Table 8.
Comparison of chronic hepatitis B management for special populations
| KASL | AASLD | EASL | APASL | |
|---|---|---|---|---|
| Renal or bone disease | 1) Entecavir, TAF, and besifovir are preferred | 1) No preference between entecavir or TDF regarding the potential long-term risk of renal and bone complications TAF is associated with fewer bone and renal abnormalities than TDF | 1) Entecavir or TAF are preferred over TDF for patients with increasing age (>60 years), bone diseases, or renal alterations | 1) Entecavir or telbivudine are the first-line treatment options for chronic HBV-infected patients with any level of renal dysfunction and renal replacement therapy |
| 1) Selection | ||||
| 2) Switch | ||||
| 2) Treatment can be switched to TAF, besifovir, or entecavir in high risk patients | 2) TDF should be substituted with TAF or entecavir for TDF-associated renal dysfunction and/or bone disease | 2) Switching to entecavir or TAF should be considered for patients on TDF at risk of development and/or with underlying renal or bone disease | 2) Renal function and bone profiles should be monitored at least every 3 months if TDF or ADV is used | |
| HCC | 1) Antiviral therapy should be initiated in patients with HBV-related HCC if serum HBV DNA is detected | – | – | 1) NA treatment should be given to patients with HBV-related HCC (at least 1–2 weeks before, during, and after chemotherapy, locoregional therapies, resection, or liver transplantation), if there is detectable serum HBV DNA |
| 1) Treat | ||||
| 2) Prophylaxis | ||||
| 2) Prophylactic antiviral therapy should be considered in patients undergoing anticancer treatment, regardless of serum HBV DNA levels | ||||
| Immunosuppression or chemotherapy | 1) If either HBsAg is positive or HBV DNA is detected, prophylactic antiviral therapy should be initiated before immune-suppression or chemotherapy | 1) Anti-HBV prophylaxis should be initiated in HBsAg-positive anti-HBc-positive patients before starting immunosuppressive or cytotoxic therapy | 1) All HBsAg-positive patients should receive ETV, TDF, or TAF as treatment or prophylaxis | 1) Prophylactic antiviral therapy should be administered in anti-HBc-positive patients with either HBsAg-positive or detectable serum HBV DNA |
| 1) Prophylaxis (HBsAg-positive) | ||||
| 2) Monitor/treat/prophylaxis (HBsAg-negative) | ||||
| 2) HBsAg-negative anti-HBc-positive patients with undetectable HBV DNA should be monitored for serum HBsAg and HBV DNA during immunosuppression/chemotherapy and NAs should be initiated if HBV reactivation occurs | 2) HBsAg-negative anti-HBc-positive patients should be carefully monitored for ALT, HBV DNA, and HBsAg to provide therapy as needed | 2) HBsAg-negative anti-HBc-positive patients should receive anti-HBV prophylaxis if they are at high risk of HBV reactivation | 2) HBsAg-negative anti-HBc-positive patients with undetectable serum HBV DNA levels who receive chemotherapy and/or immunosuppression should be carefully monitored and be treated with NAs upon HBV reactivation | |
| If rituximab is included, initiate antiviral therapy at the start of immunosuppression or chemotherapy | For patients receiving anti-CD20 antibody therapy (e.g., rituximab) or undergoing stem cell transplantation, anti-HBV prophylaxis is recommended | |||
| Pregnant women | 1) Initiate or switch to TDF if treatment is needed | 1) TDF is preferred | 1) TDF should be continued, whereas ETV or other NAs should be switched to TDF | 1) TDF is the drug of choice for mothers requiring antiviral treatment |
| 1) Treat/switch | ||||
| 2) Prevention | ||||
| 3) Lactation | 2) For pregnant women with serum HBV DNA levels >200,000 IU/mL, TDF administration is recommended to prevent MTCT, beginning at 24–32 weeks of gestation and stopping 2–12 weeks after delivery | 2) If HBV DNA >200,000 IU/mL at 28–32 weeks of gestation, antiviral therapy is recommended to reduce the risk of perinatal transmission | 2) In all pregnant women with high HBV DNA levels (>200,000 IU/mL) or HBsAg levels >4 log10 IU/mL, antiviral prophylaxis with TDF should begin at 24–28 weeks of gestation and continue for up to 12 weeks after delivery | 2) For pregnant women with HBV DNA >6–7 log10 IU/mL, short-term maternal NA therapy with tenofovir or telbivudine is recommended beginning at 28–32 weeks of gestation |
| 3) TDF, which is relatively safe for the fetus and pregnant women, is not contraindicated during breastfeeding | 3) Breastfeeding is not contraindicated, but there are insufficient long-term safety data in infants born to mothers who received antiviral agents during pregnancy and while breastfeeding | 3) Breast feeding is not contraindicated in HBsAgpositive untreated women or on TDF-based treatment or prophylaxis | 3) Breast feeding is discouraged during maternal NA treatment | |
| Acute hepatitis B | 1) In patients with severe acute hepatitis B (e.g., coagulopathy, severe jaundice, liver failure), NA therapy can be initiated | 1) Indicators for antiviral therapy are total bilirubin >3 mg/dL, international normalized ratio >1.5, encephalopathy, or ascites | 1) Patients with severe acute hepatitis B, characterized by coagulopathy or protracted course, should be treated with NAs and considered for liver transplantation | 1) Treatment is only indicated for patients with fulminant hepatitis B or for those with severe or protracted acute hepatitis B |
| 1) Treat |
KASL, Korean Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; EASL, European Association for the Study of the Liver; APASL, Asian-Pacific Association for the Study of the Liver; TAF, tenofovir alafenamide fumarate; TDF, tenofovir disoproxil fumarate; HBV, hepatitis B virus; ADV, adefovir; HCC, hepatocellular carcinoma; NA, nucleos(t)ide analog; HBeAg, hepatitis B e antigen; anti-HBc, antibody to hepatitis B core antigen; ALT, alanine aminotransferase; ETV, entecavir; MTCT, mother-to-child transmission.