Controlling chronic hepatitis B
It is very hard to completely get rid of a chronic hepatitis B infection. But it is possible to control it. By controlling the virus, doctors mean 2 things.
- Stopping any new liver damage. Having an ALT level in the normal range is a sign that your liver isn’t being damaged.
- In some cases stopping the virus from copying itself, so it can’t be passed on. A low or undetectable DNA level (viral load) is a sign the virus isn’t copying itself.
Why is it so hard to cure hepatitis B?
The hepatitis B virus can hide in your liver cells, so your body cannot get rid of all of it. This means it can make more viruses in the future, even if it is controlled now. This is why it is important to go for regular check-ups.
Scientists are trying to find better treatments for hepatitis B. A cure is still a long way away. As a step on the way they are trying to find a ‘functional cure’. This means a treatment that puts the virus under control for good, so you can then stop treatment safely. Getting involved in research is one way you can help find better treatments for the future.
Sometimes the immune system can keep the virus under control. If your immune system isn’t controlling the virus, you might need treatment. You are likely to be offered treatment if one or more of these things are true:
- You have a viral load of 20,000 or more
- You have ALT levels above the normal range for 3 months
- You have a diagnosis of cirrhosis
- You are pregnant and have high levels of virus. Treatment reduces the chance of it getting passed on to your child. Read about how vaccines can protect your baby.
Your doctor should talk with you about treatment options and what is right for you. They might take into account things like your age, general health and how else hepatitis B affects you. Nowadays doctors are also more aware that some people would prefer to be on treatment to keep the virus very low. Ask them any questions you have and let them know what you would prefer to do.
Not everyone has treatment because people with low virus levels and no evidence of liver damage are unlikely to get seriously ill. So they won’t benefit from treatment, but can still have side-effects. So on balance doctors believe it is better not to treat the person, unless a check-up shows something has changed.
The treatment for chronic hepatitis B is antiviral therapy. There are 2 main types, nucleoside or nucleotide analogues and interferon. Each treatment has different pros and cons.
Nucleoside or nucleotide analogues – key points
- Controls the hepatitis B virus well
- You take daily medicine
- You usually need to continue treatment for the rest of your life
- Most people don’t have side effects that make daily life difficult
- Can be taken by most people with hepatitis B
- Go to the section about having a nucleoside or nucleotide analogue
Interferon – key points
- Does not control the virus in everyone (you have tests to check it is working for you)
- You give yourself daily injections
- A single course of treatment that lasts about a year
- Many people have side effects that make daily life difficult, such as constant flu-like symptoms
- Many people cannot take interferon
- Go to the section about having interferon
Interferon treatment is used much less now than it was in the past. Most people have a nucleoside or nucleotide analogue. But for some people interferon could be a better choice, for example because you don’t have to take it for the long term.
Your doctor will discuss the options with you. Once your treatment starts, you will have tests to check it is working.
Antiviral treatment with a nucleoside or nucleotide analogue
Some doctors call this type of medicine NAs or ‘nucs’ which sounds like nukes.
The main medicines used in the UK are called:
- tenofovir disproxil (TDF for short)
- entecavir (ETV)
These medicines target the virus and stop it making copies of itself. So they are very good at keeping levels of virus low. The aim is to have an undetectable viral load.
These medicines also improve liver disease in most people with chronic hepatitis B. Taking them long-term can:
- Stop new liver damage
- Repair damage that is already there
- Improve cirrhosis
- Make a transplant less likely
- Reduce the risk of getting liver cancer
There is a small chance that the first medicine you take won’t work for you. If this happens you can usually try a different one. Your doctor will check you have been taking the medicine properly. Missing tablets can stop it from working. If you have problems taking your medicine, for example due to side effects, tell your doctor.
Read the information that comes with your medicine carefully. This will tell you more about how to take it, what to do if you forget, and side effects. If you don’t understand anything, ask your doctor or pharmacist. Keep a copy of the information in case you need to check it later or show it to another doctor.
Each medicine has slightly different side effects. Common ones include:
- Tummy problems, feeling or being sick
- Headaches
- Tiredness
- Dizziness
Not everyone has side effects and you may only have one or two. They often get better once you have taken the medicine for a few weeks, so it is worth carrying on if the side effects are not too bad.
Check-ups and tests
Before you start taking your medicine, your doctor will do some blood tests called a baseline. They check future results against these to help measure changes in your health. This will usually include checking:
- Viral load (hepatitis B DNA)
- Your liver health, including ALT level
- Your kidney health (eGFR and blood phosphate levels)
Your kidneys work with your liver to process medicines and get rid of waste products in your pee. So it’s important to check they are working well. The eGFR (estimated glomerular filtration rate) relates to how quickly your kidneys clear waste products. Depending on your results, your doctor might adjust how much medicine you take (the dose).
In the first year of treatment you’ll have a check-up usually every 3 months. After a year, they will be around every 6 months. Check-ups will include blood tests for ALT and viral load. Within the first year, most people’s ALT levels are back to normal and their viral load is low.
People taking tenofovir disproxil (TDF) also have their kidney and bone health checked. Nucleoside and nucleotide analogues are likely to be safe. But there may be a small risk of kidney disease and bone problems with tenofovir disproxil.
You also have tests for the hepatitis B virus’ envelope and surface antigens. This helps your doctor understand how the virus is responding to treatment.
- Negative envelope antigen tests are usually a good sign.
- Negative surface antigen tests are very rare. It means that the virus is under control and very unlikely to come back. This is known as a ‘functional cure’.
A small number of people might be able to stop taking the medicine. Your doctor will do tests to check that you can do this safely. You will have regular check-ups for at least a year after you stop taking the medicine.
Treatment with interferon
Interferon helps your immune system get the virus under control. If it works for you, it can be effective at controlling the virus in the long-term. Over time, it can lead to a functional cure in some people. This is where the virus is under control and very unlikely to come back.
When interferon works to control hepatitis B, it can also stop liver disease getting worse. And any liver damage might be repaired. It can also reduce the risk of getting liver cancer.
The full name for interferon is pegylated-interferon alpha. You might also see it called Peg or Peg-INF.
There are a number of things that mean you cannot take interferon. These include being pregnant and having cirrhosis.
If it works, most people can stop taking interferon after a year. If interferon doesn’t work for you, your doctor will discuss other options. Most people can change to a nucleoside or nucleotide analogue.
How to take interferon
You will need to inject interferon. You will get pre-filled syringes. Your doctor or nurse will show you how to inject it under your skin. Make sure you understand what to do. Ask if there is a video or information you can take away with you to help.
When you first start taking interferon it can be helpful to take a few days off work and ask someone to help with any childcare.
Interferon can have a number of side effects. Common ones include:
- Flu-like symptoms
- Muscle pains
- Headaches
- Feeling tired
- Weight loss
- Depression
- Hair loss
- Rashes or soreness from injections
Flu-like symptoms tend to start 4 to 6 hours after the injection. So it can help to take paracetamol 2 to 3 hours after the injection and then every 4 to 6 hours. Check with your nurse or doctor how much to take, as you may need to take a lower dose. It can also help to have your injection in the evening so you can sleep through the symptoms.
It’s normal to have a high temperature (over 38 degrees) when you first start taking interferon. If it doesn’t go back to normal within 48 hours tell your doctor or specialist nurse.
Tell your doctor if side effects are a problem. For example they stop you doing your usual activities.
Read the information that comes with your medicine carefully. This will tell you more about how to take it, what to do if you forget, and side effects. If you don’t understand anything, ask your doctor or pharmacist. Keep a copy of the information in case you need to check it later or show it to another doctor.
Check-ups and tests
Before you start taking your medicine, your doctor will do some blood tests called a baseline. They check future results against these to help measure changes in your health. This will usually include checking:
- Your liver health, including ALT levels
- Your kidney health
- Levels of a hormone called thyroid stimulating hormone (TSH), which rise when your immune system is active
- Viral load (hepatitis B DNA)
- Hepatitis B surface antigen levels
- Whether you have hepatitis B envelope antigen or antibodies against it
Treatment usually lasts for a year. During this time you will have regular check-ups and tests. These will go from every 2 weeks, to monthly, to every few months. Your doctor will check your liver and kidneys are healthy and your TSH levels at most appointments.
Viral load and hepatitis B antigens and antibodies are usually checked at 3, 6 and 12 months. These show how well treatment is working. Your doctor uses these tests to decide if you should carry on with treatment or stop. This depends on the type and phase of the hepatitis B infection. Your doctor will be able to explain what they are looking for in your case.
You have more tests 6 months and 1 year after finishing treatment to check how well it has worked. A good result is to have:
- Viral load below 2,000
- Lower levels of surface antigen than your baseline
- ALT in the normal range
Most people have a check-up every year to make sure the virus is still under control and their liver is healthy. Liver damage often has no symptoms, so it is important to go to all your appointments.
Tests and check-ups for people not being treated
If you are not having treatment for chronic hepatitis B you will have regular check-ups. It is very important to go to all your check-ups. The virus can become active without causing symptoms.
You’ll have tests and a check-up every 6 months to a year, depending on the phase of the infection. They might be more often for the first year or if you are under 30.
The blood tests will include:
- ALT levels
- Viral load (hepatitis B DNA)
You should also have a scan or other test for serious liver damage and scarring (fibrosis) once a year.
These tests are the best way to be sure your liver is healthy and the virus is under control. The tests also check if there is a risk the virus can be passed on. If viral load is undetectable, it cannot be passed on. Your doctor will talk to you about your results and anything you and others can do to stop it being passed on, like vaccination.
If you develop symptoms of hepatitis B or liver disease, tell your doctor straight away.
ALT flares
People with hepatitis B should have their ALT levels monitored with blood tests. ALT is a sign of liver damage. An ALT flare is when ALT levels rapidly rise to at least 5 times the normal amount.
We don’t understand all the causes of ALT flares. They can be linked to starting or stopping treatment. ALT flares are also more common during pregnancy and the months after giving birth.
A flare can be a good sign, because it means your immune system is attacking the virus. The virus is in your liver cells, so they get damaged too. Flares can mean you need to have treatment.
Most of the time ALT flares don’t cause any symptoms. The only way doctors know that you are having flares and may need treatment of your virus is by checking your blood tests. This is why you are likely to need life-long monitoring once you are under a specialist.
Download the fact sheet
Support for you
The British Liver trust is here to support anyone with a liver condition. And their friends and family. We offer an online community and support groups where you can connect with others and share experiences.
Find out more about how we can support you here.
You can also call our helpline on 0800 652 7330
The helpline is run by specialist liver nurses. They are there from 9am, to 3pm Monday to Friday (excluding bank holidays)
Special thanks
We would like to thank Amanda, Dick, Monica and all the other people living with hepatitis B who helped us by coming to our focus groups or giving us feedback.
Also, our expert clinical reviewers:
Dr Ahmed Elsharkawy, Consultant Hepatologist, Queen Elizabeth Hospital Birmingham
Dr Kathryn Jack (PhD RN), Clinical Lead Nurse Research and Innovation, Nottingham University Hospitals
Lindsay Chalmers, British Liver Trust Nurse Helpline
Hepatitis B information published on July 27th 2023
Review date, July 2026