Deciding on the Best Treatment in Patients With Various Types of Hepatitis B

Rowen K. Zetterman, MD


April 19, 2016

In This Article

Immune-Tolerant Chronic Hepatitis B

Neonates are likely to develop immune-tolerant chronic hepatitis B after HBV infection, characterized by high levels of HBV DNA (>200,000 IU/mL), presence of HBeAg, and normal ALT levels. This phase of infection can last for 20-40 years when acquired as a neonate but is typically shorter when acquired as an adult.[21] Liver injury is not usually present in those with immune-tolerant disease, and histologic examination may be normal or show only minimal inflammation and fibrosis. Eventual transformation to immune-active disease is likely.


The AASLD recommends against antiviral therapy for adults with immune-tolerant chronic hepatitis B.[9] This stage is defined by ALT levels ≤ 30 U/L in men and ≤ 19 U/L in women. Currently, evidence is insufficient that antiviral treatment of adults with immune-tolerant chronic hepatitis B will reduce the risk for cirrhosis or hepatocellular carcinoma. These patients should be followed with assessment of ALT levels every 4-6 months to detect transformation to immune-active disease.

The AASLD suggests antiviral therapy in the selected group of adults > 40 years of age with a normal ALT level, an elevated HBV DNA level (> 1,000,000 IU/mL), and a liver biopsy showing significant necroinflammation or fibrosis.[9] The risk for liver injury in chronic hepatitis B increases with chronologic age and high circulating HBV DNA levels.[22] For patients with moderate to severe hepatic inflammation and/or fibrosis, treatment can be considered.[9]


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