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Hepatitis B reactivation during or after direct acting antiviral therapy - implication for susceptible individuals
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Expert Opin Drug Saf. 2017 Jun
Pooled results of a systematic review have demonstrated that HBV reactivation following immunosuppressive therapy for cancer causes hepatitis in 33.4%, liver failure in 13.0% and leads to death in 6.7% (150). A more recent meta-analysis and systematic review of HBV reactivation following chemotherapy for solid organ cancers found that HBV reactivation ranged from 4-68%. Owing to this significant risk and potentially severe consequences, HBV prophylaxis is now recommended according to the HBV status and the immunosuppressive regimen (151). This strategy reduces the risk of HBV reactivation (odds ratio 0.12), HBV hepatitis (4%, odds ratio 0.18), fulminant hepatic failure (0%) and death (2%) (150, 152).
Abstract
Introduction
The FDA issued a warning following 24 cases of HBV reactivation during DAA therapy for HCV, including individuals with inactive, occult and past HBV infection. Clinical presentations ranged from asymptomatic fluctuations in HBV DNA to fulminant hepatic failure, liver transplantation and death. The mechanism is unknown.
Areas covered
HCV/HBV coinfection is common, particularly in regions endemic for HBV. HCV and HBV utilize host factors to support replication; both viruses evade/impair host immunity. Clinical presentations of HBV reactivation during DAAs are summarized. Other causes of HBV reactivation are revisited and recent data regarding HBV reactivation are presented.
Expert opinion
HBV reactivation during DAAs for HCV occurs, with life-threatening consequences in some individuals. The risk of HBV reactivation is observed in all HBV stages. The rapid removal of HCV likely alters and liberates host-viral +/- viral-viral interactions that lead to increased HBV replication. As immune reconstitution occurs with HCV removal, host recognition of HBV DNA likely ensues followed by vigorous host immune responses leading to liver injury (HBV flare). These cases highlight the importance of HBV testing prior to initiating DAA therapy, the need for close monitoring of HBV during therapy and timely administration of anti-HBV therapy to prevent serious sequelae
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