Management of patients with hepatitis B who require immunosuppressive therapy

Nat Rev Gastroenterol Hepatol. 2014 Apr;11(4):209-19. doi: 10.1038/nrgastro.2013.216. Epub 2013 Nov 19.


Patients with chronic HBV infection are at risk of reactivation of HBV should they require immunosuppressive therapies for a variety of clinical settings, including chemotherapy for patients with cancer, immunosuppression for solid organ and stem cell transplant recipients, and use of anti-CD20 antibodies, TNF inhibitors, or corticosteroids in patients with oncological, gastrointestinal, rheumatological or dermatological conditions. The key to preventing HBV reactivation is the identification of patients with HBV infection prior to immunosuppressive therapy, initiation of prophylactic antiviral therapy in patients at moderate or high risk of HBV reactivation, and close monitoring of other patients so that antiviral therapy can be initiated at the first sign of HBV reactivation. Unfortunately, many patients infected with HBV are unaware of their infection or risk factors, and physicians often do not have sufficient time to systematically assess patients for risk factors for HBV prior to starting immunosuppressive therapy. In this article, we review the incidence, risk factors and outcomes of HBV reactivation, and the efficacy of antiviral therapy in preventing its occurrence. We also propose an algorithm for managing patients with HBV infection who require immunosuppressive therapy.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Algorithms
  • Antiviral Agents / therapeutic use*
  • Gastrointestinal Diseases / drug therapy
  • Graft Rejection / prevention & control
  • Hepatitis B, Chronic / drug therapy*
  • Hepatitis B, Chronic / epidemiology*
  • Humans
  • Immunosuppressive Agents / adverse effects*
  • Immunosuppressive Agents / therapeutic use*
  • Incidence
  • Rheumatic Diseases / drug therapy
  • Risk Factors
  • Treatment Outcome


  • Antiviral Agents
  • Immunosuppressive Agents