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
Classes of medications other than immunosuppressants may also trigger HBVr. The FDA has issued a warning regarding direct-acting antivirals, but optimal management of these patients is still evolving.
Once HBV status is established, a patient’s risk for HBVr can be specified as high, moderate, or low using their HBV status and the type of therapy being initiated. The AGA recommends prophylactic treatment with well-tolerated and effective agents for patients classified as high or moderate risk. If a patient’s risk is low, regular monitoring of HBV DNA and AST and ALT levels is sufficient. Recommendations of monitoring intervals span from monthly to every 3 months.13,14
CASE Given the patient’s status of resolved HBV infection and her current moderate-dose regimen of prednisone, her risk for HBV reactivation is moderate. She could either receive antiviral prophylaxis or undergo regular monitoring. Following a discussion of the options, she opts for referral to a hepatologist to discuss possible prophylactic treatment.
Increased awareness of HBVr risk associated with immunosuppressive therapy, coupled with a planned approach to appropriate screening and risk stratification, can help health care providers prevent the reactivation of HBV or initiate early intervention for CHB.
CORRESPONDENCE
Ronan Farrell, MD, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903; ronan_farrell@brown.edu.
