AASLD PRACTICE GUIDELINES
Chronic Hepatitis B: Update 2009
Anna S. F. Lok
and Brian J. McMahon
This guideline has been approved by the American Asso-ciation for the Study of Liver Diseases and represents theposition of the Association. It has been endorsed by theInfectious Diseases Society of America.
These guidelines have been written to assist physiciansand other health care providers in the recognition, diag-nosis, and management of patients chronically infected with the hepatitis B virus (HBV). These recommenda-tions provide a data-supported approach to patients withhepatitis B. They are based on the following: (1) formalreviewandanalysisofpublishedliteratureonthetopic—Medline search up to December 2006 and data from se-lected papers published through December 2008 andmeeting abstracts in 2003–2009 that impact the manage-ment of chronic HBV infection; (2) American College of PhysiciansManualforAssessingHealthPracticesandDe-signing Practice Guidelines
; (3) guideline policies, in-cluding the AASLD Policy on the Development and Useof Practice Guidelines and the AGA Policy Statement onGuidelines
; and (4) the experience of the authors in hep-atitis B. In addition, the proceedings of the 2000 and2006NationalInstitutesofHealth(NIH)conferencesonthe “Management of Hepatitis B”, the EASL ClinicalPractice Guidelines 2009 on Management of ChronicHepatitis B, the Asian-Paciﬁc Consensus Statement onthe Management of Chronic Hepatitis B in 2008 and theNIH 2008 Consensus Conference on Management of ChronicHepatitisB,wereconsideredinthedevelopmentof these guidelines.
The recommendations suggest pre-ferred approaches to the diagnostic, therapeutic, and pre-ventive aspects of care. They are intended to be ﬂexible.Speciﬁc recommendations are based on relevant pub-lishedinformation.Inanattempttocharacterizethequal-ityofevidencesupportingrecommendations,thePracticeGuidelines Committee of the AASLD requires a category to be assigned and reported with each recommendation(Table 1). These guidelines may be updated periodically as new information becomes available.
An estimated 350 million persons worldwide arechronically infected with HBV.
In the United States,there are an estimated 1.25 million hepatitis B carriers,deﬁned as persons positive for hepatitis B surface antigen(HBsAg)formorethan6months.
CarriersofHBVareat increased risk of developing cirrhosis, hepatic decom-pensation, and hepatocellular carcinoma (HCC).
Al-though most carriers will not develop hepaticcomplications from chronic hepatitis B, 15% to 40% willdevelop serious sequelae during their lifetime.
The fol-lowing guidelines are an update to previous AASLDguidelines and reﬂect new knowledge and the licensure of new antiviral agents against HBV. Recommendations inthese guidelines pertain to the (1) evaluation of patients with chronic HBV infection, (2) prevention of HBV in-fection, (3) management of chronically infected persons,and (4) treatment of chronic hepatitis B. Management of hepatitis B in patients waiting for liver transplantationand prevention of recurrent hepatitis B post-liver trans-plant have been covered in a recent review article and willnot be discussed in these guidelines.
Screening High Risk Populations to Identify HBV-infected Persons
The global prevalence of HBsAg varies greatly andcountries can be deﬁned as having a high, intermediateand low prevalence of HBV infection based on a preva-lence of HBsAg carriers of
8%, 2% to 7%, and
In developed countries, the preva-lenceishigheramongthosewhoimmigratedfromhighorintermediate prevalence countries and in those with highrisk behaviors.
Abbreviations: HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen; HCC,hepatocellular carcinoma; HBeAg, hepatitis B e antigen; cccDNA, covalently closed circularDNA;anti-HBe,antibodytohepatitisBeantigen;ALT,alanineaminotrans- ferase; anti-HBs, antibody to hepatitis B surface antigen; PCR, polymerase chain reac-tion;HCV,hepatitisCvirus;HIV,humanimmunodeﬁciencyvirus;HDV,hepatitisDvirus; HBIG, hepatitis B immunoglobulin; AFP, alpha fetoprotein; US, ultrasonogra- phy; IFN-
, interferon-alfa; pegIFN-
, pegylated interferon-alfa.Fromthe
DivisionofGastroenterology,UniversityofMichiganMedicalCenter, Ann Arbor, MI; and the
Liver Disease and Hepatitis Program, Alaska Native Medical Center and Arctic Investigations Program, Centers for Disease Control, Anchorage, AK. Address reprint requests to: Anna S. F. Lok, M.D., Division of Gastroenterology,University of Michigan Medical Center, 3912 Taubman Center, SPC5362, Ann Arbor, MI 48109. E-mail: email@example.com; fax: 734-936-7392.Copyright © 2009 by the American Association for the Study of Liver Diseases.Published online in Wiley InterScience (www.interscience.wiley.com).DOI 10.1002/hep.00000 Potentialconﬂictofinterest:Dr.McMahon’sspouseownsstockinGlaxoSmithKline.Dr. Lok has served as an advisor for Bristol-Myers Squibb, Roche, Gilead, Schering-Plough and Pharmasset and has received research support from Innogenetics, Schering-Plough, GlaxoSmithKline, Gilead, Bristol-Myers Squibb and Novartis.