GPs are urged to assess and refer patients with hepatitis B for specialist treatment, in new NICE guidance aimed at increasing specialist treatment for the disease.
The guidance, the first NICE has developed on diagnosis and management of hepatitis B, calls on GPs to arrange further tests for people who are found to be hepatitis B surface antigen positive, and refer them straight on to a hepatologist or gastroenterologist.
According to NICE, a recent London audit found a third of people with chronic hepatitis B infection diagnosed in primary care were not referred for specialist treatment and, despite substantial progress in treatments, the condition remains under-recognised and poorly understood.
People diagnosed with hepatitis B in primary care need further hepatitis B investigations as well as tests for hep A and C, hepatitis deltavirus and HIV and liver tests, including for hepatocellular carcinoma; they recommended GPs should include the results of these tests when referring patients on.
And although antiviral treatment should be initiated by the specialist, GPs can then be expected to continue therapy under shared-care arrangements.
Dr Alan Mitchell, clinical director at Renfrewshire Community Health Partnership and East Renfrewshire CHCP, said: ‘Chronic hepatitis B is a disease that for too long has been under-treated. GPs have a key role to play in the initial assessment of patients and their onward referral to specialist services and subsequent care.’
He added: ‘I am confident that this guideline will prove very useful for GPs in their everyday practice in the assessment and management of patients with this very treatable infectious disease.’
Professor Mark Baker, director of the centre for clinical practice at NICE, said: ‘Chronic hepatitis B can have a significant impact on a person’s quality of life, particularly if it progresses to the fibrosis and cirrhosis stage.
‘A great deal of progress has been made in treating hepatitis B but there is evidence that not everyone with the disease is being given the drugs they need to treat it, and not everyone who needs further assessment is referred to a specialist.
‘This guideline will reduce variation in practice and improve the care of people with chronic hepatitis B.’
NICE guidance for initial assessment and referral of people with hepatitis B
Arrange the following tests in primary care for children and adults who are hepatitis B surface antigen (HBsAg) positive:
- hepatitis B e antigen (HBeAg)/antibody (anti-HBe) status
- IgM antibody to hepatitis core antigen (anti-HBc IgM)
- hepatitis C virus antibody (anti-HCV)
- hepatitis delta virus antibody (anti-HDV)
- HIV antibody (anti-HIV)
- IgG antibody to hepatitis A virus (anti-HAV)
- Additional laboratory tests, including alanine aminotransferase (ALT) or aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), serum albumin, total bilirubin, total globulins, full blood count and prothrombin time
- Tests for hepatocellular carcinoma (HCC), including hepatic ultrasound and alphafetoprotein testing.
Refer all adults who are HBsAg positive to a hepatologist or to a gastroenterologist or infectious disease specialist with an interest in hepatology. Include the results of the initial tests with the referral
Refer pregnant women who are HBsAg positive to a hepatologist, or to a gastroenterologist or infectious disease specialist with an interest in hepatology, for assessment within 6 weeks of receiving the screening test result and to allow treatment in the third trimester
Refer all children and young people who are HBsAg positive to a paediatric hepatologist or to a gastroenterologist or infectious disease specialist with an interest in hepatology.
Refer adults who develop decompensated liver disease immediately to a hepatologist or to a gastroenterologist with an interest in hepatology. Symptoms of decompensated liver disease include (but are not limited to) ascites, encephalopathy and gastrointestinal haemorrhage.