Tenofovir disoproxil fumarate versus tenofovir alafenamide on risk of osteoporotic fracture in patients with chronic hepatitis B: A nationwide claims study in South Korea

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

Incidence of Osteopenia or Osteoporosis in Asian Patients With Chronic Hepatitis B

BACKGROUND

In an aging population, patients with chronic hepatitis B (CHB) may face a higher risk of osteopenia, osteoporosis, or fractures. We investigated the epidemiology and risk factors associated with osteopenia or osteoporosis in patients with CHB.

METHODS

This retrospective cohort study included patients ≥ 19 years who underwent bone mineral density (BMD) testing ≥ 2 times between 2005 and 2021 at Severance Hospital, Seoul, South Korea. Demographic factors and comorbidities for patients with or without CHB were matched based on a 1:4 ratio. Cox proportional hazard regression models were used to estimate hazard ratios to assess osteopenia or osteoporosis risk.

RESULTS

A total of 275 patients with CHB and 7868 patients without CHB who had normal BMD were analyzed. The incidence of osteopenia or osteoporosis in patients with and without CHB was 25.8% and 28.7%, respectively. After propensity score matching, in the second BMD test, 73.8%, 24.7%, and 1.5% of patients with CHB and 70.7%, 26.5%, and 2.8% of patients without CHB had normal BMD, osteopenia, and osteoporosis, respectively. Risk factors for osteopenia or osteoporosis in these patients were age, body mass index < 25, chronic kidney disease, and proton pump inhibitor use. There were no significant differences in cumulative hazard for patients with or without CHB.

CONCLUSIONS

Patients with or without CHB showed similar risks of osteopenia or osteoporosis. In addition to providing closer monitoring for patients with CHB with greater bone disease risk, further studies of bone disease in these patients may help to understand the factors that impact bone health.

A long term bone and renal safety of TAF treatment on renal transplant recipients

RATIONALE & OBJECTIVE

The data on tenofovir alafenamide (TAF) in kidney transplant recipients (KTRs) with chronic hepatitis B virus (HBV) infection is limited.

STUDY DESIGN

Retrospective cohort study SETTING & STUDY POPULATIONS: HBsAg-positive KTRs who received TAF between 2019 and 2022 were included in the analysis, categorized into treatment-naïve and treatment-experienced groups. Additionally, a subgroup of patients receiving ETV was analyzed for comparison.

RESULTS

Four treatment-naïve (Group I) and 35 treatment-experienced (Group II) patients received TAF for 26.4±11.3 and 43.7±19.0 months, respectively. Both groups showed significant HBV DNA reduction, but Group I achieved higher rates of undetectable HBV DNA (50%, 75%, 75%, 100% at 6, 12, 24, 30 months, compared with 16.7%, 25.3%, 31.4%, 34.7% in Group II, p=0.018). Renal allograft function remained stable during follow-up, and bone toxicity was minimal. For ETV, 10 patients demonstrated excellent viral suppression (HBV DNA undetectable in 70% at 48 weeks and 100% at 96 weeks) with stable renal function over a median of 5.2 years.

LIMITATIONS

Retrospective study with a lack of prospective comparison of TAF and ETV.

CONCLUSIONS

Our results suggest that TAF provides favorable efficacy, renal safety, and tolerability in KTRs. ETV also provided effective and sustainable viral suppression. TAF may offer additional advantages such as no concern of viral resistance and dose adjustment by eGFR levels for long-term management of HBsAg-positive KTRs.

Long-term use of tenofovir disoproxil fumarate increases fracture risk in elderly patients with chronic hepatitis B

BACKGROUND & AIMS

The use of tenofovir disoproxil fumarate (TDF) is associated with a reduction in bone mineral density and an increase in bone metabolism biomarkers. However, data on clinical bone fractures remain limited. We evaluated the impact of TDF compared to entecavir on the risk of fracture in elderly patients with chronic hepatitis B (CHB).

METHODS

Patients with CHB aged ≥60 years receiving entecavir or TDF between January 2008 and December 2022 were identified using a territory-wide database in Hong Kong. The risk of incident fracture in entecavir- and TDF-treated patients before and after month 24 were compared after propensity score matching.

RESULTS

A total of 41,531 patients with CHB (mean age 69.8±7.8 years, 61.6% male) receiving entecavir (n = 39,897 [96.1%]) and TDF (n = 1,634 [3.9%]) were analysed. At a median follow-up of 25.3 (9.1-58.5) months, 1,733 (4.2%) patients developed incident fracture. Patients with incident fracture were more likely to have diabetes, hypertension, congestive heart failure, rheumatoid arthritis, osteoporosis, and a history of fracture. Compared with propensity score-matched entecavir-treated patients, the risk of incident fracture in TDF-treated patients was comparable in the first 24 months (weighted subdistribution hazard ratio [sHR] 0.99, 95% CI 0.56-1.73, p = 0.960) but increased after month 24 (weighted sHR 1.80, 95% CI 1.11-2.93, p = 0.019). The 24-, 60-, and 96-month cumulative incidences (95% CI) of fracture in TDF-treated and entecavir-treated patients were 2.3% (1.6%-3.4%) vs. 2.6% (1.9%-3.5%), 6.4% (5.0%-8.2%) vs. 4.7% (3.8%-6.0%), and 10.2% (8.3%-12.6%) vs. 6.8% (5.4%-8.5%), respectively.

CONCLUSIONS

The risk of fracture increased with TDF treatment for ≥24 months in elderly patients with CHB. Selection of nucleos(t)ide analogues should be individualised based on age and comorbidities.

IMPACT AND IMPLICATIONS

Previous literature suggested that the use of tenofovir disoproxil fumarate (TDF) is associated with a decrease in bone mineral density. However, data on the impact of TDF on long-term incident clinical fracture remains scarce. In this real-world territory-wide study of 41,531 treated patients with chronic hepatitis B in Hong Kong, patients who received TDF were at a higher risk of fracture after 2 years of treatment than those who received entecavir. Given the ageing population of patients with chronic hepatitis B and the rising prevalence of comorbidities, our findings support the current treatment guidelines that recommend selecting antiviral treatment based on age and comorbidities.