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American Gastroenterological Association Institute Guideline
on the Prevention and Treatment of Hepatitis B Virus
Reactivation During Immunosuppressive Drug Therapy
K. Rajender Reddy,1 Kimberly L. Beavers,2 Sarah P. Hammond,3 Joseph K. Lim,4 and
Yngve T. Falck-Ytter5
1
Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania; 2Division of
Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina; 3Division of Infectious
Diseases, Brigham & Womens Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts;
4
Division of Gastroenterology and Hepatology, Yale University School of Medicine, New Haven, Connecticut; and 5Division of
Gastroenterology and Hepatology, Department of Medicine, Case and VA Medical Center, Case Western Reserve University,
Cleveland, Ohio
infection. Although the denition of HBVr has varied in the of HBVr showed that prophylaxis was associated with an
literature, it is desirable to prevent the end clinical 87% relative risk reduction of reactivation (95% con-
manifestation of hepatic decompensation or acute liver dence interval, 70%94%) and an 84% relative risk
failure. A spectrum of serological patterns indicates
ongoing or recovered hepatitis B virus (HBV) infection,
Abbreviations used in this paper: AGA, American Gastroenterological
and the risk of HBVr among patients presenting with these Association; anti-HBc, antibody to hepatitis B core antigen; anti-HBs,
serological patterns varies depending on the type of antibody to hepatitis B surface antigen; CI, condence interval; GRADE,
Grading of Recommendations Assessment, Development and Evaluation;
immunosuppression. Several aspects of HBVr prevention HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HBVr, hepatitis
remain unclear, including the optimal population to B virus reactivation.
screen, in whom to use prophylaxis with HBV therapeutic
2015 by the AGA Institute
agents, the best specic therapeutic agent to use, the 0016-5085/$36.00
duration of prophylaxis, and the type and duration of http://dx.doi.org/10.1053/j.gastro.2014.10.039
216 Reddy et al Gastroenterology Vol. 148, No. 1
decision aids are not likely to be needed to help patients make decisions consistent with their values and preferences.
B Clinicians: Most patients should receive the recommended course of action. Adherence to this recommendation according to
useful in helping patients make decisions consistent with their values and preferences.
B Clinicians: Examine a summary of the evidence to help patients make a decision that is consistent with their own values and pref-
depleting agents).
who are HBsAg negative) may reasonably select no
prophylaxis over antiviral prophylaxis.
The moderate-risk group was dened by anticipated
incidence of HBVr of 1% to 10% of cases and included the The low-risk group was dened by anticipated incidence
following: of HBVr of <1% of cases and included the following:
1. HBsAg-positive/anti-HBcpositive or HBsAg-negative/ 1. HBsAg-positive/anti-HBcpositive or HBsAg-negative/
anti-HBcpositive patients treated with tumor necro- anti-HBcpositive patients treated with traditional
sis factor alpha inhibitors (eg, etanercept, adalimu- immunosuppressive agents (eg, azathioprine,
mab, certolizumab, iniximab) 6-mercaptopurine, methotrexate)
January 2015 AGA Section 217
3. Institute of Medicine. Clinical practice guidelines we can Medical Center, San Francisco, CA), Ikuo Hirano (Northwestern University
School of Medicine, Chicago, IL), Geoffrey C. Nguyen (Mount Sinai Hospital,
trust. Washington, DC: Institute of Medicine, 2011. University of Toronto, Toronto, Ontario, Canada), Joel H. Rubenstein
4. Perrillo RP, Gish R, Falck-Ytter YT. American Gastroen- (Veterans Affairs Center for Clinical Management Research and Division of
terological Association Institute technical review on Gastroenterology, University of Michigan Medical School, Ann Arbor, MI),
Siddharth Singh (Division of Gastroenterology and Hepatology, Mayo Clinic,
prevention and treatment of hepatitis B virus reactivation Rochester, MN), Walter E. Smalley, Vanderbilt University School of Medicine,
during immunosuppressive drug therapy. Gastroenter- Nashville, TN), Neil Stollman (Northern California Gastroenterology
Consultants, University of California San Francisco, San Francisco, CA),
ology 2015;148:221244. Shahnaz Sultan (Minneapolis VA Health Care System, University of
Minnesota, Minneapolis, MN), Santhi S. Vege (Pancreas Group, Division of
Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN), Sachin B.
Wani (University of Colorado Anschutz Medical Campus, Aurora, CO), David
Reprint requests Weinberg (Department of Medicine, Fox Chase Cancer Center, Philadelphia,
Address requests for reprints to: Chair, Clinical Practice and Quality PA), and Yu-Xiao Yang (Division of Gastroenterology, Perelman School of
Management Committee, AGA National Ofce, 4930 Del Ray Avenue, Medicine at the University of Pennsylvania, Philadelphia, PA).
Bethesda, Maryland 20814. e-mail: msiedler@gastro.org; telephone: (301)
941-2618. Conicts of interest
All members were required to complete disclosure statements. These
Acknowledgments statements are maintained at the American Gastroenterological Association
The Clinical Guidelines Committee included Steven L. Flamm (Northwestern Institute headquarters in Bethesda, Maryland, and pertinent disclosures are
Feinberg School of Medicine, Chicago, IL), Lauren Gerson (California Pacic published with the report.
AGA SECTION