Implementing evidenced-based practice guidelines for the management of chronic hepatitis B virus infection

In the past 2 years, evidenced-based guidelines and statements on screening, diagnosis, and management of hepatitis B virus (HBV) from several organizations and experts have been published. The purpose of this article is to take the recommendations from these documents and help guide clinicians--whether they are primary care providers, hepatologists, gastroenterologists, or public health workers--about how to incorporate these guidelines into practice. The first task is for all providers to be involved in identifying persons with chronic HBV infection (CHB). New recommendations from the Centers for Disease Control and Prevention (CDC) advocate screening for the HBV in those at highest risk, especially persons from countries where HBV is endemic. Using information from the clinical and laboratory evaluation of the patient infected with HBV, especially the hepatitis B e antigen/antibody status, clinicians can classify the patient into 1 of the 4 phases of HBV infection. Because CHB is a dynamic process and patients can move from inactive to active infection status, and vice versa, all patients must be followed with alanine aminotransferase (ALT) and aspartate aminotransferase monitoring every 3 to 12 months for life. Those with elevated ALT and HBV DNA levels (>2,000 IU/mL) should be referred to a specialist for evaluation for possible treatment. Patients selected for antiviral therapy with nucleoside analogues should be followed every 3 to 6 months to detect emergence of antiviral resistance to the agent chosen. In addition, alpha-fetoprotein should be tested and ultrasound performed on all men aged >40 years and women >50 years of age to detect any hepatocellular carcinoma (HCC) in an early stage. Algorithms are included for primary care providers providing information on initial evaluation and management and referral of persons with CHB, and for specialists evaluating and treating HBV. Implementing steps to identify, follow, refer, and treat appropriately persons with CHB infection by all primary care and specialist healthcare providers can have a major impact on reducing the occurrence of HCC and cirrhosis in infected persons.