Most adult icteric (jaundiced) patients with acute hepatitis B resolve their infection and do not require treatment. Subacute hepatic necrosis is characterised by a more protracted acute course and transition to chronic hepatitis with ongoing HBV replication.
Patients with fulminant hepatitis, including acute and subacute forms, should be considered for liver transplantation if appropriate. Nucleoside analogue antiviral therapy (see ‘Current antiviral therapies’, page 23), should be given as soon as possible; interferons are not useful for the treatment of acute or fulminant hepatitis.
Although there are no controlled trials of lamivudine or adefovir for patients with acute hepatitis, uncontrolled reports suggest some efficacy in these patients.
Treatment remains complex with somewhat unpredictable responses. Currently used antiviral agents either inhibit HBV replication or invoke immune responses which may be necessary but not sufficient to effect viral control.
Most treatment regimes involve either one potent drug (such as tenofovir or entecavir) or a combination of drugs (such as tenofovir plus lamivudine). For many patients treatment may need to be continued for many years. Poor compliance can lead to drug resistance.
General management principles
• The patient should be encouraged to understand the natural history of hepatitis B.
• The patient should be educated about their laboratory tests (including the significance of the serum aminotransferases, HBeAg, anti-HBe or HBV-DNA levels) and their liver biopsy findings (if done).
• It will help if the patient retains a copy of their blood test results.
• Patients must be made aware of their infectivity. Methods of preventing transmission should be emphasised (for example, practising safe sex).
• Vaccination should be offered to sexual partners, other household members and children.
• Reassure the patient that close, ongoing observation will be maintained. It is important to explain the indications for treatment so that patients understand why they may not require immediate therapy.
• Advise patients to carefully consider who they should disclose their illness to outside of their healthcare team.
• Practical support networks for the patient should be encouraged and counselling services where possible should be made available to them.
• Ensure that the patient will be referred for medical or specialist supervision. Specialists may recommend ongoing primary care management.
• Severe acute hepatitis B should be immediately referred to a hospital with a liver unit or facilities for transplant assessment. Measurement of the prothrombin time is important to ascertain the severity of acute hepatitis.
• Patients with chronic hepatitis B should be referred to specialist services in a timely fashion. Severe chronic hepatitis B requires rapid treatment.
• Patients with chronic hepatitis B are recommended to avoid alcohol.