Antiviral therapy for chronic hepatitis B viral infection in adults: A systematic review and meta‐analysis

Abstract

Chronic hepatitis B viral (HBV) infection remains a significant global health problem. Evidence-based guidelines are needed to help providers determine when treatment should be initiated, which medication is most appropriate, and when treatment can safely be stopped. The American Association for the Study of Liver Diseases HBV guideline methodology and writing committees developed a protocol a priori for this systematic review. We searched multiple databases for randomized controlled trials and controlled observational studies that enrolled adults 18 years old diagnosed with chronic HBV infection who received antiviral therapy. Data extraction was done by pairs of independent reviewers. We included 73 studies, of which 59 (15 randomized controlled trials and 44 observational studies) reported clinical outcomes. Moderate-quality evidence supported the effectiveness of antiviral therapy in patients with immune active chronic HBV infection in reducing the risk of cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In immune tolerant patients, moderate-quality evidence supports improved intermediate outcomes with antiviral therapy. Only very low-quality evidence informed the questions about discontinuing versus continuing antiviral therapy in hepatitis B e antigen-positive patients who seroconverted from hepatitis B e antigen to hepatitis B e antibody and about the safety of entecavir versus tenofovir. Noncomparative and indirect evidence was available for questions about stopping versus continuing antiviral therapy in hepatitis B e antigen-negative patients, monotherapy versus adding a second agent in patients with persistent viremia during treatment, and the effectiveness of antivirals in compensated cirrhosis with low-level viremia. Conclusion: Most of the current literature focuses on the immune active phases of chronic HBV infection; decision-making in other commonly encountered and challenging clinical settings depends on indirect evidence. (HEPATOLOGY 2016;63:284-306)

Uptake of Tenofovir-Based Antiretroviral Therapy among HIV–HBV-Coinfected Patients in the EuroSIDA Study

“…There is accumulating evidence supporting that long-term antiviral therapy against HBV reduces the risk of liver failure and liver-related death (reviewed in ref [15]. ), but a sufficiently powered head-to-head comparison of the clinical effectiveness of TDF versus lamivudine/emtricitabine is lacking.…”

EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection

“…1,56,57 These drugs can be safely used in any HBV infected patient and represent the only treatment option for several patient subgroups including those with decompensated liver disease, liver transplants, extrahepatic manifestations, acute hepatitis B or severe chronic HBV exacerbation. [57][58][59][60][61] NAs are also the only option for prevention of HBV reactivation in patients under immunosuppression. In addition, preventing HBV transmission in patients with high viremia who do not fulfill the typical criteria for treatment initiation represents further indications in which only NAs should be used.…”

A methodology concern of the meta‐analysis of antiviral therapy for chronic hepatitis B virus infection in adults

“…(3) We appreciate the excellent work performed by Lok et al (3) This is the latest meta-analysis on this issue and is likely to be included in guidelines for management of CHB. Coincidently, we are doing a similar meta-analysis about CHB, and we have retrieved all of the randomized controlled trials (RCTs) included in the meta-analysis conducted by Lok et al…”