Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Escalate
Jaundice, increasing INR, encephalopathy, new ascites, variceal bleeding or a marked biochemical flare in chronic HBV requires urgent specialist assessment. Decompensated cirrhosis with detectable HBV DNA needs prompt antiviral and transplant-centre planning, not peginterferon. Never stop entecavir, tenofovir or an HBV-active HIV regimen abruptly without specialist direction because severe rebound hepatitis can follow; assess adherence, renal function, resistance and other causes while maintaining a safe antiviral plan.
Synopsis
Select chronic hepatitis B treatment from viral activity and liver risk, prescribe high-barrier antivirals safely, and sustain monitoring through suppression, pregnancy and immunosuppression.
Treat all adults with cirrhosis and detectable HBV DNA according to NICE, regardless of HBeAg status or ALT activity.
Without cirrhosis, treatment decisions integrate HBV DNA, serial ALT, fibrosis, age, family history, extrahepatic disease and future immunosuppression.
Entecavir and tenofovir disoproxil are potent oral options with high resistance barriers when used correctly; renal, bone and resistance context shapes selection.
Key red flags
Decompensated disease
Ascites, encephalopathy, variceal bleeding, jaundice or impaired synthetic function requires urgent antiviral and transplant-centre coordination; do not offer peginterferon in this setting.
Investigation priorities
01
Quantitative HBV DNA and ALT trendFirst step
Define viral activity, treatment indication and virological response over time.
Management branches
SelectDecide who needs treatment
Chronic HBV is confirmed and baseline DNA, ALT and fibrosis results are available.
Treat cirrhosis with detectable HBV DNA through specialist care, and urgently link decompensated disease to a transplant service while correcting other complications.
For non-cirrhotic disease, integrate serial DNA and ALT with fibrosis, age, HBeAg status, family HCC history, extrahepatic disease and planned immunosuppression rather than using one result.
Key medicines
EntecavirFor nucleoside-naive adults with compensated disease, 0.5 mg once daily with or without food; use 1 mg once daily on an empty stomach in lamivudine-refractory or decompensated contexts, with renal adjustment and specialist confirmation.
Tenofovir disoproxil 245 mg tabletsThe licensed adult tablet dose is 245 mg once daily with food; apply the current SmPC renal restrictions or interval adjustment and specialist HBV or HIV plan rather than extrapolating this dose to every patient.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.