Managing Older Patients With Chronic Hepatitis B: A Global Perspective

Key Takeaways:

• Older patients with hepatitis B virus are at risk for severe liver disease and liver cancer—the longer a person has chronic hepatitis B, the more likely they are to develop more advanced liver disease.
• Ongoing assessment of patients with chronic hepatitis B is crucial.

When we picture an older patient, we often don’t think of someone 40 years old. However, in the context of hepatitis B virus (HBV), a patient 40 years of age or older is considered “older.” Older patients with HBV may present with more advanced disease and may have comorbidities and comedications that affect our choice of treatment differently than if the patient were younger. Here, I illustrate the issues we face in caring for older patients with HBV through a recent patient encounter in my clinic.

Defining “Older” in Older Patients With HBV
Not that long ago, I saw a 40-year-old woman from sub-Saharan Africa in my clinic. She came in with her brother, who lives in the United States and is a faculty member at one of the local universities. They both are infected with HBV, and when they were discussing their disease, she shared with him that she had not seen a healthcare professional for a while because she had been told that she had inactive HBV and it had been monitored.

When we think about how we identify individuals with HBV who are higher risk for things such as liver cancer screening, women are not considered high risk until 50 years of age. But in older patients with HBV, it is not just cancer risk that is important to assess. The longer a person has chronic hepatitis B (CHB), the more likely they are to develop more advanced liver disease. That is partly because fibrosis pathways change as we age, and it is also because some patients have had intermittently or persistently active disease that has resulted in inflammation and scar tissue. The inflammation and scar tissue will progress gradually until the damage is more clinically apparent. When we are defining someone with HBV who is older, our guidelines define that to be 35-45 years of age. There is not complete consensus, but certainly by the time a person is in their 40s, they are considered an older person with HBV—not geriatric, but older. Our patient met the definition of being considered an older individual with HBV.

Importance of Monitoring
Because our patient was told that her HBV was inactive, she felt as if monitoring had become relatively inconsequential. She had not thought much about her HBV until she was visiting her brother, who is receiving treatment for CHB. He wanted her to have her HBV reassessed, and that is why they came to my clinic while she was visiting.

At her visit, we repeated her labs and performed a FibroScan. Based on her liver enzyme results, I could see how her HBV had been defined as inactive. Her alanine aminotransferase and aspartate aminotransferase were normal. “Normal” is defined differently by different HBV guidelines, but by the American Association for the Study of Liver Diseases HBV guidelines, an alanine aminotransferase >25 U/L is considered abnormal for women, and her value was below this. She was hepatitis B e antibody positive (HBeAb or anti-HBe), which is not unusual. Her viral load, however, was just above 2000 IU/mL. Some might define her as an inactive carrier at this level, but I think the definition of inactive carrier or someone who does not have clinical disease is evolving. To me, she fell into a gray zone because her liver enzymes were normal, but her HBV DNA was high enough that she should consider treatment. When I reviewed her old records, her HBV DNA was persistently between 2000 and 200,000 IU/mL, so her HBV DNA was fluctuating and was never undetectable. Her FibroScan was 7.2 kPa and was a good study, so we were confident with the result. This value does not indicate that she is at high risk for advanced fibrosis, but it is not perfectly normal, either.

The patient has no family history of liver cancer or cirrhosis, but her family did have several members with HBV, and there were some early deaths for non–liver-related reasons. Because her brother was receiving antiviral therapy due to having more active disease, he wanted her to be evaluated for and consider antiviral treatment, too.

Treatment Strategies
When we are discussing with this individual the advantages of HBV treatment vs no treatment and how to monitor her CHB, it is important to overlie the discussion with her chronologic age, where her risk of developing disease—whether it is more progressive fibrosis or liver cancer—increases. She also falls into a time period where, as a person, one is more likely to develop comorbid conditions such as diabetes, obesity, and metabolic syndrome. At this stage of life, one may be more likely to have stressors that lead to unhealthy alcohol use. This specific patient was not overweight, did not have diabetes, and was not a heavy drinker. But these factors should be evaluated and may drive us to look at our patients slightly differently. And when we look at epidemiologic data, we recognize that the group of individuals with active viral replication is at risk for liver cancer.

It is not perfectly clear that treating a patient who falls into the gray zone and thus does not meet well-defined guideline criteria for treatment decreases their risk of disease progression or their liver cancer rates. But when we extrapolate that to natural history data and some of the smaller studies that have looked at treating patients like this who are in the gray zone, there is the sense that you could risk reduce this individual if you engage them in treatment.

The patient was interested in starting treatment, and I supported that decision because the FibroScan was abnormal—and was abnormal in the context of persistent viral replication. Together, this indicated that she was at risk for progression to liver disease or liver cancer. We started her on antiviral therapy, and her virus was nicely suppressed over the next 3 months.

When we are discussing treatment decisions, it is important to consider patient-specific factors in drug selection. Our patient was healthy and did not have renal dysfunction or bone disease (eg, osteoporosis or osteopenia). Approved first-line treatments for HBV include entecavir or tenofovir in the form of tenofovir disoproxil fumarate or tenofovir alafenamide. She also was planning to return to her home country in Africa in several months. Because she was at lower risk for bone and renal complications, and based on drug availability in her home country, we chose tenofovir disoproxil fumarate. Had she been older and thin, or had hypertension, diabetes, or other risk factors that affect bone and/or renal health, we would have leaned more toward choosing entecavir or tenofovir alafenamide. It is important to consider comorbidities that are germane to aging when considering selection of first-line treatment for older patients with HBV.

Your Thoughts?
How do you define “older” in your older patients with HBV? How does older age affect your treatment and monitoring decisions for patients with HBV? Join the discussion by leaving a comment below.