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Should I use antiviral therapy for chronic hepatitis B?

Introduction

Antiviral therapy refers to any type of medicine that is used to treat hepatitis B. It is not recommended for everyone who has long-term (chronic) hepatitis B viral infection. It is an option for those people who have or appear most likely to develop liver damage, such as cirrhosis. Antiviral therapy may not help if you already have severe liver damage.

If you have used antiviral medicine once without success or have had a relapse after treatment, your choices are different, and this information does not apply to you. Talk with your doctor to decide what is right for you.

Consider the following when making your decision:

If you have short-term (acute) hepatitis B, you most likely do not need medicine. Acute hepatitis B usually goes away on its own.
If you have long-term (chronic) hepatitis B, the American Association for the Study of Liver Disease (AASLD) recommends antiviral therapy if you have high levels of hepatitis B virus DNA in your blood and either high levels of liver enzymes or liver disease.¹
You may not need to take antiviral medicines if you have normal or only slightly higher-than-normal liver enzyme levels and no biopsy evidence of liver damage.

Medical Information

What is hepatitis B?

Hepatitis B is liver disease caused by infection with the hepatitis B virus (HBV). Hepatitis B is one of the most common forms of viral hepatitis, which includes hepatitis A, B, C, D, and E. But hepatitis has many other causes, including some medicines, fatty deposits in the liver, long-term alcohol use, and exposure to certain industrial chemicals.

Hepatitis B can damage liver cells and cause the liver to become swollen and tender (liver inflammation). Chronic infections can cause permanent liver damage.

HBV can cause an acute or chronic infection. In acute infections, hepatitis B usually goes away on its own, and medicines are not needed.

What is chronic hepatitis B infection?

You have chronic HBV infection when the virus continues to multiply in your body for longer than 6 months. Most people with chronic HBV infection have no symptoms. But they can pass HBV to other people, especially the people they live with or have sex with. People with chronic HBV infection are at increased risk of chronic hepatitis, which can lead to complications such as scarring of the liver (cirrhosis), liver cancer, liver failure, and death.

If you need more information, see the topic Hepatitis B.

Your Information

You and your doctor will decide together whether antiviral therapy is right for you. The choices are:

Antiviral medicines called interferons such as interferon alfa-2b and pegylated interferon alfa-2a. Interferons are given as shots.
Antiviral medicines called nucleoside reverse transcriptase inhibitors (NRTIs) such as adefovir, lamivudine, entecavir, and telbivudine. You take these medicines as pills.
Regularly checking for liver damage by having blood tests and possibly a liver biopsy. If you do have liver damage, you may want to try antiviral medicines.

In general, treatment with interferons is shorter and results in fewer relapses compared to treatment with NRTIs. But fewer people are helped by interferons than by NRTIs.¹

The decision about whether to use antiviral therapy takes into account your personal feelings and the medical facts.

**Deciding about antiviral medicines**
General reasons to use antiviral medicines	General reasons not to use antiviral medicines
The hepatitis B virus is multiplying in your body. You have high levels of liver enzymes. You have liver damage or have the potential for liver damage. Are there other reasons you might want to use antiviral medicines?	You use injected illegal drugs. (This usually means you cannot use interferons.) You drink a lot of alcohol. You have normal or only slightly high liver enzyme levels and no biopsy evidence of liver damage. The treatment may not be successful, and there may be side effects. Are there other reasons you might not want to use antiviral medicines?

**Reasons for using or not using specific antiviral medicines**
Medicine	Reasons to use this antiviral medicine	Reasons not to use this antiviral medicine
Interferon	Interferon stops viral growth in about 35% of people who use it.¹ Viral resistance to HBV has not developed with interferon. Interferon is given as a shot only 3 times a week.	You have cirrhosis. You have had an organ transplant. Common side effects include flu-like symptoms such as headache and muscle aches. You may also have symptoms of depression, which can be severe. A relapse may occur after treatment ends.¹
Peginterferon	Studies suggest that peginterferon works better than lamivudine to treat chronic hepatitis B.^2,³ Peginterferon is given as a shot only once a week.	You have cirrhosis. You have had an organ transplant. Common side effects include flu-like symptoms such as headache and muscle aches. You may also have symptoms of depression, which can be severe. Peginterferon was approved by the U.S. Food and Drug Administration (FDA) in 2005 to treat chronic hepatitis B, so its long-term effects are not yet known. But peginterferon has been used to treat chronic hepatitis C since 2002.
Lamivudine	You cannot tolerate the side effects of interferon. Lamivudine reduces liver damage in about half of people who use it.¹ You can use lamivudine if you have cirrhosis. You can use lamivudine if you have a weak immune system. Lamivudine rarely has side effects.	After one year of treatment, drug resistance often develops and the medicine does not work as well. The longer you take lamivudine, the more likely drug resistance will develop. You may have a relapse after treatment ends.¹ Lamivudine is usually taken every day and may need to be taken for years.
Adefovir	Adefovir reduces liver damage in about half of the people who use it.^4,⁵ Adefovir can treat HBV infections that are resistant to lamivudine. There is less resistance to adefovir than to lamivudine. Adefovir has few side effects.	After treatment with adefovir ends, liver enzymes may increase to high levels. You may not be able to stop taking the medicine. Adefovir may harm your kidneys if you are at risk for or have a kidney problem. Adefovir may make medicines for HIV less effective. Adefovir is usually taken every day and may need to be taken for years.
Entecavir	Research has shown that entecavir works better than lamivudine and greatly reduces liver inflammation and scarring.^6,⁷	Side effects of entecavir may include headache, belly pain, diarrhea, feeling tired, and feeling dizzy. Entecavir was approved in 2005, so its long-term effects are not yet known. Entecavir is usually taken every day and may need to be taken for years.
Telbivudine	Studies have shown that telbivudine works better than lamivudine.⁸	Telbivudine is more expensive than lamivudine. Telbivudine may have problems with resistance, similar to lamivudine. Telbivudine was approved in 2006, so its long-term effects are not yet known. Telbivudine is usually taken every day and may need to be taken for years.

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about using antiviral therapy. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

The hepatitis B virus is multiplying in my body.	Yes	No	Unsure
My liver enzymes are high.	Yes	No	Unsure
My liver is damaged or there is the potential for damage.	Yes	No	Unsure
I understand that different antiviral medicines have different side effects.	Yes	No	Unsure
I understand that antiviral medicines don't help everyone.	Yes	No	Unsure
I understand that I may develop resistance to some antiviral medicines.	Yes	No	Unsure
I have cirrhosis.	Yes	No	Unsure
I understand that hepatitis may come back after I use medicine.	Yes	No	Unsure

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use antiviral therapy.

Check the box below that represents your overall impression about your decision.

Leaning toward using antiviral therapy

Leaning toward NOT using antiviral therapy

References

Citations

Lok ASF, McMahon BJ (2007). Chronic hepatitis B. Hepatology, 45(2): 507–539.

Marcellin P, et al. (2004). Peginterferon alfa-2a alone, lamivudine alone, and the two in combination in patients with HBeAG-negative chronic hepatitis B. New England Journal of Medicine, 351(12): 1206–1217.

Lau GKK, et al. (2005). Peginterferon alfa-2a, lamivudine, and the combination for HBeAG-positive chronic hepatitis B. New England Journal of Medicine, 352(26): 2682–2695.

Hadziyannis SJ, et al. (2003). Adefovir dipivoxil for the treatment of hepatitis B e antigen-negative chronic hepatitis B. New England Journal of Medicine, 348(9): 800–807.

Marcellin P, et al. (2003). Adefovir dipivoxil for the treatment of hepatitis B e antigen-positive chronic hepatitis B. New England Journal of Medicine, 389(9): 808–816

Lai CL, et al. (2002) Entecavir is superior to lamivudine in reducing hepatitis B virus DNA in patients with chronic hepatitis B infection. Gastroenterology, 123(6): 2135–2140.

de Man RA, et. al. (2001) Safety and efficacy of oral entecavir given for 28 days in patients with chronic hepatitis B virus infection. Hepatology, 34(3): 578–82.

Lai C-L, et al. (2007). Telbivudine versus lamivudine in patients with chronic hepatitis B. New England Journal of Medicine, 357(25): 2576–2588.

Credits

Author	Maria G. Essig, MS, ELS
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	W. Thomas London, MD - Hepatology
Last Updated	October 15, 2007

WebMD Medical Reference from Healthwise

Last Updated: March 02, 2010

This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.