People with acute hepatitis B do not require treatment. Bed rest, drinking lots of fluids, and over-the-counter pain relievers (products containing ibuprofen, such as Motrin and Advil, are considered to be safer than products containing acetaminophen, such as Tylenol, in people with acute hepatitis) are usually all that is needed for someone who is experiencing symptoms because of acute hepatitis B.
Treatment is only recommended for people with chronic hepatitis B. The goal of therapy is to reduce HBV viral load to undetectable levels and to return liver enzymes to normal levels, with the intent of getting rid of both HBeAg and HBsAg. If these antigens are cleared from the bloodstream, the virus is less likely to rebound once treatment is stopped.
There is still some debate regarding the best time to begin anti-HBV treatment. Many experts argue that treatment should be started when the HBV viral load is high or ALT levels are increased. Other experts argue that it doesn't matter what the HBV viral load is—if it's detectable it should be treated, given that any sign of active viral replication can mean an increased risk of liver cancer.
There are several treatments approved for the management of chronic hepatitis B:
Treatments for Chronic Hepatitis B Infection
Interferon-alfa: Interferon-alfa mimics naturally occurring interferon-alfa, the body's own antiviral. Standard versions of interferon-alfa (Roferon A, Intron A) have been approved for several years for the treatment of chronic hepatitis B. Pegylated interferon-alfa—a drug that contains microscopic waxy particles (polyethylene glycol) linked to an interferon molecule—is now the preferred version of interferon-alfa for the treatment of hepatitis B. Genentech's Pegasys has been approved for the treatment of chronic HBV and Merck's Peg-Intron is currently being studied as a treatment for hepatitis B.
Studies of Pegasys indicated that pegylated interferon-alfa is more effective than standard interferon-alfa for treating HBeAg-positive HBV infection. Studies have demonstrated that pegylated interferon may not be as effective in people with HIV and HBV infection—it is best used while the T-cell count is above 350. Studies have also shown that HBV genotypes A and B respond better to interferon treatment than HBV genotypes C and D. In turn, if interferon-alfa is selected as a treatment for HBV infection, it is recommended that the patient's HBV genotype be checked first.
The Pegasys dose is 180 micrograms, injected subcutaneously (directly under the skin) once a week for a total of 48 weeks. Side effects of interferon-alfa are common and can include: fatigue, joint and muscle aches, low-grade fever and/or chills, headache, nausea and vomiting, skin irritation at the injection site, weight loss, low white and red blood cells, mild hair loss, irritability, depression, and/or suicidal thoughts (rare). These side effects are generally worse during the first few weeks of treatment, especially after the first injection, but usually diminish over time.
Lamivudine (Epivir, Epivir-HBV): After being approved for the treatment of HIV, the nucleoside analogue lamivudine was also approved for the treatment of chronic hepatitis B. People who are infected only with HBV (and not HIV) take one 100mg lamivudine tablet every day. People who are infected with both HBV and HIV should use the dose typically used for the treatment of HIV: one 300mg tablet (or two 150mg tablets) once a day.
As in HIV, HBV resistance to lamivudine can and does occur. When lamivudine is used alone without other anti-HBV treatments (monotherapy), approximately 25% of people with HIV/HBV develop HBV resistance to the drug within one year. After four years of lamivudine monotherapy use, approximately 90% have HBV strains resistant to the drug. (The percentage developing lamivudine resistance is somewhat lower in people infected with HBV but not HIV.)
Emtricitabine (Emtriva) is very similar to lamivudine and is known to be active against HBV. Because emtricitabine is also approved for the treatment of HIV, some healthcare providers use it instead of lamivudine to treat both infections at the same time. If an HIV-positive person's regimen contains emtricitabine, there is no need to add lamivudine.
Adefovir dipivoxil (Hepsera): Adefovir is a nucleotide analogue, which differs slightly in its chemical structure than the nucleoside analogues (lamivudine and entecavir). Originally studied as a potential treatment for HIV, the dose of adefovir needed to treat HIV was associated with kidney problems. For the treatment of HBV, the dose is much lower—one 10mg tablet every day—and carries a much lower risk of kidney-related side effects. In clinical trials, adefovir was found to be an effective treatment for people with chronic hepatitis B starting therapy for the first time and for people who have tried and failed lamivudine in the past.
Adefovir is active against HBV strains that are resistant to lamivudine.
HBV can develop resistance to adefovir, but not as quickly as HBV develops resistance to lamivudine. After four years of HBV monotherapy treatment, approximately 18% of people develop HBV resistance to the drug. After five years of adefovir monotherapy treatment, HBV resistance occurs in approximately 29%. Rates of resistance are likely higher in people who become resistant to lamivudine and then switch to adefovir monotherapy.
It is not clear if people living with HIV and HBV should be treated with adefovir. Adefovir is very similar to tenofovir (Viread, Truvada and Atripla), a drug that is approved for the treatment of HIV and is also active against HBV. If an HIV-positive person's regimen contains tenofovir, there is no need to add adefovir. In fact, trials have now confirmed that tenofovir is superior to adefovir and it is approved as a first-line treatment for HBV. Truvada, a once-daily tablet that contains Viread and Emtriva (see above), is frequently prescribed for people living with both HIV and HBV, always in combination with another HIV medication.
Because the adefovir dose used to treat HBV is considered too low to be active against HIV, it has been suggested that adefovir monotherapy can be used by people infected with both viruses to treat HBV before combination antiretroviral therapy is necessary. However, experts caution that this may be a risky choice—it is still possible that there will be a low-level effect of adefovir on HIV, when used as monotherapy for hepatitis B, which may cause HIV to become resistant to adefovir and similar HIV medications (e.g., tenofovir).
Entecavir (Baraclude): Entecavir is a nucleoside analogue like lamivudine. It was approved in March 2005 for the treatment of chronic hepatitis B. The dose of entecavir will depend on a person's hepatitis B treatment history. For example, if the person is starting a nucleoside analogue for the first time, the entecavir dose is one 0.5-mg tablet per day. If the person has taken Epivir or Emtriva in the past—and has HBV that is resistant to either of these drugs—the correct entecavir dose is one 1-mg tablet per day.
Very little is known about entecavir's resistance profile. After two years of entecavir monotherapy, no cases of HBV resistance to the drug have been reported. However, long-term follow-up data is needed from studies to better understand if, and how quickly, HBV develops resistance to entecavir.
While entecavir is not specifically approved for people with HIV/HBV coinfection, it has been studied in a trial involving people infected with both viruses. Entecavir was found to be effective, including against HBV resistant to lamivudine.
When entecavir was first approved, it was believed to have no effect on HIV replication. In turn, some experts suggested that it be used, as monotherapy, to treat HBV before combination therapy is prescribed for HIV, without the risk of HIV becoming resistant to the drug (and, in turn, cross resistant to other HIV medications). In early 2007, reports emerged showing that entecavir does have HIV activity and caused HIV drug resistance in some patients. In turn, experts and the U.S. Food and Drug Administration are urging caution if entecavir monotherapy is being considered for the treatment of HBV in HIV-positive patients.
Telbivudine (Tyzeka): Tyzeka is a once-daily anti-HBV treatment approved by the FDA in October 2006.
Tyzeka was studied in a year-long international clinical trial involving 1,367 patients with chronic HBV. Three-quarters of the trial participants were male, and all were 16 years of age or older. The trial produced evidence of antiviral effectiveness, including the suppression of HBV, and improvement in liver inflammation comparable to Epivir.
It is not known how well Tyzeka works in people infected with HIV and HBV, nor is it known how well the drug works in people with HBV resistance to other available medications.
Telbivudine is not believed to have any activity against HIV. In turn, some healthcare providers may prescribe it, as monotherapy, to treat HBV before combination therapy is considered necessary for HIV, without the risk of HIV becoming resistant to the drug (and, in turn, cross resistant to other HIV medications). However, due to the emergence of data indicating that entecavir has anti-HIV activity, some experts are urging caution regarding the use of telbivudine as monotherapy in HIV/HBV-coinfected patients until additional studies exploring the effects of the drug on HIV are conducted and completed.
The U.S. Department of Health and Human Services has discussed how best to treat chronic HBV in people who are infected with HIV. These recommendations first appeared in the May 2006 publication of the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. The Guidelines list a number of important general recommendations, including being vaccinated against the hepatitis A virus (if not already immune to the virus), avoiding alcohol, and learning about methods to prevent the transmission of HBV to others.
While there is some overlap between the drugs used to treat HIV and HBV (this can make things much easier), it is sometimes necessary to carefully consider which medications to use if it is necessary to treat one infection but not the other. For example, someone may have a very high HBV viral load and elevated liver enzymes, but a healthy T-cell count and low HIV viral load. In other words, this person may need treatment for his HBV but not his HIV. To help patients and doctors figure out what to do in situations like this, the DHHS makes the following recommendations:
Need to treat HIV, but not HBV
Need to treat HIV and HBV
Need to treat HBV, but not HIV
Use tenofovir (Viread) pluslamivudine (Epivir) or tenofovir plus emtricitabine (Truvada) in the anti-HIV drug regimen. Do not use tenofovir without lamivudine or emtricitabine (or vice versa), as this may lead to HBV drug resistance.
The combination of tenofovir plus lamivudine or emtricitabine should be included in the first anti-HIV drug regimen. Another option might be entecavir (Baraclude) plus either tenofovir, lamivudine, or emtricitabine. Do not use only one drug with anti-HBV activity in an anti-HIV drug combination.
Pegylated interferon monotherapy is an option. It does not lead to the development of drug-resistant HIV or HBV. Given recent HIV treatment guidelines changes toward earlier HIV treatment, many experts now recommend that people coinfected with both HBV and HIV start a full HIV regimen right away regardless of their CD4 count.
It is very important that people with chronic hepatitis B take their medications exactly as prescribed. Missing doses can cause HBV to become resistant to HBV medications. Prematurely stopping HBV medications can also cause HBV viral load and liver enzymes to quickly increase, which can damage the liver and cause severe symptoms. This can also happen in people who have HBV that develops resistance to the medications they are using. In turn, for people with chronic hepatitis B who are receiving treatment, it is very important to be monitored frequently and carefully by a healthcare provider.
Last Revised: November 19, 2010
This content is written by the POZ and AIDSmeds editorial team. For more information, please visit our "About Us" page.