| |
AASLD 2009 |
APASL 2012 |
EASL 2012 |
| Immune tolerant |
HBeAg positive, ALT ≤ 2 X ULN Observe. Consider tx when ALT becomes elevated (degree of elevation not mentioned). Consider biopsy in >40 yrs/ ALT high normal/ FHx HCC. Consider tx if HBV DNA >20,000 and biopsy significant inflammation/fibrosis |
HBeAg Positive, ALT normal (regardless of HBV DNA) – monitor HBV DNA/ALT/HBeAg 3-6 monthly
HBeAg positive, HBV DNA ≥ 20,000IU/ml, ALT 1-2 x ULN → No tx. Monitor and consider liver biopsy or fibroscan if >40 yrs and tx if moderate/severe inflammation/fibrosis. |
HBeAg Positive, PNALT and high HBV DNA. If <30 yrs and no FHX of HCC or evidence of liver disease – 3 monthly followup. No tx required. Consider liver biopsy if >30yrs and/or FHx HCC/cirrhosis. |
| Immune clearance |
HBeAg positive HBV DNA >20,000 IU/ml ALT > 1-2 X ULN. →Observe for 3-6 months.
If no spontaneous HBeAg loss, HBV DNA≥20,000 IU/ml and ALT >2x ULN – treat. .
If HBV DNA>20,000. ALT <2xULN or >40 years→Consider liver biopsy and treat if mod/severe inflammation/fibrosis. |
HBV DNA ≥ 20,000: and ALT 2-5 x ULN - Treat if persistent over 3-6 months or if concerns about decompensation.
Or ALT > 5 X ULN . Treat, although if HBV DNA < 2 x 10 5 may choose to observe for 3 months for spontaneous seroconversion, if no risk of decompensation. |
Obviously active CHB (HBeAg positive, ALT >2xULN and HBV DNA>20,000) - start tx (no liver biopsy required but fibroscan useful).
Any patient with elevated HBV DNA>2000, ALT >ULN and mod-severe fibrosis can be considered for treatment. |
| |
AASLD 2009 |
APASL 2012 |
EASL 2012 |
| Immune control |
HBeAg negative, HBV DNA ≤2000 IU/ml, ALT ≤ ULN → Observe. |
HBV DNA <2000 IU/ml and ALT normal → Observe with ALT/DNA 6-12 monthly. |
HBeAg negative, PNALT, HBV DNA<2000 – no tx. 3/12ly ALT and HBV DNA 6-12 monthly for at least 3 years |
| Immune Escape |
HBeAg negative, HBV DNA >2000 IU/ml, ALT > 2 x ULN → Treat.
HBeAg negative, HBV DNA >2000 IU/ml and ALT 1-2 X ULN → Consider liver biopsy and treat if moderate/severe inflammation or fibrosis. |
HBV DNA ≥ 2000 IU/ml and ALT <2 X ULN → No tx. If age >40 yrs liver biopsy or fibroscan and tx if moderate/severe inflammation.
HBV DNA ≥ 2000 IU/ml and ALT > 2 X ULN → treat if persistent for 3-6 months or concern re decompensation. |
Obviously active CHB (HBeAg positive, ALT >2xULN and HBV DNA>20,000) - start tx (no liver biopsy required but fibroscan useful).
Any patient with elevated HBV DNA>2000, ALT >ULN and mod-severe fibrosis can be considered for treatment. |
| Cirrhosis – compensated |
HBV DNA > 2000 IU/ml → treat.
HBV DNA <2000 IU/ml consider tx if ALT elevated. |
HBV DNA <2000 IU/ml → No tx. MonitorALT/HBeAg or HBV DNA 3 monthly.
HBV DNA ≥ 2000 IU/ml and ALT elevated →treat.
Can consider IFN only if ALT not ≥ 5 X ULN. |
Consider starting tx if detectable HBV DNA even if ALT normal. |
| Cirrhosis - decompensated |
If HBV DNA detectable coordinate tx with NA with transplant centre. |
Urgent treatment with NAs. (HBV DNA level not mentioned). |
Urgent commencement of NA treatment if any detectable HBV DNA. Consider transplant |
