Long-term management

Ongoing and consistent monitoring is an essential component of the management of this dynamic condition.1

It is critical to remain vigilant about regular screening for liver damage and liver cancer.1

Routine monitoring for possible nonadherence or the development of resistance is also recommended for patients on treatment.1

Patients with chronic hepatitis B can remain asymptomatic until they reach advanced stages of liver disease.2,3

Routine tests

Ongoing monitoring may include:

Blood tests every 3-6 months

Blood tests every 3-6 months to monitor HBV DNA and ALT levels1,4,5

Ongoing HCC surveillance for 6 months

Ongoing HCC surveillance including ultrasound with/without AFP every 6 months for high risk patients1

Ongoing evaluations for patients

Order HBeAg, HBV DNA, and ALT tests for all patients with chronic hepatitis B.

AASLD 2018 guidance1

HBeAg HBV DNA (IU/mL) ALT Recommended Follow-up
+ >20,000 ≥2x ULN or significant histologic diseasea Treat patients
(Immune-active CHB)
- >2000
+ / - Detectable Cirrhosis, regardless of ALT Treat patients
+ ≤20,000 <2x ULN Consider treatment based on:
  • Age (>40 yr)
  • Family history of HCC
  • Previous treatment historyb
  • Extrahepatic manifestationsc
- ≤2,000
ULN for ALT is 35 U/L for men and 25 U/L for women
  • a Liver biopsy/non-invasive testing showing moderate-to-severe necroinflammatory activity on histology and/or fibrosis.
  • b Delayed (months or years after discontinuation) serologic benefits may occur with pegylated interferon. For patients with prior exposure to nucleos(t)ide analogs, there is a risk of drug resistance.
  • c Presence of extrahepatic manifestations is an indication for treatment, independent of liver disease severity.

HCC surveillance recommendations—
AASLD guidance overview1

Recommended HCC surveillance of hepatitis B carriers at high risk for HCC

  • Ultrasound surveillance every 6 months
  • Periodic screening for AFP alone when ultrasound is not available or is cost-prohibitive

Populations at high risk for HCC

  • HBsAg+ Asian or African American men >40 years of age
  • HBsAg+ Asian women >50 years of age
  • Patients with cirrhosis
  • People with a family history of HCC
  • People with hepatitis D infection
  • Patients with fatty liver
  • People coinfected with HIV or HCV

Adherence to treatment in clinical practice may be lower than in clinical trials. This could be because patients are less motivated, less frequently monitored, and often have to pay for part of the costs of the medications.2

It may be helpful to discuss the following points about chronic hepatitis B management with your patients.

  • Engage in an open dialogue with your patients and listen carefully to their concerns. Encouraging your patients to express what is on their minds may help them become more involved in and committed to their chronic hepatitis B treatment plan.
  • Advise patients to check with you before taking any new medications, over-the-counter medicines, or herbal supplements, and to let you know if they experience any side effects.6
  • Urge your patients to take their chronic hepatitis B medicine exactly as prescribed. Explain to your patients that they should not stop taking their chronic hepatitis B medicine without first discussing it with you.6
  • Suggest medication reminder tools, such as a cell phone app, an alarm clock, or a 7-day pill box, for those patients who are prescribed oral antivirals and need help remembering to take them.
  • Encourage patients to avoid alcohol and smoking. Alcohol and smoking can be harmful to a liver already infected with the hepatitis B virus.7
  • Discuss lifestyle changes that can benefit the health of the liver. Although there is no special diet for people with chronic hepatitis B, eating a well-balanced, low-fat diet that includes plenty of fruits and vegetables is recommended.7

AASLD=American Association for the Study of Liver Diseases; AFP=alpha-fetoprotein; ALT=alanine aminotransferase; CHB=chronic hepatitis B; HBeAg=hepatitis B e-antigen; HBsAg=hepatitis B surface antigen; HBV DNA=hepatitis B virus deoxyribonucleic acid; HCC=hepatocellular carcinoma; HCV=hepatitis C virus; HIV=human immunodeficiency virus; ULN=upper limit of normal.