Prophylaxis and treatment of Hepatitis B in immunocompromised patients

Abstract

The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion.Moreover it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants, and in liver transplantation the universal prophylaxis with nucleos(t) ides analogues (frequently combined with specific anti-HBV REVIEW ARTICLE24 immunoglobulins) in HBsAg-positive candidates and in HBsAgnegative recipients of antiHBc-positive grafts should be adopted.

Safety of tumor necrosis factor α blockers in hepatitis B virus occult carriers (hepatitis B surface antigen negative/anti–hepatitis B core antigen positive) with rheumatic diseases

“…Of 732 patients, 72 were identified as anti-HBc carriers, but 5 of them were HBsAg positive and therefore were not enrolled in the study; the latter were treated with lamivudine prophylaxis before the onset of anti-TNF␣ therapy, and are still under treatment in accordance with the current guidelines (4,32). Sixty-seven patients were included in the study.…”

“…Recent guidelines from the Italian Association for the Study of the Liver (AISF) on the management of HBV infection during immunosuppressive therapy suggest the use of lamivudine, a nucleoside analog, in HBsAg carriers undergoing immunosuppressive therapies, including TNF␣ blockers (4). However, the use of lamivudine in patients receiving an extended course of immunosuppressive therapy has an uncertain benefit versus risk rate, as its prolonged employ is associated with the emergence of lamivudine-resistant mutants (30,33,50).…”

“…The disappearance of anti-HBc in 2 patients during the followup could also be related to fluctuations in antibody titers, even though we cannot exclude testing failure or unspecific reactions. These considerations led us to give particular importance, for study purposes, to direct indicators of viral replication, including both HBsAg and HBV DNA, as is also suggested by AISF guidelines (4).…”

“…Patients who present antibodies to hepatitis B core antigen (anti-HBc) with concurrent HBsAg negativity do not have chronic hepatitis, but only experienced HBV infection and were able to clear it. Nevertheless, some of these patients may be occult carriers, in whom intrahepatic HBV replication can be detected despite HBsAg and HBV DNA negativity in the serum and despite the absence of signs of active liver disease (4,5).…”

“…On the other hand, many cases have been described in which TNF blockade, either in association with lamivudine prophylactic therapy or not, did not lead to HBV reactivation (6,(25)(26)(27)(28)(29)(30), and recently a retrospective study showed no reactivation during anti-TNF␣ therapy (31). The use of lamivudine to prevent HBV reactivation is recommended in HBsAg-positive patients undergoing immunosuppressive therapies, including anti-TNF␣ drugs (4,32), but its use can lead to viral resistance (33). There are no prospective studies regarding HBV reactivation and TNF␣ blocker therapy, and in particular few data are available about HBsAg-negative, antiHBc-positive patients.…”