The management of hepatitis B involves assessing the need for ongoing treatment, which may be initiated in secondary care and continued in primary care under a shared care arrangement NICE CKS. Supportive symptomatic care can include simple measures for itch, such as a cool environment and loose clothing, or chlorphenamine at night, with caution in severe liver impairment NICE CKS. For nausea, metoclopramide or cyclizine may be offered for mild liver disease, but caution is advised with more severe impairment, and metoclopramide should not be used for longer than 5 days due to risks of neurological effects NICE CKS. Potentially hepatotoxic drugs should be withheld, and specialist advice sought if unsure NICE CKS. Referral to a genito-urinary medicine department for STI screening or a drug rehabilitation agency may be appropriate NICE CKS. Patient information on hepatitis B should be provided, and local Health Protection Units notified promptly for surveillance and contact tracing NICE CKS. Close contacts should be offered hepatitis B vaccination and immunoglobulin if indicated NICE CKS. Pregnant women with hepatitis B should be aware that their infant requires immunisation from birth to prevent transmission NICE CKS. Hepatitis A vaccination should be ensured for those with chronic hepatitis B who are not immune NICE CKS. Regular review by a liver specialist is required for all individuals with chronic hepatitis B to monitor serology, screen for complications like hepatocellular cancer, and manage treatment NICE CKS.
For chronic hepatitis B, antiviral treatment is considered for adults aged 30 years and older with HBV DNA > 2000 IU/ml and abnormal ALT on two consecutive tests 3 months apart NICE CG165. Younger adults with the same viral load and ALT levels may be treated if there is evidence of necroinflammation or fibrosis NICE CG165. Adults with HBV DNA > 20,000 IU/ml and abnormal ALT also warrant antiviral treatment regardless of age or liver disease extent NICE CG165. Antiviral treatment is also offered to adults with cirrhosis and detectable HBV DNA, and considered for those with HBV DNA > 2000 IU/ml and evidence of necroinflammation or fibrosis NICE CG165. Treatment should be initiated by a specialist NICE CG165. For HBeAg-positive chronic hepatitis B with compensated liver disease, a 48-week course of peginterferon alfa-2a is offered as first-line treatment NICE CG165. For children and young people with chronic hepatitis B and compensated liver disease, antiviral treatment is offered if there is significant fibrosis or abnormal ALT on two consecutive tests 3 months apart NICE CG165. Peginterferon alfa-2a can be considered as first-line treatment, with a nucleoside or nucleotide analogue as second-line NICE CG165. Adults with decompensated liver disease require management in conjunction with a liver transplant centre, and entecavir or tenofovir disoproxil may be used as first-line treatment depending on resistance history NICE CG165. Tenofovir disoproxil is offered to women in the third trimester with HBV DNA > 10^7 IU/ml to reduce transmission risk to the baby NICE CG165.
For acute hepatitis C, spontaneous viral clearance occurs in 15-45% of cases within 6 months without treatment NICE CKS. If spontaneous resolution does not occur, treatment should be started promptly, as treatment during the acute phase is more effective NICE CKS. All individuals with chronic hepatitis C infection should be considered for antiviral therapy, initiated by a specialist, with the goal of eradicating the virus and achieving a sustained virological response (SVR), which is considered a cure NICE CKS. Direct-acting antivirals (DAAs) are the first-line treatment, are well-tolerated, and result in high SVR rates NICE CKS.