Indications for treatment: Whom to treat and whom not to treat!

Despite the development of an effective vaccine, Hepatitis B virus (HBV) infection remains a major public health problem worldwide with a significant proportion of chronic HBV infected patients developing liver cirrhosis, liver failure, and primary hepatocellular carcinoma (HCC). Chronic hepatitis B is one of the 10 major causes of death worldwide. Although a number of antiviral agents against HBV are now available, proper selection of patients who would be ideal candidates for therapy is essential. The rationale for treatment is to reduce the risk of progressive chronic liver disease, transmission to others, and other long-term complications from chronic HBV such as hepatocellular carcinoma. The decision to commence treatment must balance the likelihood of a sustained treatment response, with the future risk of liver-related morbidity and mortality. Consideration of further factors, including patient age, concurrent illness, medication compliance, liver disease activity, likelihood of long-term benefit, and potential therapeutic risks such as side effects, must be included as part of a risk-benefit analysis. A large amount of new data have become available in recent years, suggesting that conventional criteria for treatment initiation based on existing disease progression do not necessarily correlate with the future risk of disease complications. This review summarizes the various factors which have to be considered before selecting the patient for treatment.