AASLD Guideline-2016, for treatment of chronic Hepatitis B

The American Association for the Study of Liver Diseases (AASLD) recommends antiviral therapy for adults with immune-active CHB (hepatitis B e antigen [HBeAg] negative or HBeAg positive) to decrease the risk of liver-related complications. (Quality/Certainty of Evidence: Moderate, Strength of Recommendation: Strong)

The AASLD recommends pegylated interferon (Peg-IFN), entecavir, or tenofovir as preferred initial therapy for adults with immune-active CHB. (Quality/Certainty of Evidence: Low, Strength of Recommendation: Strong)

Treatment of Adults with Immune-Tolerant CHB

The AASLD recommends against antiviral therapy for adults with immune-tolerant CHB. (Quality/Certainty of Evidence: Moderate, Strength of Recommendation: Strong)

The AASLD suggests that alanine aminotransferase (ALT) levels be tested at least every 6 months for adults with immune-tolerant CHB to monitor for potential transition to immune-active or -inactive CHB. (Quality/Certainty of Evidence: Very low, Strength of Recommendation: Conditional)

The AASLD suggests antiviral therapy in the select group of adults >40 years of age with normal ALT and elevated hepatitis B virus deoxyribonucleic acid (HBV DNA) (≥1,000,000 IU/mL) and liver biopsy showing significant necroinflammation or fibrosis. (Quality/Certainty of Evidence: Very low, Strength of Recommendation: Conditional)

Treatment of HBeAg Positive Immune-Active Chronic Hepatitis Persons Who Seroconvert to Anti-HBe on Nucleos(t)ide Analog (NA) Therapy

The AASLD suggests that HBeAg-positive adults without cirrhosis with CHB who seroconvert to anti-HBe on therapy discontinue NAs after a period of treatment consolidation. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Conditional)

The AASLD suggests indefinite antiviral therapy for HBeAg-positive adults with cirrhosis with CHB who seroconvert to anti-HBe on NA therapy, based on concerns for potential clinical decompensation and death, unless there is a strong competing rationale for treatment discontinuation. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Conditional)

Duration of Treatment in Persons with HBeAg-Negative Immune-Active CHB

The AASLD suggests indefinite antiviral therapy for adults with HBeAg-negative immune-active CHB unless there is a competing rationale for treatment discontinuation. (Quality/Certainty of Evidence: Low, Strength of Recommendation: Conditional)

Renal and Bone Disease in Persons on NA Therapy

The AASLD suggests no preference between entecavir and tenofovir regarding potential long-term risks of renal and bone complications. (Quality/Certainty of Evidence: Very Low (bone); Low (renal), Strength of Recommendation: Conditional)

Management of Persons with Persistent Low-Level Viremia on NA Therapy

The AASLD suggests that persons with persistent low level viremia (<2,000 IU/mL) on entecavir or tenofovir monotherapy continue monotherapy, regardless of ALT. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Conditional)

The AASLD suggests one of two strategies in persons with virological breakthrough on entecavir or tenofovir monotherapy: either switch to another antiviral monotherapy with high barrier to resistance or add a second antiviral drug that lacks cross-resistance. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Conditional)

Management of Adults with Cirrhosis and Low-Level Viremia

The AASLD suggests that adults with compensated cirrhosis and low levels of viremia (<2,000 IU/ mL) be treated with antiviral therapy to reduce the risk of decompensation, regardless of ALT level. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Conditional)

The AASLD recommends that hepatitis B surface antigen (HBsAg)-positive adults with decompensated cirrhosis be treated with antiviral therapy indefinitely regardless of HBV DNA level, HBeAg status, or ALT level to decrease risk of worsening liver-related complications. (Quality/Certainty of Evidence: Moderate, Strength of Recommendation: Strong)

Treatment of CHB in Pregnancy

The AASLD suggests antiviral therapy to reduce the risk of perinatal transmission of hepatitis B in HBsAg-positive pregnant women with an HBV DNA level >200,000 IU/mL. (Quality/Certainty of Evidence: Low, Strength of Recommendation: Conditional)

The AASLD recommends against the use of antiviral therapy to reduce the risk of perinatal transmission of hepatitis B in the HBsAg-positive pregnant woman with an HBV DNA ≤200,000 IU/mL. (Quality/Certainty of Evidence: Low, Strength of Recommendation: Strong)

Treatment of CHB in Children

The AASLD suggests antiviral therapy in HBeAg-positive children (ages 2 to <18 years) with both elevated ALT and measurable HBV DNA levels, with the goal of achieving sustained HBeAg seroconversion. (Quality/Certainty of Evidence: Moderate, Strength of Recommendation: Conditional)

The AASLD recommends against use of antiviral therapy in HBeAg-positive children (ages 2 to <18 years) with persistently normal ALT, regardless of HBV DNA level. (Quality/Certainty of Evidence: Very Low, Strength of Recommendation: Strong)

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