Two different treatment strategies are applicable in both HBeAg-positive and HBeAg-negative chronic hepatitis B patients: treatment of finite duration with pegylated interferon alpha or nucleosides, and long-term treatment with nucleosides.
Finite-duration treatment (a 48-week course) with pegylated interferon alpha is mainly recommended for HBeAg-positive patients considered to have a good chance of HBe seroconversion. Finite-duration treatment may be possible with nucleosides for HBeAgpositive patients who develop HBe seroconversion on treatment.
The EASL guidelines suggest that an attempt at finite treatment with nucleosides should use the most potent agents with the highest barrier to resistance (entecavir or tenofovir) to rapidly reduce levels of viremia to undetectable levels and to avoid resistance.
For most, long term treatment is required. Patients who cannot achieve a sustained virological response off-treatment require extended therapy, namely HBeAg-positive patients who do not develop HBe seroconversion and in HBeAg-negative patients. This strategy is also recommended in patients with cirrhosis irrespective of HBeAg status or HBe seroconversion on treatment. Again, the most potent drugs with the optimal resistance profile i.e. tenofovir or entecavir, should be used as first-line monotherapies.
There is, as yet, no data to indicate an advantage of de novo combination treatment with tenofovir or entecavir in naïve patients. Therapeutic trials are in progress. Some experts recommend a de novo combination therapy approach to prevent potential resistance in patients with a high likelihood of developing resistance.
Co-infection
Some people carry two or more different blood-borne viruses, such as hepatitis B, hepatitis C, and HIV as they share similar routes of transmission. Co-infection tends to lead to faster progression of liver damage and an increased risk of liver cancer and cirrhosis. It can make treatment more difficult, but co-infection is not a bar to any particular treatment option.
In agreement with recent HIV guidelines, it is recommended that most coinfected patients be simultaneously treated for both HIV and HBV de novo.
In addition, patients with hepatitis B can also become infected with hepatitis D virus (HDV), an incomplete virus that requires the presence of HBV to survive in the body. Super-infection with HDV of a patient with HBV is more likely to cause severe chronic hepatitis and cirrhosis. Around 5% of people with HBV also have HDV, which is seen mainly in central Africa, the Middle East and central South America but rare in Europe and the US. Interferon alpha (conventional or pegylated) is the only drug effective on HDV replication.