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  • Review Article
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Management of patients with hepatitis B who require immunosuppressive therapy

Nature Reviews Gastroenterology & Hepatology volume 11, pages 209–219 (2014)Cite this article

Subjects

Key Points

  • Imprecision surrounding the nomenclature of HBV reactivation has contributed to confusion regarding its incidence; standardization of terminology and definitions are needed

  • Patients positive for hepatitis B surface antigen (HBsAg) and those who are HBsAg-negative and anti-HBc (hepatitis B core antibody IgG)-positive are at risk of HBV reactivation during immunosuppressive therapies

  • Level of risk of HBV reactivation depends not only on the serological profile of the patient, but also their underlying medical conditions and the immunosuppressive therapies that will be used

  • Strong evidence exists to support antiviral prophylaxis to prevent reactivation of HBV infection; in general, HBsAg-positive patients should be started on antiviral prophylaxis before immunosuppression

  • HBsAg-negative–anti-HBc-positive patients receiving immunosuppressive therapy might be monitored unless they are considered for certain therapies (such as anti-CD20 antibodies), in which case, these patients should receive antiviral prophylaxis

  • Screening for HBV prior to the start of immunosuppressive therapy is the key to preventing reactivation of HBV infection

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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Figure 1: Phases of HBV reactivation.
Figure 2: Types of HBV reactivation.
Figure 3: A management algorithm for patients with HBV infection prior to starting immunosuppressive therapy.

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Acknowledgements

The authors acknowledge Laurissa Gann for assistance with the literature search. The work of A. S.-F. Lok is partially funded by a National Institute of Diabetes and Digestive and Kidney Diseases grant U01DK082863. J. P. Hwang is a recipient of a National Cancer Institute (NCI) KO7 Career Development Award (CA132955) and NCI R21 (CA167202). The content of this Review is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

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  1. Department of General Internal Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, 77030, TX, USA

    Jessica P. Hwang

  2. Department of Internal Medicine and Gastroenterology, A. Alfred Taubman Health Care Center, University of Michigan, 1500 East Medical Center Drive, Room 3912, Ann Arbor, 48109–5362, MI, USA

    Anna S.-F. Lok

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Correspondence to Anna S.-F. Lok.

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A. S.-F. Lok is a consultant and/or advisor to GlaxoSmithKline, Gilead, and Novartis, and she has grant funding from Gilead and Bristol-Myers Squibb. J. P. Hwang declares no competing interests.

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Hwang, J., Lok, AF. Management of patients with hepatitis B who require immunosuppressive therapy. Nat Rev Gastroenterol Hepatol 11, 209–219 (2014). https://doi.org/10.1038/nrgastro.2013.216

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