Management of newly diagnosed hepatitis B in the elderly

Confirm and characterise the infection. Repeat HBsAg at 6 months to confirm chronicity; check HBeAg/anti-HBe, quantitative HBV DNA, ALT, and screen for anti-HDV, anti-HCV and HIV. Assess fibrosis with APRI, FIB-4 and transient elastography, and perform an ultrasound of the liver.

Determine the phase of infection. HBeAg-positive chronic infection (immune-tolerant), HBeAg-positive chronic hepatitis, HBeAg-negative chronic infection (inactive carrier), HBeAg-negative chronic hepatitis, and resolved/occult infection. Older patients are usually HBeAg-negative with fluctuating DNA and ALT, so a single normal ALT does not exclude active disease.

Who to treat. All patients with cirrhosis and any detectable HBV DNA, regardless of ALT; those with HBV DNA >2000 IU/mL and ALT above the upper limit of normal; significant fibrosis (≥F2) on elastography or APRI; extrahepatic manifestations (glomerulonephritis, vasculitis); and a family history of hepatocellular carcinoma.

Antiviral therapy. An oral nucleos(t)ide analogue with a high genetic barrier to resistance — tenofovir disoproxil fumarate, tenofovir alafenamide or entecavir — once daily and usually lifelong. In older adults prefer tenofovir alafenamide or entecavir, because TDF causes renal tubular dysfunction and reduced bone mineral density; entecavir requires dose adjustment for creatinine clearance. Pegylated interferon is generally unsuitable in the elderly.

Prophylaxis and prevention of flares. Give antiviral prophylaxis before immunosuppression or chemotherapy — especially rituximab and high-dose corticosteroids — in HBsAg-positive and anti-HBc-positive patients, continuing for 6–12 months afterwards, because reactivation can be fatal. Never stop antivirals abruptly. Vaccinate household and sexual contacts, and give hepatitis A vaccine.

Monitoring and surveillance. ALT and HBV DNA every 3–6 months; renal function, phosphate and bone density on tenofovir. Six-monthly ultrasound ± alpha-fetoprotein for hepatocellular carcinoma in all cirrhotics, and also in non-cirrhotic HBsAg-positive Asian men over 40 and women over 50; endoscopy for varices if cirrhotic. Counsel on alcohol avoidance, drug interactions and transmission.

WHO Guidelines for chronic hepatitis B, March 2024 — treatment eligibility has been substantially expanded and simplified. Treat if there is significant fibrosis or cirrhosis (APRI >0.5 or elastography); or HBV DNA >2000 IU/mL with raised ALT; or the presence of coinfection (HIV, HDV, HCV), a family history of cirrhosis or liver cancer, immunosuppression, comorbidity such as diabetes or MASLD, or extrahepatic manifestations — regardless of DNA and ALT levels; and, where DNA testing is unavailable, on persistently abnormal ALT alone. The guideline also recommends point-of-care HBV DNA and reflex viral load testing, and testing every HBsAg-positive person for hepatitis D.