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home - Liver - Hepatitis B - Hepatitis B Treatment Written by Dr Sebastian Zeki
Knowledge


Understands the serological interpretation categorisation and
investigation of patients with chronic hepatitis B and/or C with
particular emphasis on the need for treatment and surveillance

Recognises the particular populations at risk
Aware of national and international agreed guidelines on viral
hepatitis management and use of interferon and antiviral drugs

Aware of hepatitis B reactivation in the context of immunosuppression
Skills
Uses appropriate diagnostic modalities including serology
genotyping viral load measurements liver biopsy and related
investigations

Monitors anti-viral and immunomodulatory therapies with appropriate
investigations

Behaviours
Communicates effectively with patients and relatives in the context of
viral liver disease and underlying social and psychological risk factors

Marshals multi-disciplinary support networks and in particular
recognise the crucial role of nurse practitioners in disease
management

Also...

Knowledge


Identifies patients with acute hepatitis B and can a rtain the
severity of their illness

Defines the different phases of chronic hepatitis B infection with a
clear understanding of serological results

Appreciates risks of transmission to close contacts
Has awareness of indications for therapy in both HBeAg positive and
negative hepatitis and the potential influence of genotype on choice of
therapy

Identifies patients where prophylaxis is required to prevent
reactivation and vertical transmission

Can determine an appropriate surveillance programme for those
patients with varices and/or hepatocellular carcinoma

Identifies patients who are appropriate candidates for liver transplant


Skills
Demonstrates ability to take a relevant history perform examination
and organise appropriate investigations

Able to advise risks of viral transmission
Interprets results of blood tests for hepatitis B antigen and antibody
Appreciates when liver biopsy is appropriate
Be able to select the most appropriate treatment and how to monitor
patient response

Able to select appropriate imaging techniques for evaluation of
abnormal results
Behaviours
Appreciates the cultural differences in the ethnic populations infected
and the influence this may have on screening


Provides advice and education to families and shows appreciation of
the potential difficulties that may arise

Understands the importance of cooperation with virologists and staff
in other clinical laboratories

Hepatitis B Treatment

Treatment Endpoints HBV DNA>20,000IU/ml HBV DNA<20,000IU/ml No treatment ALT normal ALT 1-2X normal value ALT >2X normal value No treatment Treat or Bx first to determine if significant disease present Treat HBeAg +ve Spurious indications: Chronic HBV- Immune tolerant phase (+ high levels of serum HBV DNA but N serum ALT levels/ little activity on liver bx).Inactive carrier or low replicative phase (with low levels of or no detectable HBV DNA in serum and normal serum ALT levels).Latent HBV infection (HBV DNA without HBsAg). Possible Indications for therapy: Patients in the immune-active phase who do not have advanced fibrosis or cirrhosis (HBeAg-positive or HBeAg-negative chronic hepatitis). Special Indications for Therapy:Acute liver failure, Clinical complications of cirrhosis, Cirrhosis or advanced fibrosis with HBV DNA in serum, Reactivation of chronic HBV after chemotherapy or immunosuppression Indications for Treatment:Compensated cirrhosis and HBV DNA >2,000 IU/mL.Decompensated cirrhosis and detectable HBV DNA. Hepatitis B Treat- Treat: Can use IFNa,LAM,ADV,ETV or LdT Treat: Can use IFNa,LAM,ADV,ETV or LdT HBV DNA+ with decompensated cirrhosis —Refer to liver transplant centers.They may benefit from antiviral therapy such as lamivudine,telbuvidine(either best used in combo with last two) entecavir, adefovir, , tenofovir. Interferon is contraindicatedDecompensated cirrhosis —If adefovir monotherapy is used, HBV DNA levels and liver function should be monitored closely (monthly or more often) and treatment modified by switching to tenofovir or adding lamivudine, telbivudine, or entecavir if virus suppression is slow or inadequateRenal function (creatinine every one to three months) should be monitored closely in patients receiving adefovir or tenofovir.Compensated cirrhosis —In patients with clinically and biochemically compensated cirrhosis, interferon may be used with caution but nucleosides/nucleotides are saferBecause of the need for long-term treatment, adefovir, entecavir, or tenofovir is preferred. Counselling and PreventionEtoh is associated with a worse prognosis and HCC, therefore if the patient has cirrhosis then advise abstinence.Advise appropriate immunizationsCounsel regarding the risk of transmission to others- (ie, vaccination of spouses and steady sex partners in individuals with monogamous partners, and safe sex practice including use of condoms in subjects with multiple partners), perinatal transmission, and risk of environmental exposure from blood.Vaccinate Hep B -ve household members.Baby of HBsAg +ve pregnant women need Hep B Ig + vaccine immedi-ately after delivery.HBeAg positive healthcare workers should not perform invasive procedures without prior counseling and advice from an expert review panel. No treatment unless:Recurrent hepatitis flares + fail to clear HBeAg-Patients with icteric flares-Those with active or advanced histologic findings (such as moderate/severe inflammation or bridging fibrosis/cirrhosis),> 40 with persistently high HBV DNA levels-HBV-related polyarteritis nodosa Delay tx for 3-6m if newly diagnosed HBeAg +ve with compensated liver disease to see if spontaneous HBeAg seroconversion will occur HBeAg-positive endpoint: SeroconversionContinue treatment for 6 months after seroconversion50% patients will need several years of treatmentContinue if viral suppression maintained but have not serocon-verted Duration and Treatment Endpoints—HBeAg -ve chronic hepatitis —Not been establishedCan stop after seroconversionSeroconversion only happens in 5% so usually require many years of treatmentCirrhosis —The aim of treatment is to prevent liver failure and HCCTreatment is life long HBV DNA>2,000IU/ml HBV DNA<2,000IU/ml No treatment ALT normal ALT 1-2X normal value ALT >2X normal value No treatment Treat or Bx first to determine if significant disease present Treat HBeAg -ve Written by Dr Sebastian Zeki

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