APASL 2012 : Recommendation for treatment of HBV patients

Recommendation 3. Assessment of fibrosis

Assessment of liver fibrosis is recommended in viremic patients with high normal or
minimally raised ALT levels and older than 40 except patient with clinical evidence of
cirrhosis (IIA)
*iopsy to grade! stage and excl"de other ca"ses as a g"ide to the indication# assesment by
non$invasisve method(s) is an alternative
Recommendation 4. Wen to start
%atient with ALT & 'x (L) and *+$,)A &'x-0
4
I(.ml (if *beAg (/)) or &'x-0
0
I(.ml (if
*beAg ($)) and advanced fibrosis.cirrhosis with any ALT level sho"ld be considered fore
treatment (IA)
*%atients with rising ALT or ALT12x (L) may be developing an exacerbation followed by3
4evere hepatitis or decompensation3 start therapy as early as possible (IA)
4pontaneo"s *beAg seroconversion.remission 3 0$5 mo observation (IIA)
Recommendation !. Wic dr"# or strate#$
)"c$naive patients can be treated with I6)7 (I)! %eg I6) (IA)! 8T+ (IA)! T,6 (IA)! A,+
(I)! Ldt (I) or LA9 (I): Thymosin$7 can also be "sed (I): 8T+ or T,6 is the preferred
)"c:
*;onsider d"ration! cost! rapidity of action and adverse effects
Recommendation %. Ho& to monitor d"rin# terap$
ALT! *beAg and.or *+$,)A sho"ld be monitored! at least 0 month (IA)
<enal f"nction sho"ld be monitored if T,6 or A,+ is "sed (IA)
9"scle wea=ness sho"l be monitored especially if LdT is "sed (IIIA)
,"ring I6)$based therapy! monitoring of blood cell co"nts and other adverse effects are
mandatory (IA)
Recommendation '. Ho& to monitor after end of terap$
ALT and *+ mar=ers (incl"ding *+$,)A) sho"ld be monitored monthly for the first 0
month and then every 0 month in the -st year: If "neventf"l! monitor every 0 month (for
cirrhotics) to 5 month (IIA)
6or non$responders! f"rther monitoring is re>"ired to recogni?e a delayed response and to
plan retreatment when indicated (IIA)
Recommendation (. )inite d"ration of terap$
I6)73 4$5 months for *eAg (/) patients and at least a year for *eAg ($) patients (IA)
%eg I6)3 -' months (IA)
Thymosin 7-3 5 months for *eAg (/) patients (IA) and *eAg ($) patients (II)
* 5$-' months post$therapy observation
Recommendation *. Wen to stop anti+ira, a#ent-s.
*beAg (/) patients 3 *beAg seroconversion with "ndetectable *+ ,)A
maintained 1 -' months (IIA)
*beAg ($) patients 3 *+$,)A "ndetectable on separate occasions 5 months apart
(IIA)
6or primary treatment fail"re (months 0) or s"boptimal response (months 5)! stop and
swtich to a more potent )"c or add$on a )"c witho"t cross resistance if LA9! LdT
or A,+ was "sed (IIIA)
Recommendation 10. )ema,e patients in te ci,d/bearin# a#e
-: )on$pregnant women re>"ire treatment3 I6).%eg I6) is preferred# disco"raged
pregnancy d"ring therapy (IA)
%regnant women re>"ire treatment 3 LdT or T,6 * (IIA)
': %regnant women with *+ ,)A 1 'x-0
5
I(.mL can be treated with LdT on the 0rd
trimester to prevent transmission (IIA): T,6 is an alternative (IIIA)
* ;ategory dr"g(s)3 no ris= in animal! "n=nown in h"man
Recommendation 11. H0V co/infected patients
Active antiretroviral therapy (A<T) containing T,6 / 6T;.LA9 is the treatment of choice
for the ma@ority of *I+$*+ individ"als: If the ;,4 co"nt is 1200 and A<T is not
warranted! A,+ or %8A$I6) can be considered: (IIA)
Recommendation 12. Patients &it conc"rrent H1V or H2V infection
,etermine which vir"s is dominant: Treat the patients as monoinfection accordingly (IA)
Recommendation 13. Patients &it decompensated ,i+er diseases
8T+ or T,6 is the choice for patients with impending.obvio"s hepatic decompensation (IA):
LdT! LA9 or A,+ can also be "sed in )"c$naive patients (I)
<enal f"nction and lactic asidosis sho"ld be monitored! especially in those with 98L, score
1 '0 (IIIA)
* 4tart treatment as early as possible
* I6) is "s"ally contraindicated
Recommendation 14. Patients &it dr"# resistance
* LA9 or LdT resistance3 add$on A,+ (IA) or swtich to T,6 (IIA): 9ay switch to 8T+ -
mg.day for LA9 resistance (I):
A,+ resistance3 add$on or swtich to LA9! LdT or 8T+ if the patient was naive for these
dr"gs or switch to T,6 (IIIA)
8T+ resistance3 add$on T,6 or A,+ (IIIA)
<esistance to LA9 or LdT and A,+3 switch to 8T+/T,6 (IIA)
* 4witch to I6) based therapy is an optional (IIIA)
Recommendation 1!/1. 0mm"nos"ppression or cemoterap$
%atients sho"ld be screened for *bsAg (I+A):
If *bsAg (/)! start )"c if clinically indicated (IA): Btherwise! prophylactic "se of LA9
before the start and at least 5 months after the end of imm"nos"ppression or chemotherapy
(IA): 8T+ or T,6 is an option (IIIA)
Recommendation 1!/2. Bio,o#ic a#ent3 and4or corticosteroid containin# re#imens
Anti *c sho"ld be screened: If anti *c positive! *+ ,)A sho"ld be closely monitored
(IIIA) C
C To start )"c therapy accordingly
* anti$;, '0 (rit"ximab)! and anti$T)67 (etanercept) etc
Recommendation 1%/1. Li+er transp,antation
)"c(s) sho"ld be commenced in all *+ patients who are listed for organ transplantation and
have detectable *+$,)A (IIA)
LA9 pl"s low dose *IA (400$D00 (! i:m daily for - wee=s followed by 400$D00 (
monthly long term) for safe and effective prophylaxis againts *+ reinfection (IIA)
LA9/A,+ or 8T+ prophylaxis can be considered (IIA)
This may resc"e some patients from need for liver transplantation and will red"ce rec"rrence
post transplant (IIA)

Recommendation 1%/2. Li+er transp,antation
Late (at least -' months post transplant) *IA s"sbstit"ion by A,+ provides asfe and cost$
effective prophylaxis (IIA)
Late conversion to LA9 mono therapy may be considered in Elow$ris=F patients (IA)
(-): ,)A ($) pretransplant ('): %rotective levels of de novo anti$*bs
Recommendation 1%/3. Anti/HBc donor
*+$naive patient receiving a liver from anti$*bc (/) donor sho"ld receive long$term
prophylaxis with either LA9 or *IA (IIIA)
Recommendation 1'. Patients before and4or after c"rati+e or ,oca,/re#iona, terap$ of
H11
)"c sho"ld be commenced in all *;; patients with *+ ,)A 1 '000 I(.ml before and.or
after c"rative therapy of *;; as their co"nterparts witho"t *;; (III): %reemptive )"c
therapy sho"ld be initiated in all *;; patients who are to receive transarterial
chemoemboli?ation (IIA)
(nresolved iss"es. areas for st"dy
(-) <o"tine *+ genotyping in designing treatment planG
(') Treatment strategy for ;* childrenG E)ecessityF or Eli=elihood to responseFG
(0) 9ore effective therapy for patients with cronic *,+ infectionG
(4) The role of >*sAg in the treatment strategyG
(2) 9ost ideal non$invasive meas"re for liver fibrosisG
(5) The role for corticosteroid withdrawal! )"c p"lse therapy or other imm"nomod"lating
agents and modes of imm"nomod"lationG
(H) The optimal combination therapy to enhance efficacy
(D) Bptimal treatment for m"lti$dr"g resistanceG