Chronic hepatitis B in 2014: Great therapeutic progress, large diagnostic deficit

Table 3 Indication for treatment in European Association for the Study of the Liver, Asian Pacific Association for the Study of the Liver, and American Association for the Study of Liver Diseases guidelines[3-5]

EASL

Indication similar for both HBeAg-positive and HBeAg-negative patients

Consider therapy if HBV-DNA is > 2000 IU/mL, ALT is > ULN and there is moderate to severe active necroinflammation and/or at least moderate fibrosis on liver biopsy

Consider biopsy and therapy separately in immunotolerant patients: HBeAg-positive patients < 30 yr with persistently normal ALT and high HBV-DNA, without evidence of liver disease and family history of HCC or cirrhosis, do not require liver biopsy or therapy. Follow-up is mandatory

Consider biopsy or therapy in patients > 30 yr and/or with a family history of HCC or cirrhosis

HBeAg-negative patients with persistently normal ALT and HBV-DNA of 2000-20000 IU/mL and without evidence of liver disease do not require liver biopsy or therapy. Follow-up is mandatory

Patients with ALT > 2 times ULN and HBV-DNA >20000 IU/ml may start treatment without biopsy

Therapy indicated in compensated cirrhosis and detectable HBV-DNA even if ALT is normal

Patients with decompensated cirrhosis and any detectable HBV-DNA require urgent therapy

APASL

HBeAg positive: consider therapy if ALT >2 times ULN and HBV DNA > 20000 IU/mL

HBeAg-negative: consider therapy if ALT > 2 times ULN and HBV DNA > 2000 IU/mL

Consider therapy in advanced fibrosis or cirrhosis with any ALT level

Therapy in all patients with decompensated cirrhosis independent of HBV-DNA

Therapy in compensated cirrhosis if HBV-DNA is > 2000 IU/mL

In the absence of cirrhosis/severe fibrosis patients with persistently normal or minimally elevated ALT should not be treated irrespective of the height of HBV-DNA. Follow-up is mandatory

AASLD

HBeAg-positive: consider therapy if ALT >2 times ULN with moderate/severe hepatitis on biopsy and HBV-DNA > 20000 IU/mL

In general no therapy if ALT is persistently normal or minimally elevated (< 2 times ULN); consider biopsy in patients with fluctuating /minimally elevated ALT especially in those > 40 yr; consider therapy if there is moderate or severe necroinflammation or significant fibrosis on biopsy

HBeAg-negative: consider therapy if HBV-DNA > 20000 IU/mL and ALT > 2 times ULN

Consider biopsy if HBV-DNA is 2000-20000 IU/mL and ALT is borderline normal or minimally elevated. Consider therapy if there is moderate/severe inflammation or significant fibrosis on biopsy

HBV: Hepatitis B virus; EASL: European Association for the Study of the Liver; APASL: Asian-Pacific Association for the Study of the Liver; AASLD: American Association for the Study of Liver Diseases; ALT: Alanine aminotransferase.