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Hepatitis B virus (HBV) reactivation can be a serious complication for patients with chronic (HBsAg+) as well as resolved HBV (HBsAg−/anti-HBc+) infection when treated with biologics. All patients should be screened for HBsAg, anti-HBc, and HBV DNA before starting biologics.
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Patients with chronic HBV infection should generally receive prophylactic treatment with nucleos(t)ide analogues before the initiation of biologics, except in cases of biologics with very low risk of immunosuppression.
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Hepatitis B Virus Reactivation Potentiated by Biologics
Section snippets
Key points
Definition and Epidemiology
HBV reactivation is characterized by an abrupt elevation of serum HBV DNA in patients with chronic (hepatitis B surface antigen [HBsAg]- positive) or resolved HBV infection (HBsAg-negative, hepatitis B core antibody [anti-HBc]-positive and undetectable HBV DNA).10 HBV reactivation in HBsAg-positive patients is defined as a ≥2 log rise in HBV DNA from baseline (3 log if baseline is negative, 4 log if baseline unknown).4 In the case of HBsAg-negative/anti-HBc-positive patients, having detectable
Hepatitis B virus reactivation for hepatitis B surface antigen–positive patients treated with biologics
For HBsAg-positive patients receiving biologics, the risk of HBV reactivation is moderate to high in most cases, particularly if a tumor necrosis factor-alpha (TNF-α) inhibitor or B-cell-depleting agent is used (Table 1). Therefore, in the vast majority of cases, HBsAg-positive patients should be considered for antiviral prophylaxis and should be referred to an infectious disease, gastroenterology, or hepatology specialist who is familiar with HBV management.
Hepatitis B virus reactivation for hepatitis B surface antigen–negative/anti–hepatitis B core–positive patients treated with biologics
Although hepatitis B surface antigen (HBsAg)-negative/anti–hepatitis B core (HBc)-positive patients are at lower risk of HBV reactivation than HBsAg-positive patients, the risk is still considerable with certain classes of biologics and fatal HBV reactivation cases are well documented (Table 2).64 Among the various biologics, anti-CD20 agents, such as rituximab, are considered high risk for reactivation, and patients with resolved HBV infection initiated on anti-CD20 agents should be given
Screening, management, and prophylaxis for hepatitis B virus reactivation
All patients undergoing chemotherapy should be screened for HBsAg, anti-HBc, and HBV DNA before the initiation of biologics (see Fig. 1). Testing for the titer of anti-HBs also may be beneficial, because besides those without detectable anti-HBs, those with low titer of anti-HBs are also at higher risk for HBV reactivation, although no recommendations have been made concerning stratified management based on the titer of anti-HBs.4 A study evaluating the cost-effectiveness of different HBV
Special population coinfected with hepatitis C virus or human immunodeficiency virus
HBV monitoring and treatment should be done in accordance with patient HBV status and the specific biologic used for HBV/hepatitis C virus (HCV) coinfection, as with HBV monoinfection. However, a special situation can arise when HBV/HCV coinfected patients are treated with direct-acting antivirals (DAAs) for HCV infection. Although there are ethnic influences in the pattern of viral dominance,82 HBV replication often can be inhibited by HCV-induced intrahepatic immune activation.83 When HCV is
Summary
All candidates for biologics should be tested with HBsAg, anti-HBc, and HBV DNA before initiations of biologics. All HBsAg-positive patients who initiate biologic therapy but are not otherwise candidates for antiviral for CHB should be offered prophylactic NAs with ETV, TDF, or TAF, except for those treated with very low risk agents. In contrast, HBsAg-negative/anti-HBc positive patients should take NAs if they will initiate on high-risk agents for HBV reactivation such as anti-CD20 biologics.
Disclosure
M.H. Nguyen: Grant/research support: Bristol-Myers Squibb, Gilead Sciences, Janssen Pharmaceutical; Advisory board/consultant: Dynavax Laboratories, Gilead Sciences, Intercept Pharmaceutical; Anylam Pharmaceutical; Roche Laboratories; and Novartis Pharmaceuticals. The other authors have nothing to disclose.
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2022, Journal of Immunological MethodsCitation Excerpt :Sinopulmonary infections are the most commonly reported, particularly in the context of hypogammaglobulinemia (Winthrop et al., 2018; Gottenberg et al., 2010). RTX also carries the risk of reactivation of the hepatitis B virus in HBsAg-positive patients as well as in anti-HBc-positive patients, previously thought to have cleared the infection (Ogawa et al., 2020). Therefore, all patients should be screened for evidence of prior hepatitis B exposure before RTX initiation (Sandherr et al., 2015).
Recommendations for prevention of infection in systemic autoimmune rheumatic diseases
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2022, Pharmacological ResearchCitation Excerpt :In patients with negative HBsAg and positive HBcAb, we only retrieved one study including 27 patients with RA; 19% of them took anti-viral prophylaxis and reported no occurrence of HBVr [174]. In view of its immunosuppressive mechanism of action, abatacept is considered to have a moderate-to-high HBVr rate [82,175]. Tocilizumab (TCZ) is a genetically engineered humanized monoclonal antibody against the receptor of IL-6 [176].
Late Hepatitis B reactivation after treatment with rituximab
2022, IDCasesCitation Excerpt :Testing for hepatitis B virus before chemotherapy and immunosuppressive treatments is a well-established practice and is recommended in current guidelines [4,5,10]. In patients considered at high risk for reactivation (more than 10% chance of HBV reactivation), both American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL) recommend antiviral prophylaxis [3,4,6,10]. In selected patients, antiviral prophylaxis could be replaced by frequent (usually monthly) HBV-DNA monitoring and pre-emptive antiviral treatment in case of a positive result [6,8,10].
Hepatitis B reactivation in patients on biologics: A perfect storm
2022, Journal of the American Academy of DermatologyVariable Outcomes of Hepatitis E Infections in Patients with Hemato-Oncologic Diseases
2023, Oncology Research and Treatment