Nancy Reau, MD, is Professor of Internal Medicine, Richard B. Capps Chair of Hepatology, Associate Director of Solid Organ Transplantation, and Section Chief of Hepatology at Rush University Medical Center.

Nancy Reau, MD

Making Hepatitis B Care Simpler for Frontline Clinicians

, hosts Kimberly Brown, MD, and Nancy Reau, MD, continue their conversation with Su Wang, MD, about one of the biggest barriers to improving hepatitis B care: the perception that the disease is simply too complicated for most clinicians to manage.

Brown notes that when hepatitis B is discussed in educational settings, many physicians quickly disengage. The complex interplay between viral load, ALT levels, and disease phases—often visualized through complicated graphs and algorithms—can make the topic feel intimidating, particularly for clinicians outside hepatology. That reaction, Wang says, is understandable. Many providers remember struggling through those concepts during training and may assume hepatitis B management is best left to specialists.

However, she emphasizes that that mindset presents a major obstacle to achieving global viral hepatitis elimination goals. She says hepatitis B is far too common to be managed exclusively by hepatologists. Many patients never reach specialty care, making screening, vaccination, and early evaluation in primary care settings essential.

To address this challenge, Wang highlights efforts to simplify guidance for frontline clinicians. One particularly practical resource, developed through primary care-focused guidance hosted by the University of Washington, distills hepatitis B management into a concise one-page reference. The tool outlines key screening tests, provides simple interpretation of serologic results, summarizes vaccination options, and identifies straightforward criteria that may indicate treatment.

Importantly, Wang says, newer guidance also reflects a shift in philosophy around treatment eligibility. Rather than emphasizing strict thresholds that exclude patients, recent guidelines increasingly acknowledge that treatment may be appropriate across a broader range of scenarios. Laboratory markers such as elevated ALT or viral load remain important, but additional factors, including fibrosis, comorbidities, pregnancy with high viral load, and risk of transmission, can also inform decisions.

Wang additionally points to survey data suggesting many people living with hepatitis B were never even told that antiviral therapy exists. Simply informing patients about available treatments, she says, is an important first step.

Relevant disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for Wang include Gilead Sciences.

Ghany MG, Pan CQ, Lok AS, et al. AASLD ISDA Practice Guideline on treatment of chronic hepatitis B. Hepatology ():10.1097/HEP.0000000000001549, November 4, 2025. | DOI: 10.1097/HEP.0000000000001549

European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. 

. 2025;83(2):502-583. doi:10.1016/j.jhep.2025.03.018

You H, Wang F, Li T, et al. Guidelines for the Prevention and Treatment of Chronic Hepatitis B (version 2022). 

. 2023;11(6):1425-1442. doi:10.14218/JCTH.2023.00320

Videos

A trio of experts discuss how simplifying hepatitis B guidance could help more clinicians diagnose, treat, and support patients living with chronic infection.

Empowering More Clinicians to Treat Hepatitis B

Is Guideline Complexity Holding Back Hepatitis B Treatment?

, hosts Kimberly Brown, MD, and Nancy Reau, MD, continue their conversation with Su Wang, MD, MPH, exploring an uncomfortable but important question about 

 care: have complex guidelines unintentionally discouraged clinicians from treating the disease?

Brown frames the issue through the lens of paternalism. While medicine has increasingly recognized the need to move away from paternalistic relationships with patients, she suggests the hepatology community may have created a different form of paternalism, one aimed toward other clinicians. The complexity of hepatitis B algorithms and treatment thresholds, she argues, may have inadvertently signaled to frontline providers that they should defer care to specialists for fear of doing something wrong.

Wang agrees the concern is real and points to the restrictive nature of many historical treatment criteria. From the patient perspective, she says, those restrictions can feel confusing and even unfair. Patients often ask why treatment is withheld if medications are safe, effective, and increasingly affordable. The traditional explanation that therapy may be lifelong or that flares could occur if treatment stops does not always resonate with patients weighing the potential benefits of earlier intervention.

Wang also shares her own experience navigating the treatment decision as someone living with chronic hepatitis B. When she sought advice from specialists, she found many clinicians uncomfortable discussing treatment options outside strict guideline thresholds. Yet some privately acknowledged they would choose therapy themselves under the same circumstances. That disconnect, Wang notes, highlights an important tension between guideline-based medicine and evolving scientific understanding of hepatitis B biology.

Emerging research, including insights into viral DNA integration, immune exhaustion, and long-term oncogenic risk, continues to reshape how experts think about disease progression. However, the group says that much of that mechanistic science does not easily translate into the evidence frameworks used to generate formal guideline recommendations.

The result, Wang suggests, may be a gap between how experts think about hepatitis B risk and how treatment decisions are communicated in practice. She emphasizes that empowering clinicians, especially those in primary care, to feel comfortable initiating treatment will be essential to expanding access.

For Wang, the ultimate goal is clear: hepatitis B care should not remain confined to specialists. As this 

 discussion highlights, addressing guideline complexity and clinician hesitation may be a crucial step toward improving care for the millions of people living with hepatitis B worldwide.

In this segment of Liver Lineup, experts discuss the complexity of hepatitis B guidelines and why it’s important to empower clinicians and expand care beyond specialists.

Are We Making Hepatitis B Treatment Too Complicated?

Liver Lineup: Breaking Down Barriers in Hepatitis B Management

In this new episode of Liver Lineup, hosts Nancy Reau, MD, and Kimberly Brown, MD, welcome a special guest who brings a uniquely multidimensional perspective to hepatitis B care: Su Wang, MD, MPH.

An internist specializing in hepatitis B, Medical Director of the Center for Asian Health and Viral Hepatitis Programs at Cooperman Barnabas Medical Center, and a person living with chronic hepatitis B herself, Wang bridges the worlds of clinical medicine, guideline development, and patient advocacy.

The conversation centers on a timely and increasingly complex topic: the expanding, and at times confusing, landscape of hepatitis B guidelines. From the World Health Organization to US and European liver societies, multiple guidance documents have emerged over the past few years.

Rather than viewing this proliferation as fragmentation, Wang frames it as progress. Different guidelines serve different audiences, from hepatologists in resource-rich settings to frontline primary care clinicians and providers in low- and middle-income countries.

Still, confusion persists, particularly among non-specialists. Reau and Brown highlight a critical challenge: many clinicians see hepatitis B infrequently and may feel overwhelmed by nuanced algorithms and phase-based classifications. Wang acknowledges that complexity has historically created a kind of “paternalism,” not only toward patients but toward providers, implicitly signaling that hepatitis B management belongs solely to subspecialists.

A key shift in newer guidance, the panel notes, is the embrace of shared decision-making. Importantly, this does not simply mean deferring to patient preference—it means explicitly informing patients that treatment is an option. Wang shares sobering survey data suggesting that many individuals living with hepatitis B were never told antiviral therapy existed. The group discusses how withholding that conversation, even with good intentions, limits autonomy.

The episode also explores emerging themes reshaping hepatitis B care: recognition of metabolic comorbidities as treatment modifiers, the growing appreciation of patient-reported outcomes like fatigue and anxiety, and evolving thinking around integration and long-term oncogenic risk,not just ALT-driven inflammation.

Ultimately, this discussion moves beyond guideline minutiae to a broader call to action. Hepatitis B is common, often acquired in childhood, and too prevalent to remain siloed within hepatology. Empowering primary care clinicians to screen, vaccinate, and initiate treatment, while equipping patients with accessible tools, will be essential to meeting elimination goals.

Podcasts

Hosts are joined by Su Wang, MD, MPH, to discuss the evolving management of hepatitis B and how to move care beyond silos with expanded treatment and provider empowerment.

Why Alcohol Recommendations in the New Dietary Guidelines Fall Short

In this segment from the latest episode of 

Liver Lineup: Updates & Unfiltered Insights

, the conversation around the newly updated US Dietary Guidelines turns to one of their most debated and most limited areas: alcohol.

While the guidelines emphasize reducing ultra-processed foods, Kimberly Brown, MD, presses the panel on whether there was a similarly clear message when it came to alcohol consumption. According to guest Jessica Mellinger, MD, the answer is yes, but only in the broadest sense.

“The message on alcohol was pretty limited,” Mellinger explains. “It was basically: drink less.”

While she says she does not disagree with that recommendation, she notes that the guidance lacks specificity and clinical nuance, particularly for patients with liver disease or conditions known to increase alcohol-related risk. Compared with prior guidelines, which defined “moderate” drinking using sex-based thresholds, the updated recommendations remove specific quantities altogether, reflecting a growing body of evidence suggesting that even low levels of alcohol consumption are associated with adverse health outcomes.

Mellinger highlights cancer risk as one of the most consistent findings in the literature, noting that alcohol is a known carcinogen with measurable associations even at low intake levels. Although certainty diminishes at lower levels of consumption, the overall trend has been toward recommending less alcohol across populations. From a hepatology standpoint, she emphasizes that this shift aligns with what clinicians increasingly see in practice.

However, Mellinger views the updated guidance less as a comprehensive directive and more as a starting point for individualized clinical conversations. In her alcohol-associated liver disease clinic, discussions often extend well beyond quantity and frequency, focusing instead on how alcohol affects a patient’s health, relationships, and quality of life.

From her perspective, there is no safe level of alcohol consumption she can ethically recommend to patients with liver disease based on the available data. Rather than offering reassurance around low-level use, she encourages clinicians to meet patients where they are, exploring motivation, readiness for change, and realistic next steps toward reduction or abstinence.

Nancy Reau, MD, adds that important at-risk populations remain absent from the public-facing guidance. Beyond pregnancy, she notes that patients who have undergone gastric bypass surgery represent another growing group for whom alcohol use carries significant risk, yet they are not explicitly addressed.

Ultimately, the panel agrees that while “drink less” may be an appropriate population-level message, it leaves critical gaps for clinicians to fill.

Editors’ Note: Relevant disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for Mellinger include GlaxoSmithKline. Van Jacobs reports no relevant disclosures.

Brooks A. New Dietary Guidelines Draw Criticism For High Fat Dairy, Protein Recommendations. HCPLive. January 8, 2026. Accessed February 9, 2026. 

https://www.hcplive.com/view/new-dietary-guidelines-draw-criticism-high-fat-dairy-protein-recommendations

AASLD. AASLD Raises Concern Over Removal of Evidence-Based Alcohol Guidance in 2025–2030 Dietary Guidelines for Americans. January 9, 2026. Accessed February 9, 2026. 

https://www.aasld.org/aasld-raises-concern-over-removal-evidence-based-alcohol-guidance-2025-2030-dietary-guidelines

In this segment of a Liver Lineup episode, experts discuss where the new US Dietary Guidelines miss the mark for alcohol recommendations.

Nancy Reau, MD

Articles