Dr Patrick Kennedy, consultant hepatologist, discusses the importance of appropriate diagnosis and access to care.

Dr Kennedy explains, the first thing to do when a patient presents with possible chronic HBV infection is to take a detailed history to get an understanding of their origin, risk factors, family history and ethnicity, which are all important factors for making a diagnosis.

Beyond that, abnormal liver function tests (LFTs) need to be investigated further. As part of that routine chronic liver disease screens should be undertaken, and that should include screens for viral hepatitis, such as HBV and Hepatitis C (HCV) and even Hepatitis E.

Importantly, Dr Kennedy says “normal liver function tests do not exclude a diagnosis of chronic HBV […] you shouldn’t be  automatically reassured that there’s no underlying condition” Understanding the clinical context of the patient is essential when considering potential HBV patients. HBV is a dynamic disease, with potential long periods of inactivity. But even when inactive, the underlying disease gives the risk of progression to chronic liver disease and liver cancer.

“Normal liver function tests do not exclude a diagnosis of chronic HBV […] you shouldn’t be automatically reassured that there’s no underlying condition”

Only a HBV surface antigen (HBsAg) test can confirm for sure whether a patient has HBV. When a GP detects HBV using a SA test, they can refer the patient to a specialist clinic, where disease stratification will occur. However, in line with NICE guidelines they may want to do additional tests to better understand the disease and phase. These tests may include: HBV e antigen/antibody status and HBV DNA level.3 This is important information for determining risk of transmission to family members.

HBV patients with a new diagnosis will be assessed for whether they can be monitored to ensure they remain in a stable disease state, or they may need to start treatment. Hybrid care between the GP and specialist clinic is important.

Long-term outlook for HBV patients

Once a diagnosis is made, patients will likely attend a specialist clinic for their lifetime. Chronic HBV integrates into the host’s DNA.4 If HBsAg loss or a functional cure is achieved in the long term, there is the possibility of the patients being discharged from the care of a clinic. However, specialist monitoring services within a clinic's setting are required to get to this point.

Evolution of care pathways for HBV patients

Dr Kennedy states, “We are on the cusp of major change for patients with chronic HBV” with increasingly better tools to understand it – including the risk of disease progression. “This is why it’s critical for patients to be engaged in specialist clinics where they have this appropriate level of disease assessment and specialist care […] The next 5–10 years will be hugely exciting for the management of HBV, as new therapies are being developed with the potential to achieve HBsAg loss and functional cure.”

“We are on the cusp of major change for patients with chronic HBV”

Watch the full interview with Dr Patrick Kennedy

 

References

  1. The World Health Organization. Hepatitis B. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-b Accessed March 2019.
  2. Cancer Council Victoria. Available from: https://www.cancervic.org.au/for-health-professionals/community-health-professionals/hepatitis-b-and-liver-cancer Accessed March 2019.
  3. Hepatitis B (chronic): diagnosis and management Available from: https://www.nice.org.uk/guidance/CG165/chapter/1-Recommendations#assessment-and-referral-in-primary-care Accessed March 2019.
  4. Tu T, et al. J Virology 2018;92(11):1–22.

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