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

Rowen K. Zetterman, MD


April 19, 2016

In This Article

Inactive Chronic Hepatitis B

Loss of HBeAg with reduction of HBV DNA levels and normalization of liver tests can indicate transition to inactive chronic hepatitis B. Liver inflammation can be minimal or absent, and some patients will have improvement in liver fibrosis. Of these patients, 0.7% will clear HBsAg annually[31]; this is most likely to occur in those with very low HBV DNA levels. The loss of HBsAg appears to lessen the risk for subsequent cirrhosis and hepatocellular carcinoma.

For patients with long-standing immune-tolerant disease who seroconvert to anti-HBe after 40 years of age, there is a greater association with cirrhosis and hepatocellular carcinoma, whereas seroconversion at an earlier age seems to be associated with a lesser risk.[32]

Some patients may revert to immune-active disease from inactive chronic hepatitis B. Reactivation may follow chemotherapy or immunosuppression. Patients with inactive chronic hepatitis B or those with isolated anti-HBc who undergo chemotherapy or long-term immunosuppression should be considered for treatment with nucleoside/nucleotide analogues during such treatment and for an additional 6 months after it.[33,34] If these patients are not treated with antiviral drugs during chemotherapy, they should be followed with periodic measurement of ALT levels and treated when evidence of HBV relapse is found. In China, 70% of cases of acute-on-chronic liver failure is due to reactivation of quiescent HBV infection.[35]


Treatment for patients with inactive chronic hepatitis B, as characterized by normal aminotransferase values and low levels of HBV DNA (< 2000 IU/mL), is generally not indicated.[10] These patients should be evaluated periodically with measurement of serum ALT levels to assess for HBV reactivation. Because prior treatment with antiviral drugs will not completely eliminate risk, these patients should be screened for hepatocellular carcinoma with ultrasound every 6 months.


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