Management of hepatitis B reactivation in immunosuppressed patients: An update on current recommendations

Table 1 Diagnostic tools suggested for hepatitis B screening prior to immunosuppression therapy by different major guidelines

Recommendations	Hepatitis B screening tests before immunosuppression
	HBsAg	AntiHBc	HBV DNA	AntiHBs
CDC	Yes	Yes	No	Yes
AASLD	High risk	High risk	No	No
EASL	Yes	Yes	No	No
APASL	Yes	No	No	No
ASCO	High risk	High risk	No	Yes1

¹Only suggested in antiHBc-positive patients. CDC: Center for Disease Control; AASLD: American Association for the Study of Liver Disease; EASL: European Association for the Study of the Liver; APASL: Asian Pacific Association for the Study of the Liver; ASCO: American Society Clinical Oncology; HBV: Hepatitis B virus; HBsAg: Hepatitis B surface antigen; AntiHBc: Antibody to hepatitis B core antigen; AntiHBs: Antibody to hepatitis B surface antigen.

Table 2 Recommendations for treatment and follow-up in different clinical scenarios, according to Asian Pacific Association for the Study of the Liver, American Association for the Study of Liver Disease and European Association for the Study of the Liver guidelines

	Recommendations in different clinical scenarios
	HBsAg (+) HBV DNA≥2000 U/mL	HBsAg (+) HBV DNA < 2000 U/mL	HBsAg (-) antiHBc (+)	HBsAg (-) antiHBc (-) antiHBs (-)	HBV-HCC TACE
Action	Treat	Treat	Close mon/treat if HBV DNA (+) or rituximab/stem cell transplant1	Vaccination	Treat3
Onset	Before IS	Before IS	Before IS	-	Before IS
Duration	6-12 mo (except CI)	6-12 mo (except CI)	6-12 mo	-	-
Drug	Short IS: LAM (LdT) preferred ETV/TDF	Short IS: LAM (LdT) (ETV/TDF)	Short IS: LAM (LdT) (ETV/TDF)	-	LAM (ETV/TDF)
Follow-up	-	-	Every 1-3 mo/treat if HBV DNA (+)2	-	-

In HBsAg-positive patients, duration could be determined by CI as in immunocompetent patients. A 12-mo treatment was only endorsed by EASL. Drug selection depends on treatment duration and clinical setting.

¹In isolated antiHBc-positive patients when treated with biologic agents, close follow-up and treatment, if necessary, is suggested by AASLD/APASL; however, EASL proposes that isolated antiHBc-positive patients, if HBV DNA-positive, antiHBs-negative or undergoing rituximab/stem cell transplantation, should be treated with the same strategy as HBsAg positive patients;

²When monitored, treatment should start when HBV DNA becomes positive, before ALT rise (EASL);

³Treatment in all HBV-related HCC patients undergoing TACE is suggested by APASL guidelines. CI: Clinical indication; IS: Immunosuppression; HBsAg: Hepatitis B surface antigen; AntiHBc: Hepatitis B core antibody; AntiHBs: Hepatitis B surface antibody; HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; LAM: Lamivudine; ETV: Entecavir; TDF: Tenofovir; LdT: Telbivudine (only listed as an option in AASLD guidelines); AASLD: American Association for the Study of Liver Disease; APASL: Asian Pacific Association for the Study of the Liver; EASL: European Association for the Study of the Liver.