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.
- Tenofovir alafenamide or other alternatives may be commissioned for selected patients through current specialist pathways, so do not substitute from an outdated algorithm.
- Check HIV status before HBV monotherapy because entecavir or a single HBV-active nucleotide can select HIV resistance in untreated coinfection.
- Nucleos(t)ide analogues suppress replication but seldom eradicate intrahepatic viral templates, making treatment long term for many patients.
- Treatment does not abolish HCC risk; continue six-monthly surveillance whenever cirrhosis or NICE HBV risk criteria indicate it.
- Adherence and uninterrupted supply are safety-critical because virological rebound may cause a severe flare, especially in cirrhosis or pregnancy-related stopping.
Key red flags
Ascites, encephalopathy, variceal bleeding, jaundice or impaired synthetic function requires urgent antiviral and transplant-centre coordination; do not offer peginterferon in this setting.
New malaise, jaundice or a sharp ALT and DNA rise after stopping therapy can become life-threatening, particularly with cirrhosis, and requires same-day review.
Investigation priorities
Define viral activity, treatment indication and virological response over time.
Management branches
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.
- Check renal and bone risk, HIV status, previous antiviral exposure, pregnancy plans and likely adherence before agreeing oral therapy or a selected finite peginterferon strategy.
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.Confirm HIV status and previous lamivudine resistance, adjust for renal impairment and monitor for rebound after withdrawal. Lactic acidosis and severe hepatomegaly with steatosis are rare concerns; decompensated patients need close specialist monitoring.
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.Assess renal and bone risk, monitor kidney function and phosphate, and avoid unreviewed nephrotoxic combinations. Confirm HIV status and never use isolated HBV dosing as inadequate HIV treatment; abrupt withdrawal can cause severe hepatitis flare.