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Hepatitis B virus reactivation associated with immunosuppressive therapy

Anna SF Lok, MD
Peter A L Bonis, MD
Section Editor
Rafael Esteban, MD
Deputy Editor
Jennifer Mitty, MD, MPH


The natural course of hepatitis B virus (HBV) infection is determined through the interplay between viral replication and the host's immune response. HBV persists in the body of all patients with infection, even those with evidence of serological recovery. Thus, individuals with a history of HBV infection who receive immunosuppressive therapy are at risk for HBV reactivation and a flare of their HBV disease. This can result in increased serum aminotransferase levels, fulminant hepatic failure, and/or death [1]. In addition, reactivation of HBV can lead to an interruption of immunosuppressive therapy (eg, chemotherapy), delaying treatment of the underlying disease.

This topic review will discuss the clinical manifestations, diagnosis, management, and prevention of HBV reactivation among those receiving immunosuppressive therapy. Other topics relevant to the diagnosis and treatment of HBV infection are found elsewhere. (See "Diagnosis of hepatitis B virus infection" and "Clinical manifestations and natural history of hepatitis B virus infection" and "Overview of the management of hepatitis B and case examples".)


Overview — Prior to initiating immunosuppressive therapy, we test patients for evidence of hepatitis B virus (HBV) infection; for adults receiving glucocorticoids alone, we only screen those who will receive doses of prednisone ≥20 mg/day for at least four weeks. This approach to HBV screening, which tests patients for HBV regardless of their risk for infection, is supported by several guideline panels [2-7]. However, some UpToDate authors suggest more limited screening as outlined by the American Society of Clinical Oncology [8]. (See 'Recommendations of others' below and "Chemotherapy hepatotoxicity and dose modification in patients with liver disease", section on 'Hepatitis B'.)

Serologic testing should include assessment of HBV core antibody (anti-HBc) and HBV surface antigen (HBsAg). We do not routinely check HBV surface antibody (anti-HBs) since this information is not used to determine if preventive therapy is indicated; the impact of anti-HBs on HBV reactivation is not well understood [7]. (See "Diagnosis of hepatitis B virus infection".)

Depending upon the results of this initial testing, the following applies:


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Literature review current through: Sep 2016. | This topic last updated: Jan 21, 2016.
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