Hepatitis B is a common problem worldwide with serious sequelae. Despite the explosion of new agents, management has grown even more complicated. The treatment paradigm is evolving from limited therapy to lifelong viral suppression in several populations. This shift has been a direct result of not only well-tolerated oral medications, but also the increasing recognition that active viral replication leads to untoward events such as cirrhosis, liver failure and hepatocellular carcinoma. However, therapy is not without risk, which includes side effects, cost and drug resistance. Controversy surrounds several clinical questions, including which patients are eligible for therapy, which treatment is optimal and at what point may therapy be discontinued. This commentary will discuss these questions as well as the limitations of the literature used to support our current treatment recommendations.