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Mak JWY, Law AWH, Law KWT, Ho R, Cheung CKM, Law MF. Prevention and management of hepatitis B virus reactivation in patients with hematological malignancies in the targeted therapy era. World J Gastroenterol 2023; 29:4942-4961. [PMID: 37731995 PMCID: PMC10507505 DOI: 10.3748/wjg.v29.i33.4942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/22/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023] Open
Abstract
Hepatitis due to hepatitis B virus (HBV) reactivation can be serious and potentially fatal, but is preventable. HBV reactivation is most commonly reported in patients receiving chemotherapy, especially rituximab-containing therapy for hematological malignancies and those receiving stem cell transplantation. Patients with inactive and even resolved HBV infection still have persistence of HBV genomes in the liver. The expression of these silent genomes is controlled by the immune system. Suppression or ablation of immune cells, most importantly B cells, may lead to reactivation of seemingly resolved HBV infection. Thus, all patients with hematological malignancies receiving anticancer therapy should be screened for active or resolved HBV infection by blood tests for hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen. Patients found to be positive for HBsAg should be given prophylactic antiviral therapy. For patients with resolved HBV infection, there are two approaches. The first is pre-emptive therapy guided by serial HBV DNA monitoring, and treatment with antiviral therapy as soon as HBV DNA becomes detectable. The second approach is prophylactic antiviral therapy, particularly for patients receiving high-risk therapy, especially anti-CD20 monoclonal antibody or hematopoietic stem cell transplantation. Entecavir and tenofovir are the preferred antiviral choices. Many new effective therapies for hematological malignancies have been introduced in the past decade, for example, chimeric antigen receptor (CAR)-T cell therapy, novel monoclonal antibodies, bispecific antibody drug conjugates, and small molecule inhibitors, which may be associated with HBV reactivation. Although there is limited evidence to guide the optimal preventive measures, we recommend antiviral prophylaxis in HBsAg-positive patients receiving novel treatments, including Bruton's tyrosine kinase inhibitors, B-cell lymphoma 2 inhibitors, and CAR-T cell therapy. Further studies are needed to determine the risk of HBV reactivation with these agents and the best prophylactic strategy.
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Affiliation(s)
- Joyce Wing Yan Mak
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
| | | | | | - Rita Ho
- Department of Medicine, North District Hospital, Hong Kong 852, China
| | - Carmen Ka Man Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
| | - Man Fai Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
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2
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Ho JCL, Mak JWY, Yip TCF, Lam HM, Cheng TY, Lam TO, Tam LS, Law MF, Cheung CKM, Ng SC, Wong VWS, Wong GLH. Risk of alanine aminotransferase flare in patients with previous hepatitis B virus exposure on biological modifier therapies-A population-based study. Liver Int 2023; 43:588-598. [PMID: 36516362 DOI: 10.1111/liv.15499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/22/2022] [Accepted: 11/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND It is uncertain whether biological therapies would increase the risk of hepatitis among patients with past hepatitis B virus (HBV) infection. This study aimed to evaluate the risk of alanine aminotransferase (ALT) flare in patients with past HBV infection while using biological therapies. METHODOLOGY Patients who received biological therapies for ≥3 months from 2000 to 2019 were identified from a population-based database in Hong Kong. Patients with past HBV infection were compared with a control group without prior HBV exposure. The primary endpoint was development of ALT flare within 5 years of starting biological therapies, defined as ALT >80 IU/L. RESULTS There were 2471 and 2394 patients with and without past HBV infection respectively. There was a non-significant increase in risk of ALT flare among the HBV-exposed group (27.6% vs. 23.7%, p = .055). In multivariable analysis, using prednisolone-equivalent dose of >20 mg daily, male sex and concomitant immunosuppressants were risk factors for ALT flare. The risk of ALT flare was significantly higher with anti-CD20 when compared to other biological agents (36.1% vs. 14.5%, p < .01), but was not significantly different among anti-tumour necrosis factor, anti-cytokine, Janus kinase inhibitors and T cell/B cell inhibitors or anti-integrin (15.2% vs. 14.6% vs. 11.7% vs. 11.1%, p = .82). Among patients with documented hepatitis B surface antigen seroreversion, 96% were on anti-CD20. CONCLUSIONS Our study further supports the current suggestion of prophylactic anti-viral before starting anti-CD20 in HBV-exposed patients. While other biological therapies appear to have a lower risk for ALT flare, this result needs further confirmation.
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Affiliation(s)
- Jacky C L Ho
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hong Man Lam
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Tsz Yan Cheng
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Tsz On Lam
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lai Shan Tam
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Man Fai Law
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Carmen K M Cheung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Guo X, Ji T, Xin S, Xu J, Yu Y. A case report of hepatitis B virus reactivation 19 months after cessation of chemotherapy with rituximab. Front Immunol 2022; 13:1083862. [PMID: 36532005 PMCID: PMC9755885 DOI: 10.3389/fimmu.2022.1083862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022] Open
Abstract
A 72-year-old woman presented to our hospital with elevation of serum transaminases. Her blood tests showed the hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) negative. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) were given for the diffuse large B-cell lymphoma. She didn't receive anti- hepatitis B virus (HBV) drug for the isolated HBcAb positive. HBV reactivation confirmed based on the serum HBV DNA detectable until 19 months after stopping R-CHOP regimen. HBV DNA became undetectable after 4 weeks therapy with Tenofovir alafenamide fumarate (TAF). Serum transaminases went down to normal 3 months later after receiving TAF. HBV reactivation is a substantial risk for patients with isolated HBcAb positive receiving rituximab-containing chemotherapy without anti- HBV drug. Regular monitoring with a frequency of 1-3 months is the basis for timely diagnosis and treatment of HBV reactivation. Serum transaminases abnormalities may be the initial manifestation of HBV reactivation.
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Affiliation(s)
- Xiangjuan Guo
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China,Department of Infectious Diseases, Handan Central Hospital, Handan, China
| | - Tongtong Ji
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Shengliang Xin
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Jinghang Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China,*Correspondence: Yanyan Yu, ; Jinghang Xu,
| | - Yanyan Yu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China,*Correspondence: Yanyan Yu, ; Jinghang Xu,
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Alalawi M, Bakr AS, Reda R, Sadak KT, Nagy M. Late-onset toxicities of monoclonal antibodies in cancer patients. Immunotherapy 2022; 14:1067-1083. [PMID: 35892252 DOI: 10.2217/imt-2022-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer therapy duration is variable and may take years, adding a new challenge of maintaining the best life quality for cancer survivors. In cancer patients, late-onset toxicities have been reported with monoclonal antibodies and may involve several body organs or systems. They are defined as an autoimmune illnesses that can happen months to years after treatment discontinuation. Late-onset toxicities have become a focus of clinical care and related research. After cancer therapy is completed, the patient should receive longitudinal follow-up to detect these late effects as early as possible. The current review summarizes the recently reported late-onset toxicities of four classes of monoclonal antibodies (anti-CD52, anti-CTLA-4, anti-PD-1 and anti-CD20) with guidance for the diagnostic tools, appropriate management and treatment.
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Affiliation(s)
- Mai Alalawi
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, 23323, Saudi Arabia
| | - Abrar Saeed Bakr
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Alexandria Vascular Center, Alexandria, 5431118, Egypt
| | - Rowaida Reda
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Woman Health Hospital, Assiut University, Assiut, 2074020, Egypt
| | - Karim Thomas Sadak
- University of Minnesota Masonic Cancer Center, Minneapolis, MN 55455, USA.,University of Minnesota Masonic Children's Hospital, Minneapolis, MN 55455, USA
| | - Mohamad Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Personalized Medication Management Unit, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt
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Lau G, Yu ML, Wong G, Thompson A, Ghazinian H, Hou JL, Piratvisuth T, Jia JD, Mizokami M, Cheng G, Chen GF, Liu ZW, Baatarkhuu O, Cheng AL, Ng WL, Lau P, Mok T, Chang JM, Hamid S, Dokmeci AK, Gani RA, Payawal DA, Chow P, Park JW, Strasser SI, Mohamed R, Win KM, Tawesak T, Sarin SK, Omata M. APASL clinical practice guideline on hepatitis B reactivation related to the use of immunosuppressive therapy. Hepatol Int 2021; 15:1031-1048. [PMID: 34427860 PMCID: PMC8382940 DOI: 10.1007/s12072-021-10239-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM Hepatitis B reactivation related to the use of immunosuppressive therapy remains a major cause of liver-related morbidity and mortality in hepatitis B endemic Asia-Pacific region. This clinical practice guidelines aim to assist clinicians in all disciplines involved in the use of immunosuppressive therapy to effectively prevent and manage hepatitis B reactivation. METHODS All publications related to hepatitis B reactivation with the use of immunosuppressive therapy since 1975 were reviewed. Advice from key opinion leaders in member countries/administrative regions of Asian-Pacific Association for the study of the liver was collected and synchronized. Immunosuppressive therapy was risk-stratified according to its reported rate of hepatitis B reactivation. RECOMMENDATIONS We recommend the necessity to screen all patients for hepatitis B prior to the initiation of immunosuppressive therapy and to administer pre-emptive nucleos(t)ide analogues to those patients with a substantial risk of hepatitis and acute-on-chronic liver failure due to hepatitis B reactivation.
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Affiliation(s)
- George Lau
- Humanity and Health Clinical Trial Center, Humanity and Health Medical Group, Hong Kong SAR, China.
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China.
| | - Ming-Lung Yu
- Hepatitis Center and Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tz-You 1st Rd, Chinese Taipei, Kaohsiung, Taiwan.
| | - Grace Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Hasmik Ghazinian
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - Jin-Lin Hou
- Department of Infectious Diseases, Institute of Hepatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Teerha Piratvisuth
- Department of Medicine, NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, Thailand
| | - Ji-Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Beijing, China
| | - Masashi Mizokami
- Genome Medical Science Project, National Center for Global Health and Medicine, Ichikawa, Japan
| | - Gregory Cheng
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
- Faculty of Health Science, Macau University, Macau SAR, China
| | - Guo-Feng Chen
- Department of Liver Diseases, Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Zhen-Wen Liu
- Research Center for Liver Transplantation, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Oidov Baatarkhuu
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Ann Lii Cheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Woon Leung Ng
- Department of Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Patrick Lau
- Humanity and Health Clinical Trial Center, Humanity and Health Medical Group, Hong Kong SAR, China
| | - Tony Mok
- Department of Clinical Oncology, State Key Laboratory of South China, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jer-Ming Chang
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Saeed Hamid
- Department of Medicine, Aga Khan University and Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - A Kadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Rino A Gani
- Liver Transplantation Team, Ciptomangunkusumo Hospital, Jakarta, Indonesia
| | - Diana A Payawal
- Department of Medicine, Cardinal Santos Medical Center, Mandaluyong, Metro, Manila, Philippines
| | - Pierce Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Joong-Won Park
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rosmawaiti Mohamed
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Khin Maung Win
- Yangon Gastroenterology and Liver Centre, Yangon, Myanmar
| | - Tanwandee Tawesak
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Masao Omata
- Yamanashi Prefectural Central Hospital, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
- The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Management of Hepatitis B Virus Reactivation in Malignant Lymphoma Prior to Immunosuppressive Treatment. J Pers Med 2021; 11:jpm11040267. [PMID: 33918206 PMCID: PMC8066124 DOI: 10.3390/jpm11040267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/25/2022] Open
Abstract
Hepatitis B reactivation is a common complication in lymphoma patients under immunosuppressive treatment with potentially serious and life-threating consequences. In this review, we discuss the basis of chronic Hepatitis B virus (HBV) infection, the definition and risk factors for HBV reactivation. We overview the management of HBV reactivation based on virological status and immunosuppressive regimen risk stratification. We also highlight and update information about the HBV reactivation in lymphoma patients under novel agent treatment, including newer monoclonal antibodies, small molecule inhibitors, and even chimeric antigen receptor T-cell immunotherapy.
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Ruan J, Sun S, Cheng X, Han P, Zhang Y, Sun D. Mitomycin, 5-fluorouracil, leflunomide, and mycophenolic acid directly promote hepatitis B virus replication and expression in vitro. Virol J 2020; 17:89. [PMID: 32611423 PMCID: PMC7331192 DOI: 10.1186/s12985-020-01339-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/07/2020] [Indexed: 12/26/2022] Open
Abstract
Background Reactivation of hepatitis B virus is a common complication that occurs in patients with hepatitis B virus (HBV) infection who have received cytotoxic chemotherapy or immunosuppressive therapy. This clinical phenomenon not only occurs in overt HBV infection patients but also occurs in patients with resolved HBV infection. Previous research has confirmed that epirubicin and dexamethasone can stimulate HBV replication and expression directly rather than indirectly through immunosuppression. Mitomycin and 5-fluorouracil are currently used as cytotoxic chemotherapy drugs for cancer patients. Leflunomide and mycophenolic acid are regarded as immunosuppressants for autoimmune diseases, and numerous clinical studies have reported that these drugs can reactivate HBV replication. In this study, we aimed to investigate whether mitomycin, 5-fluorouracil, leflunomide and mycophenolic acid induce HBV reactivation directly rather than indirectly through immunosuppression. Methods To observe the effect of mitomycin, 5-fluorouracil, leflunomide and mycophenolic acid on HBV replication and expression, we employed HepG2.2.15 and HBV-NLuc-35 cells as a cell model. Next, by native agarose gel electrophoresis (NAGE), quantitative PCR (qPCR), luciferase assay and HBV e antigen (HBeAg) enzyme-linked immunosorbent assay (ELISA) we detected changes in HBV replication and expression induced by these drugs. We also investigated whether lamivudine could inhibit the observed phenotype. SPSS 18.0 software was employed for statistical analysis, One-way ANOVA was used to compare multiple groups. Results Expression of HBV capsids and HBeAg in HepG2.2.15 cells was increased by increasing concentration of mitomycin, 5-fluorouracil, leflunomide, and mycophenolic acid. This phenomenon was also demonstrated in HBV-NLuc-35 cells, and the expression of capsids and luciferase activity increased in the same concentration-dependent manner. Replication levels of intracellular capsid DNA and extracellular HBV DNA in HepG2.2.15 cells gradually increased in a dose-dependent manner. In addition, although epirubicin, mitomycin, 5-fluorouracil, dexamethasone, leflunomide and mycophenolic acid enhanced HBV replication, lamivudine inhibited this process. Conclusion Our study confirmed that mitomycin, 5-fluorouracil, leflunomide and mycophenolic acid directly upregulated HBV replication and expression in vitro. This effect was investigated not only in HepG2.2.15 cells but also in the HBV-NLuc-35 replication system. Moreover, this effect could be prevented by nucleoside analogs, such as lamivudine (LAM). Thus, for patients with HBV infection, prophylactic antiviral therapy is necessary before receiving cytotoxic chemotherapy or immunosuppressive therapy.
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Affiliation(s)
- Jie Ruan
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China.,Department of Infection and Liver Disease, Shaanxi University of Chinese Medicine, Xianyang, 712000, Shaanxi Province, China
| | - Shuo Sun
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China
| | - Xin Cheng
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China
| | - Pengyu Han
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China
| | - Yinge Zhang
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China
| | - Dianxing Sun
- The Liver Disease Diagnosis and Treatment Center of PLA, Bethune International Peace Hospital, Zhongshanxi street, Shijiazhuang, 050082, Hebei Province, China.
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Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:33/3/e00035-19. [PMID: 32522746 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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Koutsianas C, Thomas K, Vassilopoulos D. Reactivation of hepatitis B virus infection in rheumatic diseases: risk and management considerations. Ther Adv Musculoskelet Dis 2020; 12:1759720X20912646. [PMID: 32206094 PMCID: PMC7076579 DOI: 10.1177/1759720x20912646] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
In patients with rheumatic diseases undergoing immunosuppressive treatment, hepatitis B virus reactivation (HBVr) has been long recognized as a major treatment-related adverse event with substantial morbidity and mortality. Because HBVr is easily preventable with appropriate screening and monitoring strategies, and, when indicated, prophylactic antiviral treatment, awareness of this complication is of the utmost importance, especially in the era of biologic treatments. As a condition, it continues to be topical, in view of the emergence of novel classes of immunosuppressive drugs (i.e. Janus kinase inhibitors) acquiring licenses for a variety of rheumatic diseases. The class-specific risk of these agents for HBVr has not yet been determined. Moreover, ambiguity still exists for the management of patients planned to be treated with traditional agents, such as cyclophosphamide and glucocorticoids, particularly in the setting of resolved HBV infection. Clinicians in the field of rheumatic diseases should be tailoring their practice according to the host's profile and treatment-specific risk for HBVr. In this review, the authors attempt to critically review the existing literature and provide practical advice on these issues.
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Affiliation(s)
- Christos Koutsianas
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Thomas
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Ave., Athens, 115 27, Greece
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10
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Cheung CKM, Law MF, Chao DC, Wong SH, Ho R, Chao ACW, Lai JWY, Chan TYT, Tam MTK, Lau SLF, Tam THC. Prevention of hepatitis B virus reactivation in patients with hematological malignancies and resolved hepatitis B virus infection: a systematic review and meta-analysis. J Dig Dis 2020; 21:160-169. [PMID: 32040243 DOI: 10.1111/1751-2980.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/25/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Patients with resolved hepatitis B virus (HBV) infection are at risk of HBV reactivation during treatment for hematological malignancies. We conducted a systematic review and meta-analysis of the data on the efficacy of antiviral prophylaxis for the prevention of HBV reactivation in this group of patients. METHODS We conducted a systemic literature search of PubMed including MEDLINE and EMBASE databases to 31 January 2019 to identify studies published in English comparing antiviral prophylaxis with no prophylaxis for HBV reactivation in patients treated for hematological malignancies. The search terms used were ("occult hepatitis B" OR "resolved hepatitis B") AND ("reactivation") AND ("haematological malignancy" OR "hematological malignancy" OR "chemotherapy" OR "immunotherapy" OR "chemoimmunotherapy" OR "lymphoma" OR "leukemia" OR "transplant"). The primary outcome was the reactivation of HBV infection. Pooled estimates of relative risk (RR) were calculated. RESULTS We identified 13 relevant studies including two randomized controlled trials (RCT), one post hoc analysis from RCT and 10 cohort studies. There was a trend towards a lower rate of HBV reactivation using antiviral prophylaxis, but the difference was not significant (RR 0.57, 95% confidence interval [CI] 0.23-1.40, P = 0.22). When limiting the analysis to the three prospective studies of patients receiving anti-CD20 monoclonal antibodies, we found antiviral prophylaxis was associated with a significantly lower risk of HBV reactivation (RR 0.17, 95% CI 0.06-0.49, P = 0.001). CONCLUSION Antiviral prophylaxis reduced the risk of HBV reactivation in patients receiving anti-CD20 monoclonal antibodies for hematological malignancies but not in a broader group of patients receiving anticancer therapy.
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Affiliation(s)
- Carmen Ka Man Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Man Fai Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - David Chun Chao
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Sunny Hei Wong
- Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rita Ho
- Department of Medicine, North District Hospital, Hong Kong SAR, China
| | - Amelia Chien Wei Chao
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Jennifer Wing Yan Lai
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Ted Yun Tat Chan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Mark Tsz Kin Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Sam Lik Fung Lau
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Tommy Ho Chi Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
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Li Z, Dong Y, Fan M, Yin Y, Zhu J, Li B, Huang W. Analysis of Hepatitis B Virus Reactivation After Radiotherapy in Patients With Hepatocellular Carcinoma Using the Lyman NTCP Model. Technol Cancer Res Treat 2020; 18:1533033819875136. [PMID: 31526114 PMCID: PMC6749789 DOI: 10.1177/1533033819875136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Purpose: To analyze the correlation of hepatitis B virus reactivation with patient-related and treatment-related dose–volume factors and to describe the feasibility of hepatitis B virus reactivation analyzed by a normal tissue complication probability model for patients with hepatocellular carcinoma treated with radiotherapy. Materials and Methods: Ninety patients with hepatitis B virus-related hepatocellular carcinoma treated with radiotherapy were enrolled in this retrospective study and were followed from June 2009 to December 2015. Of the 90 patients, 78 had received conventional fractionation radiotherapy to a mean dose of 39.6 to 50.4 Gy and 12 patients were scheduled to receive hypofractionation. The physical doses were converted into 2 Gy equivalents for analysis. The parameters, TD50 (1), n, and m, of the Lyman-Kutcher-Burman normal tissue complication probability model were derived using maximum likelihood estimation. Bootstrap and leave-one-out were employed to against model overfitting and improve the model stability. Results: Radiation-induced liver diseases were 17.8%, hepatitis B virus reactivation was 22.2%, and hepatitis B virus reactivation-induced hepatitis was 21.1%, respectively. In multivariate analysis, the V5Gy was associated with hepatitis B virus reactivation; TD50 (1), m, and n were 32.3, 0.55, and 0.71 Gy, respectively, for hepatitis B virus reactivation. Bootstrap and leave-one-out results showed that the hepatitis B virus parameter fits were extremely robust. Conclusion: A Lyman-Kutcher-Burman normal tissue complication probability model has been established to predict hepatitis B virus reactivation for patients with hepatocellular carcinoma who received radiotherapy.
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Affiliation(s)
- Zhenjiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yinping Dong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Min Fan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Huang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
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12
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Riveiro-Barciela M, Gubern P, Roade L, Abrisqueta P, Carreras MJ, Farriols A, Bosch F, Esteban R, Buti M. An electronic alert system increases screening for hepatitis B and C and improves management of patients with haematological disorders. Sci Rep 2020; 10:3038. [PMID: 32080253 PMCID: PMC7033156 DOI: 10.1038/s41598-020-59476-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/15/2020] [Indexed: 01/18/2023] Open
Abstract
Treatment of haematological disorders in patients with chronic hepatitis B or resolved infection (anti-HBc-positive) is associated with a risk of hepatitis B reactivation. Moreover, patients with chronic hepatitis C have a higher risk of haematological malignancies than general population. An electronic alert system was developed to promote screening of hepatitis B (HBV) and C (HCV) in patients starting haematological therapies. The system included screening and linkage to care and a request for testing in those without data. From March, 2017 to March, 2018 data from 420 consecutive patients with haematological diseases were included. At first prescription before the alerts, the HCV and HBV screening rate was 60.5%. Following the alerts, an additional 115 were screened, increasing the overall screening rate to 87.9%. Anti-HBc alone was detected in 57, anti-HCV in 13, and HBsAg in 2 patients. Overall, 68% of patients with any viral hepatitis markers were previously not know, and the impact was particularly important for anti-HBc detection (47/57 unknown). Nucleoside analogues were prescribed in 28 (49.1%) anti-HBc-positive and the 2 HBsAg-positive patients. Prospective follow-up with HBV DNA and HBsAg testing showed no cases of HBV reactivation. An estimated 1.2 HBV reactivations were avoided as consequence of the alert system. In summary, an electronic alert system increased viral hepatitis screening in patients receiving haematological treatment and led to improvements in the management of these patients, including avoided HBV reactivation.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Paula Gubern
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Luisa Roade
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Farriols
- Pharmacy Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - María Buti
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
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13
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Kim HK, Kang W, Sinn DH, Lee JH, Kim WS, Kim SJ. Real world data on follicular lymphoma patients treated by rituximab-containing immunochemotherapy and rituximab maintenance. Korean J Intern Med 2020; 35:194-204. [PMID: 30935195 PMCID: PMC6960034 DOI: 10.3904/kjim.2018.196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Real-world data about the treatment outcomes of patients receiving rituximab-containing immunochemotherapy followed by rituximab maintenance are required to understand better the treatment for follicular lymphoma (FL). METHODS A cross-sectional study analyzed FL patients who were treated with R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone) or R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab maintenance. RESULTS Of 139 patients, 85 patients received R-CVP and 54 received R-CHOP. The characteristics did not differ significantly between the groups. Only grade 3 of FL was more common in R-CHOP. The complete response rate did not differ significantly between R-CHOP (50/54, 92.6%) and R-CVP (77/85, 90.6%). The number of disease relapses during rituximab maintenance did not differ significantly between the groups (p = 0.798). Therefore, the comparison of progression-free survival (PFS) showed no significant difference: the 3-year PFS rates for R-CVP and R-CHOP were 77% and 85%, respectively (p = 0.567). Although five of 56 hepatitis B virus (HBV) core antibody (anti-HBc)-positive patients experienced HBV reactivation, all cases of HBV reactivation were identified during regular monitoring for HBV DNA in blood, and were successfully managed with antiviral treatment. CONCLUSION The survival outcomes of FL patients on rituximab maintenance after responding to R-CVP or R-CHOP were similar. Rituximab-containing immunochemotherapy followed by rituximab maintenance can be safely used for anti-HBc-positive patients if HBV DNA titer in blood can be regularly monitored.
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Affiliation(s)
- Hee Kyung Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Wonseok Kang
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
- Correspondence to Seok Jin Kim, M.D. Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-1766 Fax: +82-2-3410-1754 E-mail:
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14
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Nishida T, Matsubara T, Yakushijin T, Inada M. Prediction and clinical implications of HBV reactivation in lymphoma patients with resolved HBV infection: focus on anti-HBs and anti-HBc antibody titers. Hepatol Int 2019; 13:407-415. [PMID: 31290069 DOI: 10.1007/s12072-019-09966-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
Hepatitis B virus (HBV) reactivation (HBV-R) and hepatitis related to HBV-R are well-recognized complications that occur in patients who have undergone cytotoxic chemotherapy or immunosuppressive therapy. The degree of HBV-R in this population varies from self-limited or asymptomatic hepatitis to acute liver failure, which may lead to life-threatening events. However, no established treatment or standard surveillance method exists for monitoring patients to predict the development of HBV-R during or after chemotherapy or immunosuppressive therapy, particularly regarding resolved HBV infection. Prophylactic antiviral agents and regular monitoring of HBV-DNA levels are known to be useful methods for preventing HBV-R; however, these methods require considerable financial resources, and such resources are limited in the endemic areas of HBV infection. Most patients with resolved HBV infection do not develop a hepatitis flare or self-limited HBV-R with only an increase in HBV DNA. However, some patients may develop HBV-R even 1 year or more after the last chemotherapy treatment. Therefore, predicting the development of HBV-R and its timing is difficult, and exploring markers that could help predict whether or when HBV reactivation occurs is necessary. In this review, we address the predictive risk factors for HBV-R in patients with resolved HBV infection, focusing on the ability of anti-HBs and anti-HBc to predict HBV-R. We conclude that the combination of anti-HBc and anti-HBs titers may be a reliable and useful predictor for managing HBV-R.
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Affiliation(s)
- Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan.
| | - Tokuhiro Matsubara
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, 3-1-56, Bandaihigashi, Sumiyoshi-ku, Osaka, 558-0056, Japan
| | - Masami Inada
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
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15
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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2019; 25:93-159. [PMID: 31185710 PMCID: PMC6589848 DOI: 10.3350/cmh.2019.1002] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
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16
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Lau CS, Chia F, Dans L, Harrison A, Hsieh TY, Jain R, Jung SM, Kishimoto M, Kumar A, Leong KP, Li Z, Lichauco JJ, Louthrenoo W, Luo SF, Mu R, Nash P, Ng CT, Suryana B, Wijaya LK, Yeap SS. 2018 update of the APLAR recommendations for treatment of rheumatoid arthritis. Int J Rheum Dis 2019; 22:357-375. [PMID: 30809944 DOI: 10.1111/1756-185x.13513] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022]
Abstract
AIM To update recommendations based on current best evidence concerning the treatment of rheumatoid arthritis (RA), focusing particularly on the role of targeted therapies, to inform clinicians on new developments that will impact their current practice. MATERIALS AND METHODS A search of relevant literature from 2014 to 2016 concerning targeted therapies in RA was conducted. The RA Update Working Group evaluated the evidence and proposed updated recommendations using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, to describe the quality of evidence and strength of recommendations. Recommendations were finalized through consensus using the Delphi technique. RESULTS This update provides 16 RA treatment recommendations based on current best evidence and expert clinical opinion. Recommendations 1-3 deal with the use of conventional synthetic disease-modifying antirheumatic drugs. The next three recommendations (4-6) cover the need for screening and management of infections and comorbid conditions prior to starting targeted therapy, while the following seven recommendations focus on use of these agents. We address choice of targeted therapy, switch, tapering and discontinuation. The last three recommendations elaborate on targeted therapy for RA in special situations such as pregnancy, cancer, and major surgery. CONCLUSION Rheumatoid arthritis remains a significant health problem in the Asia-Pacific region. Patients with RA can benefit from the availability of effective targeted therapies, and these updated recommendations provide clinicians with guidance on their use.
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Affiliation(s)
- Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Faith Chia
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Leonila Dans
- Department of Pediatrics, University of the Philippines Manila, Manila, Philippines.,Department of Clinical Epidemiology, University of the Philippines Manila, Manila, Philippines
| | - Andrew Harrison
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Tsu Yi Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St Luke's International Hospital, St Luke's International University, Tokyo, Japan
| | - Ashok Kumar
- Department of Rheumatology, Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India
| | - Khai Pang Leong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Juan Javier Lichauco
- Rheumatology, Allergy and Immunology Center, St. Luke's Medical Center, Quezon City, Philippines
| | - Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shue Fen Luo
- Department of Rheumatology, Allergy, Immunology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Rong Mu
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Peter Nash
- Department of Medicine, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Chin Teck Ng
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Bagus Suryana
- Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia
| | | | - Swan Sim Yeap
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Malaysia
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17
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Ciccullo A, Ponziani FR, Maiolo E, Pallavicini F, Pompili M. Late reactivation of hepatitis B virus after rituximab-containing chemotherapy for mantle cell lymphoma: a case report. Infection 2018; 47:313-316. [PMID: 30368733 DOI: 10.1007/s15010-018-1242-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatitis B virus (HBV) reactivation is commonly observed in HBsAg-positive hematologic patients undergoing immunosuppressive chemotherapy. Recent guidelines recommend antiviral prophylaxis to be continued for up to 12 months after the discontinuation of the anticancer regimen. CASE PRESENTATION We report a case of a patient who underwent antiviral prophylaxis for 26 months after the discontinuation of a rituximab-containing chemotherapy regimen for a lymphoma and was admitted in the infectious diseases department with a 3-day history of jaundice, itching, and dark urine. After excluding other possible causes of acute liver damage, HBV reactivation was suspected. HBV-DNA was 4497000 IU/mL. Following reintroduction of entecavir, we observed a steady decline of ALT, AST, bilirubin and HBV-DNA serum levels, with a rapid resolution of acute hepatitis and an improvement in clinical conditions; one year after the event of HBV reactivation and beginning of antiviral therapy, the patient was virologically suppressed. DISCUSSION Our study demonstrates that the risk of HBV reactivation in HBsAg-positive patients with undetectable HBV-DNA can occur even after three years from the last administration of rituximab and several months after the withdrawal of prophylactic antiviral therapy in patients with hematological malignancies. This implies that a close monitoring of HBV-related markers including HBV-DNA must continue after the withdrawal of prophylactic NA therapy.
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Affiliation(s)
- Arturo Ciccullo
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Italy.
| | - F R Ponziani
- Internal Medicine, Gastroenterology and Hepatology Unit, Fondazione Agostino Gemelli Hospital, Catholic University, Rome, Italy
| | - E Maiolo
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Pallavicini
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Italy
| | - M Pompili
- Internal Medicine, Gastroenterology and Hepatology Unit, Fondazione Agostino Gemelli Hospital, Catholic University, Rome, Italy
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18
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Incidence and risk factors for reactivation from resolved hepatitis B virus in rheumatoid arthritis patients treated with biological disease‐modifying antirheumatic drugs. Int J Rheum Dis 2018; 22:574-582. [DOI: 10.1111/1756-185x.13401] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/29/2018] [Accepted: 09/08/2018] [Indexed: 02/06/2023]
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19
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HBV reactivation after hematopoietic stem cell transplantation and rituximab-containing chemotherapy: a 12-year experience at a single center. Bone Marrow Transplant 2018; 54:629-631. [PMID: 30287937 DOI: 10.1038/s41409-018-0355-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 12/15/2022]
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20
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Schwaneck EC, Krone M, Kreissl-Kemmer S, Weißbrich B, Weiss J, Tony HP, Gadeholt O, Schmalzing M, Geier A. Management of anti-HBc-positive patients with rheumatic diseases treated with disease-modifying antirheumatic drugs-a single-center analysis of 2054 patients. Clin Rheumatol 2018; 37:2963-2970. [PMID: 30238380 DOI: 10.1007/s10067-018-4295-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 12/14/2022]
Abstract
Hepatitis B virus (HBV) reactivation is a common complication of immunosuppressive treatment in high prevalence countries. Biological disease-modifying antirheumatic drugs (bDMARDs) cause this adverse event more often than conventional immunosuppressants. The incidence of HBV reactivation during treatment for rheumatic diseases in Germany is unclear. Furthermore, it remains open how to treat and monitor patients at risk during immunosuppressive therapy with bDMARDs. We examined 2054 patients from a German tertiary rheumatology center in order to analyze the prevalence of HBc-antibody-positivity and the incidence of HBV reactivation in German rheumatology patients treated with immunosuppressants. Of 1317 patients treated with bDMARDs and 737 conventional synthetic DMARD (csDMARDs) patients between 2008 and 2017, 86 had a history of HBV infection (anti-HBc positive). Only two patients were suffering from chronic infection (HBsAg positive). Three patients were treated pre-emptively with entecavir, and eight patients after HBV DNA reappearance. No liver failure occurred due to HBV reactivation. Compared to anti-HBc-positive patients without reactivation, the reactivation group included more patients exposed to three or more classes of bDMARDs (p = 0.017). The median HBs antibody titer was significantly lower in the reactivation group (15.0 IU/l vs. 293.5 IU/l; p = 0.001). This study shows that bDMARDs and csDMARDs can safely be administered to patients with a history of HBV, provided they are closely monitored. Low titers of anti-HBs antibodies and a history of ≥ 3 classes of immunosuppressants increase the risk of HBV reactivation. These data highlight major differences to high prevalence regions.
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Affiliation(s)
- Eva C Schwaneck
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany.
| | - Manuel Krone
- Institute for Hygiene and Microbiology, University of Wuerzburg, Würzburg, Germany
| | | | - Benedikt Weißbrich
- Institute for Virology and Immunobiology, University of Wuerzburg, Würzburg, Germany
| | - Johannes Weiss
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Ottar Gadeholt
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Marc Schmalzing
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Andreas Geier
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
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21
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Bath RM, Doering BE, Nailor MD, Goodlet KJ. Pharmacotherapy-Induced Hepatitis B Reactivation Among Patients With Prior Functional Cure: A Systematic Review. Ann Pharmacother 2018; 53:294-310. [PMID: 30203666 DOI: 10.1177/1060028018800501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To describe and quantify the incidence and morbidity of hepatitis B reactivation (HBVr) secondary to pharmaceutical agents (eg, rituximab, tumor necrosis factor inhibitors, direct-acting antivirals [DAAs] for hepatitis C) among patients with previously resolved hepatitis B infection. DATA SOURCES The MEDLINE database was searched from inception through July 2018 using the terms hepatitis B + ( reactivation OR [drug or drug class linked to HBVr]). STUDY SELECTION AND DATA EXTRACTION Relevant English-language cohort studies or randomized trials quantifying the incidence of HBVr secondary to pharmacotherapy among patients negative for hepatitis B surface antigen and DNA and positive for hepatitis B core antibody were included. DATA SYNTHESIS Among 2045 articles, 102 met inclusion criteria. Receipt of rituximab was associated with the highest risk of HBVr (for oncological indication: 6.2% rate [225/3601 patients]) and subsequent hepatitis (up to 52.4% of all HBVr cases). Biologic agents for autoimmune disease were uncommonly associated with HBVr (2.4%, 56/2338), with only 4 cases of hepatitis, all attributable to rituximab. Reactivation caused by DAAs was rare (0.3%, 28/8398), with no cases of hepatitis. Relevance to Patient Care/Clinical Practice: This review compares and contrasts the incidence and clinical relevance of HBVr for various pharmacotherapies among patients with functionally cured hepatitis B, with discussion of appropriate risk mitigation strategies. CONCLUSIONS Among patients with prior functional cure of hepatitis B, prophylactic antiviral therapy is recommended with rituximab administration irrespective of indication because of a high risk for HBVr-associated morbidity. Enhanced monitoring alone is reasonable for patients receiving nonrituximab biologics or DAAs.
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Affiliation(s)
- Rhiannon M Bath
- 1 Midwestern University College of Pharmacy, Glendale, AZ, USA
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22
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Cholongitas E, Haidich AB, Apostolidou-Kiouti F, Chalevas P, Papatheodoridis GV. Hepatitis B virus reactivation in HBsAg-negative, anti-HBc-positive patients receiving immunosuppressive therapy: a systematic review. Ann Gastroenterol 2018; 31:480-490. [PMID: 29991894 PMCID: PMC6033767 DOI: 10.20524/aog.2018.0266] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/27/2018] [Indexed: 12/17/2022] Open
Abstract
Background: The optimal management of HBsAg-negative, anti-HBc-positive patients who receive immunosuppression remains unclarified. We systematically reviewed the available data on potential predictors of the risk of hepatitis B virus (HBV) reactivation in such patients. Methods: A literature search identified 55 studies with 3640 HBsAg-negative, anti-HBc-positive patients who received immunosuppressive regimens. Results: HBV reactivation was reported in 236 (6.5%) patients. The pooled HBV reactivation rates did not differ between patients with detectable or undetectable HBV DNA in studies with hematological diseases or regimens containing rituximab, but it was higher in patients with detectable than in those with undetectable HBV DNA who were taking rituximab-free regimens (14% vs. 2.6%; risk ratio [RR] 12.67, 95% CI: 95%CI 2.39-67.04, P=0.003) or had non-hematological diseases, although the latter was not confirmed by sensitivity analysis (RR 8.80, 95%CI 0.71-109.00, P=0.09). The pooled HBV reactivation rates were lower in patients with positive than in those with negative anti-HBs in studies with hematological (7.1% vs. 21.8%; RR 0.29, 95%CI 0.19-0.46, P<0.001) or non-hematological (2.5% vs. 10.7%; RR 0.28, 95%CI 0.11-0.76, P=0.012) diseases, and rituximab-containing (6.6% vs. 19.8%; RR 0.32, 95%CI 0.15-0.69, P=0.003) or rituximab-free (3.3% vs. 9.2%; RR 0.36, 95%CI 0.14-0.96, P=0.042) regimens. Conclusions: The risk of HBV reactivation is high; therefore, anti-HBV prophylaxis should be recommended in HBsAg-negative, anti-HBc-positive patients with hematological diseases and/or rituximab-containing regimens, regardless of HBV DNA and anti-HBs status. In contrast, patients with non-hematological diseases or rituximab-free regimens have a low risk of HBV reactivation and may not require anti-HBV prophylaxis if they have undetectable HBV DNA and positive anti-HBs.
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Affiliation(s)
- Evangelos Cholongitas
- 1st Department of Internal Medicine, Medical School of National & Kapodistrian University, Athens (Evangelos Cholongitas), Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School of Aristotle University of Thessaloniki (Anna-Bettina Haidich, Fani Apostolidou-Kiouti), Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene and Epidemiology, Medical School of Aristotle University of Thessaloniki (Anna-Bettina Haidich, Fani Apostolidou-Kiouti), Greece
| | - Parthenis Chalevas
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki (Parthenis Chalevas), Greece
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital of Athens (George V. Papatheodoridis), Greece
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23
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Yeo D, Hossain I, Lim ST, Farid M, Tao M, Quek R, Tang T, Chan A. Management of hepatitis B reactivation in lymphoma patients on rituximab with past hepatitis B exposure: An observational study. J Oncol Pharm Pract 2018; 25:1042-1052. [PMID: 29554828 DOI: 10.1177/1078155218763039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Currently, a standardized approach to prevent and manage hepatitis B reactivation in lymphoma patients with past hepatitis exposure receiving rituximab in Singapore is lacking. This study is designed to report the current management approach and outcomes associated with hepatitis B reactivation. OBJECTIVES The primary objective was to report 6-, 12-, 24-month cumulative hepatitis B reactivation-related outcomes. Secondary objectives were to report monitoring frequencies of hepatitis B DNA and liver function tests performed in lymphoma patients with resolved hepatitis B receiving rituximab, and anti-viral prophylaxis use. METHODOLOGY This was a single centre, retrospective observational study. Patients with resolved hepatitis B initiated on rituximab from January 2011 to December 2015 were identified and reviewed over a two-year period starting from the date of rituximab initiation. Relevant parameters were obtained from electronic medical records. Hepatitis B reactivation was defined by hepatitis B DNA levels 20 IU/ml (1.30 log/ml) and above. Data were analysed using descriptive statistics. RESULTS Seventy-five patients were retrospectively reviewed over a two-year period. Hepatitis B reactivation was defined as hepatitis B DNA levels ≥20 IU/ml (1.30 log/ml). The 24-month cumulative hepatitis B reactivation rate was 4.0%. The median (interquartile range) number of hepatitis B DNA tests performed during treatment, initial six-month follow-up, and subsequent follow-up were 1.0 (0.0-2.6), 1.0 (0.0-2.0), and 1.0 (0.0-3.1), respectively. CONCLUSION Large variations in hepatitis B reactivation monitoring and management strategies were observed. Further studies are required to develop and determine a standardised protocol that could contribute to safer and more cost-effective care for lymphoma patients with resolved hepatitis B on rituximab.
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Affiliation(s)
- Denise Yeo
- 1 Department of Pharmacy, National University of Singapore, Singapore
| | - Ihtimam Hossain
- 2 Department of Pharmacy, Singapore General Hospital, Singapore
| | - Soon Thye Lim
- 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Mohamad Farid
- 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Miriam Tao
- 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Richard Quek
- 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Tiffany Tang
- 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Alexandre Chan
- 1 Department of Pharmacy, National University of Singapore, Singapore.,4 Department of Pharmacy, National Cancer Centre Singapore, Singapore
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Marrone A, Capoluongo N, D'Amore C, Pisaturo M, Esposito M, Guastafierro S, Siniscalchi I, Macera M, Boemio A, Onorato L, Rinaldi L, Minichini C, Adinolfi LE, Sagnelli E, Mastrullo L, Coppola N. Eighteen-month lamivudine prophylaxis on preventing occult hepatitis B virus infection reactivation in patients with haematological malignancies receiving immunosuppression therapy. J Viral Hepat 2018; 25:198-204. [PMID: 29029365 DOI: 10.1111/jvh.12802] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 08/31/2017] [Indexed: 12/11/2022]
Abstract
This study evaluated the long-term efficacy and safety of an 18-month lamivudine prophylaxis in 68 HBsAg-negative/anti-HBc-positive patients with oncohaematological disease. All 68 consecutive HBsAg-negative/anti-HBc-positive patients with an oncohaematological disease and naïve for chemotherapy observed from April 2008 to December 2012 at 2 Hematology Units in Naples were treated with lamivudine for 18 months after stopping chemotherapy and monitored for HBsAg at months 1 and 3 during chemotherapy and then every 3 months after its discontinuation. During follow-up, 13 (19.1%) of the 68 patients died of complications related to their oncohaematological disease, and 3 (4%) showed a virological HBV reactivation (retroconversion to HBsAg positivity) 1-7 months after the discontinuation of lamivudine prophylaxis (2 treated for chronic lymphocytic leukaemia and one for Waldenstrom's disease); of these, 2 showed a biochemical reactivation. Comparing the demographic and clinical characteristics of the 3 patients with a virological HBV reactivation to the 65 without, the former were older (median age and range: 67 years [75-78] vs. 61 [24-88]; P = .05) and were less frequently treated for B-cell non-Hodgkin lymphoma (B-NHL) (0 vs. 70.7%, P = .03). In conclusion, a 18 months of lamivudine prophylaxis was effective in preventing HBV reactivation in HBsAg-negative/anti-HBc-positive patients treated for B-NHL. However, in patients with chronic and severe immunodepression, such as those with chronic lymphocytic leukaemia and Waldenstrom's disease, prophylaxis should be continued for an indefinite period.
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Affiliation(s)
- A Marrone
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - N Capoluongo
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - C D'Amore
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - M Pisaturo
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - M Esposito
- Hematology Unit, Ascalesi Hospital, Naples, Italy
| | - S Guastafierro
- Hematology Unit, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - I Siniscalchi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - M Macera
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - A Boemio
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - L Onorato
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - L Rinaldi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - C Minichini
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - L E Adinolfi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - E Sagnelli
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - L Mastrullo
- Hematology Unit, Ascalesi Hospital, Naples, Italy
| | - N Coppola
- Department of Mental Health and Public Medicine, University of Campania, Luigi Vanvitelli, Naples, Italy
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25
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Tang Z, Li X, Wu S, Liu Y, Qiao Y, Xu D, Li J. Risk of hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients with undetectable serum HBV DNA after treatment with rituximab for lymphoma: a meta-analysis. Hepatol Int 2017; 11:429-433. [PMID: 28856548 DOI: 10.1007/s12072-017-9817-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 08/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatitis B surface antigen (HBsAg)-negative/hepatitis B core antibody (HBcAb)-positive patients with undetectable serum hepatitis B virus (HBV) DNA have experienced and resolved hepatitis B virus (HBV) infection. Lymphoma patients with resolved HBV infection have high risk of HBV reactivation when treated with robust immunosuppressive agents, but the reported rate varies extensively between different studies. This study aims to estimate the risk of HBV reactivation in HBsAg-negative/HBcAb-positive patients receiving rituximab-containing chemotherapy for lymphoma. METHODS Databases were searched for papers published in English until 8 August 2016. The pooled risk of HBV reactivation was estimated using a random-effects model. RESULTS Data from 15 studies were retrieved, including a total of 1312 HBsAg-negative/HBcAb-positive lymphoma patients treated with rituximab-containing chemotherapy. The results revealed HBV reactivation rate of 9.0 % [95 % confidence interval (CI) 0.05-0.15]. In subgroup analysis, the reactivation rates for prospective and retrospective studies were 17 % (I 2 = 87.3 %; 95 % 0.08-0.39, p < 0.001) and 7 % (I 2 = 43.1 %; 95 % CI 0.05-0.11, p = 0.07), respectively. CONCLUSIONS This meta-analysis confirms a measurable and potentially substantial risk of HBV reactivation in HBsAg-negative/HBcAb-positive patients with rituximab treatment for lymphoma. Prophylactic use of anti-HBV agents should be seriously considered for such patients.
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Affiliation(s)
- Zilin Tang
- Clinical Medical School, Guilin Medical University, Guilin, 541004, Guangxi Zhuang Autonomous Region, China
| | - Xiaodong Li
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, 100039, China
| | - Shunquan Wu
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, 100039, China
| | - Yan Liu
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, 100039, China
| | - Yan Qiao
- Clinical Medical School, Guilin Medical University, Guilin, 541004, Guangxi Zhuang Autonomous Region, China
| | - Dongping Xu
- Clinical Medical School, Guilin Medical University, Guilin, 541004, Guangxi Zhuang Autonomous Region, China. .,Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, 100039, China.
| | - Jin Li
- Clinical Medical School, Guilin Medical University, Guilin, 541004, Guangxi Zhuang Autonomous Region, China. .,Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, 100039, China.
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26
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Cerva C, Maffongelli G, Svicher V, Salpini R, Colagrossi L, Battisti A, Mariotti B, Cerretti R, Cudillo L, Sarmati L. Hepatitis B reactivation characterized by HBsAg negativity and anti-HbsAg antibodies persistence in haematopoietic stem cell transplanted patient after lamivudine withdrawal. BMC Infect Dis 2017; 17:566. [PMID: 28806922 PMCID: PMC5557326 DOI: 10.1186/s12879-017-2672-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/07/2017] [Indexed: 12/11/2022] Open
Abstract
Background HBV reactivation is associated with high mortality rates in hematopoietic stem cell transplantation (HSCT) and prophylactic lamivudine (LMV) treatment is suggested to prevent this phenomenon. However, the duration of LMV treatment in HSCT patients is not fully defined and the time of immune recovery is considered the best parameter for a drug to be safely interrupted. In patients undergoing allogeneic HSCT, the time of immune recovery is not easy to define and may take years after transplantation and prolonged LMV treatments, which can lead to drug-resistant viral strains. Case presentation An anti-HBc-positive hematological patient who was undergoing prolonged immunosuppression and who experienced HBV reactivation 3 months after the suspension of a prolonged LMV prophylaxis is described. HBV-DNA matching an atypical serological profile characterized by HbsAg negativity and anti-HBs positivity was detected in the patient. The genotypic analysis of the HBV strain identified T127P, F170FL and S204R mutations of HbsAg, which can hinder HBsAg recognition in a diagnostic assay. Conclusions HBV reactivation in the HSCT host can be sustained by HBsAg viral variants with characteristics of altered immunogenicity that cannot be detected by usual laboratory tests. This clinical case description suggests the importance of screening for serum HBV-DNA levels in the diagnosis of HBV reactivation and monitoring HBV-DNA after prophylaxis suspension, particularly in HSCT subjects who have undergone prolonged periods of LMV treatment.
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Affiliation(s)
- C Cerva
- Clinical Infectious Disease, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - G Maffongelli
- Clinical Infectious Disease, Department of Systems Medicine, Tor Vergata University, Rome, Italy.
| | - V Svicher
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - R Salpini
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - L Colagrossi
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - A Battisti
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - B Mariotti
- Department of Hematology, Stem Cell Transplant Unit, Tor Vergata University, Rome, Italy
| | - R Cerretti
- Department of Hematology, Stem Cell Transplant Unit, Tor Vergata University, Rome, Italy
| | - L Cudillo
- Department of Hematology, Stem Cell Transplant Unit, Tor Vergata University, Rome, Italy
| | - L Sarmati
- Clinical Infectious Disease, Department of Systems Medicine, Tor Vergata University, Rome, Italy
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Paul S, Dickstein A, Saxena A, Terrin N, Viveiros K, Balk EM, Wong JB. Role of surface antibody in hepatitis B reactivation in patients with resolved infection and hematologic malignancy: A meta-analysis. Hepatology 2017; 66:379-388. [PMID: 28128861 PMCID: PMC6485929 DOI: 10.1002/hep.29082] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/21/2016] [Accepted: 12/17/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Patients with resolved hepatitis B virus (HBV) infection who are treated for hematological malignancies remain at risk for HBV reactivation. Because of conflicting studies about whether the antibody to hepatitis B surface antigen (anti-HBs) protects against reactivation in patients with resolved infection (hepatitis B surface antigen negative) receiving chemotherapy for hematological malignancies, we conducted a meta-analysis to determine if anti-HBs reduces HBV reactivation risk. We sought English-language studies through March 1, 2016, in Medline and other sources that examined reactivation in patients with resolved HBV infection receiving chemotherapy for hematologic malignancies. The absolute risks and odds ratio (OR) of reactivation with versus without anti-HBs were estimated in random-effects model meta-analyses. In 20 studies involving 1,672 patients not receiving antiviral prophylaxis, the reactivation risk was 14% (95% confidence interval [CI] 9.4%-19%) in 388 patients who had antibodies to hepatitis B core antigen only versus 5.0% (95% CI 3.0%-7.0%) in 1,284 patients who also had anti-HBs. Anti-HBs reduced reactivation risk with a pooled OR of 0.21 (95% CI 0.14-0.32) versus patients with antibody to hepatitis B core antigen only. Similar results were found when limiting the analysis to rituximab chemotherapy (OR = 0.19, 95% CI 0.11-0.32) and lymphoma (OR = 0.18, 95% CI 0.11-0.28). CONCLUSION In patients with resolved HBV receiving chemotherapy for hematological malignancies without antiviral prophylaxis, anti-HBs positivity is associated with a decreased risk of reactivation; HBV screening in this patient population should include the routine use of anti-HBs, and those who are anti-HBs-negative should receive antiviral prophylaxis. Future studies should examine the effect of anti-HBs serum titers, the potential role for booster vaccinations, and antiviral prophylaxis prior to chemotherapy in this patient population. (Hepatology 2017;66:379-388).
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Affiliation(s)
- Sonali Paul
- Section of Gastroenterology, Center for Liver Diseases; The University of Chicago Medicine, Chicago, IL 60637
| | - Aaron Dickstein
- Division of Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA 02111
| | - Akriti Saxena
- Division of Gastroenterology, Boston Medical Center, Boston, MA 02118
| | - Norma Terrin
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, and Biostatistics, Epidemiology and Research Design (BERD) Center, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA 02111
| | - Kathleen Viveiros
- Division of Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA 02111
| | - Ethan M. Balk
- Brown Center for Evidence-Based Medicine, Brown University School of Public Health, Providence, RI 02912
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, MA 02111
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28
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Chronic Hepatitis B, C, and D. Microbiol Spectr 2017; 4. [PMID: 27726758 DOI: 10.1128/microbiolspec.dmih2-0025-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic hepatitis B, C, and D virus infections contribute significantly to the morbidity and mortality of immunocompromised individuals. To contextualize discussion of these infections in immunocompromised patients, this paper provides an overview of aspects of infection in normal hosts. It then describes differences in disease, diagnostic testing, and therapeutic management observed in immunocompromised patients.
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29
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Prevalence and clinical outcomes of hepatitis B virus infection in patients with aplastic anemia. Int J Hematol 2017; 106:484-489. [PMID: 28612279 DOI: 10.1007/s12185-017-2276-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 12/22/2022]
Abstract
The association of HBV infection with other hematopoietic diseases has been discussed previously. However, the clinical significance and clinical outcomes of HBV infection in AA patients have not been clarified. In this study, we sought to investigate the prevalence and related events of HBV in patients with AA who received immunosuppressive therapy. We retrospectively analyzed 245 patients with acquired AA. The HBsAg positivity rate was 14.69% in this group of AA patients. No significant difference was observed in the severity of AA patients with HBV infection and in those without (P = 0.6358). HBV reactivation occurred in 4.76% of HBsAg-positive patients who received ATG/ALG + CsA treatment without anti-viral prophylaxis. HBV-infected patients who received CsA alone did not develop reactivation. Patients with HBV reactivation showed favorable clinical outcomes, with no HBV-related deaths. There was no significant difference in overall probability of survival in patients with different HBV infection status (P = 0.8617). Given the low rate of reactivation and favorable outcomes after reactivation in AA patients, close monitoring of HBV DNA, hepatic function and patient immune status may be a more effective approach than routine prophylaxis for AA patients with HBV infection undergoing ATG/ALG + CsA treatment. Further studies are warranted to clarify the optimal time to initiate anti-viral treatment.
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30
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Guarino M, Picardi M, Vitiello A, Pugliese N, Rea M, Cossiga V, Pane F, Caporaso N, Morisco F. Viral Outcome in Patients with Occult HBV Infection or HCV-Ab Positivity Treated for Lymphoma. Ann Hepatol 2017. [DOI: 10.5604/16652681.1231579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
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Merli M, Rattotti S, Gotti M, Arcaini L. Antiviral therapies for managing viral hepatitis in lymphoma patients. Expert Opin Pharmacother 2017; 18:363-376. [PMID: 28140702 DOI: 10.1080/14656566.2017.1288718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION In patients with lymphoma the detection of positive hepatitis B or C viruses (HBV and HCV) serology involves crucial therapeutic consequences. In HBV-infected patients the serological profile of active (HBsAg-positive) or resolved (HBsAg-negative/anti-HBcAb-positive) infection is associated to differential risk of viral reactivation during rituximab-based therapy and require appropriate strategies of monitoring and of antiviral prophylaxis. In HCV-associated NHL patients consolidated data demonstrated that interferon (IFN)-based antiviral therapy (AT) is able to induce lymphoma regression strictly related to viral eradication, while preliminary data of the new direct-acting antivirals (DAAs) are very promising. Areas covered: This review summarizes current evidences about HBV reactivation risk in patients undergoing rituximab-based treatments and appropriate options of antiviral prophylaxis with lamivudine, entecavir or tenofovir, as well as pre-emptive strategy in HBsAg-negative/HBcAb-positive patients. Moreover previous experiences with IFN-based AT as well as recent studies with DAAs in HCV-associated indolent lymphomas or diffuse large B-cell lymphoma (DLBCL) are reviewed. Expert opinion: Entecavir or tenofovir prophylaxis is recommended for HBsAg-positive patients, while universal prophilaxis with lamivudine may be preferred in HBsAg-negative/anti-HBc-positive patients. In asymptomatic patients with HCV-associated indolent lymphoma DAA-based AT should be used as first-line option, while in DLBCL its deliver after immunochemotherapy-induced complete remission is suggested.
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Affiliation(s)
- Michele Merli
- a Division of Hematology , University Hospital Ospedale di Circolo & Fondazione Macchi, University of Insubria , Varese , Italy
| | - Sara Rattotti
- b Department of Hematology-Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Manuel Gotti
- b Department of Hematology-Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Luca Arcaini
- b Department of Hematology-Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy.,c Department of Molecular Medicine , University of Pavia , Pavia , Italy
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Chen LF, Mo YQ, Jing J, Ma JD, Zheng DH, Dai L. Short-course tocilizumab increases risk of hepatitis B virus reactivation in patients with rheumatoid arthritis: a prospective clinical observation. Int J Rheum Dis 2017; 20:859-869. [PMID: 28160426 DOI: 10.1111/1756-185x.13010] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM To investigate the impact of short-course tocilizumab (TCZ) on hepatitis B virus (HBV) reactivation in rheumatoid arthritis (RA) patients. METHODS RA patients with moderate to high disease activity, with at least one feature of poor prognosis and inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) were recruited. Three consecutive doses of intravenous TCZ were given combined with csDMARDs. Liver function and HBV infection status were evaluated at baseline, weeks 4, 8 and 12. RESULTS Sixty-three RA patients who were qualified for statistics were classified as chronic HBV infection (n = 7), resolved HBV infection (n = 41) and non-HBV infection (n = 15). Three patients with chronic HBV infection and without antiviral prophylaxis developed HBV reactivation after 1-3 doses of TCZ. They were asymptomatic of hepatitis B with normal aminotransferases and the HBV-DNA of three patients with HBV reactivation became undetectable after therapeutic antiviral therapy. No HBV reactivation developed in patients with resolved HBV infection. Aminotransferases elevated in 22% of all patients, but became elevated ≥ 2-fold of normal range in only two patients: one was treated with adefovir before TCZ for active hepatitis B and the other had resolved HBV infection, with aminotransferases returning to normal 4 weeks later. Thirty-two patients with resolved HBV infection had positive anti-HBs (≥ 10 IU/L) which is a protective antibody. The anti-HBs titer reduced significantly at week 4 and week 8 after the first dose of TCZ compared to baseline (P < 0.05) and even reduced to negative in six (19%). The anti-HBs did not return to positive in three patients during follow-up of 12-36 weeks. CONCLUSIONS This prospective clinical observation preliminarily indicated three-dose TCZ combined with csDMARDs might increase the risk of HBV reactivation in RA patients with chronic HBV infection, but in this study patients remained asymptomatic and had a benign outcome after antiviral treatment. To identify the exact risk of TCZ on HBV infection and the prognosis of TCZ-related HBV reactivation, further studies with larger sample sizes and fewer confounding factors are needed.
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Affiliation(s)
- Le-Feng Chen
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying-Qian Mo
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jun Jing
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian-Da Ma
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Dong-Hui Zheng
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lie Dai
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Yağcı M, Suyanı E, Kızıl Çakar M. The Impact of Chemotherapy on Hepatitis B Antibody Titer in Patients with Hematological Malignancies. Turk J Haematol 2017; 32:251-6. [PMID: 26376591 PMCID: PMC4563201 DOI: 10.4274/tjh.2013.0342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective: To investigate the influence of chemotherapy (CT) on HBsAb titer in patients receiving CT due to hematological malignancy. Materials and Methods: The data of 75 patients who received CT with the diagnosis of various hematological malignancies and who had serum HBsAb levels measured prior to and after the cessation of CT were evaluated retrospectively. Results: The median age of the patients was 52 years (range: 16-78) with 49 (65%) males and 26 (35%) females. Median HBsAb titer decreased significantly after CT compared to the pre-CT median HBsAb titer [68 (range: 0-1000) vs. 100 (range: 6.2-1000)] (p=0.001). In subgroup analysis, median HBsAb titer decreased significantly after CT in acute leukemia patients [110 (range: 6.2-1000) vs. 67.8 (range: 0-1000)] (p=0.003) and in patients receiving intensive CT [97.2 (range: 6.2-1000) vs. 71 (range: 0-1000)] (p=0.036). The decrease in median HBsAb titer was significant in male patients (p<0.001). HBsAb became negative after CT in 9 patients who were HBcAb-negative and had lower pre-CT HBsAb levels. Conclusion: HBsAb decreased after CT, especially in acute leukemia and male patients, and in patients receiving intensive CT.
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Affiliation(s)
- Münci Yağcı
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey Phone: +90 312 202 63 17 E-mail:
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Koutsianas C, Thomas K, Vassilopoulos D. Hepatitis B Reactivation in Rheumatic Diseases: Screening and Prevention. Rheum Dis Clin North Am 2016; 43:133-149. [PMID: 27890170 DOI: 10.1016/j.rdc.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) reactivation (HBVr) has been an increasingly recognized and appreciated risk of immunosuppressive therapies in rheumatic patients. Despite its potential for significant morbidity and mortality, HBVr is a fully preventable complication with appropriate pretreatment screening and close monitoring of susceptible patients. Better knowledge of the risk for HBVr with the different antirheumatic agents and the establishment of the new-generation oral antivirals in clinical practice has greatly improved the design of screening and therapeutic algorithms. In this review, all available data regarding HBVr in rheumatic patients are critically presented and a screening and therapeutic algorithm is proposed.
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Affiliation(s)
- Christos Koutsianas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece; Department of Rheumatology, The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley DY1 2HQ, West Midlands, UK
| | - Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece.
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Sorà F, Ponziani FR, Laurenti L, Chiusolo P, Autore F, Gasbarrini A, Sica S, Pompili M. Low risk of hepatitis B virus reactivation in patients with resolved infection and chronic myeloid leukemia treated with tyrosine kinase inhibitors. Leuk Lymphoma 2016; 58:993-995. [DOI: 10.1080/10428194.2016.1219906] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Law MF, Ho R, Cheung CKM, Tam LHP, Ma K, So KCY, Ip B, So J, Lai J, Ng J, Tam THC. Prevention and management of hepatitis B virus reactivation in patients with hematological malignancies treated with anticancer therapy. World J Gastroenterol 2016; 22:6484-6500. [PMID: 27605883 PMCID: PMC4968128 DOI: 10.3748/wjg.v22.i28.6484] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/24/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatitis due to hepatitis B virus (HBV) reactivation can be severe and potentially fatal, but is preventable. HBV reactivation is most commonly reported in patients receiving cancer chemotherapy, especially rituximab-containing therapy for hematological malignancies and those receiving stem cell transplantation. All patients with hematological malignancies receiving anticancer therapy should be screened for active or resolved HBV infection by blood tests for hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc). Patients found to be positive for HBsAg should be given prophylactic antiviral therapy to prevent HBV reactivation. For patients with resolved HBV infection, no standard strategy has yet been established to prevent HBV reactivation. There are usually two options. One is pre-emptive therapy guided by serial HBV DNA monitoring, whereby antiviral therapy is given as soon as HBV DNA becomes detectable. However, there is little evidence regarding the optimal interval and period of monitoring. An alternative approach is prophylactic antiviral therapy, especially for patients receiving high-risk therapy such as rituximab, newer generation of anti-CD20 monoclonal antibody, obinutuzumab or hematopoietic stem cell transplantation. This strategy may effectively prevent HBV reactivation and avoid the inconvenience of repeated HBV DNA monitoring. Entecavir or tenofovir are preferred over lamivudine as prophylactic therapy. Although there is no well-defined guideline on the optimal duration of prophylactic therapy, there is growing evidence to recommend continuing prophylactic antiviral therapy for at least 12 mo after cessation of chemotherapy, and even longer for those who receive rituximab or who had high serum HBV DNA levels before the start of immunosuppressive therapy. Many novel agents have recently become available for the treatment of hematological malignancies, and these agents may be associated with HBV reactivation. Although there is currently limited evidence to guide the optimal preventive measures, we recommend antiviral prophylaxis in HBsAg-positive patients receiving novel treatments, especially the Bruton tyrosine kinase inhibitors and the phosphatidylinositol 3-kinase inhibitors, which are B-cell receptor signaling modulators and reduce proliferation of malignant B-cells. Further studies are needed to clarify the risk of HBV reactivation with these agents and the best prophylactic strategy in the era of targeted therapy for hematological malignancies.
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Persistent risk of HBV reactivation despite extensive lamivudine prophylaxis in haematopoietic stem cell transplant recipients who are anti-HBc-positive or HBV-negative recipients with an anti-HBc-positive donor. Clin Microbiol Infect 2016; 22:946.e1-946.e8. [PMID: 27475741 DOI: 10.1016/j.cmi.2016.07.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 07/08/2016] [Accepted: 07/16/2016] [Indexed: 02/08/2023]
Abstract
The overall rate of hepatitis B virus (HBV) reactivation was evaluated in a population of 373 haematological stem cell transplant (HSCT) patients treated with lamivudine (LMV) if they were anti-HBc-positive/HBV-DNA-negative recipients or if they were HBV-negative recipients with an anti-HBc-positive donor. The incidence of HBV reactivation was calculated in two groups of autologous (auto) or allogeneic (allo) HSCT patients who were stratified according to their HBV serostatus. The former group included 57 cases: 10 auto-HSCT and 27 allo-HSCT anti-HBc-positive recipients, two auto-HSCT and three allo-HSCT inactive carriers, and 15 allo-HSCT recipients with an anti-HBc-positive donor. Forty-seven (82.4%) patients in this group received LMV prophylaxis (the median (interquartile range, IQR) of LMV treatment was 30 (20-38) months). The second group consisted of 320 anti-HBc-negative auto-HSCT and allo-HSCT recipients with anti-HBc-negative donors. None of these patients received any prophylaxis. Two patients in the first group and two in the second group experienced reactivation of HBV infection, with an incidence of 3.5% (95% CI 0.4-12.1%) and 0.6% (95% CI 0.1-2.2%), respectively. Only one out of four reactivated patients was LMV-treated. The cumulative probability of HBV reactivation at 6 years from HSCT was 15.8% (95% CI 15.2-16.4%). Three of four viral isolates obtained from the HBV-reactivated patients harboured mutations in the immune-active HBsAg-region. In a HSCT population carefully evaluated for HBV prophylaxis, a risk of HBV reactivation persisted in the group of patients who were not LMV-treated. Only one LMV-treated patient experienced reactivation of HBV with a resistant HBV isolate.
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Han JW, Yang H, Lee HL, Bae SH, Choi JY, Lee JW, Kim HJ, Lee S, Cho SG, Min CK, Kim DW, Yoon SK. Risk factors and outcomes of hepatitis B virus reactivation in hepatitis B surface antigen negative patients with hematological malignancies. Hepatol Res 2016; 46:657-68. [PMID: 26445232 DOI: 10.1111/hepr.12603] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 12/25/2022]
Abstract
AIM Current guidelines recommend all patients scheduled to receive chemotherapy should be screened for hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B virus core antigen (anti-HBc) status. However, still, more research is needed to identify the risk factors for hepatitis B virus (HBV) reactivation. We retrospectively investigated the incidence, risk factors and outcome of HBV reactivation in HBsAg negative patients with hematological malignancies. METHODS Seven hundred and thirty-eight HBsAg negative patients with hematological malignancies were included in the study. HBV reactivation was defined as reverse seroconversion of HBsAg (HBsAg reappearance). Risk factors, cumulative incidence and overall survival of HBV reactivation were analyzed. RESULTS Reactivation occurred in 23 of the 738 (3.1%) enrolled patients. As expected, the reactivation rate of the anti-HBc positive group was significantly higher than that of the anti-HBc negative group (5.4% vs 0.8%). Multivariate analysis indicated that loss of antibody to the hepatitis B surface antigen (anti-HBs) was an independent risk factor. Patients with acute lymphoblastic leukemia and multiple myeloma showed significantly higher reactivation rate than those with other diseases. The cumulative incidence of HBV reactivation after starting chemotherapy in the anti-HBc positive subgroup was 0.3% at 1 year, 1.7% at 2 years and 10.5% at 3 years. CONCLUSION Close monitoring of HBV markers, including anti-HBs, should be performed for longer than 24 months. Further study is needed to establish a strategy to prevent HBV reactivation after chemotherapy in HBsAg negative patients with hematological malignancies.
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Affiliation(s)
- Ji Won Han
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Hyun Yang
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Hae Lim Lee
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Si Hyun Bae
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Jong Young Choi
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Jong-Wook Lee
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Hee Je Kim
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Seok Lee
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Seok Goo Cho
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Chang Ki Min
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Dong Wook Kim
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
| | - Seung Kew Yoon
- Division of Hepatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, Korea
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Sagnelli C, Macera M, Pisaturo M, Zampino R, Coppola M, Sagnelli E. Occult HBV infection in the oncohematological setting. Infection 2016; 44:575-82. [PMID: 27076347 DOI: 10.1007/s15010-016-0891-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/07/2016] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Occult hepatitis B infection (OBI), a virological condition characterized by a low release of Hepatitis B Virus (HBV) from liver cells and low HBV-DNA levels in serum and/or liver tissue of HBsAg-negative subjects, may reactivate in oncohematological patients undergoing immunosuppression by aggressive chemotherapy or hematopoietic stem cell transplantation. The entity of OBI reactivation varies from an increase in HBV replication without liver damage to an active HBV replication followed by liver cell necrosis, frequently severe and in some cases life threatening. Because of a possible severe outcome associated with OBI reactivation (hepatic failure or death due to the discontinuation of chemotherapy), prophylaxis with anti-HBV nucleot(s)ide analogues is recommended in relation to the foreseeable degree of immunosuppression. MATERIALS AND METHODS This review article focuses on the clinical impact of OBI in the oncohematological setting and is addressed to all health care workers having in care oncohematological patients or involved in the treatment of HBV infection and OBI prophylaxis. CONCLUSION International guidelines have indicated lamivudine prophylaxis in hematopoietic stem cell transplantation and when high-dose corticosteroids or anti-CD20 or anti-CD52 monoclonal antibodies are used. Entecavir or tenofovir should replace lamivudine for patients with advanced liver diseases for whom reactivation of OBI may be life threatening. When anti-CD20 or anti-CD52 sparing schedules or other non-aggressive chemotherapies are used, monitoring may be indicated, but very early treatment with highly effective antiviral drugs (entecavir or tenofovir) should be administered once a reactivation of OBI has occurred.
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Affiliation(s)
- C Sagnelli
- Department of Clinical and Experimental Medicine and Surgery "F. Magrassi e A. Lanzara", Second University of Naples, 80131, Naples, Italy
| | - M Macera
- Azienda Ospedaliera Universitaria-Second University of Naples, 80131, Naples, Italy
| | - M Pisaturo
- Division of Infectious Diseases, AORN Sant'Anna e San Sebastiano di Caserta, 81100, Caserta, Italy
| | - R Zampino
- Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, 80131, Naples, Italy
| | - M Coppola
- Section of Infectious Diseases, Department of Mental Health and Public Medicine, Second University of Naples, Via: L. Armanni 5, 80131, Naples, Italy
| | - E Sagnelli
- Section of Infectious Diseases, Department of Mental Health and Public Medicine, Second University of Naples, Via: L. Armanni 5, 80131, Naples, Italy.
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Yilmaz B, Erdem D, Teker F, Goren I, Yildirim B, Kut E, Sarikaya D, Atay MH, Yucel I. The effect of anticancer therapy on anti-hepatitis B antibody titres in patients with haematological malignancies and solid tumours. J Int Med Res 2016; 44:627-38. [PMID: 27048386 PMCID: PMC5536710 DOI: 10.1177/0300060516638992] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
Objective To investigate the effect of immunosuppressive anticancer therapy on titre levels of anti-hepatitis B surface antibodies (anti-HBs) in hepatitis B surface antigen (HBsAg) negative and anti-HBs positive patients with haematological malignancies or solid tumours. Methods This retrospective study reviewed the medical records of patients with haematological malignancies or solid tumours. Pretreatment HBsAg negative and anti-HBs positive patients were included in the analysis. Anti-hepatitis B core antibody status was used to evaluate vaccinated patients and those with resolved HBV infections. Results The medical records of 237 patients were reviewed retrospectively. The median anti-HBs titre decreased significantly after anticancer therapy compared with the pretreatment median anti-HBs titre in all patients (71 mIU/ml versus 57 mIU/ml). Anti-HBs titre decreased significantly in patients with haematological malignancies (70 mIU/m versus 37 mIU/ml) and in patients administered rituximab-based chemotherapy (67 mIU/ml versus 33 mIU/ml) following chemotherapy, whereas there was no significant change in patients with solid tumours. After chemotherapy, patients with low pretreatment anti-HBs titres (<100 mIU/ml) were more likely to become seronegative (<10 mIU/ml). Conclusion High levels of anti-HBs may have a protective effect against the reactivation of HBV especially in patients with haematological malignancies who received immunosuppressive anticancer therapy.
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Affiliation(s)
- Bahiddin Yilmaz
- Department of Medical Oncology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Dilek Erdem
- Division of Medical Oncology, Medical Park Hospital, Samsun, Turkey
| | - Fatih Teker
- Division of Medical Oncology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Ibrahim Goren
- Department of Gastroenterology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Beytullah Yildirim
- Department of Gastroenterology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Engin Kut
- Department of Medical Oncology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Derya Sarikaya
- Department of Medical Oncology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Memis H Atay
- Department of Haematology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Idris Yucel
- Department of Medical Oncology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Tavakolpour S, Alavian SM, Sali S. Hepatitis B Reactivation During Immunosuppressive Therapy or Cancer Chemotherapy, Management, and Prevention: A Comprehensive Review-Screened. HEPATITIS MONTHLY 2016; 16:e35810. [PMID: 27257429 PMCID: PMC4887960 DOI: 10.5812/hepatmon.35810] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 01/17/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
CONTEXT Due to the close relationship between the immune system and the hepatitis B virus (HBV) replication, it is essential to monitor patients with current or past HBV infection under any type of immunosuppression. Cancer chemotherapy, immunosuppressive therapies in autoimmune diseases, and immunosuppression in solid organ and stem cell transplant recipients are the major reasons for hepatitis B virus reactivation (HBVr). In this review, the challenges associated with HBVr are discussed according to the latest studies and guidelines. We also discuss the role of treatments with different risks, including anti-CD20 agents, tumor necrosis factor-alpha (TNF-α) inhibitors, and other common immunosuppressive agents in various conditions. EVIDENCE ACQUISITION Through an electronic search of the PubMed, Google Scholar, and Scopus databases, we selected the studies associated with HBVr in different conditions. The most recent recommendations were collected in order to reach a consensus on how to manage patients at risk of HBVr. RESULTS It was found that the positive hepatitis B surface antigen (HBsAg), the high baseline HBV DNA level, the positive hepatitis B virus e antigen (HBeAg), and an absent or low hepatitis B surface antibody (HBsAb) titer prior to starting treatment are the most important viral risk factors. Furthermore, rituximab, anthracycline, and different types of TNF-α inhibitors were identified as the high-risk therapies. By analyzing the efficiency of prophylaxis on the prevention of HBVr, it was concluded that those with a high risk of antiviral resistance should not be used in long-term immunosuppressants. Receiving HBV antiviral agents at the commencement of immunosuppressant therapy or chemotherapy was demonstrated to be effective in decreasing the risk of HBVr. Prophylaxis could also be initiated before the start of therapy. For most immune suppressive regimes, antiviral therapy should be kept up for at least 6 months after the cessation of immunosuppressive drugs. However, the optimal time of prophylaxis keeping should be increased in cases associated with rituximab or hematopoietic stem cell transplants. According to the latest studies and guidelines from different bodies, recommendations regarding screening, monitoring, and management of HBVr are outlined. CONCLUSIONS Identification of patients at the risk of HBVr before immunosuppressive therapy is an undeniable part of treatment. Starting the antiviral therapy, based on the type of immunosuppressive drugs and the underlying disease, could lead to better management of disease.
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Affiliation(s)
- Soheil Tavakolpour
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqyiatallah University of Medical Sciences, Tehran, IR Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqyiatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Seyed Moayed Alavian, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqyiatallah University of Medical Sciences, Tehran, IR Iran. Tel/Fax: +98-2181264070, E-mail:
| | - Shahnaz Sali
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Varisco V, Viganò M, Batticciotto A, Lampertico P, Marchesoni A, Gibertini P, Pellerito R, Rovera G, Caporali R, Todoerti M, Covelli M, Notarnicola A, Atzeni F, Sarzi-Puttini P. Low Risk of Hepatitis B Virus Reactivation in HBsAg-negative/Anti-HBc-positive Carriers Receiving Rituximab for Rheumatoid Arthritis: A Retrospective Multicenter Italian Study. J Rheumatol 2016; 43:869-74. [PMID: 26879359 DOI: 10.3899/jrheum.151105] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Patients with resolved hepatitis B virus (HBV) infection, i.e., hepatitis B surface antigen (HBsAg)-negative/antihepatitis B core antigen (anti-HBc)-positive, undergoing rituximab (RTX)-based chemotherapy for hematological malignancies without anti-HBV prophylaxis are at risk of HBV reactivation, but the risk in such patients receiving RTX for rheumatological disorders is not clear. We evaluated this risk in HBsAg-negative/anti-HBc-positive patients with rheumatoid arthritis (RA) undergoing RTX without prophylaxis. METHODS Thirty-three HBsAg-negative/anti-HBc-positive outpatients with RA with undetectable HBV DNA by sensitive PCR assay [73% women, median age 60 years, 85% with HBsAg antibodies (anti-HBs), 37% with antihepatitis B envelope antigen] received a median of 3 cycles of RTX (range 1-8) over 34 months (range 0-80) combined with disease-modifying antirheumatic drugs (DMARD) without prophylaxis. All underwent clinical and laboratory monitoring during and after RTX administration, including serum HBsAg and HBV DNA measurements every 6 months or whenever clinically indicated. RESULTS None of the patients seroreverted to HBsAg during RTX treatment, but 6/28 (21%) showed a > 50% decrease in protective anti-HBs levels, including 2 who became anti-HBs-negative. One patient (3%) who became HBV DNA-positive (44 IU/ml) after 6 months of RTX treatment was effectively rescued with lamivudine before any hepatitis flare occurred. Among the 14 patients monitored for 18 months (range 0-70) after RTX discontinuation, no HBV reactivation was observed. CONCLUSION The administration of RTX + DMARD in patients with RA with resolved HBV infection leads to a negligible risk of HBV reactivation, thus suggesting that serum HBsAg and/or HBV DNA monitoring but not universal anti-HBV prophylaxis is justified.
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Affiliation(s)
- Valentina Varisco
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Mauro Viganò
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Alberto Batticciotto
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Pietro Lampertico
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Antonio Marchesoni
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Patrizia Gibertini
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Raffaele Pellerito
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Guido Rovera
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Roberto Caporali
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Monica Todoerti
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Michele Covelli
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Antonella Notarnicola
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Fabiola Atzeni
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco
| | - Piercarlo Sarzi-Puttini
- From the Rheumatology Unit, Ospedale L. Sacco; Hepatology Unit, Ospedale San Giuseppe, University of Milan; A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan; Rheumatology Day Hospital, Istituto Ortopedico G. Pini, Milan; Rheumatology Unit, Ospedale Mauriziano, Turin; Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia, Pavia; University Rheumatology Department, Azienda Ospedaliero Universitaria (AOU) Policlinico, Bari, Italy.V. Varisco*, MD, Rheumatology Unit, Ospedale L. Sacco; M. Viganò*, MD, Hepatology Unit, Ospedale San Giuseppe, University of Milan; A. Batticciotto, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Lampertico, MD, PhD, Professor, A.M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan; A. Marchesoni, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; P. Gibertini, MD, Rheumatology Day Hospital, Istituto Ortopedico G. Pini; R. Pellerito, MD, Rheumatology Unit, Ospedale Mauriziano; G. Rovera, MD, Rheumatology Unit, Ospedale Mauriziano; R. Caporali, MD, Professor, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Todoerti, MD, Rheumatology Division, IRCCS Fondazione San Matteo, Università di Pavia; M. Covelli, MD, University Rheumatology Department, AOU Policlinico; A. Notarnicola, MD, University Rheumatology Department, AOU Policlinico; F. Atzeni, MD, PhD, Rheumatology Unit, Ospedale L. Sacco; P. Sarzi-Puttini, MD, Rheumatology Unit, Ospedale L. Sacco.
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Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, Chen DS, Chen HL, Chen PJ, Chien RN, Dokmeci AK, Gane E, Hou JL, Jafri W, Jia J, Kim JH, Lai CL, Lee HC, Lim SG, Liu CJ, Locarnini S, Al Mahtab M, Mohamed R, Omata M, Park J, Piratvisuth T, Sharma BC, Sollano J, Wang FS, Wei L, Yuen MF, Zheng SS, Kao JH. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016; 10:1-98. [PMID: 26563120 PMCID: PMC4722087 DOI: 10.1007/s12072-015-9675-4] [Citation(s) in RCA: 1661] [Impact Index Per Article: 207.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023]
Abstract
Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.
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Affiliation(s)
- S K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - M Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - G K Lau
- Division of Gastroenterology and Hepatology, Humanity and Health Medical Centre, Hong Kong SAR, China
- The Institute of Translational Hepatology, Beijing, China
| | - Z Abbas
- Department of Hepatogastroenterlogy, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - H L Y Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - C J Chen
- Genomics Research Center, Academia Sinica, National Taiwan University, Taipei, Taiwan
| | - D S Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - H L Chen
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - P J Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R N Chien
- Liver Research Unit, Chang Gung Memorial Hospital and University, Chilung, Taiwan
| | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - J L Hou
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Guangzhou, China
| | - W Jafri
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - J Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | | | - C L Lai
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - H C Lee
- Internal Medicine Asan Medical Center, Seoul, Korea
| | - S G Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - C J Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S Locarnini
- Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia
| | - M Al Mahtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - R Mohamed
- Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - M Omata
- Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
| | - J Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - T Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Prince of Songkla University, Songkhla, Thailand
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - J Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - F S Wang
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - L Wei
- Peking University Hepatology Institute, Beijing, China
| | - M F Yuen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Pofulam, Hong Kong
| | - S S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - J H Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Mozessohn L, Chan KKW, Feld JJ, Hicks LK. Hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients receiving rituximab for lymphoma: a meta-analysis. J Viral Hepat 2015; 22:842-9. [PMID: 25765930 DOI: 10.1111/jvh.12402] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/11/2015] [Indexed: 12/18/2022]
Abstract
Patients with chronic hepatitis B (HBsAg-positive) are at risk of viral reactivation if rituximab is administered without antiviral treatment, a potentially fatal complication of treatment. Patients with so-called 'resolved hepatitis B virus infection' (HBsAg-negative/cAb-positive) may also be at risk. We performed a systematic review of the English and Chinese language literature to estimate the risk of hepatitis B virus (HBV) reactivation in HBsAg-negative/cAb-positive patients receiving rituximab for lymphoma. A pooled risk estimate was calculated for HBV reactivation. The impact of HBsAb status and study design on reactivation rates was explored. Data from 578 patients in 15 studies were included. 'Clinical HBV reactivation', (ALT >3 × normal and either an increase in HBV DNA from baseline or HBsAg seroreversion), was estimated at 6.3% (I(2) = 63%, P = 0.006). Significant heterogeneity was detected. Reactivation rates were higher in prospective vs retrospective studies (14.2% vs 3.8%; OR = 4.39, 95% CI 0.83-23.28). Exploratory analyses found no effect of HBsAb status on reactivation risk (OR = 0.083; P = 0.151). Our meta-analysis confirms a measurable and potentially substantial risk of HBV reactivation in HBsAg-negative/cAb-positive patients exposed to rituximab. However, heterogeneity in the existing literature limits the generalizability of our findings. Large, prospective studies, with uniform definitions of HBV reactivation, are needed to clarify the risk of HBV reactivation in HBsAg-negative/cAb-positive patients.
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Affiliation(s)
- L Mozessohn
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
| | - K K W Chan
- Division of Hematology/Oncology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - J J Feld
- Toronto Centre for Liver Disease, Toronto Western Hospital Liver Centre, Toronto, ON, Canada
| | - L K Hicks
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
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Chen YF, Chong CL, Wu YC, Wang YL, Tsai KN, Kuo TM, Hong MH, Hu CP, Chen ML, Chou YC, Chang C. Doxorubicin Activates Hepatitis B Virus Replication by Elevation of p21 (Waf1/Cip1) and C/EBPα Expression. PLoS One 2015; 10:e0131743. [PMID: 26121644 PMCID: PMC4486450 DOI: 10.1371/journal.pone.0131743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 06/05/2015] [Indexed: 01/10/2023] Open
Abstract
Hepatitis B virus reactivation is an important medical issue in cancer patients who undergo systemic chemotherapy. Up to half of CHB carriers receiving chemotherapy develop hepatitis and among these cases a notable proportion are associated with HBV reactivation. However, the molecular mechanism(s) through which various chemotherapeutic agents induce HBV reactivation is not yet fully understood. In this study, we investigated the role of the cell cycle regulator p21 (Waf1/Cip1) in the modulation of HBV replication when a common chemotherapeutic agent, doxorubicin, is present. We showed that p21 expression was increased by doxorubicin treatment. This elevation in p21 expression enhanced the expression of CCAAT/enhancer-binding protein α (C/EBPα); such an increase is likely to promote the binding of C/EBPα to the HBV promoter, which will contribute to the activation of HBV replication. Our current study thus reveals the mechanism underlying doxorubicin modulation of HBV replication and provides an increased understanding of HBV reactivation in CHB patients who are receiving systemic chemotherapy.
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Affiliation(s)
- Yu-Fang Chen
- Institute of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan; Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan
| | - Chin-Liew Chong
- Faculty of Traditional Chinese Medicine, Southern University College, Johor Bahru, Malaysia
| | - Yi-Chieh Wu
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan
| | - Yi-Ling Wang
- Institute of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan; Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan
| | - Kuen-Nan Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan; Institute of Molecular Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Tzer-Min Kuo
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Ming-Hsiang Hong
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Cheng-Po Hu
- Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Mong-Liang Chen
- Center for Molecular Medicine, China Medical University and Hospital, Taichung, Taiwan
| | - Yu-Chi Chou
- Institute of Molecular Biology, Academia Sinica, Taipei, Taiwan
| | - Chungming Chang
- Institute of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan; Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan
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Chen KL, Chen J, Rao HL, Guo Y, Huang HQ, Zhang L, Shao JY, Lin TY, Jiang WQ, Zou DH, Hu LY, Wirian ML, Cai QQ. Hepatitis B virus reactivation and hepatitis in diffuse large B-cell lymphoma patients with resolved hepatitis B receiving rituximab-containing chemotherapy: risk factors and survival. CHINESE JOURNAL OF CANCER 2015; 34:225-34. [PMID: 26058465 PMCID: PMC4593350 DOI: 10.1186/s40880-015-0015-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/22/2015] [Indexed: 12/23/2022]
Abstract
Introduction Hepatitis B virus (HBV) reactivation has been reported in B-cell lymphoma patients with resolved hepatitis B (hepatitis B surface antigen [HBsAg]-negative and hepatitis B core antibody [HBcAb]-positive). This study aimed to assess HBV reactivation and hepatitis occurrence in diffuse large B-cell lymphoma (DLBCL) patients with resolved hepatitis B receiving rituximab-containing chemotherapy compared with HBsAg-negative/HBcAb-negative patients to identify risk factors for HBV reactivation and hepatitis occurrence and to analyze whether HBV reactivation and hepatitis affect the survival of DLBCL patients with resolved hepatitis B. Methods We reviewed the clinical data of 278 patients with DLBCL treated with rituximab-containing therapy between January 2004 and May 2008 at Sun Yat-sen University Cancer Center, China. Predictive factors for HBV reactivation, hepatitis development, and survival were examined by univariate analysis using the chi-square or Fisher’s exact test and by multivariate analysis using the Cox regression model. Results Among the 278 patients, 165 were HBsAg-negative. Among these 165 patients, 6 (10.9%) of 55 HBcAb-positive (resolved HBV infection) patients experienced HBV reactivation compared with none (0%) of 110 HBcAb-negative patients (P = 0.001). Patients with resolved hepatitis B had a higher hepatitis occurrence rate than HBsAg-negative/HBcAb-negative patients (21.8% vs. 8.2%, P = 0.013). HBcAb positivity and elevated baseline alanine aminotransferase (ALT) levels were independent risk factors for hepatitis. Among the 55 patients with resolved hepatitis B, patients with elevated baseline serum ALT or aspartate aminotransferase (AST) levels were more likely to develop hepatitis than those with normal serum ALT or AST levels (P = 0.037, P = 0.005, respectively). An elevated baseline AST level was an independent risk factor for hepatitis in these patients. Six patients with HBV reactivation recovered after immediate antiviral therapy, and chemotherapy was continued. HBcAb positivity, HBV reactivation, or hepatitis did not negatively affect the survival of DLBCL patients. Conclusions DLBCL patients with resolved hepatitis B may have a higher risk of developing HBV reactivation and hepatitis than HBsAg-negative/HBcAb-negative patients. Close monitoring and prompt antiviral therapy are required in these patients.
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Affiliation(s)
- Kai-Lin Chen
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Jie Chen
- Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Radiotherapy Department, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, 510120, Guangdong, P. R. China.
| | - Hui-Lan Rao
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Ying Guo
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Clinical Trial Center, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Hui-Qiang Huang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Liang Zhang
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, Texas, 77030, USA.
| | - Jian-Yong Shao
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Tong-Yu Lin
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Wen-Qi Jiang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - De-Hui Zou
- Lymphoma and Myeloma Center, Institute of Hematology and Blood Diseases Hospital, Tianjin, P. R. China. .,State Key Lab of Experimental Method of Hematology, Chinese Academy of Medical Sciences and Peking Union of Medical College, Tianjin, 300020, P. R. China.
| | - Li-Yang Hu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Michael Lucas Wirian
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Qing-Qing Cai
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
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Chen CY, Huang SY, Cheng A, Chou WC, Yao M, Tang JL, Tsay W, Sheng WH, Tien HF. High Risk of Hepatitis B Reactivation among Patients with Acute Myeloid Leukemia. PLoS One 2015; 10:e0126037. [PMID: 25973905 PMCID: PMC4431821 DOI: 10.1371/journal.pone.0126037] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/27/2015] [Indexed: 12/18/2022] Open
Abstract
Background Hepatitis B virus (HBV) infections are common and associated with significant morbidity and mortality in cancer patients. However, the incidence and risk factors of HBV reactivation in patients with acute myeloid leukemia (AML) are rarely investigated. Methods AML patients followed-up at the National Taiwan University Hospital between 2006 and 2012 were analyzed. The clinical characteristics and laboratory data were retrospectively reviewed. Results Four hundred and ninety patients comprising 265 men and 225 women were studied. The median age was 52 years (range, 18 - 94). Chronic HBV carriage was documented at the time of leukemia diagnosis in 57 (11.6%) patients. Forty-six (80.7%) of the 57 HBV carriers received prophylaxis with anti-HBV agents. Sixteen HBV carriers (28.1%) developed hepatitis B reactivation during or after chemotherapy, including 7 patients who had discontinued antiviral therapy. The incidence of hepatitis B reactivation among AML patients with HBV carriage was 9.5 per 100 person-years. Prophylaxis with anti-HBV agents significantly decreased the risk of hepatitis B reactivation among HBV carriers (13% vs. 61%, p<0.001). Four (2.8%) of 142 patients with initial positive anti-HBsAb and anti-HBcAb experienced hepatitis B reactivation and lost their protective anti-HBsAb. Multivariate analysis revealed that diabetes mellitus (p=0.008, odds ratio (OR) = 2.841, 95% confident interval (CI): 0.985-8.193) and carriage of HBsAg (p<0.001, OR=36.878, 95% CI: 11.770-115.547) were independent risk factors for hepatitis B reactivation in AML patients. Conclusions Hepatitis B reactivation is not uncommon in the HBsAg positive AML patients. Prophylaxis with anti-HBV agent significantly decreased the risk of hepatitis B reactivation.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Viral/blood
- Antineoplastic Agents/therapeutic use
- Antiviral Agents/therapeutic use
- Female
- Follow-Up Studies
- Hepatitis B/complications
- Hepatitis B/diagnosis
- Hepatitis B/drug therapy
- Hepatitis B/epidemiology
- Hepatitis B virus/drug effects
- Hepatitis B virus/isolation & purification
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/virology
- Male
- Middle Aged
- Taiwan/epidemiology
- Virus Activation/drug effects
- Young Adult
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Affiliation(s)
- Chien-Yuan Chen
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Yi Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Aristine Cheng
- Division of Infectious disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming Yao
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Luh Tang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Tai- Cheng stem cell therapy center, National Taiwan University Hospital, Taipei, Taiwan
| | - Woei Tsay
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Division of Infectious disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Hwei-Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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48
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Civan J, Hann HW. Giving rituximab in patients with occult or resolved hepatitis B virus infection: are the current guidelines good enough? Expert Opin Drug Saf 2015; 14:865-75. [PMID: 25826452 DOI: 10.1517/14740338.2015.1032243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Hepatitis B virus (HBV) reactivation after 'resolved' infection can occur in the setting of immunosuppression, including iatrogenically induced by anti-CD20 antibodies. The presence of antibodies against the HBV core antigen (anti-HBc) is a marker of risk for this phenomenon. The risk of this occurring in patients with circulating HBV surface antigen (HBsAg) is well characterized, but is less well characterized in patients who are HBsAg negative. AREAS COVERED This article reviews the literature regarding HBV reactivation in the context of rituximab therapy. We have limited our review to HBsAg-negative patients, and clinical outcomes following HBV reactivation. EXPERT OPINION We have recommended prophylactic anti-viral therapy for all HBsAg-negative/anti-HBc-positive patients undergoing rituximab therapy in combination with other immunosuppressive therapy.
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Affiliation(s)
- Jesse Civan
- Thomas Jefferson University, Division of Gastoenterology and Hepatology, Department of Medicine , Philadelphia, PA 19107 , USA
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49
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Nard FD, Todoerti M, Grosso V, Monti S, Breda S, Rossi S, Montecucco C, Caporali R. Risk of hepatitis B virus reactivation in rheumatoid arthritis patients undergoing biologic treatment: Extending perspective from old to newer drugs. World J Hepatol 2015; 7:344-361. [PMID: 25848463 PMCID: PMC4381162 DOI: 10.4254/wjh.v7.i3.344] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) reactivation in rheumatoid arthritis (RA) patients undergoing biological therapy is not infrequent. This condition can occur in patients with chronic hepatitis B as well as in patients with resolved HBV infection. Current recommendations are mainly focused on prevention and management strategies of viral reactivation under tumor necrosis factor-α inhibitors or chimeric monoclonal antibody rituximab. In recent years, growing data concerning HBV reactivation in RA patients treated with newer biological drugs like tocilizumab and abatacept have cumulated. In this review, epidemiology, pathogenesis and natural history of HBV infection have been revised first, mainly focusing on the role that specific therapeutic targets of current biotechnological drugs play in HBV pathobiology; finally we have summarized current evidences from scientific literature, including either observational studies and case reports as well, concerning HBV reactivation under different classes of biological drugs in RA patients. Taking all these evidences into account, some practical guidelines for screening, vaccination, prophylaxis and treatment of HBV reactivation have been proposed.
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50
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Perrillo RP, Gish R, Falck-Ytter YT. American Gastroenterological Association Institute technical review on prevention and treatment of hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology 2015; 148:221-244.e3. [PMID: 25447852 DOI: 10.1053/j.gastro.2014.10.038] [Citation(s) in RCA: 369] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Robert P Perrillo
- Hepatology Division, Baylor University Medical Center, Department of Medicine, University of Texas Southwestern, Dallas, Texas
| | - Robert Gish
- Division of Gastroenterology and Hepatology, Department of Medicine,Stanford University, Palo Alto, California; Hepatitis B Foundation, Doylestown, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Department of Medicine, Case and VA Medical Center, Case Western Reserve University, Cleveland, Ohio
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