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EASL HDV Guideline
How the First International HDV Clinical Practice Guideline Will Influence Practice

Released: August 16, 2023

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Key Takeaways
  • European Association for the Study of the Liver (EASL) Clinical Practice Guidelines on hepatitis delta virus (HDV) are now available.
  • The Hep B Consult tool has been updated to reflect recommendations from the new EASL guidelines and can assist in managing people with chronic HDV infection.

The first Clinical Practice Guidelines on hepatitis delta virus (HDV) were published in August 2023 by the European Association for the Study of the Liver (EASL). These guidelines support healthcare professionals in identifying, assessing, and managing people living with chronic hepatitis delta (CHD). Here’s what these new HDV guidelines mean for clinical practice.

HDV Screening Recommendations
The EASL guidelines provide a strong recommendation that all people who are hepatitis B surface antigen (HBsAg) positive should be screened at least once in their lifetime for anti-HDV antibodies. Screening should be repeated in people who are HBsAg positive with persistent risk factors for infection (eg, people who inject drugs) or when clinically indicated (eg, elevated alanine aminotransferase level). This universal screening recommendation of all people who are HBsAg positive—a shift from risk-based screening—will help eliminate missed HDV infections.

Reflex anti-HDV testing, whereby any blood sample that is positive for HBsAg is automatically testing for HDV antibodies, can increase HDV diagnosis up to 5-fold. However, routine use of anti-HDV reflex testing in all people who test positive for HBsAg is not currently recommended by the EASL guidelines because there are not enough resources in many European countries to support the cost and infrastructure of reflex testing. In addition, studies need to be done to demonstrate if this is cost effective. In the future, reflex testing and use of analytical models to predict who should be screened for anti-HDV antibodies will help to increase early diagnosis and improve our understanding of HDV epidemiology.

HDV Treatment Recommendations
The EASL guidelines strongly recommend that all people with CHD be considered for antiviral treatment of their HDV. Although there is currently no licensed treatment for patients with CHD and decompensated cirrhosis, peginterferon-α and bulevirtide are potential treatment options for people with CHD and compensated liver disease.

If treating with peginterferon-α, a finite 48-week course of treatment is recommended.

The optimal bulevirtide dose and duration of treatment have yet to be determined, so long-term treatment is recommended until other data to inform treatment duration become available.

Either agent can be started as monotherapy and then the other agent added if needed for therapeutic benefit (ie, in the case of a partial response to monotherapy). There are no data to support starting a patient with CHD on dual therapy to treat their HDV, but data on this topic are expected to be presented at the American Association for the Study of Liver Diseases conference (“The Liver Meeting”) this fall.

Lonafarnib and peginterferon-λ are currently in late phases of clinical trials, and they may represent therapeutic options in future versions of the EASL guidelines.

Support From the Hep B Consult Tool
The EASL section of the Hep B Consult tool now includes updated information to reflect the screening and treatment guidance from the EASL guidelines on HDV. You can use the tool to get the most up-to-date patient-specific information on HDV screening and treatment recommendations based on the guideline that best fits your patient population.

Your Thoughts?
How do you envision the EASL guidelines on HDV will affect your practice? Join the discussion by leaving a comment.