Immunotolerant HBeag positive patients: To treat or not to treat

Immunotolerant hepatitis B e antigen (HBeAg) positive subjects are typically young, asymptomatic, have high serum hepatitis B virus (HBV) DNAwith normal alanine aminotransferase (ALT) and no or minimal histologic changes. In addition, there is usually no or minimal disease progression if ALT remains normal. The response to currently available antiviral agents in immunotolerant subjects is poor in terms of HBeAg seroconversion. Therefore, current guidelines recommend regular follow-up for immunotolerant subjects instead of drug therapy. However, normal ALT does not always reflect an absence of significant inflammation and/or fibrosis, especially in those over age 35 and those with high “normal” ALT. Liver biopsy/fibrosis detection may help to identify patients in need of therapy. Preemptive antiviral therapy is mandatory for immunotolerant HBeAg-positive patients about to receive organ transplantation or immuno/ chemotherapy. Immunotolerant HBeAg-positive pregnant women with HBV DNA>2×106 IU/mL can be treated in the third trimester to prevent perinatal HBV transmission.