Long-term immunosuppressive therapy can cause the hepatitis B virus (HBV) to become active, even in patients who are not aware that they are infected with the virus. A new guideline from the American Gastroenterological Association (AGA) provides guidance to physicians and patients who use immunosuppressive agents for the treatment of a variety of disorders, including gastrointestinal, dermatologic, neurologic and rheumatologic, among others. The new guideline1 and accompanying technical review2 and clinical decision support tool3 have been published in Gastroenterology, the official journal of the AGA Institute.
"Many specialists are unaware that they should conduct hepatitis B screening on their patients prior to beginning long-term immunosuppressive therapy," according to K. Rajender Reddy, MD, lead author of the guidelines, from the division of gastroenterology and hepatology, University of Pennsylvania, Philadelphia. "Preventing HBV reactivation in these patients involves screening those at risk, identifying patients for risk based on HBV serologic status and the type of immunosuppression, and consideration of prophylaxis with anti-hepatitis B therapeutics."
Several aspects of HBVr prevention remain unclear, including which patients to screen, in whom to use which HBV preventive therapies and for how long, and how to monitor those at risk but not on preventive therapy.
AGA developed the guideline using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and best practices as outlined by the Institute of Medicine. Despite a large number of published studies, in most cases the recommendations for prophylaxis are weak because either the quality of the available data and/or the baseline risk of HBVr is low or uncertain, and/or risks and benefits for a particular strategy do not overwhelmingly support its use.
Recognizing these and other limitations, the recommendations included here represent a rigorous, evidence-based summary of extensive literature describing the prevention of HBVr. Review of this guideline, plus the associated technical review, will facilitate effective shared decision making with patients at risk for HBVr.
1& 2. Is antiviral prophylaxis needed for hepatitis B surface antigen-positive patients who will undergo immunosuppressive drug therapy? Is antiviral prophylaxis needed for hepatitis B surface antigen-negative, antibody to hepatitis B core antigen-positive patients who will undergo immunosuppressive drug therapy?
3.Does the presence of antibody to hepatitis B surface antigen in addition to anti-HBc in HBsAg-negative patients confer additional protection against HBVr?
4.Is prophylactic treatment with third-generation nucleos(t)ide analogues more effective than first- or second-generation nucleos(t)ide agents?
5.Is HBV DNA monitoring followed by on-demand antiviral therapy as effective as prophylactic antiviral therapy?
6.Is treatment of established HBVr with third-generation nucleos(t)ide agents more effective than first- or second-generation drugs?
7.Should patients who will undergo long-term immunosuppressive drug therapy be screened for HBV before starting treatment?
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