To avoid Hep B reactivation, screen before immunosuppression
Universal HBV screening before immunosuppression is prudent and cost effective, even when local HBV prevalence is just 0.3%.
PRACTICE RECOMMENDATIONS
› 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
Prophylactic treatment options are safe and well tolerated. For this reason, committing a high- or moderate-risk patient to a course of treatment should be less of a concern than the risk for HBVr.
In the early randomized controlled trials for HBVr prophylaxis, lamivudine, although effective, unfortunately led to a high incidence of viral resistance after prolonged use, thus diminishing its desirability.18 Newer agents, such as entecavir and tenofovir, have proven just as effective as lamivudine and are largely unaffected by viral resistance.27
In retrospective and prospective studies on HBVr prophylaxis, patients treated with entecavir had less HBV-related hepatitis, less delay in chemotherapy, and a lower rate of HBVr when compared with lamivudine.28,29 Tenofovir is recommended, however, if patients were previously treated with lamivudine.30
A recent meta-analysis demonstrated that tenofovir and entecavir are preferable to lamivudine in preventing HBVr.31
Looking ahead
Screening for HBsAg and anti-HBc total before starting immunosuppressive therapy can reduce morbidity and mortality in patients undergoing such treatment. The AGA recommends screening all patients about to begin high- or moderate-risk therapy or patients in populations with a prevalence of CHB ≥2%, per the CDC.6,21
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