Evaluation of Hepatitis B Reactivation Among Patients With Chronic Myeloid Leukemia Treated With Tyrosine Kinase Inhibitors

Abstract

Hepatitis B reactivation (HBVr) in cancer patients is a well-established complication due to chemotherapy-induced immunosuppression. Studies have reported HBVr associated with immunosuppressive medications, such as rituximab, methotrexate, and high dose steroids. There are different risks for different types of chemotherapy with rituximab carrying one of the highest risks for hepatitis B reactivation. Tyrosine kinase inhibitors (TKIs) are the standard of care in patients with chronic myeloid leukemia (CML). The risk of HBVr in chronic myeloid leukemia has been reported in many studies, but to this date, there are no clear guidelines or recommendations regarding screening and monitoring of HBV in CML patients receiving TKIs. We conducted this review to identify the risk of HBVr in patients with CML who are treated with tyrosine kinase inhibitors. We recommend testing for HBV status in patients who are to be treated with TKIs and to consider giving prophylaxis in those who are positive for HBsAg at baseline. More studies are needed to assess the risk of reactivation in patients with Hepatitis B core antibody positive receiving TKIs. Currently, monitoring such patients for reactivation may be the best strategy.

Chronic Myeloid Leukemia in a Patient with Hepatitis B Virus Infection: A Case Report

“…A recent publication addressed the issue of follow-up in such a population, and we agree with the authors [ 4 ]. Baseline liver function tests were established before starting treatment and followed at 1 month, 3 months, and 6 months.…”

“…It can be self-limited and reversible upon discontinuation of the inducing agent, and it can be serious and fatal. HBV reactivation (HBVr) is increasingly recognized as an important adverse effect with an incidence approaching 10.8 per 100 person-years in a retrospective cohort study [ 4 ]. Most of the reported cases are triggered by the use of imatinib [ 12 , 13 , 14 , 15 , 16 ].…”

“…Several definitions have been proposed for HBVr based on virologic, serologic, or both criteria; a simple definition would be an increase in HBV replication usually associated with a rise in serum aminotransferase levels [ 4 , 17 , 18 ]. Although there are recommendations to screen for HBV infection before starting immune-suppressing medications, however, guidelines about the prevention of HBVr in the context of TKIs remain uncertain.…”

“…The management of Ph chromosome-positive and BCR-ABL1-positive CML has undergone a profound evolution with the tyrosine kinase inhibitors (TKIs) [ 3 ]. Currently, there are 5 TKIs approved by the FDA for the treatment of CML, including imatinib, dasatinib, nilotinib, bosutinib, and ponatinib [ 4 ].…”

Chronic Myeloid Leukemia in Children: Immune Function and Vaccinations

“…However, there are no clear guidelines or recommendations regarding the screening and monitoring of hepatitis B virus (HBV). Atteya et al reviewed the literature to estimate the risk of chronic HBV reactivation associated with TKI treatment and addressed the following unanswered questions: (1) is there a need to screen all patients who will receive TKIs; (2) how long should patients with CML be on HBV prophylaxis, and (3) which are the best antiviral agents to use for prophylaxis against HBV for patients on TKIs [22]? The authors concluded that (1) it is advisable to screen all patients scheduled for TKI treatment by testing with ALT, a complete hepatitis B serology panel (including HBsAg, anti-HBs antibodies, anti-HBc antibodies, HBeAg, anti-HBe antibodies), and HBV DNA, (2) in HBsAg positive patients, prophylaxis against HBV reactivation should be started, as reactivation may happen any time after the commencement of TKIs with a median time of 9-10 months (range: 1-69 months), and (3) there was no clear answer from the literature as to which antiviral drug should be used.…”