What is the recommended approach for hepatitis screening and treatment in at-risk individuals?

Hepatitis Screening and Treatment in At-Risk Individuals

The American Gastroenterological Association (AGA) strongly recommends universal hepatitis B testing for all adults aged 18 years and older, with antiviral prophylaxis for those at high risk of reactivation. 1

Screening Recommendations

Who to Screen

• Universal screening for hepatitis B is recommended for all adults aged 18 years and older 1, 2
• Risk-based screening should be performed regardless of age for individuals with:
  • History of injection drug use
  • Men who have sex with men
  • HIV infection
  • Sexual or household contacts of HBV-infected persons
  • Incarceration history
  • Multiple sexual partners or STI history
  • History of HCV infection
  • Birth in regions with HBV prevalence ≥2% (Africa, Asia, Pacific Islands, parts of South America) 2, 3
• Anyone who requests HBV testing should receive it, regardless of disclosed risk factors 2

Recommended Tests

• Hepatitis B screening panel:
  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis B surface antibody (anti-HBs) 1, 4
• Follow-up testing: HBV DNA viral load if HBsAg and/or anti-HBc is positive 1

Risk Assessment for HBV Reactivation

After identifying HBV infection, assess reactivation risk based on:

High Risk (>10% risk)

• HBsAg-positive patients receiving:
  • B cell-depleting agents
  • High-dose corticosteroids (≥4 weeks)
  • Anti-TNF therapy
• HBsAg-negative/anti-HBc-positive patients with:
  • B cell-depleting agents
  • HCV co-infection undergoing DAA therapy 1

Moderate Risk (1-10% risk)

• HBsAg-positive patients receiving:
  • Anthracycline derivatives
  • Anti-IL-6 therapy
  • CAR-T cell therapy
  • TKI therapy
  • TACE 1

Low Risk (<1% risk)

• Short-term corticosteroids (≤1 week)
• Anti-T cell therapy (≤2 weeks)
• Immune checkpoint inhibitors
• Cytokine/integrin inhibitors
• JAK inhibitor therapy
• Intra-articular corticosteroids 1

Management Recommendations

Antiviral Prophylaxis

• High-risk patients: Strongly recommended to receive antiviral prophylaxis over monitoring alone (strong recommendation, moderate certainty evidence) 1
• Moderate-risk patients: Suggested to receive antiviral prophylaxis over monitoring alone (conditional recommendation, moderate certainty evidence) 1
• Low-risk patients: Suggested to undergo monitoring alone without prophylaxis (conditional recommendation, moderate certainty evidence) 1

Antiviral Selection

• Preferred agents: Entecavir or tenofovir (high barrier to resistance) 4
• Avoid: Lamivudine for long-term prophylaxis due to higher resistance rates 4

Timing and Duration

• Start antiviral prophylaxis before beginning immunosuppressive therapy 1
• Continue for at least 6 months after discontinuation of immunosuppressive therapy 1
• For B cell-depleting agents, continue for at least 12 months after discontinuation 1

Monitoring Protocol

• For patients not receiving prophylaxis: Monitor HBV DNA and liver enzymes every 1-3 months during immunosuppressive therapy 1, 4
• Continue monitoring for 6-12 months after discontinuation of immunosuppressive therapy 4

Special Considerations

Hepatitis C Co-infection

• Patients with HCV/HBV co-infection are at high risk for HBV reactivation during HCV treatment with direct-acting antivirals 1, 5
• Screening for HBV is essential before initiating HCV therapy 6

Patients with Chronic Liver Disease

• Patients with chronic liver disease should be vaccinated against both HAV and HBV if not already immune 7
• Postvaccination testing is recommended in patients with advanced liver disease due to lower seroconversion rates 7

Common Pitfalls to Avoid

1. Failing to screen: Up to 60% of HBV-infected persons are unaware of their infection 3
2. Inadequate monitoring: Not following patients at appropriate intervals during immunosuppressive therapy
3. Premature discontinuation: Stopping antiviral prophylaxis too early after immunosuppressive therapy
4. Overlooking HBV/HCV co-infection: Not screening for HBV before HCV treatment
5. Using lamivudine for long-term prophylaxis: Higher resistance rates make entecavir or tenofovir preferable 4

By following these evidence-based recommendations, clinicians can effectively identify at-risk individuals, prevent HBV reactivation, and reduce morbidity and mortality associated with hepatitis B infection.