Hepatitis B virus reactivation (HBVr) is a serious risk for individuals undergoing immunosuppressive therapy. The American Gastroenterological Association (AGA) has released updated guidelines to help prevent and manage HBVr, ensuring at-risk individuals receive proper care.
 
This guide explains who is at risk, how to prevent HBVr, and the latest AGA recommendations on antiviral prophylaxis and monitoring.
 

What is Hepatitis B Virus Reactivation (HBVr)?

HBVr occurs when the immune system weakens, allowing the hepatitis B virus (HBV) to multiply again. This can cause liver inflammation, organ damage, and severe complications.

 

Who is at Risk for HBVr?

Individuals at the highest risk of HBVr include those who:

• Are HBV surface antigen (HBsAg) positive or have HB core antibody (anti-HBc) positivity, indicating past exposure to HBV.
• Receive immunosuppressive treatments, which reduce the body's ability to control HBV.

Risk Levels Based on Immunosuppressive Therapy

AGA classifies HBVr risk as low, moderate, or high, based on HBV status and treatment type.

 

For HBsAg-Positive Individuals:

• Low Risk (<1%): Short-term corticosteroids (<1 week), joint injections.
• Moderate Risk (1-10%): Low-dose corticosteroids (<10 mg/day for ≥4 weeks), anti-T cell therapy.
• High Risk (>10%): B cell–depleting agents (e.g., rituximab), anti-TNF therapy, CAR-T cell therapy, JAK inhibitors.

 

For HBsAg-Negative, Anti-HBc-Positive Individuals:

• Low Risk (<1%): Checkpoint inhibitors, short-term corticosteroids.
• Moderate Risk (1-10%): Anti-TNF therapy, JAK inhibitors.
• High Risk (>10%): B cell–depleting agents.

How to Prevent HBVr: AGA Recommendations

1. High-Risk Individuals: Antiviral Prophylaxis is Essential

• Start antiviral therapy before immunosuppressive treatment.
• Continue for at least 6 months after stopping immunosuppressive therapy (12 months for B cell–depleting agents).
• Preferred medications include entecavir, tenofovir disoproxil fumarate (TDF), or tenofovir alafenamide (TAF).

2. Moderate-Risk Individuals: Consider Antiviral Prophylaxis or Monitoring

• Antiviral treatment is recommended, but monitoring may be an alternative.
• If choosing monitoring, check HBV DNA and liver enzymes (ALT) every 1-3 months.

3. Low-Risk Individuals: Monitoring is Preferred

• Routine monitoring is sufficient for low-risk patients.
• Those on multiple low-risk treatments may opt for antivirals to further reduce risk.

4. Routine Hepatitis B Testing is a Must
The AGA strongly recommends HBV testing for all at-risk individuals.

 

Who should get tested?

• All adults aged 18+ (per CDC guidelines).
• Anyone about to start immunosuppressive therapy.

What tests are needed?

• HBsAg and anti-HBc (to check past/current infection).
• HBV DNA test if any results are positive.

Why This Matters: Protect Your Health

HBVr can lead to severe liver damage, failure, or even death. Preventive care can save lives by identifying at-risk individuals early.

• Know your HBV status before starting treatment.
• Understand your risk level (low, moderate, or high).
• Follow AGA guidelines for antiviral therapy or monitoring.
• Monitor HBV DNA and liver enzymes if in the moderate-risk category.
• Discuss prevention strategies with your doctor.

Final Thoughts

The AGA guidelines offer clear steps to prevent HBVr and protect individuals on immunosuppressive therapy. If you are at risk, talk to your doctor about HBV screening and prevention.
Don't wait—schedule your HBV screening today.

 

Need More Information?

Consult with a hepatologist, gastroenterologist, or infectious disease specialist to get personalized guidance. Early detection and prevention can save lives.
 
 
Tossapol Kerdsirichairat, MD, FACG, FASGE
Clinical Associate Professor of Medicine
Advanced/Bariatric Endoscopy, Digestive Disease Center
Bumrungrad International Hospital