Preventing Hepatitis B Reactivation During Anti‐CD20 Antibody Treatment in the Veterans Health Administration

Abstract

Hepatitis B virus (HBV) reactivation may occur with high risk immunosuppression, such as anti‐cluster of differentiation (CD)20 antibodies (Abs). Appropriate HBV prophylaxis during anti‐CD20 Ab therapy averts hepatitis, chemotherapy disruption, and death. Serologic evidence of prior HBV exposure is present in one in nine veterans in the Veterans Health Administration (VHA). In 2014, most (61%‐73%) patients in the VHA who were receiving anti‐CD20 Ab treatment underwent HBV testing, yet <20% of eligible patients received HBV antiviral prophylaxis. We aimed to prevent HBV reactivation by increasing HBV testing and antiviral treatment rates among anti‐CD20 Ab recipients through prospective interventions. A multidisciplinary team of clinicians, pharmacists, and public health professionals developed comprehensive prevention systems, including national seminars/newsletters/websites; pharmacy criteria for HBV screening/treatment prior to anti‐CD20 Ab use; changes to national formulary restrictions to expand HBV prophylaxis prescribing authority; Medication Use Evaluation Tracker to identify omissions; national e‐mail alert to all VHA oncology providers detailing specific testing and HBV antiviral treatment needs; and a voluntary electronic medical record “order check” used at interested facilities (n = 11) to automatically assess pretreatment HBV testing and antiviral treatment and only generate a reminder to address deficiencies. Analysis of monthly data from June 2016 through September 2017 among anti‐CD20 Ab recipients revealed pre‐anti‐CD20 Ab treatment HBV testing increased to 91%‐96% and appropriate HBV antiviral prophylaxis to 76%‐85% nationally following implementation of the intervention. Medical centers using the voluntary electronic medical record order check increased HBV testing rates to 93%‐98% and HBV antiviral prophylaxis rates to 99%. Conclusion: Multimodal intervention systems to prevent HBV reactivation among VHA patients receiving anti‐CD20 Ab therapies increased national rates of HBV testing to >90% and antiviral prophylaxis to >80%.

Impact of universal hepatitis B virus (HBV) screening using chemotherapy orders on the HBV reactivation in cancer patients

“…We can also think that more awareness and education to clinicians about HBVr risk associated with chemotherapy could be necessary as many patients increased their hepatic enzymes during chemotherapy but the majority have not been tested for HBV. In other centers, strategies to promote and increase universal HBV screening and follow-up in cancer patients range from the use of computer alert programs [36][37][38][39] , electronic medical order check for anti-CD20 antibody treatment 40 or electronic alerts to monitor HBV-DNA every 3 months 41 . All those methods are considered imperfect and strategies need to be adapted to the local clinical environment.…”

A krónikus limfocitás leukémia terápiájában alkalmazott célzott hatásmechanizmusú szerek okozta mellékhatások megelőzése és kezelése, fókuszban a Bruton-féle tirozin-kinázok okozta kardiovaszkuláris toxicitás

“…Az anti-CD20 antitestek egyik fő mellékhatása a fertőzések megnövekedett gyakorisága. A hepatitis B reaktiváció lehetősége régóta ismert, ennek megelőzésére különböző stratégiák léteznek, melyek a reaktiváció rendszeres szűrésén vagy profilaktikus antivirális kezelésen alapulnak a vírushordozó, de nem beteg egyének esetében [42]. A fertőzések és súlyos fertőzések gyakorisága a CLL11 tanulmányban nem különbözött szignifikánsan a két anti-CD20-terápia mellett (38% vs. 37% és 12% vs. 14%) [43].…”