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HBV Treatment Candidacy
The Gray Zone of Chronic Hepatitis B: To Treat or Not to Treat

Released: April 06, 2020

Expiration: April 05, 2021

Mindie H. Nguyen
Mindie H. Nguyen, MD, MAS, AGAF, FAASLD
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Hepatitis B is a complex disease, and some of the basics of when and how to treat patients with chronic HBV infection are not always straightforward. I find that one of the most difficult aspects of managing patients with chronic hepatitis B (CHB) is distinguishing patients who have active disease, requiring intervention or more intensive monitoring, from patients who have inactive disease, requiring only standard monitoring without treatment. The complexity comes in part from the definition of a normal ALT level, which is used to assess liver inflammation, and from what constitutes a high HBV DNA level. We use these parameters to categorize our patients for optimal clinical management.

ALT and HBV DNA Thresholds
The American Association for the Study of Liver Diseases (AASLD) practice guidance recommends treatment for patients with ALT levels ≥ 2 x the upper limit of normal (ULN) (where normal is defined as 25 U/mL for women and 35 U/mL for men) and HBV DNA > 20,000 IU/mL for patients with HBeAg-positive CHB or HBV DNA ≥ 2000 IU/mL for patients with HBeAg-negative CHB. However, there are many patients whose elevated ALT levels do not quite reach ≥ 2 x ULN, but who are at risk for hepatocellular carcinoma or cirrhosis and could benefit from more intervention. In addition, HBV DNA levels should be considered in the context of other risk characteristics such as age, sex, duration of infection, and family history. For example, being male or older increases the risk of hepatocellular carcinoma. It is important to understand that the AASLD guidelines do not say that anyone with ALT < 2 x ULN does not need treatment. Instead, the guidelines allow clinicians to consider multiple factors, and some patients fall into the gray zone not clearly defined by the guidelines.  

Patients With Fluctuating ALT Levels
One group of patients I often encounter in my practice whose management is not clearly outlined in the guidelines are patients with fluctuating ALT levels. Because ALT monitoring is done every 3-6 months, it is possible to miss ALT elevations that occur between testing intervals. Given that CHB is a very dynamic disease, having a normal ALT in June does not mean that the ALT will be normal in August. In my practice, I would consider a patient with an ALT that has fluctuated more than once during a 1-year to 2-year period to have active disease and would consider therapeutic intervention for that patient.

Immune-Tolerant CHB
Another group of gray zone patients are those with high HBV DNA levels but persistently normal ALT, known as immune-tolerant CHB. In some cases, these patients are truly immune tolerant with no active liver disease. The current AASLD practice guidance states that these patients do not warrant treatment. However, does this patient have no risk at all? Once again you must consider their age, sex, family history, and other factors that may place them at higher risk of poor outcomes. The guidance notes that a liver biopsy should be considered in patients with persistently borderline normal or slightly elevated ALT levels, particularly those who have been infected with HBV for a long period of time and are now older than 40 years of age. Patients with moderate to severe inflammation and/or fibrosis can be considered for treatment, even with borderline normal or slightly elevated ALT levels. At this time, I generally do not treat patients with a persistently normal ALT.

Your Thoughts
Do you consider factors other than ALT and HBV DNA levels when deciding if a patient should be treated for CHB? Please elaborate in the comments section.

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How do you manage patients with CHB with very high HBV DNA (> 1 million IU/mL) but with borderline normal or slightly elevated ALT levels?
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