Hepatitis B reactivation and timing for prophylaxis

Abstract

It is known that immunotherapy and cancer chemotherapy may cause hepatitis B virus (HBV) reactivation in hepatitis B surface antigen carriers and inactive chronic hepatitis B patients. Guidelines recommend antiviral prophylaxis regardless of HBV DNA levels to prevent reactivation. We read from the article written by Liu et al that Lamivudine was given inadequate time for antiviral prophylaxis.

Key Words: Hepatitis B; Immunotherapy; Hepatitis B reactivation; Antiviral prophylaxis; Inadequate time; Lamivudine

Core tip: Lamivudine is the most commonly used drug in hepatitis B virus (HBV) reactivation prophylaxis. However, if Rituximab is included in the immunochemotherapy regime, HBV reactivation is expected to occur more severely.

TO THE EDITOR

We read the article entitled “Hepatitis B surface antigen seroconversion after HBV reactivation in non-Hodgkin’s lymphoma” with great interest[1]. In this article, following termination of Lamivudine (LAM) prophylaxis in inactive chronic hepatitis B (CHB), reactivation and hepatitis B surface antigen (HBsAg) seroconversion was reported after 6 mo of entecavir treatment. Lamivudine is the most commonly used drug in hepatitis B virus (HBV) reactivation prophylaxis. However, if Rituximab is included in the immunochemotherapy regime, HBV reactivation is expected to occur more severely. Despite LAM prophylaxis the reactivation might remain severe[2]. According to the case report, LAM prophylaxis had been initiated for the patient with Hodgkin’s lymphoma and inactive CHB prior to immunochemotherapy. But we have discovered that even though Rituximab was included in this treatment regime, LAM prophylaxis was initiated on the first day of treatment simultaneously with immunochemotherapy. Moreover, LAM prophylaxis continued for 4 mo following the completion of chemotherapy. According to the recent guidelines, prophylaxis must be initiated at least 2-3 wk before the immunochemotherapy and continued for at least six months or one year after chemotherapy in HBV positive patients taking immunosuppressive drugs[3]. If the antiviral prophylaxis had been initiated earlier and ended later in this case, reactivation might not have occurred. In addition, we believe that following the rules laid out in the guidelines will prevent complications (acute hepatic failure) that are much more costly.