The American Gastroenterological Association has issued new advice for patients on immunosuppressive therapy.
Patients at a high risk of hepatitis B reactivation, such as those on immunosuppressants, should have antiviral prophylaxis, according to new US recommendations.
The American Gastroenterological Association gave four key recommendations for managing HBVr risk in its new clinical practice guideline, designed to address new immunosuppressive and interventional therapies introduced since the previous 2014 guideline.
“HBVr is generally a consequence of chronic immunosuppression, induced either by drug therapy or by pathologic immunosuppression. The incidence of HBVr varies by the degree and mechanism of immunosuppression,” Dr Faisal Ali, from the division of gastroenterology and hepatology at Beth Israel Deaconess Medical Center, US, and colleagues wrote.
The authors developed their recommendations based on the patient’s infection status, such as whether they were hepatitis B surface antigen positive or HBsAg negative/anti-HB core antibody (HBc)-positive, and their risk of reactivation due to the interventions they were receiving.
“B cell–depleting agents, such as rituximab, are traditionally associated with a notably high risk of HBVr,” the authors wrote.
“The current update sought to provide guidance on the prevention and management of HBVr in individuals taking immune checkpoint inhibitors (ICIs), anti-interleukin (IL) therapies, chimeric antigen receptor T cell (CAR-T) therapies, cytokine/integrin inhibitor therapies, tyrosine kinase inhibitors (TKIs), anti T-cell therapies, and Janus kinase (JAK) inhibitors, and update the guidance provided for anti–tumor necrosis factor (TNF) therapies in light of new evidence,” the authors wrote.
Antiviral prophylaxis rather than monitoring alone was strongly recommended for patients who were at high risk of reactivation (>10%). Patients should begin antivirals before starting therapies that increase the risk of hepatitis B reactivation, and continue for at least six months after discontinuing the medications and at least 12 months for B cell–depleting agents.
“For individuals at high risk of HBVr, the magnitude of absolute reduction in the risk of reactivation is expected to be the largest; at a representative baseline risk of 50%, antiviral prophylaxis would lead to 410 fewer cases of HBVr and 390 fewer hepatitis flares from HBVr per 1000 individuals,” the authors wrote.
Related
Patients at a moderate risk (1-10%) were given a conditional recommendation for antiviral prophylaxis, but monitoring could be appropriate.
“Patients who place a higher value on avoiding long-term use of antiviral therapy and the cost associated with its use, and a lower value on avoiding the small risk of reactivation (particularly in those who are HBsAg-negative) may reasonably select active monitoring over antiviral prophylaxis, with careful consideration of feasibility and likelihood of adherence to long-term monitoring,” Dr Ali and colleagues wrote.
“Monitoring should be performed at 1- to 3-month intervals, and must include assessment of hepatitis B viral load in addition to assessment of alanine aminotransferase.”
The AGA suggested that those at low risk (<1%) could be managed with monitoring alone, providing they had regular and sufficient follow-up that ensured continued monitoring.
But it was reasonable for these patients to receive antiviral therapy, especially if they were taking multiple low-risk immunosuppressive therapies.
Hepatitis B testing was recommended for all patients at potential risk for reactivation, first for serologic markers to determine whether the patient was HBsAg or anti-HBc positive, followed by viral load testing if positive.
