to start taking a drug called peginterferon alfa‑2a, you or a family member or carer should be given additional information about how to inject the drug.

Contact tracing

NICE has produced guidance on ways to promote and offer testing to people at increased risk of hepatitis B and C (www.nice.org.uk/ph43). Healthcare professionals may ask for your help in encouraging people you have been in contact with to be tested for HBV, such as previous sexual partners.

Drug treatment in adults

A number of factors influence whether drug treatment is recommended, such as your age, the amount of virus found in the bloodstream (called viral load), whether your liver tests are normal (called liver function), and the extent of any liver disease (which may be called fibrosis, cirrhosis or inflammation).

If you also have HIV, hepatitis C or hepatitis D, the information on drug treatments below may not apply to you. Information on treatments for people who have chronic hepatitis B and either hepatitis C or hepatitis D is covered in Drug treatment in adults with hepatitis C or hepatitis D below.

Which drug treatment will I be offered?

  • If you are starting drug treatment for the first time and your liver continues to work adequately (called compensated liver disease), you should be offered a drug called peginterferon alfa‑2a as a first course of treatment.

  • You may need to change treatment if monitoring tests suggest this is needed. If so, your doctor will offer either tenofovir disoproxil or entecavir.

  • Alternatively, if your treatment is working well, your doctor may advise you to stop drug treatment altogether.

  • Once you have started antiviral treatment, you should not stop taking it without speaking to your doctor.

NICE has produced guidance on the use of drug treatments in people with chronic hepatitis B (see Other NICE guidance for details). You should not be offered treatment with either telbivudine or adefovir dipivoxil because more effective drugs are now available. If you are taking one of these drugs, you should discuss this with your doctor.

Drug treatment in adults with decompensated liver disease

If your liver is showing signs of failing (called decompensated liver disease), you should be offered entecavir as a first course of treatment, or tenofovir disoproxil if entecavir is not suitable for you. You should not be offered treatment with peginterferon alfa‑2a.

Drug treatment in women who are pregnant or breastfeeding

If you have chronic hepatitis B and are pregnant or breastfeeding, a specialist doctor or nurse should discuss whether drug treatment is needed to prevent your baby from being infected with HBV.

While you are pregnant, you should be offered blood tests to check the amount of HBV in your bloodstream (called viral load). If your viral load is high, you should be offered a drug called tenofovir disoproxil in the final 3 months of pregnancy to lower the chance of your baby becoming infected with HBV. This treatment should be continued until 4 to 12 weeks after the birth. If remaining on drug treatment may benefit your own health, your doctor will suggest you continue taking treatment long term. Women who take tenofovir disoproxil during or after pregnancy should receive regular monitoring for any sudden worsening in the signs or symptoms of chronic hepatitis B (called postnatal HBV flares).

Your baby should be offered immunisation against HBV and follow-up care in line with current guidance from NICE and the Department of Health (see Antiviral treatment recommendations for women who are pregnant or breastfeeding in the NICE guideline on Hepatitis B (chronic) for details). You should be aware that there is no risk of your baby becoming infected with HBV through breastfeeding if this guidance is followed and your baby completes the immunisation course, and that you can continue taking antiviral treatment while breastfeeding.

'Off-label' drug treatment

Drugs are approved for use (licensed) in particular conditions or for particular groups of people. At the time of publication (June 2013), some of the drugs mentioned in this guideline are being recommended for use 'off label'. This means they may not be prescribed exactly as set out in the licence. You can find more information about licensing drugs at NHS Choices.

If a healthcare professional offers a drug treatment 'off label', they should explain the treatment and discuss the possible benefits and harms with the patient (or their parent or carer) so that they have enough information to decide whether or not to have the treatment. This is called giving informed consent. The antiviral drugs that NICE is recommending 'off label' are described in Medical terms explained.

Drug treatment in adults with hepatitis C or hepatitis D

If you have another viral infection as well as chronic hepatitis B, any treatment that you take should be suitable for both conditions.

If you have hepatitis C infection and chronic hepatitis B, you should be offered treatment with a peginterferon alfa and ribavirin.

If you have hepatitis D infection (also called hepatitis delta) and chronic hepatitis B you should be offered treatment with peginterferon alfa-2a if you have significant liver disease (called fibrosis). The recommended course of treatment is 48 weeks, but your doctor may advise a longer treatment course, depending on the response.

Drug treatment in children and young people

If you are a child or young person with chronic hepatitis B, you should be offered drug treatment if you have significant liver disease (called fibrosis or cirrhosis), or if your liver tests are abnormal (called abnormal liver function). If your liver continues to work adequately (called compensated liver disease) and you have not taken drug treatment before, you may be offered peginterferon alfa-2a. This treatment is usually taken for 48 weeks. You will be monitored once treatment starts and you may be offered a different treatment if monitoring tests suggest this is needed.

Drug treatment in people receiving cancer chemotherapy or immunosuppressive therapy

People who have previously been infected with HBV and have cleared the infection may be at risk of the infection reappearing if they take immunosuppressive therapy. This is the name for a range of treatments that are given to control the body's immune response, including chemotherapy, drugs given to people having bone marrow or organ transplants, or to people who have certain diseases of the immune system.

If you are due to begin immunosuppressive therapy and test positive for hepatitis B surface antigen (HBsAg) or antibodies to hepatitis B core antigen (anti-HBc), you should have further tests before you start treatment to determine whether HBV may reappear and whether you may need to take antiviral treatment.

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