Hepatitis B — chronic infection

Red Flags

HBV reactivation with ALT >5× ULN and rising HBV DNA — start antiviral immediately; can progress to acute liver failure^[1]
Acute hepatitis B with coagulopathy (INR ≥1.5) and encephalopathy — acute liver failure; transplant centre referral^[1]
HBeAg-negative chronic hepatitis with HBV DNA >2000 IU/mL and persistently elevated ALT — initiate antiviral; high progression risk to cirrhosis and HCC^[1]
Pregnancy with HBV DNA ≥200,000 IU/mL — tenofovir from week 28 to prevent vertical transmission; combine with infant immunoprophylaxis^[1]

First-line treatment

Interventions

HCC surveillance^[1]
Cirrhotics: ultrasound + AFP every 6 months. Non-cirrhotic with high-risk features: same surveillance schedule
Family screening and vaccination^[1]
Test sexual contacts and household members; vaccinate susceptibles (HBsAg-, anti-HBs-)
HBV reactivation prophylaxis^[1]
Anti-HBc-positive patients starting immunosuppression (rituximab, anthracyclines, anti-TNF, high-dose steroids) — TDF/TAF or entecavir prophylaxis throughout treatment + 6–12 months after

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF)^[1]	Nucleotide analogue (NRTI)	TDF 300 mg or TAF 25 mg PO once daily	TDF 8 mg/kg ≥2 years; TAF ≥12 years	First-line antiviral; high genetic barrier to resistance; TAF preferred over TDF if osteoporosis or renal impairment
Entecavir^[1]	Nucleoside analogue (carbocyclic guanosine)	0.5 mg PO once daily on empty stomach (1 mg if lamivudine-resistant or decompensated)	Per weight ≥2 years	Alternative first-line; high genetic barrier; cross-resistance with lamivudine partial
Pegylated interferon alpha-2a^[1]	Pegylated interferon	180 mcg SC weekly × 48 weeks	—	Selected HBeAg-positive young patients with high ALT, low HBV DNA, genotype A; finite course; numerous side effects (cytopenias, mood, autoimmune)
TDF in pregnancy^[1]	Pregnancy-safe antiviral	TDF 300 mg PO once daily from week 28 to delivery (or beyond per maternal indication)	—	Maternal HBV DNA ≥200,000 IU/mL; reduces vertical transmission to <1% combined with infant immunoprophylaxis

Tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF)^[1]

Nucleotide analogue (NRTI)

Adult: TDF 300 mg or TAF 25 mg PO once daily
Paediatric: TDF 8 mg/kg ≥2 years; TAF ≥12 years

First-line antiviral; high genetic barrier to resistance; TAF preferred over TDF if osteoporosis or renal impairment

Entecavir^[1]

Nucleoside analogue (carbocyclic guanosine)

Adult: 0.5 mg PO once daily on empty stomach (1 mg if lamivudine-resistant or decompensated)
Paediatric: Per weight ≥2 years

Alternative first-line; high genetic barrier; cross-resistance with lamivudine partial

Pegylated interferon alpha-2a^[1]

Pegylated interferon

Adult: 180 mcg SC weekly × 48 weeks
Paediatric: —

Selected HBeAg-positive young patients with high ALT, low HBV DNA, genotype A; finite course; numerous side effects (cytopenias, mood, autoimmune)

TDF in pregnancy^[1]

Pregnancy-safe antiviral

Adult: TDF 300 mg PO once daily from week 28 to delivery (or beyond per maternal indication)
Paediatric: —

Maternal HBV DNA ≥200,000 IU/mL; reduces vertical transmission to <1% combined with infant immunoprophylaxis

Safety-net

Take antiviral therapy daily without interruption — stopping causes severe HBV flare and possible acute liver failure^[1]
Avoid alcohol completely; minimise paracetamol use^[1]
Inform first-degree relatives and sexual contacts to be tested and vaccinated^[1]

Referral criteria

Acute hepatitis B with coagulopathy and encephalopathyLiver transplant centre^[1]
HBV reactivation with ALT >5× ULNHepatology + ID^[1]
Pregnancy with HBV DNA ≥200,000 IU/mLHepatology + obstetric medicine for tenofovir initiation^[1]
HBV-HCV or HBV-HIV co-infectionHepatology + ID for combined antiviral selection^[1]
HCC suspected on surveillance imagingHepatology + hepatobiliary surgery / oncology^[1]

Clinical summary

Indian-perspective management of chronic hepatitis B — risk-stratified treatment with tenofovir or entecavir, surveillance for HCC, and prevention of vertical transmission.

References

1.INASL Guidelines for Management of Hepatitis B (2023); EASL 2025 HBV Clinical Practice Guidelines (2023)