2025 Hepatitis B Guideline Update: What Family Doctors Need to Know

The Canadian Association for the Study of the Liver (CASL) and Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada) have released the 2025 Clinical Practice Guidelines for the management of chronic hepatitis B virus (HBV) infection. These recommendations reflect Canada’s commitment to the WHO goal of eliminating hepatitis B as a public-health threat by 2030.

For us practicing and studying Family Medicine, we are the front line in HBV detection and prevention. This update introduces major changes in screening, vaccination, and treatment that have immediate relevance in primary care.

1. Universal Adult Screening and Vaccination

For the first time, CASL-AMMI recommends one-time universal HBV screening for all adults ≥ 18 years, regardless of risk factors.Screening uses a triple-panel approach:

• HBsAg, anti-HBs, and anti-HBc.This simplifies practice and removes stigma or missed risk-based opportunities - especially important in a diverse country where many cases occur among newcomers from higher-prevalence regions.

Physicians should also:

• Offer universal catch-up vaccination to any adult not previously immunized or unsure of status.

• Advocate for birth-dose HBV vaccination across all provinces and territories as it isn't currently available across all of Canada

2. Expanded Treatment Indications

Treatment thresholds have been broadened beyond classic “immune-active” disease. Now, patients previously classified in the indeterminate or “grey-zone” phase—normal ALT but elevated HBV DNA (> 2,000 IU/mL) - may be started antiviral therapy by their hepatologist, particularly if aged > 40 years or with a family history of cirrhosis or HCC.

First-line oral agents remain:

• Tenofovir alafenamide (TAF)

• Tenofovir disoproxil fumarate (TDF)

• Entecavir (ETV)

TAF is now favored for its improved renal and bone safety profile. Family physicians following treated patients should monitor renal function (eGFR) and bone mineral density as well as adherence.

3. Routine Reflex HDV Testing

Every patient who is HBsAg positive should automatically be tested for hepatitis D virus (HDV) antibodies. HDV is associated with more rapid liver damage and higher mortality. Positive cases should be referred to specialists for RNA confirmation and management; new treatments are in the works.

4. Updated Laboratory and Monitoring Tools

• Quantitative HBsAg (qHBsAg) is a new test, not yet available across Canada; measurement every 1 to 2 years helps gauge treatment response and functional cure.

• HBV DNA should be checked every 6 months for patients on nucleos(t)ide analogues.

• Point-of-care tests are encouraged in community, remote, and resource-limited settings to improve access to diagnosis and linkage to care.

  
  

5. Practical Implications for Primary Care

• Normalize hepatitis B discussions with all adult patients

• Document vaccination history and initiate catch-up immunization if uncertain

• Coordinate follow-up for abnormal results with hepatology or infectious disease specialists

• Educate high-risk or newcomer communities about HBV prevention, testing, and treatment availability

• Integrate reflex HDV testing and use centralized electronic records to avoid duplicate testin.

Top 3 Updates

1. Universal adult HBV screening recommended.

2. Expanded antiviral treatment for “grey zone” patients.

3. Routine reflex HDV testing for HBsAg positive.

   
   

References

https://pubmed.ncbi.nlm.nih.gov/40677987/