COMMENTARY

HBV: React Before the Virus Does

The Key to Preventing HBV Reactivation

William F. Balistreri, MD

Disclosures

April 01, 2015

In This Article

When to Initiate Antiviral Therapy

Di Bisceglie and colleagues[2] reviewed five randomized trials that demonstrated that prophylactic antiviral therapy, initiated prior to or at the same time as chemotherapy, was more effective than preemptive antiviral therapy (initiated when HBV DNA levels begin to rise or clinical symptoms appear) in preventing HBV reactivation.[2,38,40,41,44,45]

In one study, consecutive HBsAg-positive patients with lymphoma undergoing chemotherapy were randomly assigned to receive lamivudine prior to chemotherapy or when there was a more than 10-fold increase in serum HBV DNA level or the appearance of HBV DNA in patients with previously undetectable serum HBV DNA.[38] None of the patients who received prophylactic lamivudine, vs 53% of those who received preemptive lamivudine, experienced HBV reactivation.

In another study, HBsAg-positive patients who were receiving chemotherapy for non-Hodgkin lymphoma were randomly assigned to either prophylactic lamivudine or preemptive therapy when ALT levels increased to more than 1.5-fold the upper normal limit.[40] Compared with those who received preemptive lamivudine, fewer patients receiving prophylactic lamivudine had HBV reactivation (12% vs 56%).

Huang and colleagues[41] reported that in HBsAg-negative and anti-HBc–positive patients with lymphoma receiving chemotherapy regimens that included anti-CD20 agents, the rate of HBV reactivation was lower in the prophylactic group than the preemptive group.[41] The cumulative HBV reactivation rates at months 6, 12, and 18 after chemotherapy were 8%, 11%, and 26%, respectively, in the therapeutic group, and 0%, 0%, and 4%, respectively, in the prophylactic group. The cumulative HBsAg reverse seroconversion rates at months 6, 12, and 18 after initiation of chemotherapy were 0%, 6%, and 16%, respectively, in the therapeutic group, which were significantly higher than those in the prophylactic group.

These studies not only re-emphasize the value of assessing hepatitis B serology before initiation of chemotherapy but also provide strong support for prophylactic administration of therapy in anti-HBc–positive patients.[2,34]

How Long to Treat?

The appropriate duration of antiviral prophylaxis has not been established. Extension of antiviral administration to 6-12 months following completion of chemotherapy has been suggested as a reasonable empiric strategy.[17,34]

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