My Doctor Online The Permanente Medical Group

Symptoms and Diagnosis

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Most people with hepatitis B have no symptoms related to the infection. Symptoms may be experienced during an acute infection, although most people remain relatively asymptomatic. The absence of symptoms does not mean the liver is not being damaged.

Hepatitis B can be accurately diagnosed with a blood test. Serum markers commonly used include the following:

• Surface antigen (HBsAg). Indicates ongoing viral infection.
• Core antibody (HBcAb). Indicates prior exposure to the virus but does not allow us to determine whether someone has the ability to pass on the virus to others or is currently infectious.
• Hepatitis B surface antibody (HBsAb).Indicates immunity to hepatitis B.
• Hepatitis B virus DNA. These tests measure the amount of virus in the blood. They confirm active ongoing infection and help us determine the virus' response to different therapies.

There are other pieces of the virus and other antibodies present in the body that are important in some circumstances, but hepatitis B is usually diagnosed with this standard set of blood tests.

Prevention

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Hepatitis B vaccine is the best way to prevent infection. We strongly recommend that you receive a vaccine to protect you from getting the virus. The hepatitis B vaccine is a series of three injections that provide long-term protection against the hepatitis B virus.

Many people receive this vaccine when they are young. California is one of many states that require all children to be vaccinated as part of their school registration process. Older children who did not receive the vaccine as infants should be vaccinated. If you are an adult who has not received the vaccine, it's important that you are immunized as well.

Avoid exposure to hepatitis B by avoiding the following:

• Unprotected sex. If there is any chance that your partner could have the hepatitis B virus, always use latex condoms to protect yourself. Condoms can also protect you from other sexually transmitted diseases, like HIV, chlamydia, and gonorrhea.
• Unsterilized needles. If you use needles to inject intravenous drugs, it's important not to share them with others. Clean needles and syringes are available through local needle exchange programs. We recommend you seek treatment if you use illicit drugs, and we have resources that can help you.

Treatments

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While there is no cure for hepatitis B, there is treatment for chronic hepatitis that can make the virus inactive or prevent it from further damaging the liver. Treatments include:

• In people who are at risk for cirrhosis, certain medicines can stop liver scarring from getting worse.
• In those who already have cirrhosis, certain medicines can stop the condition from getting worse. This can sometimes help a patient who might otherwise need a liver transplant.
• In those with normal or nearly normal livers, the benefits of treatment are less clear.
• Certain drugs may reduce the chances of getting liver cancer from hepatitis B, though this has not yet been proven.

Recommendations on who should take the medications are constantly evolving, and ongoing research is used to help determine who should consider treatment.

Antiviral treatment is available and may benefit those patients with chronic hepatitis B who have evidence of ongoing liver damage, significant scarring, and/or cirrhosis. Others may not benefit from treatment at this time but should have regular blood tests to monitor the status of the hepatitis B virus. A liver biopsy may be helpful in some cases to determine if treatment is needed.

The purpose of treatment is to decrease the chance of significant scar formation in the liver, as well as to limit the spread of the virus.

Medications

Two main kinds of medications are used to treat hepatitis B: interferon (injection) and oral antiviral agents.

Pegylated interferon. The exact mechanism of action is unknown; it is believed to increase the body's ability to clear the virus. At present, it is the only agent shown to fight off the virus long-term. Side effects of interferon injections vary from person to person. They usually include flulike symptoms, like fever or body aches. Occasionally, we see patients with more serious side effects, but this is very rare.

Oral antiviral agents. Current oral agents include antinucleoside and nucleotide agents. These include:

• Lamivudine (Epivir)
• Adefovir (Hepsera)
• Entecavir (Baraclude)
• Tenovofovir (Viread)
• Telbivudine (Tyzeka)

The medicines must be taken every day, because the virus quickly mutates and can become resistant to the drug. This is the same thing that happens with antibiotics. Beginning these medications is a significant commitment. Once started, medication often has to be continued for years, if not a lifetime.

Side effects of these medications are very mild. Very rarely, the medicine can affect muscles or nerves. Even rarer is a condition called lactic acidosis in which the medication can affect how the body gets energy from food. This condition mainly happens in people taking hepatitis B drugs along with drugs for HIV.

Lifestyle Management

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We recommend a healthy lifestyle for our patients who are diagnosed with hepatitis B. Regular medical checkups and ongoing care are important in maintaining your health. A healthy diet and a regular routine of exercise can improve your health and strengthen your immune system.

A healthy lifestyle includes the following:

• For those who have chronic hepatitis B, the most important thing is to avoid alcohol and tobacco products. Alcohol abuse makes cirrhosis more likely.
• We know that exercise and a diet rich in fruits, vegetables, and whole grains help prevent cancer and heart disease. It is even more valuable to follow these guidelines if you have chronic hepatitis.

Preventing the spread of hepatitis B

If you have hepatitis B, there are precautions you can take to protect others from catching the virus. These include:

• Vaccinate your family. The most important measure is to vaccinate family, close friends, and anyone else you have regular contact with.
• Practice safe sex by using latex condoms. Tell your sex partner(s) that you have the hepatitis B virus.
• Don't donate blood or organs.
• Don't share certain personal items. Razors and toothbrushes can carry the virus.
• Don't share needles. If you use needles to inject intravenous drugs, it's important not to share them with others. Clean needles and syringes are available through local needle exchange programs. We recommend you seek treatment if you use illicit drugs, and we have resources that can help you.

If someone you know is exposed to hepatitis B without being immune, that person can be treated with gamma globulin high in hepatitis B (HBIg). Let this person know that immediate treatment can prevent them from catching the virus, and that he or she should see the doctor immediately.

Monitoring your health

People can have hepatitis B over many decades, with their condition changing slowly, if at all, over the years. Depending on your condition, blood tests monitoring liver function and disease activity are recommended at 6-month intervals. We use these tests to determine if and when we should prescribe medicines to help your body regulate the virus.

Preventing cancer

As you get older, your risk for liver cancer increases. This risk becomes significant for men when they turn 40 and for women when they turn 50. If this applies to you, we recommend monitoring your liver once or twice a year with imaging tests. For certain patients (for example, if you have a family history of liver cancer or were born in Africa), we recommend that these tests start earlier.

Generally, we do this imaging with ultrasound exams, which have the virtue of not exposing patients to radiation. Sometimes a CT or MRI may be needed.

Pregnancy and hepatitis B

If a woman with hepatitis B is thinking of having children, if possible it is best to delay medications until she gives birth. Her newborn is then treated with special gamma globulin against hepatitis B (HBIg) and with vaccination. This works well most of the time. In the rare cases where this treatment does not work, doctors think it is usually when the mother has very high levels of the virus. In cases with a very high viral load, some doctors recommend treatment in the last 2 or 3 months of pregnancy. We do not recommend that you breastfeed while taking these medications, so they may need to be discontinued after delivery and should be discussed with your obstetrician. The risks and benefits of these medicines need to be determined on an individual basis.

The Centers for Disease Control and Prevention (CDC) encourages all women with hepatitis B to breastfeed their newborns. While there is a very small risk of infection, the benefits of breastfeeding outweigh the potential risks.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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