Applied Evidence

To avoid Hep B reactivation, screen before immunosuppression

Author and Disclosure Information

Universal HBV screening before immunosuppression is prudent and cost effective, even when local HBV prevalence is just 0.3%.


› Measure levels of hepatitis B surface antigen and core antibody total. Although testing for IgG alone can be acceptable, testing for IgM alone is unacceptable. C

› Use both a patient’s serologic findings and the recognized risk associated with intended therapy to determine the threat of hepatitis B virus (HBV) reactivation. C

› Offer antiviral prophylaxis when risk for HBV reactivation is high. Consider prophylaxis or monitoring for those at moderate risk. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



CASE A 53-year-old woman you are seeing for the first time has been taking 10 mg of prednisone daily for a month, prescribed by another practitioner for polymyalgia rheumatica. Testing is negative for hepatitis B surface antigen but is positive for hepatitis B core antibody total, indicating a resolved hepatitis B infection. The absence of hepatitis B DNA is confirmed.

How would you proceed with this patient?

Patients with resolved hepatitis B virus (HBV) or chronic hepatitis B (CHB) infections are at risk for HBV reactivation (HBVr) if they undergo immunosuppressive therapy for a condition such as cancer. HBVr can in turn lead to delays in treatment and increased morbidity and mortality.

HBVr is a well-documented adverse outcome in patients treated with rituximab and in those undergoing stem cell transplantation. Current oncology guidelines recommend screening for HBV prior to initiating these treatments.1,2 More recent evidence shows that many other immunosuppressive therapies can also lead to HBVr.3 Such treatments are now used across a multitude of specialties and conditions. For many of these conditions, there are no consistent guidelines regarding HBV screening.

In 2013, the US Food and Drug Administration (FDA) announced the requirement of a Boxed Warning for the immunosuppressive drugs ofatumumab and rituximab. In 2016, the FDA announced the same requirement for certain direct-acting antiviral medicines for hepatitis C virus.

Among patients who are positive for hepatitis-B surface antigen (HBsAg) and who are treated with immunosuppression, the frequency of HBVr has ranged from 0% to 39%.4,5

As the list of immunosuppressive therapies that can cause HBVr grows, specialty guidelines are evolving to address the risk that HBVr poses.

Continue to: An underrecognized problem


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