Chronic hepatitis B (CHB) remains a significant global health concern, affecting millions worldwide and posing risks of liver cirrhosis, liver failure, and hepatocellular carcinoma (HCC).

Effective management of CHB requires timely diagnosis, tailored antiviral treatment, ongoing monitoring, and comprehensive patient care.

Early Diagnosis and Screening

A cornerstone in managing CHB is the early identification of infected individuals. Universal screening, especially within high-risk populations such as immigrants from regions with high HBV prevalence, is advocated to detect infections before significant liver damage occurs.

Laboratory assessments include serological markers like hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and quantitative viral load measures (HBV DNA). Reflex testing for hepatitis D virus (HDV) is recommended where appropriate, given the increased severity associated with coinfection.

Determining the phase of infection—including immune tolerance, immune active, inactive carrier status, or reactivation is critical to guide treatment decisions. This stratification hinges on levels of viral replication, liver enzyme elevations, and histological evaluation when warranted.

Antiviral Therapy: The Mainstay of Treatment

Current clinical guidelines recommend antiviral therapy for multiple patient categories, including those with active liver inflammation or fibrosis, elevated viral loads, cirrhosis, or a family history of HCC. First-line antiviral agents encompass nucleos(t)ide analogues such as tenofovir alafenamide, tenofovir disoproxil fumarate (TDF), and entecavir (ETV), all characterized by potent viral suppression and high genetic barriers to resistance.

Long-term studies affirm that tenofovir alafenamide is associated with superior renal and bones safety profiles compared to TDF, exhibiting minimal declines in estimated glomerular filtration rate and bones mineral density over extended treatment periods. Although modest increases in LDL cholesterol and body weight have been observed with tenofovir alafenamide, no corresponding surge in cardiovascular events has been reported.

Pegylated interferon-alpha (PEG-IFN) serves as an alternative in selected patients, offering finite-duration therapy with potential for sustained immunological control, albeit with greater side effects and contraindications.

Treatment duration depends on the patient's HBeAg status and clinical response. For HBeAg-positive patients without cirrhosis, therapy continues until HBeAg loss or seroconversion occurs, with an additional consolidation phase. In contrast, HBeAg-negative patients often require prolonged treatment, sometimes indefinitely, as defined by viral and serological markers.

Monitoring for Safety and Efficacy

Regular clinical and laboratory monitoring is essential during antiviral therapy to assess efficacy and detect adverse effects. Periodic evaluation of liver function tests, HBV DNA levels, and serological markers guides ongoing management, while renal function (e.g., estimated glomerular filtration rate) and bones mineral density require monitoring in patients receiving TDF.

The risk of hepatocellular carcinoma persists despite viral suppression, necessitating continued surveillance with imaging modalities and alpha-fetoprotein measurements, especially in patients with cirrhosis or other risk factors.

Dr. Jordan J. Feld, a leading hepatologist, has frequently emphasized this point, stating, "Current antiviral treatments successfully control viral replication and prevent the advancement of liver disease, yet they do not provide a cure. The risk of hepatocellular carcinoma, while reduced, is not eliminated, particularly in those who started treatment with established cirrhosis."

Lifestyle Considerations and Patient Education

Supporting antiviral treatment with lifestyle modifications enhances liver health. Maintaining a healthy weight, and managing comorbidities such as diabetes and obesity are recommended. Patients benefit from education on medication adherence, potential side effects, and the importance of regular follow-up to optimize outcomes.

Managing chronic hepatitis B safely entails a multifaceted approach combining early and accurate diagnosis, initiation of effective antiviral therapy tailored to patient-specific factors, routine safety and disease monitoring, and comprehensive care addressing special populations and lifestyle factors. Advances in antiviral medications, particularly the use of tenofovir alafenamide, have improved safety profiles and patient tolerability.

Continuous medical evaluation and adherence to updated clinical guidelines ensure optimal suppression of viral replication, reduced risk of liver complications, and better quality of life for those affected by CHB. Through vigilant and personalized care, chronic hepatitis B can be effectively controlled, mitigating its global health impact.