From the Guidelines
The best approach to monitor for HBV reactivation involves regular screening of HBV serologic markers and HBV DNA levels, particularly in high-risk patients, with baseline testing for HBsAg, anti-HBc, and anti-HBs before starting immunosuppressive therapy, chemotherapy, or biologic agents, as recommended by the most recent guidelines 1.
Key Recommendations
- Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy for the duration of anticancer therapy, as well as for at least 12 months after receipt of the last anticancer therapy, with monitoring of ALT and HBV DNA levels at baseline and every 6 months during antiviral therapy 1.
- Patients with past HBV receiving anticancer therapies associated with an established high risk of HBV reactivation should be started on antiviral prophylaxis at the beginning of anticancer therapy and continued on antiviral therapy for at least 12 months after the cessation of anticancer therapy, with HBV DNA monitoring every 6 months 1.
- For HBsAg-negative but anti-HBc-positive patients, monitoring HBV DNA levels every 1-3 months is recommended, as they can still experience reactivation, with prophylactic antiviral therapy considered for those at high risk 1.
Monitoring Approach
- Liver function tests (ALT, AST) should be checked at similar intervals to HBV DNA monitoring, at least monthly for the first 3 months after the cessation of antiviral therapy and every 3 months thereafter 1.
- Prophylactic antiviral therapy with entecavir or tenofovir is recommended for high-risk patients before starting immunosuppressive therapy and should continue for at least 6-12 months after therapy completion, as supported by recent studies 1.
Importance of Monitoring
- HBV reactivation can lead to severe hepatitis, liver failure, and death, making proactive monitoring essential for early intervention, as the virus can remain dormant in hepatocytes and reactivate when the immune system is suppressed, with viral replication often preceding clinical symptoms by weeks to months 1.
From the FDA Drug Label
Discontinuation of anti-HBV therapy, including tenofovir disoproxil fumarate, may be associated with severe acute exacerbations of hepatitis Patients infected with HBV who discontinue tenofovir disoproxil fumarate should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment. Severe acute exacerbations of hepatitis B virus infection after discontinuation: Monitor hepatic function closely for at least several months.
The best approach to monitor for HBV reactivation is to closely monitor hepatic function with both clinical and laboratory follow-up for at least several months after stopping anti-HBV therapy, such as tenofovir disoproxil fumarate or entecavir 2 3. Key aspects of monitoring include:
- Clinical follow-up
- Laboratory tests to assess hepatic function It is essential to be aware of the potential for severe acute exacerbations of hepatitis after discontinuation of treatment.
From the Research
Monitoring for HBV Reactivation
To test for HBV reactivation, the following approaches can be considered:
- Universal screening for hepatitis B virus is recommended for all patients who plan to initiate immunosuppressive therapy 4
- Risk stratification of patients at risk with appropriate antiviral prophylaxis can prevent HBV reactivation effectively 5
- Several emerging biomarkers have been proved to help determine the risk precisely 5
- Early detection and timely administration of antiviral agents are crucial for management 5, 6
- Screening for hepatitis B virus should include serological profile, underlying disease, and planned type of immunosuppression to contribute to their risk of HBV reactivation 4
Laboratory Tests
Laboratory tests for HBV reactivation may include:
- Hepatitis B surface antigen (HBsAg) test
- Antibody to hepatitis B core antigen (anti-HBc) test
- Antibody to hepatitis B e antigen (anti-HBe) test
- Serum HBV DNA level test to detect increased viral replication 6
- Liver function assay, including alanine transaminase (ALT) and aspartate transaminase (AST) levels, as well as total bilirubin (TBIL) and direct bilirubin (DBIL) levels 6
Prevention and Management
Prevention and management of HBV reactivation may involve: