## Management of Acute Hepatitis B **Key Point:** Acute hepatitis B infection in immunocompetent adults is typically self-limiting and does NOT require antiviral therapy. Supportive care is the standard approach. ### Rationale for Supportive Care 1. **Natural history**: 90–95% of immunocompetent adults spontaneously clear acute HBV infection within 6 months 2. **Fulminant hepatic failure risk**: Only 0.5–1% of immunocompetent adults develop fulminant hepatic failure; antiviral therapy does not reduce this risk in acute infection 3. **No evidence of benefit**: Antivirals are NOT indicated in acute HBV unless there is evidence of acute liver failure or prolonged cholestasis ### When Antivirals ARE Indicated | Scenario | Drug of Choice | |---|---| | **Chronic HBV** (HBsAg+ >6 months) | Tenofovir or Entecavir | | **Acute HBV with fulminant failure** | Lamivudine or Tenofovir (supportive care primary) | | **Immunosuppressed with acute HBV** | Consider antiviral therapy | **High-Yield:** Acute hepatitis B ≠ Chronic hepatitis B. Acute infection requires *observation*, not antivirals. **Clinical Pearl:** Monitor for signs of fulminant hepatic failure (INR >1.5, encephalopathy, hypoglycaemia). If fulminant failure develops, antiviral therapy + ICU support + transplant evaluation are indicated. ### Why Other Options Are Wrong - **Lamivudine, Tenofovir**: Reserved for chronic HBV or acute fulminant failure, not uncomplicated acute infection - **Interferon-alpha**: Historically used; now rarely used due to poor efficacy in acute HBV and significant side effects [cite:Harrison 21e Ch 297]
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