INASL Guidelines on Management of Hepatitis B Virus Infection in Patients receiving Chemotherapy, Biologicals, Immunosupressants, or Corticosteroids (original) (raw)

EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection q

Hepatitis B virus (HBV) infection remains a global public health problem with changing epidemiology due to several factors including vaccination policies and migration. This Clinical Practice Guideline presents updated recommendations for the optimal management of HBV infection. Chronic HBV infection can be classified into five phases: (I) HBeAg-positive chronic infection , (II) HBeAg-positive chronic hepatitis, (III) HBeAg-negative chronic infection, (IV) HBeAg-negative chronic hepatitis and (V) HBsAg-negative phase. All patients with chronic HBV infection are at increased risk of progression to cirrhosis and hepatocellular carcinoma (HCC), depending on host and viral factors. The main goal of therapy is to improve survival and quality of life by preventing disease progression, and consequently HCC development. The induction of long-term suppression of HBV replication represents the main endpoint of current treatment strategies, while HBsAg loss is an optimal endpoint. The typical indication for treatment requires HBV DNA [2,000 IU/ml, elevated ALT and/or at least moderate histological lesions, while all cirrhotic patients with detectable HBV DNA should be treated. Additional indications include the prevention of mother to child transmission in pregnant women with high viremia and prevention of HBV reac-tivation in patients requiring immunosuppression or chemother-apy. The long-term administration of a potent nucleos(t)ide analogue with high barrier to resistance, i.e., entecavir, tenofovir disoproxil or tenofovir alafenamide, represents the treatment of choice. Pegylated interferon-alfa treatment can also be considered in mild to moderate chronic hepatitis B patients. Combination therapies are not generally recommended. All patients should be monitored for risk of disease progression and HCC. Treated patients should be monitored for therapy response and adherence. HCC remains the major concern for treated chronic hepatitis B patients. Several subgroups of patients with HBV infection require specific focus. Future treatment strategies to achieve 'cure' of disease and new biomarkers are discussed.

Reactivation of hepatitis B virus associated with chemotherapy and immunosuppressive agent

Acta medica Indonesiana, 2013

Hepatitis B virus (HBV) reactivation after chemotherapy or immunosuppressive therapy is a serious cause of liver-related morbidity and mortality. The mechanism of HBV reactivation is still unclear, but it is believed due to the suppression of immune response hence increasing the viral load. No uniform diagnostic criteria are available, HBV reactivation can be confirmed by an increase in serum HBV-DNA level. There are many consensus regarding this issue, including the type and duration of nucleoside analogue therapy which need to be understood as not all chronic hepatitis B patients will lead to HBV reactivation. Recently, there has been an increased awareness of reactivation of occult hepatitis B virus, especially in hepatitis B virus endemic area, including Indonesia as part of Asia Pacific region. Preempative antiviral therapy was the best approach to prevent the HBV reactivation.

The Importance of Antiviral Prophylaxis against Hepatitis B Virus in Patients under Immunosuppressive Therapy

Viral Hepatitis Journal, 2019

Amaç: İmmünosupresif tedaviler, önceki veya bilinen hepatit B virüsü (HBV) enfeksiyonu olan hastalarda reaktivasyon açısından bir risk oluşturur ve mortalite ve morbiditeye neden olabilir. Bu tedavilere başlamadan önce, hastalar HBV serolojileri test edilerek antiviral tedavi açısından değerlendirilmelidir. Gereç ve Yöntemler: Altta yatan hastalıklar nedeniyle immünosupresif tedavi planlanan veya daha önce başlanan 18 yaş üstü hepatit B yüzey antijeni (HBsAg)-pozitif veya HBsAg-negatif ve anti-HBs ve/veya anti-HBc immünoglobulin-pozitif hastalar retrospektif olarak değerlendirildi. Çalışmaya antiviral proflaksi başlanan hastalardan ilk 6 ay boyunca aylık transaminaz, sonraki takiplerinde her üç ayda bir transaminaz ve HBV-DNA seviyeleri bakılan hastalar dahil edildi. Bulgular: Altmış üç hasta çalışmaya alındı. Kırk sekiz (%76) hastaya immünosupresif tedavi ile birlikte profilaksi başlandı, 15 (%24) hastada profilaksi uygun zamanda başlanmadı. Uygun zamanda profilaksi alamayan hastaların üçünde HBV reaktivasyonu (HBVr) görüldü. Tüm hastalarımızda HBVr insidansı %4,8 idi, ancak gecikmiş profilaksi olan hastalarda %20 idi. Sonuç: İmmünsupresif tedaviler HBV reaktivasyonu açısından önemli bir risk oluşturmaktadır. Bu tedavilere başlamadan önce, hastalar HBV serolojilerini test ederek antiviral profilaksi açısından değerlendirilmelidir. Anahtar Kelimeler: Hepatit B virüs, profilaksi, immünosupresif tedavi Objectives: Immunosuppressive (IS) therapies present a risk of reactivation in patients with previous or known hepatitis B virus (HBV) infection and may cause mortality and morbidity. Before starting these therapies, patients should be tested for HBV serology and evaluated for antiviral therapy. Materials and Methods: hepatitis B surface antigen (HBsAg)positive or HBsAg-negative and Anti-HBs and/or anti-HBc immunoglobulin-positive patients aged over 18 years old who were scheduled to undergo or who were already on IS therapy due to underlying diseases were evaluated retrospectively. The study included patients who had monthly transaminase levels during the first six months of antiviral prophylaxis, and then who had transaminase and HBV-DNA levels every three months during subsequent follow-ups. Results: Sixty-three patients were included in the study. Fortyeight patients (76%) received prophylaxis with IS therapy and 15 patients (24%) did not receive prophylaxis at the appropriate time. HBV reactivation (HBVr) was observed in three patients who did not receive prophylaxis at the appropriate time. The incidence of HBVr in all our patients was 4.8%, but was 20% in patients with delayed prophylaxis. Conclusion: IS therapies represent a major risk in terms of HBVr. Before starting these therapies, patients should be evaluated for antiviral prophylaxis by testing their HBV serology.

Hepatitis B Reactivation During Immunosuppressive Therapy or Cancer Chemotherapy, Management, and Prevention: A Comprehensive Review

Hepatitis Monthly, 2016

Context: Due to the close relationship between the immune system and the hepatitis B virus (HBV) replication, it is essential to monitor patients with current or past HBV infection under any type of immunosuppression. Cancer chemotherapy, immunosuppressive therapies in autoimmune diseases, and immunosuppression in solid organ and stem cell transplant recipients are the major reasons for hepatitis B virus reactivation (HBVr). In this review, the challenges associated with HBVr are discussed according to the latest studies and guidelines. We also discuss the role of treatments with different risks, including anti-CD20 agents, tumor necrosis factor-alpha (TNF-α) inhibitors, and other common immunosuppressive agents in various conditions. Evidence Acquisition: Through an electronic search of the PubMed, Google Scholar, and Scopus databases, we selected the studies associated with HBVr in different conditions. The most recent recommendations were collected in order to reach a consensus on how to manage patients at risk of HBVr. Results: It was found that the positive hepatitis B surface antigen (HBsAg), the high baseline HBV DNA level, the positive hepatitis B virus e antigen (HBeAg), and an absent or low hepatitis B surface antibody (HBsAb) titer prior to starting treatment are the most important viral risk factors. Furthermore, rituximab, anthracycline, and different types of TNF-α inhibitors were identified as the high-risk therapies. By analyzing the efficiency of prophylaxis on the prevention of HBVr, it was concluded that those with a high risk of antiviral resistance should not be used in long-term immunosuppressants. Receiving HBV antiviral agents at the commencement of immunosuppressant therapy or chemotherapy was demonstrated to be effective in decreasing the risk of HBVr. Prophylaxis could also be initiated before the start of therapy. For most immune suppressive regimes, antiviral therapy should be kept up for at least 6 months after the cessation of immunosuppressive drugs. However, the optimal time of prophylaxis keeping should be increased in cases associated with rituximab or hematopoietic stem cell transplants. According to the latest studies and guidelines from different bodies, recommendations regarding screening, monitoring, and management of HBVr are outlined. Conclusions: Identification of patients at the risk of HBVr before immunosuppressive therapy is an undeniable part of treatment. Starting the antiviral therapy, based on the type of immunosuppressive drugs and the underlying disease, could lead to better management of disease.

Hepatitis B Reactivation in Immunosupressed Patients, Prophylaxis and Management

The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy, 2017

Hepatitis B virus (HBV) reactivation is a clinical problem associated with high morbidity and mortality rates. Currently, this incidence seems to be increasing around the world. The reactivation commonly developes in immunosuppressed individuals, although it may also occur spontaneously. Individuals who develop malignancy with chronic hepatitis B virus infection are at high-risk for hepatitis B virus reactivation, since they are closely related to immunosuppression, especially when undergoing chemotherapy. The loss of immune control in these patients may results in the reactivation of HBV replication within hepatocytes. This review article will focus on HBV reactivation related to immunosuppressed patients, immunosuppressive drug classes and corresponding risk estimates of hepatitis B virus reactivation, screening test recommended before getting this drugs, choice of antiviral drugs for prophylaxis, and duration of prophylaxis treatment based on European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), and Asian Pacific for the Study of the Liver (APASL) guidelines.

Status on Hepatitis B Virus Infection and Anti Viral Therapy : A Perspective

Journal of Pharmacy Research

Globally, hepatitis B is a significant health problem leading to one million deaths annually from liver failure, cirrhosis and hepatocellular carcinoma. It is estimated that 400 million people worldwide are hepatitis B virus (HBV) carriers. HBV infection is an important cause of morbidity and mortality after kidney transplantation. Progressive liver diseases affect more than 80% of hepatitis B surface antigen (HBsAg) in positive renal transplant recipients. The natural history of HBV infection is complex, which is influenced by many factors such as viral factors which includes HBV genome type, viral mutations, level of HBV replication and host factors such as gender, age and immune status. It is also influenced by exogenous factors such as concurrent infection with other viruses, most notably HIV and hepatitis C virus. Dual infection can modify the epidemiology, natural history and the development of complications of infection. The management of dually infected patients also varies from that of HBV mono infected patients. The implementation of mass immunization programme has considerably decreased the incidence of HBV infection among infants, children and adolescents across the world. But the immune response varies with individual and declines with increasing age. Despite, the prevention of hepatitis B virus infection by vaccination programme, the infection is still prevalent worldwide. Treatment with antiviral drugs is the major way to reduce morbidity and mortality of established chronic hepatitis B virus infection. Drugs like adefovir, entecavir, telbivudine, lamivudine & interferon α 2a has been approved for the treatment of chronic hepatitis B. The ultimate aim of anti viral therapy is to suppress viral replication, reduce the liver inflammation, reverse the liver fibrosis and thereby protect the liver. Even though antiviral drugs are effective but drug resistance remains a global public health problem.

Current trends in management of hepatitis B virus reactivation in the biologic therapy era

World Journal of Gastroenterology, 2011

Hepatitis B virus (HBV) reactivation represents an emerging cause of liver disease in patients undergoing treatment with biologic agents. In particular, the risk of HBV reactivation is heightened by the use monoclonal antibodies, such as rituximab (anti-CD20) and alemtuzumab (anti-CD52) that cause profound and longlasting immunosuppression. Emerging data indicate that HBV reactivation could also develop following the use of other biologic agents, such as tumor necrosis factor (TNF)-α inhibitors. When HBV reactivation is diagnosed, it is mandatory to suspend biologic treatment and start antiviral agents immediately. However, preemptive antiviral therapy prior to monoclonal antibody administration is crucial in preventing HBV reactivation and its clinical consequences. Several lines of evidence have shown that risk of HBV reactivation is greatly reduced by the identification of high-risk patients and the use of prophylactic antiviral therapy. In this article, we discuss current trends in the management of HBV reactivation in immunosuppressed patients receiving biologic therapy, such as rituximab, alemtuzumab and TNF-α antagonists.