Challenges and Controversies

In this setting, the preferred management would be with Bulevirtide (which is the choice selected), but I would also consider shared decision making. The patient has several treatment options. She should obtain treatment as she has F3 fibrosis and is at risk of progression to cirrhosis and HCC, and therefore not initiating treatment is not an option. The only FDA approved treatment for HDV is Bulevirtide; the MYR301 study demonstrated its efficacy for the long-term treatment of HDV. However, she can also try pegylated interferon monotherapy (current AASLD HBV Guidance but off label) or combination therapy. Combination therapy of bulevirtide and pegylated interferon can be considered as the MYR204 study demonstrated higher HDV cure rates after finite treatment with bulevirtide + pegylated interferon compared to bulevirtide alone. In regards to shared decision making, patient may have a preference for weekly injections (pegylated interferon) versus daily injections (bulevirtide). Although there is an AGA expert commentary on HDV, there are no formal guidelines in the United States. EASL has dedicated HDV guidelines. Per EASL, the recommendation is: "All patients with chronic HDV and compensated liver disease, irrespective of whether they have cirrhosis or not, should be considered for treatment with PegIFNα". Additionally, "All patients with CHD and compensated liver disease should be considered for treatment with Bulevirtide". Thus, both are viewed as suitable treatment options.

It all depends on her HDV viral load. "HDV coinfection” is a vague term – is she just HDV antibody positive, or also PCR positive? I would checked an HDV PCR at least 2 times 3 months or so apart. If her HDV PCR is positive both times, she should be on Bulevirtide, unless contraindicated. The fact she has F3 already does provide a sense of urgency to check her HDV PCR and one could argue that a one time measurement, or 2 measurements 1 month apart should suffice.