Vous êtes sur la page 1sur 8


Received: 28 October 2016 Accepted: 1 November 2016

DOI: 10.1111/liv.13309


Treatment of chronic hepatitis B infection-2017

Guo-Feng Chen1,2|Cheng Wang1,3,4|George Lau1,3,5

Beijing 302-Hong Kong Humanity and Health
Hepatitis C Diagnosis and Treatment Center, Abstract
Beijing, China Since the registration of the first effective nucleoside analogue against the hepatitis B
Second Liver Cirrhosis Diagnosis and
virus almost two decades ago, major progress has been made in the management of
Treatment Center,302 Hospital, Beijing, China
3 chronic hepatitis B infection. However, hepatitis B-related morbidity and mortality
Division of Gastroenterology and
Hepatology,Humanity and Health Medical remain a major global health threat. This is partly due to the escalating costs and the
Centre, Hong Kong, SAR, China
decrease in compliance related to the need for prolonged therapy for most patients
State Key Laboratory of Organ Failure
Research,Guangdong Provincial who cannot be cured. New biomarkers such as quantitative hepatitis B surface
Key Laboratory of Viral Hepatitis antigen might help to determine if hepatitis B e antigen negative patients can be taken
Research,Department of Infectious
Diseases,Nanfang Hospital,Southern Medical off nucleos(t)ide analogues. On the other hand, novel compounds that target the viral
University, Guangzhou, China life cycle or modulate host immune response are in the pipeline. In the next few years,
Institute of Translational Hepatology,302 one should expect breakthrough advancement to be made leading to a cure for
Hospital, Beijing, China
patients with chronic hepatitis B infection by inducing hepatitis surface antigen loss
Correspondence with or without the development of the hepatitis B surface antibody. In addition,
George Lau, Division of Gastroenterology and
Hepatology, Humanity and Health Medical attention and necessary actions should also be taken in patients with hepatitis B
Centre, Hong Kong, SAR, China. infection who are being treated with immunosuppressive therapy and direct anti-viral
Email: gkklau@netvigator.com
(DAAs) agents for hepatitis C infection to prevent hepatitis from hepatitis B
Funding information
Cheng Si-yuan (China-international) hepatitis reactivation.
research foundation and Humanity and Health
Medical group. KEYWORDS
hepatitis B, hepatitis B reactivation, management, new therapy
Handling Editor: Mario Mondelli

1| INTRODUCTION for nearly 70% of all chronic hepatitis B infection globally.5,7 (Figure1)
Despite recommendations for universal hepatitis B vaccination in
Chronic hepatitis B infection affects around 250 million people world- 1992, it has not been fully implemented in endemic countries due
wide (3.61% of the global population) and if left untreated, around to economic and logistic constraints. This is further compounded by
one-quarter of them will die of cirrhosis, liver failure or hepatocel- the use of unsafe blood products and medical procedures in resource-
lular carcinoma.1-6 Variations in hepatitis B surface antigen (HBsAg) poor countries and has contributed to the increase in mortality and
seroprevalence are wide it is the lowest in Norway and the UK disability-adjusted life years (DALYs) due to hepatitis B infection8
(0.01%) and the highest (more than 20%) in countries such as South between 1990 and 2013. Thus, chronic hepatitis B (CHB) infection
Sudan and Kiribati.5 The number of affected individuals is highest in remains one of the most important causes of morbidity and mortality
the Western Pacific region, defined by the World Health Organization in humans.
as 37 countries including China, Japan, South Korea, Philippines This review represents my personal view on the treatment of
and Vietnam, with 95.3 million (prevalence estimates of 5.26%) and chronic hepatitis B infection based on the treatment guidelines pub-
Africa, with 75.6 million (prevalence estimates of 8.83%) accounting lished by the three continental hepatology societies.1,4,6

Abbreviations: AFP, a-foetoprotein; ALT, alanine aminotransferase; BR, biologic relapse; cccDNA, covalently closed circular DNA; CHB, chronic hepatitis B; DAAs, direct-acting antivirals; DALYs,
disability-adjusted life years; eGRF, estimated glomerular filtration rate; HBeAg, hepatitis B e antigen; HBs, hepatitis B surface antigen; HCC, hepatocellular carcinoma; NPV, negative predictive
value; OBI, occult hepatitis B virus infection; PEG-IFN, pegylated interferon; TAF, tenofovir alafenamide; TDF, tenofovir disoproxil fumarate; VR, virological relapse.

Liver International 2017; 37 (Suppl. 1): 5966 wileyonlinelibrary.com/journal/liv 2017 John Wiley & Sons A/S. | 59
Published by John Wiley & Sons Ltd
60 Chen etal.


Key points
Current therapy suppresses hepatitis B virus (HBV) repli-
The goal of therapy for CHB infection is to improve quality of life and cation but cannot lead to a cure with loss of HBsAg.
survival in infected persons by preventing disease progression to cir- A better understanding of the HBV life cycle and its inter-
rhosis, decompensated cirrhosis, end-stage liver disease, hepatocel- actions with the host led to new antiviral approaches,
lular carcinoma (HCC) and death.1,4,6 This goal can be achieved with focusing on interference with viral life cycle and spread,
significant suppression of HBV replication which has been shown to immune modulation and cccDNA-targeted therapy.
correlate with a significant reduction in hepatic necroinflammation, Future therapy against hepatitis B infection may integrate
reversal of liver fibrosis and reduction in the development of cirrhosis several strategies to achieve a better control of the virus
and HCC. The ideal endpoint in both hepatitis Be antigen (HBeAg)- and perhaps even a cure.
positive and HBeAg-negative patients is sustained off-therapy HBsAg HBV reactivation after immunosuppressive therapy or
loss, with or without seroconversion to anti-HBs. This is associated pan-oral direct-acting antiviral agents for hepatitis C in-
with complete and permanent remission of CHB activity and improved fection, leading to liver-related morbidity and mortality,
long-term outcome.9 However, such a cure, with loss of HBsAg can be prevented by increased awareness.
with or without the development of HBsAb can rarely be achieved
with current registered therapies against CHB because eradication of
covalently closed circular DNA (cccDNA) in the nucleus of infected
hepatocytes and integrated hepatitis B virus (HBV) is very difficult.10 achieved then maintained, virological remission (undetectable HBV
This is at least partly due to the inability of current therapeutic agents DNA by a sensitive PCR assay) with long-term antiviral therapy in
to effectively repair virus-specific and global T-cell dysfunction medi- HBeAg-positive patients who do not achieve anti-HBe seroconver-
ated by multiple regulatory mechanism, such as virus-specific IL-10 sion and in HBeAg-negative patients is the next best endpoint.1,3,4,6
response, FOXP3+ regulatory T-cell frequency and T-cell expression To better estimate the risk of the development of cirrhosis or HCC
of PD-1 and CTLA-4.11 Thus, a more realistic endpoint is the induc- and hence to allow one to prioritise therapy for CHB patients, various
tion of sustained or maintained virological remission. Induction of sus- risk models have been developed. Based on routinely available clini-
tained off-therapy virological response in both HBeAg-positive (with cal and laboratory data on CHB in Chinese, three prediction models
sustained anti-HBe seroconversion) and HBeAg-negative patients is a (REACH-B, CU-HCC and GAG-HCC) were developed. These models
satisfactory endpoint, because it has been shown to be associated with allow one to predict the 5- and 10-year risk of HCC. At our centres in
an improved prognosis. If a sustained off-therapy response cannot be Hong Kong and Beijing, all three models have been used to determine

HBsAg seroprevalence (%)*


F I G U R E 1 Global burden of hepatitis

B virus [Colour figure can be viewed at
*Data source: Schweitzer et al. Lancet
2015; 386: 1546-55.
# Age-standardized rates of deaths per
Age-standardized rates of deaths# 100,000 person years; Data source:
(3,5] Stanaway et al. Lancet 2016; 388: 1081-88.
(11,16.5] Stata command spmap was used to draw
the map.
Chen etal. |

the frequency of monitoring, the need for HCC surveillance, and the and -negative patients, but with fewer detrimental effects on bone
urgency of antiviral treatment. However, it is unclear whether these and kidney biomarkers. In both studies, patients receiving TAF experi-
models can be applied to patients outside Asia (genotypes B and C), enced a significantly smaller mean percentage decrease from baseline
where the genotypes (mainly A and D) are different.12-15 in hip and spine bone mineral density at week 48 compared to patients
Based on clinical evidence and experts opinion, the American, receiving TDF. Smaller increases in serum creatinine were observed in
Asian-Pacific and European Liver Associations (AASLD, APASL and HBeAg-positive patients receiving TAF. Moreover, the median change
EASL) have formulated management guidelines to help physicians in estimated glomerular filtration rate (eGFR) from baseline to week 48
make treatment decisions. All these guidelines are based on clinical favoured TAF in both studies.30,31
status, serum HBV DNA and alanine aminotransferase (ALT) levels, All guidelines recommend initial treatment with PEG-IFN, entecavir
HBeAg status, and the degree of liver fibrosis. All guidelines rec- or tenofovir as monotherapy.1,3,4,6 Although IFN is not recommended
ommend starting treatment as soon as possible in patients with life- in patients with acute liver failure, decompensated cirrhosis or severe
threatening liver disease: acute liver failure, decompensated cirrhosis exacerbations of chronic hepatitis B, it may be used with caution in
or severe acute exacerbation of chronic hepatitis B, regardless of HBV patients with compensated cirrhosis. While guidelines consider PEG-
DNA and ALT levels. These guidelines also recommend antiviral treat- IFN, entecavir and tenofovir to be equivalent first-line anti-HBV drugs,
ment for patients with compensated cirrhosis whatever the ALT levels in our clinical practice as do many others, entecavir and tenofovir are
but there are minor differences in threshold HBV DNA levels for initi- used much more often than PEG-IFN even in patients with no contra-
ating treatment. All guidelines agree that treatment should be initiated indications to the use of IFN. This is related to patients preference for
in patients without cirrhosis with serum HBV DNA levels >20000IU/ route of administration (injection vs oral) and the presence of medical/
mL and persistently elevated ALT levels and/or histological evidence of psychiatric comorbidities that contraindicate use of or decrease tol-
moderate or severe inflammation or fibrosis. However, cut-off values erance to IFN, as well as the cost of the treatment. However, in some
of ALT and the need for liver biopsy or the noninvasive assessment of circumstances, other factors such as the desire to raise a family in the
liver fibrosis to determine treatment indications differs among guide- near future in female patients or the desire to use a more finite rather
lines. All guidelines agree that serial HBV DNA and ALT levels are more than long-term therapy (PEG-IFN for 1year vs >3years of nucleos(t)
important than values at a single time point in making treatment deci- ide analogues) can make PEG-IFN more preferable. Recently, the cost
sions, because HBV DNA and ALT levels fluctuate during the course has become a less important concern because entecavir and tenofovir
of chronic HBV infection. Furthermore, all guidelines recommend has or will soon go off-patent, and both drugs have markedly lower
that patients who do not start treatment should be monitored so that rates of drug resistance (0-1% after 5-6years of continuous therapy)
treatment can be initiated later when HBV replication or liver disease compared to lamivudine, adefovir or telbivudine. Tenofovir and ente-
becomes more active. However, none of the guidelines have included cavir have similar potencies and barriers to antiviral resistance, and
prediction models for cirrhosis or HCC into recommendations because either drug may be used as first-line treatment in nucleoside-nave
in real-life predicting how CHB patients will progress is difficult and patients. Because of a low risk of nephrotoxicity, entecavir is preferred
adapting indications16,17 to these risk models may not decrease the in older patients, patients with baseline impaired renal function and
incidence of HCC.18 Instead, CHB patients who do not meet treatment those with other medical conditions such as hypertension or diabetes
criteria at presentation should be carefully monitored allowing timely that increase the risk of renal insufficiency. Although telbivudine has
initiation of treatment.18 These guidelines emphasise that patient age, been reported to improve renal function,25 the high risk of antiviral
a family history of HCC, occupational requirements, plans to start a drug resistance and the potential for other adverse reactions such as
family (for women) and patient preference should also be considered myopathy and polyneuropathy make this a poor choice as a first-line
when making treatment decisions. There are many settings in which treatment.20 Tenofovir effectively suppresses not only wild type HBV
a patients medical or social circumstances warrant a personalised but also lamivudine, telbivudine or entecavir resistant HBV and to a
approach that may be at odds with the guidelines but appropriate for lesser extent adefovir resistant HBV. It is therefore a better choice in
the patient (Table1, Figures2 and 3). patients who have been previously treated with other nucleos(t)ide
In the past two decades, seven drugs have been approved for analogues. Tenofovir is also a preferred choice for women of reproduc-
the treatment of chronic hepatitis B infection, namely conventional tive age because of its safety record in pregnancy.27
and pegylated interferon (PEG-IFN), and five nucleos(t)ide analogues Recently, the use of PEG-IFN was further fine-tuned with the use
lamivudine, telbivudine, adefovir, entecavir and tenofovir.19-27 The of a 12-week stopping rule, based on no decline or a <0.5 log10 decline
effectiveness of these antiviral therapies in reducing the risk of cir- of qHBsAg or qHBsAg >20000 as the stopping rule. However, these
rhosis, decompensated liver diseases and hepatocellular carcinoma in rules are based on retrospective analyses of data from large clinical
CHB patients with treatment indications, was supported by a recent trials and have never been tested prospectively.2,3,7-14 An ideal stop-
systemic review and meta-analysis. In addition, based on recent ping rule should have a negative predictive value (NPV) of 95% for
encouraging phase 3 data, tenofovir alafenamide (TAF), a new form both intermediate-term and long-term response and should be applied
of tenofovir, is expected to be the next registered agent for the treat- to all patients. The NPV from these studies varies between 72% and
ment of CHB. TAF has been shown to be as effective as the teno- 97%, with the lowest NPV in Asian patients. Furthermore, different
fovir disoproxil fumarate (TDF) formulation in both HBeAg-positive stopping rules have been identified to predict a long-term response
62 Chen etal.

T A B L E 1 Comparison of AASLD, APASL and EASL guideline recommendations regarding treatment of hepatitis B

AASLD (2015) APASL (2015) EASL (2012)

HBV DNA cut-off level, IU/mL

HBeAg-positive 20000 20000 2000
HBeAg-negative 2000 2000 2000
ALT cut-off level, U/L 30 for men, 19 for women Traditional cut-off value of 40U/L Traditional cut-off value of
Recommendations for treatment and monitoring
Noncirrhotic patients
HBeAg-positive HBV DNA >20000IU/mL, HBV DNA >20000IU/mL, ALT>2x ULN HBV DNA >2000IU/mL, ALT
ALT>2x ULN Monitor for 3months >ULN
Monitor for 3-6months Treat if no spontaneous HBeAg loss Monitor for 3-6months
Treat if no spontaneous Histology should be obtained or assessed Liver biopsy (or noninvasive
HBeAg loss noninvasively markers of fibrosis) is recom-
Liver biopsy before treatment mended
is optional Treat if no spontaneous HBeAg
loss and biopsy shows
moderate-severe inflammation
and/or at least moderate fibrosis
HBV DNA >20000IU/mL, HBV DNA >20000IU/mL, ALT 1-2x ULN HBV DNA >20000IU/mL,
ALT2x ULN Monitor every 3months ALT<ULN
Monitor every 3-6months Consider biopsy in patients >35years, ALT Monitor every 3-6months
Consider biopsy in patients persistently >ULN, or with family history of Consider biopsy in patients
>40years, ALT persistently HCC >30years, ALT persistently 1-2
1-2 ULN, or with family history Treat if biopsy shows moderate/severe ULN, or with family history of
of HCC inflammation or fibrosis HCC
Treat if biopsy shows Treat if biopsy shows moderate-
moderate/severe inflammation severe inflammation or
or significant fibrosis significant fibrosis
HBeAg-negative HBV DNA >20000IU/mL, ALT HBV DNA >2000IU/mL, ALT >2x ULN HBV DNA >20000IU/mL, ALT
>2x ULN Treatment is clearly indicated, liver biopsy >2x ULN
Treatment is clearly indicated, is optional Treatment is clearly indicated,
liver biopsy is option liver biopsy is optional
HBV DNA 2000-20000IU/mL, HBV DNA >2000IU/mL, ALT 1-2x ULN HBV DNA >2000IU/mL,
ALT 1-2x ULN Monitor ALT and HBV DNA every ALT>ULN Liver biopsy (or
Consider liver biopsy 1-3months. Consider liver biopsy if patient noninvasive markers of fibrosis)
Treat if liver biopsy shows is 40years. Treat if biopsy shows is recommended
moderate/severe moderate/severe inflammation or fibrosis Treat if biopsy shows moderate-
fibrosis is recommended severe inflammation and/or at
Treat if biopsy shows least moderate fibrosis
moderate-severe inflammation
or significant fibrosis
Monitor Monitor
Compensated HBV DNA >2000IU/mL HBV DNA >2000IU/mL HBV DNA detectable
Treat regardless of ALT level Treat regardless of ALT level Treat regardless of ALT level
HBV DNA <2000IU/mL HBV DNA <2000IU/mL
Treat regardless of ALT level Consider treatment if ALT>ULN
Decompensated Regardless of HBV DNA or ALT Regardless of HBV DNA or ALT level Regardless of HBV DNA or ALT
level Treat and refer for liver transplantation level
Treat and refer for liver Treat and refer for liver
transplantation transplantation
HCC surveillance US every 6months US and AFP every 6months US every 6months
Chen etal. |

F I G U R E 2 Algorithm showing guideline

recommendations for the treatment of
patients with HBeAg-positive CHB
* APASL indicates treatment may be
initiated in patients with normal ALT level
if the biopsy shows moderate-severe
inflammation or significant fibrosis. EASL:
age,>30 years; APASL: age >35 years;
AASLD: age >40 years.

F I G U R E 3 Algorithm showing guideline

recommendations for the treatment of
patients with HBeAg-negative CHB
*APASL and EASL indicate treatment may
be initiated in patients with normal ALT
level if the biopsy shows moderate-severe
inflammation or fibrosis.

and it has been shown that some patients who meet criteria for stop-
ping treatment based on a low probability of intermediate response
might have a late response with HBsAg clearance. These data show
that one universal stopping rule probably cannot provide sufficiently
accurate predictions for a response to PEG-IFN for it to be applied in With the wide availability of nucleos(t)ide analogues for nearly two dec-
clinical practice. ades, many patients with chronic hepatitis B infection have been main-
tained on treatment. One of the frequent concerns is the long-term safety
and cost of this infinite treatment. Most of these patients have been
3|HEPATOCELLULAR treated with entecavir or tenofovir because these drugs have a very low
CARCINOMA SURVEILLANCE rate of drug resistance. Recommendations on when to stop nucleos(t)ide
analogues vary. All guidelines recommend that nucleos(t)ide analogues
Most deaths related to hepatocellular carcinoma are due to a late diag- be stopped in HBeAg-positive patients when the patient has completed
nosis. Indeed, early detection by monitoring offered the best chance 6-12months of consolidation therapy after HBeAg seroconversion. EASL
of having resectable HCC and thus a cure. The AASLD, EASL and guidelines recommend continuing treatment until HBsAg loss in patients
APASL guidelines recommend HCC surveillance for HBV carriers who with advanced fibrosis or cirrhosis to avoid flares associated with viral
are Asian men older than 40 and Asian women older than 50, patients relapse. AASLD and EASL guidelines recommend that nucleos(t)ide ana-
with cirrhosis, with a family history of HCC, first- generation African logues be continued in HBeAg-negative patients until HBsAg loss while
Americans older than 20, and any carrier older than 40 with persis- APASL guidelines state that treatment may be withdrawn after completing
tent or intermittent increased ALT and/or HBV DNA levels >2000IU/ at least 2years of treatment with undetectable HBV DNA documented on
mL.1,3,4,6 Ultrasound surveillance at 6-month intervals is recommended three occasions 6months apart. All three guidelines recommend lifelong
by EASL and AASLD guidelines.5,13,14 The APASL recommends a combi- nucleos(t)ide analogue treatment in patients with cirrhosis before treat-
nation of ultrasound and a-foetoprotein testing every 6months.4 ment unless they had compensated cirrhosis and had cleared HBsAg.
64 Chen etal.

T A B L E 2 HBsAg loss to monotherapies and combination therapies in chronic hepatitis B patients

Monotherapies Combination therapies



HBeAg-positive patients
At week 48 or 52
HBsAg loss, % <1 0 2 0 3 3 6 1 3 1
Cumulative percentage during extended treatment
HBsAg loss, % 0-3 (2-3) 2 (5) 5 (2) 1.3 (2) 10 (5) 11 (3.5) 9 (1.5) 1 (2.5) 3 (0.5) 5 (2)
(in years)
HBeAg-negative patients
At week 48 or 52
HBsAg loss, % <1 0 <1 <1 0 4 5 0
Cumulative percentage during extended treatment
HBsAg loss, % <1 (4) 5 (5) NA <1 (2) 0.3 (5) 8 (3) 5 (1.5) 0 (2)
(in years)

3TC, lamivudine; ADV, adefovir; CHB, chronic hepatitis B; ETV, entecavir; LdT, telbivudine; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface anti-
gen; PEG-IFN, pegylated interferon; TDF, tenofovir disoproxil fumarate.

In a recent meta-analysis including 25 studies with more than now known that liver damage due to HBV reactivation is a two-stage
1700 patients in whom nucleos(t)ide analogues were discontinued, the process. Initially, there is markedly enhanced viral replication during
duration of an on-therapy virological response was shown to be the intense cytotoxic or immunosuppressive therapy reflected by increases
most important predictor of a durable off-therapy virological relapse in serum levels of HBV DNA, hepatitis Be antigen (HBeAg) and HBV
(VR) with a significantly increased pooled probability (12months: 36% DNA polymerase, resulting in widespread infection of hepatocytes.
vs 75%) in patients who remained in VR under nucleos(t)ide analogues With the restoration of immune function following withdrawal of cyto-
for more than 24months. These findings contradict APASL guide- toxic or immunosuppressive therapy, there is rapid immune-mediated
lines, which recommend discontinuation of nucleos(t)ide analogues destruction of HBV-infected hepatocytes, resulting clinically in hepa-
in HBeAg CHB who remain in VR for only 18months. However, the titis, hepatic failure and even death.35 All of these fatal hepatic events
optimal duration of on-therapy VR before stopping nucleos(t)ide ana- can be prevented by identifying a patients HBV status (HBsAg and
logues remains unknown.32 On the other hand, recent data suggest the hepatitis B core antibody) before beginning immunosuppressive or
usefulness of end-of-therapy and post-treatment quantitative hepati- chemotherapy and by pre-emptive treatment with nucleos(t)ide ana-
tis B surface antigen (qHBsAg) to predict VR and biological relapse logues.36 Although this has been clearly set out in all treatment guide-
(BR). The usefulness of end-of-treatment qHBsAg in predicting a sus- lines, fatal hepatitis due to HBV reactivation still occurs due to lack
tained viral response after stopping nucleos(t)ide analogue treatment of HBV screening and timely administration of antiviral therapy.37
has been explored. It has been suggested that end-of-treatment serum Recently, with the advent of pan-oral direct-acting antiviral agents for
qHBsAg levels can predict off-therapy sustained virological response chronic hepatitis C infection, there is increased awareness of HBV reac-
and patients with a low qHBsAg level <10IU/mL did not relapse.34 tivation in CHC patients with HBV coinfection treated with pan-oral
However, larger prospective studies are certainly needed for valida- direct acting antivirals (DAAs).38 The severity of hepatitis ranged from
tion. Nevertheless, patients with CHB and without cirrhosis who are HBV reactivation without hepatitis to fulminant hepatic failure, requir-
receiving nucleos(t)ide analogues with virological response >2years ing liver transplantation. The underlying mechanisms of HBV reactiva-
can stop treatment as long as they can be closely monitored.32 tion during pan-oral DAAs therapy for CHC remain speculative. Several
previous reports have documented that de novo HCV superinfection
in patients with CHB can result in HBeAg seroconversion and in some
5| HBV REACTIVATION SHOULD cases, clearance of HBsAg. This suggests that HCV infection can sup-
DRAW MORE ATTENTION PRE- press HBV replication, but the detailed mechanism is not clear. New
EMPTIVE TREATMENT WITH NUCLEOS(T) insights have been obtained from cell culture studies, where HBV and
IDE ANALOGUES HCV were shown to replicate in the same hepatocyte without evidence
of interference. This suggests that HCV suppresses HBV replication via
Hepatitis B reactivation in patients with CHB who were treated with an indirect immune mechanism.39 Like patients with occult hepatitis B
immunosuppressive or chemotherapeutic agents, can lead to fatal virus infection (OBI) treated with intense immunosuppressive therapy,
liver failure. With careful prospective serial serological testing, it is life-threatening fulminant hepatitis due to HBV reactivation has also
Chen etal. |

T A B L E 3 Emerging treatments for chronic hepatitis B virus infection

Target Example drug Mechanism of action Phase of clinical trial

Virus replication cycle

Viral entry Myrcludex B Targets sodium taurocholate cotransporting 2
polypeptide to inhibit virus entry
HBV DNA polymerase Tenofovir alafenamide Besifovir DNA polymerase inhibition 3
DNA polymerase inhibition 3
HBV cccDNA Zinc finger proteins CCC-0975/ Block transcription of cccDNA Inhibit cccDNA Preclinical
CCC-0346 MC2791/ production Repression of cccDNA transcriptional Preclinical
MC3119CRISPR/Cas activity Gene editing to mutate cccDNA Preclinical
HBV gene expression ARC-520 siRNA/ddRNA HBV RNA interference 2
RNAi-based gene silencing
Viral nucleocapsid Bay 41-4109 Destabilisation of HBV nucleocapsids 1
GLS4 Destabilisation of HBV nucleocapsids 1
GLP-26 HBV capsid disruption Preclinical
Viral protein secretion REP 2139-Ca Inhibits the release of HBsAg 2
Host immune system
Innate immune response GS-9620 TLR-7 agonist 2
Pegylated interferon lambda Stimulates cell-mediated immune responses 2
STING agonists Produces type I IFN-dominant cytokine response Preclinical
Adaptive immune NASVAC HBsAg/HBcAg-based therapeutic vaccine 3
response HBsAg-HBIG Immunogenic vaccine 3
GS-4774 Therapeutic vaccines 2
ABX 203 Therapeutic vaccines 2
DV-601 Therapeutic vaccines 1
PD-1/PD-L1 inhibitors Restoration of T-cell function Preclinical

cccDNA, covalently closed circular DNA; HBV, hepatitis B virus; HBcAg, hepatitis B core antigen; HBIG, hepatitis B immunoglobulin; HBsAg, hepatitis B
surface antigen; TLR, toll-like receptor.

been reported in CHC patients with OBI treated with NS3/4A protease have been combined in various fashions (sequential or concomitant)
inhibitor- containing regimens. These events have recently prompted with little success (Table2). Thus, new therapeutic agents are clearly
the US FDA to issue a box warning about the risk of HBV reactivation, needed. To date, various anti-HBV drugs or biological agents that
to have the warning added to the drug labels of these DAAs, and to are directed at specific steps in the viral life cycle and spread, that
direct healthcare professionals to screen and monitor for HBV in all increase and restore host immune response and target cccDNA, are
patients receiving DAA treatment. Thus, it is highly important to evalu- in the development pipeline, either in the preclinical or early clinical
ate HBV status (HBsAg and hepatitis B core antibody) before initiating phases40 (Table3). Among them, siRNA, HBsAg inhibitors and capsid
pan-oral DAAs therapy, especially in HBV endemic areas. inhibitors have reached clinical trials. However, none of these agents
are expected to become available before the next few years and
these agents will probably need to be combined with existing ones.

In 2017, PEG-IFN and nucleos(t)ide analogues with high resistant bar-

None of the existing anti-HBV agents is effective in achieving the riers (tenofovir and entecavir) are expected to remain the mainstay of
ideal goal of therapy-HBsAg loss (functional cure) or HBsAg sero- treatment for CHB, based on guidelines from the different continental
conversion (complete cure). This is mainly because current therapy is hepatology societies. In the near future, TAF will become available to
ineffective in clearing cccDNA or preventing transcriptional cccDNA provide safer long-term use of nucleotide analogues in CHB patients.
activity. Even following 48weeks of PEG-IFN, HBsAg loss will only With the development of new therapeutic agents targeting various key
occur in less than ten per cent of the patients. This means that most steps in the viral life cycle and/or improving the host immune response
patients must be maintained on lifelong nucleos(t)ide analogue ther- to the virus, a cure for CHB can be expected in the next decade. This,
apy, resulting in escalating costs and an increased risk of side effects. together with full implementation of the HBV vaccine programme,
In an attempt to increase the rate of HBsAg loss, registered agents should pave the way to a Hepatitis B free generation by 2030.
66 Chen etal.

CO NFLI CTS OF I NTE RE S T 20. Hadziyannis SJ, Tassopoulos NC, Heathcote EJ, etal. Adefovir dipiv-
oxil for the treatment of hepatitis B e antigen-negative chronic hepa-
None. titis B. N Engl J Med. 2003;348:800807.
21. Lai CL, Chien RN, Leung NW, etal. A one-year trial of lamivudine for
chronic hepatitis B. Asia Hepatitis Lamivudine Study Group. N Engl J
REFERENCES Med. 1998;339:6168.
1. European Association For The Study Of The Liver. EASL clinical prac- 22. Lai CL, Gane E, Liaw YF, etal. Telbivudine versus lamivudine in patients
tice guidelines: management of chronic hepatitis B virus infection. with chronic hepatitis B. N Engl J Med. 2007;357:25762588.
JHepatol. 2012;57:167185. 23. Lai CL, Shouval D, Lok AS, et al. Entecavir versus lamivudine for
2. Lau G, Marcellin P, Peters M. Chronic hepatitis B: a global health prob- patients with HBeAg-negative chronic hepatitis B. N Engl J Med.
lem requiring coherent worldwide treatment strategies. Hepatol Int. 2006;354:10111020.
2007;1:316325. 24. Lau GK, Piratvisuth T, Luo KX, etal. Peginterferon Alfa-2a, lamivudine,
3. World Health Organization. Guidelines for the prevention, care and the combination for HBeAg-positive chronic hepatitis B. N Engl J
and treatment of persons with chronic hepatitis B infection. Med. 2005;352:26822695.
WHO Press, World Health Organization, 20 Avenue Appia, 1211 25. Marcellin P, Chang TT, Lim SG, etal. Adefovir dipivoxil for the treat-
Geneva 27, Switzerland; 2015. http://apps.who.int/iris/bitstream/ ment of hepatitis B e antigen-positive chronic hepatitis B. N Engl J
10665/154590/1/9789241549059_eng.pdf. Accessed October 15, Med. 2003;348:808816.
2016. 26. Marcellin P, Heathcote EJ, Buti M, et al. Tenofovir disoproxil fuma-
4. Sarin SK, Kumar M, Lau GK, etal. Asian-Pacific clinical practice guide- rate versus adefovir dipivoxil for chronic hepatitis B. N Engl J Med.
lines on the management of hepatitis B: a 2015 update. Hepatol Int. 2008;359:24422455.
2016;10:198. 27. Marcellin P, Lau GK, Bonino F, etal. Peginterferon alfa-2a alone, lami-
5. Schweitzer A, Horn J, Mikolajczyk RT, Krause G, Ott JJ. Estimations vudine alone, and the two in combination in patients with HBeAg-
of worldwide prevalence of chronic hepatitis B virus infection: a sys- negative chronic hepatitis B. N Engl J Med. 2004;351:12061217.
tematic review of data published between 1965 and 2013. Lancet. 28. Jonas MM, Lok AS, McMahon BJ, etal. Antiviral therapy in manage-
2015;386:15461555. ment of chronic hepatitis B viral infection in children: a systematic
6. Terrault NA, Bzowej NH, Chang KM, etal. AASLD guidelines for treat- review and meta-analysis. Hepatology. 2016;63:307318.
ment of chronic hepatitis B. Hepatology. 2016;63:261283. 29. Lok AS, McMahon BJ, Brown RS Jr, etal. Antiviral therapy for chronic
7. Global Burden of Disease Study Collaborators. Global, regional, and hepatitis B viral infection in adults: a systematic review and meta-
national incidence, prevalence, and years lived with disability for 301 analysis. Hepatology. 2016;63:284306.
acute and chronic diseases and injuries in 188 countries, 1990-2013: 30. Buti M, Gane E, Seto WK, etal. Tenofovir alafenamide versus tenofovir
a systematic analysis for the Global Burden of Disease Study 2013. disoproxil fumarate for the treatment of patients with HBeAg-negative
Lancet. 2015;386:743800. chronic hepatitis B virus infection: a randomised, double-blind, phase
8. Stanaway JD, Flaxman AD, Naghavi M, et al. The global burden of 3, non-inferiority trial. Lancet Gastroenterol Hepatol. 2016;1:196206.
viral hepatitis from 1990 to 2013: findings from the Global Burden of 31. Chan H, Fung S, Seto WK, etal. Tenofovir alafenamide versus tenofo-
Disease Study 2013. Lancet. 2016;388:10811088. vir disoproxil fumarate for the treatment of HBeAg-positive chronic
9. Liaw YF. Impact of hepatitis B therapy on the long-term outcome of hepatitis B virus infection: a randomised, double-blind, phase 3, non-
liver disease. Liver Int. 2011;31(Suppl):11171121. inferiority trial. Lancet Gastroenterol Hepatol. 2016;1:185195.
10. Nassal M. HBV cccDNA: viral persistence reservoir and key obstacle 32. Papatheodoridis G, Vlachogiannakos I, Cholongitas E, et al.
for a cure of chronic hepatitis B. Gut. 2015;64:19721984. Discontinuation of oral antivirals in chronic hepatitis B: a systematic
11. Park JJ, Wong DK, Wahed AS, et al. Hepatitis B virusspecific and review. Hepatology. 2016;63:14811492.
global T-cell dysfunction in chronic hepatitis B. Gastroenterology. 33. Wang CC, Tseng KC, Hsieh TY, et al. Assessing the durability of
2016;150:684695e5. entecavir-treated hepatitis b using quantitative HBsAg. Am J
12. Wong VW, Chan SL, Mo F, et al. Clinical scoring system to predict Gastroenterol. 2016;111:12861294.
hepatocellular carcinoma in chronic hepatitis B carriers. J Clin Oncol. 34. Hsu YC, Mo LR, Chang CY, et al. Association between serum level
2010;28:16601665. of hepatitis B surface antigen at end of entecavir therapy and risk
13. Yang HI, Sherman M, Su J, etal. Nomograms for risk of hepatocellular of relapse in E antigen-negative patients. Clin Gastroenterol Hepatol.
carcinoma in patients with chronic hepatitis B virus infection. J Clin 2016;14:14901498 e3.
Oncol. 2010;28:24372444. 35. Lau GK. Hepatitis B reactivation after chemotherapy: two decades of
14. Yang HI, Yuen MF, Chan HL, etal. Risk estimation for hepatocellular clinical research. Hepatol Int. 2008;2:152162.
carcinoma in chronic hepatitis B (REACH-B): development and valida- 36. Di Bisceglie AM, Lok AS, Martin P, etal. Recent US Food and Drug
tion of a predictive score. Lancet Oncol. 2011;12:568574. Administration warnings on hepatitis B reactivation with immune-
15. Yuen MF, Tanaka Y, Fong DY, etal. Independent risk factors and pre- suppressing and anticancer drugs: just the tip of the iceberg?
dictive score for the development of hepatocellular carcinoma in Hepatology. 2015;61:703711.
chronic hepatitis B. J Hepatol. 2009;50:8088. 37. Patel A, Yapali S, Lok AS. Admissions for hepatitis B reactivation in
16. Tong MJ, Hsu L, Chang PW, Blatt LM. Evaluation of current treat- patients receiving immunosuppressive therapy remain unchanged
ment recommendations for chronic hepatitis B: a 2011 update. J from 1999 to 2014. Hepatol Int. 2016;10:139146.
Gastroenterol Hepatol. 2011;26:829835. 38. Wang C, Ji D, Chen J, etal. Hepatitis due to reactivation of hepatitis
17. Zoulim F, Mason WS. Reasons to consider earlier treatment of chronic B virus in endemic areas among patients with hepatitis C treated with
HBV infections. Gut. 2012;61:333336. direct-acting antiviral agents. Clin Gastroenterol Hepatol. 2016; doi:
18. Yapali S, Talaat N, Fontana RJ, Oberhelman K, Lok AS. Outcomes of patients 10.1016/j.cgh.2016.06.023. [Epub ahead of print].
with chronic hepatitis B who do not meet criteria for antiviral treatment at 39. Serti E, Chepa-Lotrea X, Kim YJ, etal. Successful interferon-free ther-
presentation. Clin Gastroenterol Hepatol. 2015;13:193201 e1. apy of chronic hepatitis C virus infection normalizes natural killer cell
19. Chang TT, Gish RG, de Man R, etal. A comparison of entecavir and function. Gastroenterology. 2015;149:190200 e2.
lamivudine for HBeAg-positive chronic hepatitis B. N Engl J Med. 40. Bitton Alaluf M, Shlomai A. New therapies for chronic hepatitis B.
2006;354:10011010. Liver Int. 2016;36:775782.