Table 3. Recommendations for the Management of Chronic Hepatitis B Infection in Special Patient Populations
Patient PopulationKey IssuesRecommendations
Decompensated liver disease*∙ Higher risk of cirrhosis, HCC, and mortality
∙ Often associated with comorbidities such as renal dysfunction, protein malnutrition, or vitamin deficiencies
∙ Treatment is indicated irrespective of HBV DNA levels to improve clinical status
∙ Recommended agents: ETV and TDF (well tolerated and shown to improve liver status)
∙ Regular monitoring of renal function and lactic acidosis recommended during ETV or TDF therapy
∙ IFNs contraindicated; they may increase risk of sepsis and decompensation
HCV, HDV, or HIV coinfection∙ Multiple viruses to be managed
∙ Higher risk of cirrhosis, HCC, and mortality
∙ Treatment should target the dominant virus
∙ In HIV coinfection, LVD and TDF are active against both HBV and HIV; ETV is not recommended unless the patient also receives HAART
∙ Peg-IFN only drug effective against HDV
∙ Some reports of renal toxicity with TDF in HBV/HIV-coinfected patients
LT recipients∙ Risk of HBV reactivation∙ Anti-HBV prophylaxis before and/or after LT recommended
∙ HBIg with or without LVD historically is the most common approach; however, there is no consensus on HBIg dose and duration (that is, long-term low dose vs. short-term high dose; HBIg withdrawal; on-demand HBIg on NUC maintenance)
∙ Alternative prophylactic regimens: ETV or TDF, alone or combined with HBIg
Immune-suppressive or chemotherapy∙ Risk of HBV reactivation∙ In HBsAg-positive patients, preemptive NUC therapy should be initiated at the onset of immunesuppressive or chemotherapy to prevent HBV reactivation
∙ In anti-HBc-positive patients receiving rituximab, anti-HBV prophylaxis is recommended
Pregnancy∙ Risk of perinatal infection from highly viremic mothers
∙ Risk of fetal damage
∙ IFN-based therapy is contraindicated because of its antiproliferative effect
∙ LdT and TDF are classified as category B (no risk in animal studies but unknown in humans)
∙ LVD, ADV, and ETV are classified as category C (teratogenic in animals, unknown in humans)
Pediatric patients∙ Infection at an early age is associated with an increased risk of long-term complications
∙ Long-term safety and drug resistance are important concerns
∙ Recommended to initiate treatment if ALT persistently >2× ULN
∙ IFNs given parenterally and associated with temporarily disrupted growth43
  • Data compiled from refs. 1012.

  • * Defined as child B or C cirrhosis, or Child–Turcotte–Pugh score ≥7.

  • ADV, adefovir; ALT, alanine aminotransferase; ETV, entecavir; HAART, highly active antiretroviral therapy; HBc, hepatitis B core antigen; HBIg, hepatitis B immunoglobulin; HBsAg, hepatitis B s antigen; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HDV, hepatitis D virus; HIV, human immunodeficiency virus; IFN, interferon; LdT, telbivudine; LT, liver transplant; LVD, lamivudine; NUC, nucleo(s)tide analog; Peg-IFN, pegylated interferon; TDF, tenofovir; ULN, upper limit of normal.