Management of patients with hepatitis B who require immunosuppressive therapy - PubMed (original) (raw)

Review

Management of patients with hepatitis B who require immunosuppressive therapy

Jessica P Hwang et al. Nat Rev Gastroenterol Hepatol. 2014 Apr.

Abstract

Patients with chronic HBV infection are at risk of reactivation of HBV should they require immunosuppressive therapies for a variety of clinical settings, including chemotherapy for patients with cancer, immunosuppression for solid organ and stem cell transplant recipients, and use of anti-CD20 antibodies, TNF inhibitors, or corticosteroids in patients with oncological, gastrointestinal, rheumatological or dermatological conditions. The key to preventing HBV reactivation is the identification of patients with HBV infection prior to immunosuppressive therapy, initiation of prophylactic antiviral therapy in patients at moderate or high risk of HBV reactivation, and close monitoring of other patients so that antiviral therapy can be initiated at the first sign of HBV reactivation. Unfortunately, many patients infected with HBV are unaware of their infection or risk factors, and physicians often do not have sufficient time to systematically assess patients for risk factors for HBV prior to starting immunosuppressive therapy. In this article, we review the incidence, risk factors and outcomes of HBV reactivation, and the efficacy of antiviral therapy in preventing its occurrence. We also propose an algorithm for managing patients with HBV infection who require immunosuppressive therapy.

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Conflict of interest statement

Competing interests

S.-F. Lok declares an association with the following companies: Bristol–Myers Squibb, Gilead, GlaxoSmithKline, Novartis. Please see the article online for full details of the relationships. J. P. Hwang declares no competing interests.

Figures

Figure 1

Phases of HBV reactivation. Generally, three phases of HBV reactivation occur. Phase 1: HBV DNA levels increase, patients are typically asymptomatic, and ALT levels might not be increased. Phase 2: HBV DNA and ALT levels are increased, and in severe cases there might be symptoms of hepatitis, jaundice and liver failure. Phase 3: Resolution occurs in most, but not all, patients. Some HBsAg-positive patients might continue to have higher HBV DNA levels than at baseline, and some HBsAg-negative patients might remain HBsAg-positive. Solid lines represent the majority of patients who have resolution, whereas dashed lines represent the minority of patients in whom hepatitis B might not fully resolve. Abbreviations: ALT, alanine aminotransferase; HBsAg, hepatitis B surface antigen; IU, international unit.

Figure 2

Types of HBV reactivation. Patients with chronic HBV infection (HBsAg+ and anti-HBc+ test results) can have either an increase in HBV DNA level or an appearance of HBV DNA, depending on whether they did or did not have detectable HBV DNA before immunosuppression, respectively. Patients with past HBV infection (HBsAg− and anti-HBc+) can be diagnosed as having HBV reactivation upon the appearance of HBsAg or HBV DNA. Abbreviations: +, positive; −, negative; anti-HBc, anti-hepatitis B core antibody IgG; HBsAg, hepatitis B surface antigen.

Figure 3

A management algorithm for patients with HBV infection prior to starting immunosuppressive therapy. Algorithm based on scientific literature when available and opinions of the authors when literature lacked data. *Risk: stratify patients by risk of reactivation (see Table 2). ‡Prophylactic antiviral therapy: patients at high or moderate risk of reactivation (see Table 2) should start antiviral therapy and be assessed for virologic response through HBV DNA testing every 3 months. §Monitoring: check HBV DNA and ALT every 3 months; check HBsAg in patients who were HBsAg−/anti-HBc+ before immunosuppressive therapy. II Pre-emptive antiviral therapy: initiate antiviral therapy if ALT levels are elevated, HBV DNA levels are elevated, or appearance of HBV DNA or HBsAg in patients who had undetectable HBV DNA or HBsAg before immunosuppressive therapy, respectively. Abbreviations: +, positive; −, negative; anti-HBc, anti-hepatitis B core antibody IgG; HBsAg, hepatitis B surface antigen.

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Management of patients with hepatitis B who require immunosuppressive therapy - PubMed (original) (raw)