Chronic hepatitis B: Is it time for expanded antiviral treatment?

Table 7 Management of indeterminate chronic hepatitis B patients: Immune-tolerant and Immune-active

Phase	Pros of treatment	Cons of treatment
IT	Early viral suppression: Suppresses HBV replication, potentially preventing liver damage, cirrhosis, and HCC[47,48]	Limited immediate benefit: Patients in the IT phase typically have minimal liver damage, so treatment may not provide significant short-term benefits[48,82]
	Prevention of carcinogenesis: High HBV DNA levels are linked to increased HCC risk, so early intervention could reduce long-term cancer risk[47]	High cost and long duration: Long-term antiviral therapy can be costly and may require lifelong treatment[11,45]
	Reduced Transmission: Lowering viral load during the IT phase can reduce the risk of HBV transmission, important in endemic areas[45]	Treatment resistance: Prolonged antiviral use could lead to drug resistance, reducing effectiveness over time[11,45]
	Advances in understanding IT phase: New evidence suggests active immune responses in the IT phase, making treatment potentially more effective than previously thought[57]	Risk of side effects: Antiviral therapy, especially long-term, can cause adverse effects, such as renal toxicity and bone density loss[45,47]
IA	Proven effectiveness: Clear benefits of treatment, including reduced risk of cirrhosis, liver failure, and HCC[45,48]	Side effects: Long-term use of antivirals can lead to renal and bone complications, as well as other side effects[11,45]
	Improved liver function: Treatment significantly reduces liver inflammation and fibrosis, improving long-term liver function[45,47]	Monitoring required: Requires continuous monitoring of HBV DNA, liver enzymes, and liver function tests[11,82]
	Reduced mortality: Studies show that treating IA patients reduces the risk of death or liver transplantation[45,47]	Cost: Like the IT phase, long-term antiviral therapy in IA patients can be financially burdensome[11,45]
	Reduced complications: Treatment lowers the risk of liver decompensation and complications from cirrhosis[45,47]	Possible drug resistance: Prolonged use of antivirals may lead to resistance, necessitating a switch in therapy[45,82]

CHB: Chronic hepatitis B; IT: Immune-tolerant; IA: Immune-active; HCC: Hepatocellular carcinoma.