Treating Immune‐tolerant Hepatitis B

Summary Hepatitis B virus ( HBV ) infection is a major cause of cirrhosis and hepatocellular carcinoma worldwide. On the basis of virus–host interactions, the natural history of HBV carriers can be divided into four chronological phases. In the first immune tolerance phase, HBV carriers are positive for hepatitis B e antigen ( HB eAg) and have high HBV replication activity, normal ALT levels as well as minimal liver disease. Ample evidence has shown that patients in the immune tolerance phase have very low viral evolution and minimal risk of fibrosis progression. However, recent immunological studies argued that HBV ‐specific immune responses already exist in a proportion of immune‐tolerant patients and the immune activities are comparable to those in the immune clearance phase. Regarding antiviral therapy, whether these immune‐tolerant patients are indicated for treatment remains debated. Previous studies showed that HB eAg‐positive patients with normal or near‐normal ALT levels, who are assumed to be in the immune tolerance phase, have a lower HB eAg seroconversion rate receiving either pegylated interferon or nucleos(t)ide analogue treatment. The latest clinical trial focusing on‐treatment response of immune‐tolerant patients with tenofovir disoproxil fumarate‐based therapy also confirmed the results. The HB eAg seroconversion rates are <5% at 4 years of treatment. Considering the minimal risk of disease progression and low treatment response rates in immune‐tolerant patients, current antiviral therapy should not be recommended unless the patients have advanced liver fibrosis. In addition, novel agents targeting the HBV template known as covalently closed circular DNA and aiming to reduce or eliminate it are urgently required.