Chemoprevention of Patients with Hepatitis B Receiving Chemotherapy or Bone Marrow Transplant

Abstract

Hepatitis B virus (HBV) reactivation is a common but preventable complication of immunosuppression. With the advent of new therapies that provide efficient and prolonged immunosuppression, the incidence of HBV reactivation is likely to increase. The clinical presentation can range from mildly elevated aminotransferase values to fatal fulminant hepatitis. Despite prompt antiviral therapy, the mortality rates remain high, and it can adversely affect the outcome of immunosuppressive therapy for the underlying hematological disease. Over the past decade, several studies evaluated the risk of HBV reactivation, role of serological tests, and effectiveness of antiviral therapies in preventing severe hepatic dysfunction among patients undergoing immunosuppressive therapy. Studies show that HBV antiviral therapy given prior to chemotherapy may prevent HBV replication, and reduce the risk of HBV reactivation during the immunosuppression period. This article reviews the current literature and society guidelines on HBV reactivation, risk factors, and prophylaxis for HBV reactivation in patients undergoing chemo-/immunosuppressive therapy.

Entecavir as a first-line treatment for hepatitis B virus reactivation following polychemotherapy for chronic lymphocytic leukemia and invasive ductal carcinoma

“…Accordingly, in agreement with the association of higher viral load with higher severity of hepatitis reactivation [17] and different clinical course in hematological oncological diseases versus solid organ malignancies [10], initial ALT levels as well as viral load were more prominent in our first case with CLL. Nevertheless, entecavir yielded similar rapid normalization of liver functions in both cases within the third month of treatment and regain of former immunity to HBV in 14 months in CLL.…”

“…Therefore, the recently published society guidelines and algorithms recommend that these HBsAg-negative patients be followed carefully by means of ALT and HBV DNA testing and treated with HBV antiviral therapy upon confirmation of HBV reactivation with DNA levels before ALT elevation [10].…”

“…Considering that one-third of the population is positive for hepatitis B core antibody (HBcAb) and hepatitis B surface antibody (HBsAb), about half of the population and most likely half of the patients undergoing chemotherapy may be exposed to prior HBV infection, and the risk for reactivation may increase with the introduction of novel potent chemotherapeutic agents and immunosuppressive therapy, comprising a debate in screening and management of HBV reactivation in this patient population [10].…”

“…Lamivudine (LAM), the first nucleoside analog approved as the antiviral drug for CHB, has traditionally been the primary agent to reduce the incidence and severity of HBV reactivation following chemotherapy or immunosuppressive therapy [10,11]; however, it seems not always to confer an advantage [13], as its efficacy is hampered by the high rate of emergence of drug resistance mutations within HBV polymerase that are associated with treatment failure [4,14] and a mortality rate of up to 20% has been reported when it has been used in the treatment of reactivated cases [15]. Therefore, recently, new nucleos (t)ide analogs have also become available to obtain a more rapid viral suppression with a lower risk for subsequent resistance compared with LAM [8].…”