Individuals with current or resolved hepatitis B are at risk of viral reactivation whilst undergoing immunosuppressive therapy. Reactivation can lead to liver failure, death, or cancer treatment interruption that reduces cancer survival.  

 

Four articles have been released by Joe Sasadeusz et al. facilitated by ASHM- via an unconditional grant from Gilead Sciences. The authors included Australian experts from the hepatitis B sector and those specialties managing immune compromised patients: oncology, haematology, renal and transplant. Prof Seng Gee Lim, Director Hepatology, National University of Singapore also contributed to the articles. 

  

These articles cover a wider range of immunosuppressive states in which reactivation can occur, including those in organ transplantation, in patients with haematological and solid tumours, and in patients receiving treatment with other immunosuppressive agents, including biological response modifiers. These 4 articles have all been published in the journal ‘Clinics in Liver Disease’, Clin Liver Dis. 2019 Aug;23(3), and can be accessed using the links below. Please note that a login is required. 

  

·         Screening and Prophylaxis to Prevent Hepatitis B Reactivation. Introduction and Immunology. 

  

·         Screening and Prophylaxis to Prevent Hepatitis B Reactivation. Transplant Recipients.

  

·         Screening and Prophylaxis to Prevent Hepatitis B Reactivation. Patients with Hematological and Solid Tumor Malignancies.

  

·         Screening and Prophylaxis to Prevent Hepatitis B Reactivation. Other Populations and Newer Agents. 

  

  

ASHM recently had the opportunity to speak with Infectious Diseases Physician and lead author A/Prof Joe Sasadeusz who summarised the key findings below. 

  

  

Q. What are some key messages for treating specialists to take away from these articles? 

A.  

  1. The need to screen patients undergoing immunosuppression for markers of HBV infection. This should include testing for HBsAg, anti-Hbc and anti-HBs. 

  1. If appropriate, patients need to be given antiviral prophylaxis to prevent reactivation. 

  1. Failure to do above can be catastrophic. 

  

Q. What do you see as the role of primary care providers in managing patients undergoing immunosuppressive therapies? 

A. If primary care physicians prescribe immunosuppressive therapy, especially corticosteroids, they need to be aware of the above issues. 

Editor’s note: Treatment with direct-acting antivirals (DAAs) may also result in HBV reactivation. It is recommended that patients are tested for HBV infection (current or resolved) before commencing therapy with DAAs. 

  

Q. What patients undergoing immunosuppressive therapy should be started on antiviral therapy, and how long should a patient be on antiviral therapy? 

A. All patients who are HBsAg positive, and some patients who are HBsAg negative but anti-HBc positive, receiving significant immunosuppression should commence antiviral therapy. This should be continued for 12 months post cessation of immunosuppression. 

  

Q. What is the role of HBIG in management of patients undergoing immunosuppression? 

A. Minimal. It is used in some liver transplant settings and sometimes in a transplant setting where a recipient is receiving an HBsAg or anti-HBc donor in order to prevent transmission. 

  

Q. What is occult hep b and how should it be managed in the context of immune suppression? 

A. It is a positive HBV DNA in the setting of HBsAg negativity. As these patients are viraemic they should receive antiviral prophylaxis as though they are HBsAg positive. 

  

Further information can also be sought via the Hepatitis B management during immunosuppression for haematological and solid-organ malignancies: An Australian consensus statement 2019. This consensus statement was prepared by an expert panel of medical specialists in infectious diseases, hepatology, haematology, oncology and paediatrics, and representatives from the Australasian Society for Infectious Diseases, the Gastroenterological Society of Australia (Australian Liver Association), the Haematology Society of Australia and New Zealand, the Medical Oncology Group of Australia, and the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine