Hepatitis B Highlights: The Liver Meeting 2014
Hepatitis B Highlights: The Liver Meeting 2014
Antiviral therapy for HBV infection has been associated with a lower risk for hepatocellular carcinoma (HCC). Hoang and colleagues compared the risk for HCC in more than 1800 noncirrhotic patients with chronic HBV according to ALT levels and treatment status.
A total of 23 patients developed HCC during follow-up. In patients with ALT levels twice the upper limit of normal (ULN) or greater, those who were treated had a lower incidence of HCC than those who were untreated; HCC incidence was 4.9 per 1000 person-years in untreated patients compared with zero cases in treated patients. The annual HCC incidence was 3.5 per 1000 person-years in untreated patients and 1.2 per 1000 person-years in treated patients. Antiviral therapy significantly reduced HCC risk for patients with ALT greater than twice the ULN. HCC incidence was also high in patients with chronic HBV without cirrhosis, even at an ALT less than twice the ULN, especially if they remain untreated.
Ahn and colleagues determined the incidence of HCC in patients receiving long-term entecavir treatment in "real-world" practice settings. Patients with HBV infection receiving entecavir remained at risk for HCC, especially if they were older or had cirrhosis; therefore, continued HCC surveillance is warranted.
It is unclear whether achievement of virologic response modifies the risk for HCC to a similar degree in patients with both chronic HBV and HCV who attain SVR. Kim and colleagues noted a similar risk for HCC in a historical cohort of patients with HBV treated with entecavir and a cohort of patients with HCV treated with pegylated interferon and ribavirin. However, the risk for HCC was higher in patients with chronic HBV, suggesting that patients with chronic HBV have a risk for HCC that persists even after effective suppression of viral replication.
Yamada and colleagues reported pretreatment and on-treatment risk factors for HCC in approximately 500 patients with chronic HBV infection undergoing entecavir therapy. They recommended continued surveillance for HCC after initiation of entecavir treatment, suggesting monitoring the changes in the serum alpha-fetoprotein levels, especially among patients with advanced age or cirrhosis.
Guidelines vary across specialties with respect to HBV screening and antiviral prophylaxis in patients receiving anti-tumor necrosis factor (TNF) therapy. Pauly and colleagues sought to determine the rate of HBV testing at baseline, the incidence of HBV reactivation, and hepatotoxicity in a large cohort of patients treated with an anti-TNF regimen, roughly one half of whom were tested for HBV before initiation of therapy. Reactivation of HBV occurred in 17% of patients positive for HBsAg.
Although antiviral prophylaxis is essential during chemotherapy, even in patients in the inactive carrier state of HBV, there has been no evidence-based consensus about the choice and timing of withdrawal of the antiviral agent. Current guidelines recommend prompt preemptive antiviral treatment in HBsAg-positive patients with cancer and who are candidates for chemotherapy, regardless of the liver disease activity.
Choi and colleagues investigated the long-term virologic outcomes during and after preemptive therapy in HBV carriers undergoing chemotherapy for cancer. They also found that HBV reactivation could occur even in inactive HBV carriers during or after chemotherapy, despite antiviral prophylaxis according to the guidelines. These results suggest that patients with chronic HBV treated with anticancer regimens, including rituximab, may require a longer preemptive antiviral course and closer monitoring of their viremic status, irrespective of HBV activity before chemotherapy.
Choi and colleagues also examined the efficacy of preemptive antiviral therapy for preventing HBV reactivation. They reported that lamivudine and entecavir had similar efficacy to preemptive antiviral drugs in patients with chronic HBV receiving anticancer chemotherapy. A more prolonged course of preemptive therapy and closer virologic monitoring may be required in rituximab-treated patients.
Hepatocellular Carcinoma and HBV
Antiviral therapy for HBV infection has been associated with a lower risk for hepatocellular carcinoma (HCC). Hoang and colleagues compared the risk for HCC in more than 1800 noncirrhotic patients with chronic HBV according to ALT levels and treatment status.
A total of 23 patients developed HCC during follow-up. In patients with ALT levels twice the upper limit of normal (ULN) or greater, those who were treated had a lower incidence of HCC than those who were untreated; HCC incidence was 4.9 per 1000 person-years in untreated patients compared with zero cases in treated patients. The annual HCC incidence was 3.5 per 1000 person-years in untreated patients and 1.2 per 1000 person-years in treated patients. Antiviral therapy significantly reduced HCC risk for patients with ALT greater than twice the ULN. HCC incidence was also high in patients with chronic HBV without cirrhosis, even at an ALT less than twice the ULN, especially if they remain untreated.
Ahn and colleagues determined the incidence of HCC in patients receiving long-term entecavir treatment in "real-world" practice settings. Patients with HBV infection receiving entecavir remained at risk for HCC, especially if they were older or had cirrhosis; therefore, continued HCC surveillance is warranted.
It is unclear whether achievement of virologic response modifies the risk for HCC to a similar degree in patients with both chronic HBV and HCV who attain SVR. Kim and colleagues noted a similar risk for HCC in a historical cohort of patients with HBV treated with entecavir and a cohort of patients with HCV treated with pegylated interferon and ribavirin. However, the risk for HCC was higher in patients with chronic HBV, suggesting that patients with chronic HBV have a risk for HCC that persists even after effective suppression of viral replication.
Yamada and colleagues reported pretreatment and on-treatment risk factors for HCC in approximately 500 patients with chronic HBV infection undergoing entecavir therapy. They recommended continued surveillance for HCC after initiation of entecavir treatment, suggesting monitoring the changes in the serum alpha-fetoprotein levels, especially among patients with advanced age or cirrhosis.
Reactivation of HBV Infection
Guidelines vary across specialties with respect to HBV screening and antiviral prophylaxis in patients receiving anti-tumor necrosis factor (TNF) therapy. Pauly and colleagues sought to determine the rate of HBV testing at baseline, the incidence of HBV reactivation, and hepatotoxicity in a large cohort of patients treated with an anti-TNF regimen, roughly one half of whom were tested for HBV before initiation of therapy. Reactivation of HBV occurred in 17% of patients positive for HBsAg.
Although antiviral prophylaxis is essential during chemotherapy, even in patients in the inactive carrier state of HBV, there has been no evidence-based consensus about the choice and timing of withdrawal of the antiviral agent. Current guidelines recommend prompt preemptive antiviral treatment in HBsAg-positive patients with cancer and who are candidates for chemotherapy, regardless of the liver disease activity.
Choi and colleagues investigated the long-term virologic outcomes during and after preemptive therapy in HBV carriers undergoing chemotherapy for cancer. They also found that HBV reactivation could occur even in inactive HBV carriers during or after chemotherapy, despite antiviral prophylaxis according to the guidelines. These results suggest that patients with chronic HBV treated with anticancer regimens, including rituximab, may require a longer preemptive antiviral course and closer monitoring of their viremic status, irrespective of HBV activity before chemotherapy.
Choi and colleagues also examined the efficacy of preemptive antiviral therapy for preventing HBV reactivation. They reported that lamivudine and entecavir had similar efficacy to preemptive antiviral drugs in patients with chronic HBV receiving anticancer chemotherapy. A more prolonged course of preemptive therapy and closer virologic monitoring may be required in rituximab-treated patients.
Source...