HCV patients on DAAs need hepatitis B testing

All patients beginning hepatitis C virus (HCV) treatment with direct-acting antiviral (DAA) therapy should be tested for hepatitis B virus (HBV).

The recommendation, by a guidance panel of the American Association for the Study of Liver Diseases (AASLD) / Infectious Diseases Society of America, for HBV serologic testing for all patients with HCV infection is not a new recommendation, however.

“The Guidance Panel has highlighted this long-standing recommendation by moving the recommendation into a box due to the recent reports of HBV flare/reactivation in the setting of DAA therapy, suggesting that serologic testing for HBV is not being completed as routinely as it should be,” Susanna Naggie, MD, co-chair of the HCV Guidance Panel and associate professor of medicine at Duke University, told Medical Economics.

“The recommendation is more about ensuring that providers are aware of the patient’s concomitant HBV status, due to the fact that some of the patients may already meet criteria for HBV therapy, or to at a minimum recognize the co-infection in the case that liver enzyme levels change during the course of HCV therapy or after.”

Immune active HBV infection requires immediate medical attention regarding therapy, and immune inactive HBV infection requires monitoring due to the transition from immune inactive to immune active disease, she said.

Next: More recommendations

The panel also recommended:

·       HBV vaccination for all susceptible individuals (those not immunized or without evidence of response to immunization);

·       Obtaining a test for HBV DNA prior to DAA therapy in patients who could be actively replicating (those who are HBsAg positive);

·       Starting patients who meet criteria for treatment of active HBV infection on therapy at the same time or before HCV DAA therapy is started; and

·       Monitoring patients with low or undetectable HBV DNA levels at regular intervals (usually not more frequently than every four weeks) for HBV reactivation during treatments and placing those whose HBV DNA levels meet treatment criteria on HBV therapy as recommended by the AASLD’s HBV treatment guidelines.

When HBV reactivations occur in HCV co-infected patients during DAA treatment for HCV, “if liver enzymes increase and/or HBV DNA increases, this would warrant the initiation of a first line antiviral for HBV. This patient should then be monitored to ensure biochemical and viral response to therapy. DAA therapy should not be discontinued in this setting,” said Naggie.

Her bottom-line message is: “Knowledge is key. Clinicians who treat HCV need to know their HCV patients HBV and HIV status prior to starting therapy. Decision making around whether a HBV/HCV co-infected patient should receive HBV therapy should be based on the AASLD HBV Guideline, and if that patient does not warrant HBV therapy per guidelines (including lack of severe fibrosis/cirrhosis), then close monitoring of liver enzymes and HBV DNA during and six months after DAA therapy is recommended. Furthermore, this patient’s HBV infection needs to be monitored for transition to immune active disease for their life and appropriate hepatocellular carcinoma screening and liver-related care initiated.”

The recommendations for testing, managing and treating HCV were published online September 16, 2016.