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
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.