Update context for HBV assessment

core/hbv_assessment.py

@@ -134,52 +134,61 @@ life by reducing disease‑associated symptoms and lowering
 the risk of chronicity.[1]
 The recommendations for endpoints of chronic HBV
 therapy are shown in Table 5.
-Treatment indications
-Indications for treatment are in general the same for
-HBeAg‑positive and HBeAg‑negative patients, and
-this is based mainly upon the combination of serum
-HBV DNA levels, serum ALT levels and severity of
-disease[1] [Figure 2].
-Non‑cirrhotic patients should be considered for treatment
-if they have HBV DNA levels >2,000 IU/mL, serum
-ALT >~40 IU/L and severity of liver disease assessed by
-liver biopsy showing at least moderate necroinflammation
-and/or at least moderate fibrosis. Patients with HBV DNA
-greater than 20,000 IU/mL and ALT greater than 2x ULN
-can begin treatment without a liver biopsy. Patients with
-HBV DNA >2,000 IU/mL and at least moderate fibrosis
-may initiate treatment even if ALT levels are normal.
-In patients unwilling or unable to undergo liver biopsy,
-non‑invasive markers of fibrosis may instead be used to
-decide on treatment indications. Treatment indications
-should also take into account patient's age, health status, risk
-of HBV transmission, family history of HCC or cirrhosis
-and extrahepatic manifestations [Figure 2].[1]
-Recommendations for initiation of treatment
-• All patients with chronic hepatitis B (HBV DNA > 2,000 IU/mL, ALT >
-ULN), regardless of HBeAg status, and/or at least moderate liver
-necroinflammation or fibrosis (Grade A)
-• Patients with cirrhosis (compensated or decompensated), with any
-detectable HBV DNA level and regardless of ALT levels (Grade A)
-• Patients with HBV DNA > 20,000 IU/mL and ALT > 2xULN, regardless
-of the degree of fibrosis (Grade B)
-• Patients with HBeAg-positive chronic HBV infection (persistently normal
-ALT and high HBV DNA levels) may be treated if they are > 30 years,
-regardless of the severity of liver histological lesions (Grade D)
-• Patients with chronic HBV infection (HBV DNA > 2,000 IU/mL, ALT >
-ULN), regardless of HBeAg status, and a family history of HCC or
-cirrhosis and extrahepatic manifestations (Grade D)
-Monitoring of therapy of patients currently not treated
-Patients not candidate for antiviral therapy should be
-periodically assessed to determine whether an indication
-for treatment has developed. Serum ALT and HBV
-DNA levels as well as fibrosis severity by non‑invasive
-markers should be regularly evaluated. HBeAg‑positive
-untreated patients should be tested for ALT every 3 months,
-Figure 2: Algorithm for the management of HBV infection:
+
+===== TREATMENT RECOMMENDATIONS =====
+
+### 1. INITIATION OF TREATMENT [SASLT 2021, p. 6]
+• Treatment indications should also take into account patient's age, health status, risk of HBV transmission, family history of HCC or cirrhosis and extrahepatic manifestations 
+• All patients with chronic hepatitis B (HBV DNA > 2,000 IU/mL, ALT > ULN), regardless of HBeAg status, and/or at least moderate liver necroinflammation or fibrosis (Grade A)
+• Patients with cirrhosis (compensated or decompensated), with any detectable HBV DNA level and regardless of ALT levels (Grade A)
+• Patients with HBV DNA > 20,000 IU/mL and ALT > 2xULN, regardless of the degree of fibrosis (Grade B)
+• Patients with HBeAg-positive chronic HBV infection (persistently normal ALT and high HBV DNA levels) may be treated if they are > 30 years, regardless of the severity of liver histological lesions (Grade D)
+• Patients with chronic HBV infection (HBV DNA > 2,000 IU/mL, ALT > ULN), regardless of HBeAg status, and a family history of HCC or cirrhosis and extrahepatic manifestations (Grade D)
+
+### 2. MANAGEMENT ALGORITHM [SASLT 2021, p. 6]
 • HBsAg positive with chronic HBV infection and no signs of chronic hepatitis → Monitor (HBsAg, HBeAg, HBV DNA, ALT, fibrosis assessment). Consider: risk of HCC, risk of HBV reactivation, extrahepatic manifestations, risk of HBV transmission
 • CHB (with/without cirrhosis) → Start antiviral treatment if indicated, otherwise return to monitoring
 • HBsAg negative, anti-HBc positive → No specialist follow-up (inform about HBV reactivation risk). In case of immunosuppression: start oral antiviral prophylaxis or monitor
+
+### 3. MONITORING OF UNTREATED PATIENTS [SASLT 2021, p. 6-7]
+• Patients with HBeAg-positive chronic HBV infection who are younger than 30 years should be followed at least every 3-6 months (Grade B)
+• Patients with HBeAg-negative chronic HBV infection and serum HBV DNA <2,000 IU/ml should be followed every 6-12 months (Grade B)
+• Patients with HBeAg-negative chronic HBV infection and serum HBV DNA ≥2,000 IU/ml should be followed every 3 months for the first year and thereafter every 6 months (Grade D)
+
+### 4. CHRONIC HEPATITIS B (CHB) TREATMENT [SASLT 2021, p. 7-8]
+• The treatment of choice is the long-term administration of a potent nucleos(t)ide analogue NA with a high barrier to resistance, regardless of the severity of liver disease (Grade A)
+• Preferred regimens are ETV, TDF and TAF as monotherapies (Grade A)
+• LAM, ADV and TBV are not recommended in the treatment of CHB (Grade A)
+
+### 5. HBV-HCV COINFECTION [SASLT 2021, p. 8-9]
+• Treatment of HCV through DAAs may lead to reactivation of HBV. Patients who meet the criteria for HBV treatment should be treated concurrently or before initiation of DAA (Grade A)
+• HBV DNA and ALT should be monitored every four to eight weeks while on DAA and three months after completion of therapy (Grade D)
+• ALT level should be monitored every four weeks while on DAA for patients who are HBsAg-negative but HBcAb-positive. If ALT starts to rise, HBsAg and HBV DNA must be obtained to determine the need to start HBV treatment (Grade D)
+
+### 6. HBV-HDV COINFECTION [SASLT 2021, p. 9]
+• HDV is a defective virus that requires HBsAg to envelop its delta antigen, causing coinfection with HBV or superinfection in chronic HBV patients
+• Active HDV infection is defined by HDV IgM and RNA presence with unexplained LFT elevation
+• Treatment goal: Suppression of HDV replication
+• PEG-IFN for 1 year shows long-term benefits despite post-treatment viral relapse
+• NA monotherapy is ineffective against HDV replication
+
+### 7. HBV-HIV COINFECTION [SASLT 2021, p. 9]
+• All HIV-positive patients with HBV co-infection should start ART irrespective of CD4 cell count (Grade A)
+• HBV-HIV co-infected patients should be treated with TDF- or TAF-based ART regimen (Grade A)
+
+### 8. IMMUNOCOMPROMISED PATIENTS [SASLT 2021, p. 9]
+• Prophylaxis for all HBsAg-positive patients before chemotherapy or immunosuppressive therapy (Grade A)
+• HBsAg-negative/anti-HBc-positive patients need HBV prophylaxis if receiving anti-CD20 or stem cell transplantation
+• Continue prophylaxis for ≥6 months after immunosuppression (12 months for anti-CD20)
+
+### 9. PREGNANCY [SASLT 2021, p. 9-10]
+• Screen all pregnant women for HBV in first trimester (Grade A)
+• HBV vaccine is safe in pregnancy for non-immune women without chronic HBV
+• Treat pregnant women meeting standard therapy indications
+• Start antiviral prophylaxis with TDF (or TAF) for HBV DNA >100,000 IU/mL at 24-28 weeks (Grade D)
+• Switch to TDF/TAF if on ETV, ADV, or interferon during pregnancy (Grade D)
+• Delivery mode based on obstetric indications only
+• Breastfeeding permitted for HBsAg+ women on TDF (Grade B)
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