Treatment of hepatitis B depends on the phase of the infection. Acute hepatitis B has no specific antiviral therapy and is managed supportively, while chronic hepatitis B cannot be cured but can be suppressed with antiviral drugs in people who are at risk of progressive liver disease.
Acute hepatitis B
There is no specific antiviral treatment for acute hepatitis B. Care focuses on managing symptoms with rest, a balanced diet and plenty of fluids to prevent dehydration from vomiting and diarrhea. The decision to hospitalize patients should be made case by case, and they are watched for the rare development of fulminant hepatitis.
Who to treat in chronic infection
Not every person with chronic hepatitis B needs medication. The 2024 World Health Organization guidelines recommend antiviral treatment for adults and adolescents aged 12 years and older with chronic hepatitis B when any one of the following is present:
- evidence of significant fibrosis or cirrhosis (scarring of the liver) — an APRI score (a blood-test index of fibrosis) above 0.5, or a transient elastography value (an ultrasound-based measure of liver stiffness) above 7 kPa, or clinical features of cirrhosis — regardless of HBV DNA and ALT levels;
- HBV DNA (the amount of virus in the blood) above 2000 IU/mL together with an ALT (a liver enzyme that rises with liver-cell injury) above the upper limit of normal;
- coinfection with HIV, hepatitis D or hepatitis C, a family history of liver cancer or cirrhosis, immunosuppression, diabetes or fatty liver disease, or extrahepatic disease such as glomerulonephritis or vasculitis, regardless of HBV DNA and ALT levels.
Where HBV DNA testing is not available, persistently abnormal ALT on its own is enough to justify treatment.
Antiviral drugs
The first-line drugs are two oral nucleos(t)ide analogues, drugs that mimic the building blocks of DNA and block the viral polymerase, with a high barrier to resistance: tenofovir disoproxil fumarate (TDF) and entecavir (ETV). They suppress viral replication rather than eliminate the virus, so treatment is usually lifelong. Tenofovir alafenamide (TAF) is reserved for people with, or at risk of, kidney impairment or osteoporosis, and tenofovir combined with lamivudine or emtricitabine is an alternative where tenofovir alone is not available.
Suppressive treatment changes the course of the disease: it slows the advance of cirrhosis, reduces the incidence of liver cancer and improves long-term survival. Patients on treatment are monitored with HBV DNA and ALT, and they are screened for hepatocellular carcinoma.
Preventing transmission
Hepatitis B is also prevented from spreading to those at greatest risk, newborns of infected mothers and people recently exposed. Infants born to HBsAg-positive mothers should receive hepatitis B vaccine within 24 hours of birth, with hepatitis B immune globulin (HBIG, a preparation of ready-made anti-HBs antibodies) added in certain circumstances, followed by completion of the vaccine series. Pregnant women with an HBV DNA level of at least 200,000 IU/mL, or who are positive for HBeAg, can take tenofovir prophylaxis in the third trimester to reduce mother-to-child transmission. For other people exposed to HBV, post-exposure prophylaxis with vaccine, and in some cases HBIG, should be given as soon as possible, preferably within 24 hours.