Asian consensus recommendations on optimizing the diagnosis and initiation of treatment of hepatitis B virus infection in resource‐limited settings

Abstract

Asia has an intermediate‐to‐high prevalence of and high morbidity and mortality from hepatitis B virus (HBV) infection. Optimization of diagnosis and initiation of treatment is one of the crucial strategies for lowering disease burden in this region. Therefore, a panel of 24 experts from 10 Asian countries convened, and reviewed the literature, to develop consensus guidance on diagnosis and initiation of treatment of HBV infection in resource‐limited Asian settings. The panel proposed 11 recommendations related to diagnosis, pre‐treatment assessment, and indications of therapy of HBV infection, and management of HBV‐infected patients with co‐infections. In resource‐limited Asian settings, testing for hepatitis B surface antigen may be considered as the primary test for diagnosis of HBV infection. Pre‐treatment assessments should include tests for complete blood count, liver and renal function, hepatitis B e‐antigen (HBeAg), anti‐HBe, HBV DNA, co‐infection markers and assessment of severity of liver disease. Noninvasive tests such as AST‐to‐platelet ratio index, fibrosis score 4 or transient elastography may be used as alternatives to liver biopsy for assessing disease severity. Considering the high burden of HBV infection in Asia, the panel adopted an aggressive approach, and recommended initiation of antiviral therapy in all HBV‐infected, compensated or decompensated cirrhotic individuals with detectable HBV DNA levels, regardless of HBeAg status or alanine transaminase levels. The panel also developed a simple algorithm for guiding the initiation of treatment in noncirrhotic, HBV‐infected individuals. The recommendations proposed herein, may help guide clinicians, to optimize the diagnosis and improvise the treatment rates for HBV infection in Asia.

East Asia expert opinion on treatment initiation for chronic hepatitis B

“…As recently reported in the Asian consensus recommendations on optimising the diagnosis and initiation of treatment for HBV infection in resource‐limited settings, 5 the expert panel reviewed the Asian, American and European guidelines on the initiation of treatment of compensated and decompensated cirrhotic individuals, and of non‐cirrhotic HBeAg‐positive and ‐negative individuals. It is recommended that anti‐viral therapy should be initiated in all HBV‐infected compensated and decompensated cirrhotic individuals with detectable serum HBV DNA levels, irrespective of their ALT levels and HBeAg status.…”

“…The authors also noted that in resource‐limited settings where HBV DNA assay may not be readily available or affordable, serology and biochemical tests may serve as alternatives. However, it must be recognised that HBV DNA quantification provides critical information—especially in the setting of disagreement between serology and biochemical tests—and remains a vital component in the decision‐making process for treatment initiation 5 …”

“…These factors are proposed as treatment selection criteria in guidelines from the American Association for the Study of Liver Diseases (AASLD), 1,2 the European Association for the Study of the Liver (EASL), 3 the Asia Pacific Association for the Study of the Liver (APASL) 4 and the Asian consensus recommendations on the diagnosis and treatment of HBV infection in resource-limited settings. 5 In adult patients chronically infected with HBV, the annual risk of developing HCC varies between about 0.5% in the absence of cirrhosis and 2%-3% in the presence of compensated cirrhosis, if patients are left untreated. 4,6 Long-term suppression of HBV replication with NUC reduces the risk of HCC and mortality in patients with immune-active (IA) CHB or cirrhosis.…”

“…A number of reports on factors linked to anti‐viral therapeutic effects showed that ALT and HBV DNA levels influence disease progression and are also common factors associated with the therapeutic effects of both interferon (IFN) and nucleos(t)ide analogues (NUC). These factors are proposed as treatment selection criteria in guidelines from the American Association for the Study of Liver Diseases (AASLD), 1,2 the European Association for the Study of the Liver (EASL), 3 the Asia Pacific Association for the Study of the Liver (APASL) 4 and the Asian consensus recommendations on the diagnosis and treatment of HBV infection in resource‐limited settings 5 …”

Letter: elevated HBV DNA predicts poor survival in hepatocellular carcinoma after hepatic resection

“…The levels of serum hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) are two of the main factors to determine treatment initiation for chronic HBV infection in the recently published East Asia Consensus, 1 and in other official guidelines. [2][3][4] Serum ALT and aspartate aminotransferase (AST) levels are commonly evaluated for other aetiologies of liver injury. Our previous study found that elevated AST and AST/ALT ratio are associated with poor overall survival for patients with hepatocellular carcinoma (HCC) after hepatic resection.…”