From the Guidelines
Management for a patient with positive Hepatitis B surface and core antibodies typically indicates resolved HBV infection and generally requires no specific treatment, but regular monitoring with liver function tests every 6-12 months is recommended to ensure continued normal liver function. These serological markers suggest the patient has developed immunity after a previous infection and has cleared the virus. According to the most recent guidelines, patients with past HBV undergoing anticancer therapies that are not clearly associated with a high risk of HBV reactivation should be followed carefully during cancer treatment, with HBsAg and ALT testing every 3 months 1. If the patient requires immunosuppressive therapy or chemotherapy in the future, they should be monitored closely as there is a risk of HBV reactivation, and prophylactic antiviral therapy (such as entecavir 0.5mg daily or tenofovir 300mg daily) may be necessary during and for 6-12 months after immunosuppression, as recommended by the American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. This monitoring approach is important because although the virus is typically inactive, viral DNA may persist in liver cells and could potentially reactivate under certain conditions. Patients should also be counseled about avoiding alcohol and hepatotoxic medications to maintain liver health, and household contacts or sexual partners should be vaccinated against HBV if not already immune.
Some key points to consider in the management of these patients include:
- Regular monitoring of liver function tests every 6-12 months
- Close monitoring during immunosuppressive therapy or chemotherapy
- Prophylactic antiviral therapy may be necessary during and after immunosuppression
- Counseling on avoiding alcohol and hepatotoxic medications
- Vaccination of household contacts or sexual partners against HBV if not already immune
- Coordination of care with a clinician experienced in HBV management is highly recommended, especially to monitor for withdrawal flares, determine monitoring and antiviral therapy after the cessation of anticancer therapy, and evaluate for advanced liver disease such as cirrhosis or liver cancer 1.
It is essential to prioritize the patient's morbidity, mortality, and quality of life when making management decisions, and to consider the most recent and highest quality evidence available, such as the 2020 provisional clinical opinion update on hepatitis B virus screening and management for patients with cancer prior to therapy 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Patients with Hepatitis B Surface and Core Antibodies
- The presence of hepatitis B surface antibody (anti-HBs) in addition to hepatitis B core antibody (anti-HBc) confers protection against hepatitis B virus (HBV) infection in HBsAg-negative patients undergoing kidney transplantation 2.
- Patients with hepatitis B surface antigen (HBsAg)-negative and anti-HBc-positive status should be monitored for HBV infection regardless of anti-HBs status, according to the American Gastroenterological Association and European Association for the Study of the Liver 2.
- However, the presence of anti-HBs may provide protection against infection, and monitoring for HBV infection after kidney transplantation may not be necessary for HBsAg-negative, anti-HBc-positive, and anti-HBs-positive patients 2.
Treatment and Prophylaxis
- Entecavir and tenofovir are recommended as first-line nucleos(t)ide analogs (NAs) for patients with HBV decompensated cirrhosis 3.
- The combination of HBV immunoglobulin and NA is considered the standard of care for prophylaxis against HBV recurrence after liver transplantation 4, 3.
- Tenofovir is the best choice for hemodialysis patients and in patients with chronic kidney disease with nucleoside resistance 3.
Special Populations
- HBsAg-positive patients under immunosuppression should receive NA pre-emptively, regardless of HBV DNA levels, up to 12 months after its cessation 3.
- In HBsAg-negative, anti-HBc-positive patients under immunosuppression, further studies are needed to form a final conclusion; however, it seems that anti-HBV prophylaxis is justified in such patients with hematological diseases and/or for those receiving rituximab-containing regimens, regardless of their anti-HBs or serum HBV DNA status 3.