The American Gastroenterology Association (AGA) has provided updated guidelines for managing hepatitis B virus reactivation (HBVr) in at-risk individuals. The guidelines focus on preventive strategies and monitoring approaches based on patient risk levels.

The document outlines four key recommendations:

1. High-Risk Patients:
– Strongly recommends antiviral prophylaxis over monitoring alone
– Antiviral treatment should start before beginning immunosuppressive therapy
– Treatment should continue for at least 6 months after stopping risk-imposing therapy (12 months for B cell-depleting agents)

2. Moderate-Risk Patients:
– Suggests antiviral prophylaxis over monitoring alone
– Patients may choose monitoring instead if they prefer to avoid long-term antiviral therapy
– Monitoring should occur every 1-3 months, including viral load and liver enzyme tests

3. Low-Risk Patients:
– Suggests monitoring alone rather than antiviral prophylaxis
– Regular follow-up is essential
– Patients may opt for antiviral therapy if they’re particularly concerned about reactivation risk

4. Testing Recommendations:
– All individuals at risk should be tested for hepatitis B
– Follows CDC guidelines recommending universal screening for adults 18 and older
– Testing should include HBV surface antigen, surface antibody, and core antibody

The guidelines classify risk levels based on the type of immunosuppressive therapy and patient’s hepatitis B status. High-risk scenarios typically involve B cell-depleting agents or high-dose corticosteroids. Moderate risk includes treatments like anthracycline derivatives or moderate-dose steroids, while low risk involves medications like methotrexate or intra-articular steroid injections.

Implementation considerations emphasize using antivirals with high resistance barriers and maintaining appropriate monitoring schedules. The guidelines stress the importance of individualized decision-making, considering patient preferences, medication costs, and monitoring feasibility.

These recommendations aim to guide healthcare providers in preventing HBVr while balancing the benefits and risks of antiviral prophylaxis versus monitoring strategies. The guidelines are expected to be updated within 5 years of publication.

Source: www.gastrojournal.org/article/S0016-5085(24)05744-5/fulltext