Prevention and Management of HBV/HCV in Patients With IBD
Prevention and Management of HBV/HCV in Patients With IBD
Background Viral hepatitis is a very common infection.
Aim To review the prevention and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in inflammatory bowel disease (IBD).
Methods Bibliographical searches were performed in MEDLINE up to September 2010.
Results The prevalence of both HBV and HCV infection in IBD patients is now similar to that of the general population. All IBD patients should be screened for HBV markers at diagnosis. Liver dysfunction in IBD patients treated with immunosuppressants is more frequent and severe in HBV than in HCV carriers and is associated with combined immunosuppression. In patients receiving anti-TNF drugs, HBV reactivation is common unless anti-viral prophylaxis is administered. HBsAg-positive patients should receive anti-viral prophylaxis before starting immunosuppressants. As interferon might worsen underlying IBD, nucleoside/nucleotide analogues are preferred for anti-viral prophylaxis in patients with HBV (tenofovir/entecavir are preferred to lamivudine). IBD patients should be vaccinated against HBV at diagnosis. The response rate to HBV vaccination is low, mainly in those receiving anti-TNF therapy. The serological response to HBV vaccine should be confirmed, and patients with an inadequate response should receive a second full series of vaccine. Peginterferon (±ribavirin) for HCV infection is as effective and safe as in non-IBD patients.
Conclusions The present manuscript poses a series of questions on the prevention and management of HBV/HCV infection in IBD, and attempts to answer them using scientific evidence in order to provide practical conclusions for the clinician.
Viral hepatitis is a very common infection: over 350 million people worldwide have chronic hepatitis B virus (HBV) infection and over 250 million people have chronic hepatitis C virus (HCV) infection.
In the last 10 years, the treatment of inflammatory bowel disease (IBD), which includes both Crohn's disease (CD) and ulcerative colitis (UC), has been marked by the increasing use of immunosuppressors (mainly azathioprine/mercaptopurine and methotrexate) and by the advent of biological therapies. Increasing evidence in favour of immunosuppressors means that they are being used more often and earlier in the course of the disease.
Many issues concerning the relationship between IBD and HBV/HCV infection remain unresolved. For example, the prevalence of HBV and HCV infection in IBD patients has received little attention and it is still unclear which patients should be screened for HBV/HCV and when. Such questions are particularly relevant, as immunomodulator therapy has a clear impact on the natural history of viral hepatitis, although it is not clear which factors increase the risk of HBV reactivation in IBD patients treated with immunosuppressants. Deciding on the most suitable candidates for anti-viral prophylaxis and timing of this treatment are also matters of debate, as is the type of prophylaxis to be chosen. Although a consensus exists on the need to vaccinate IBD patients against HBV infection, vaccination seems to be under-used in clinical practice. Furthermore, the efficacy of HBV vaccination, specifically in IBD patients, and the factors influencing this efficacy are unknown. Several types, doses and schedules of HBV vaccination have been recommended in the general population, and it has been suggested that modified dosing regimens might increase response rates in IBD patients. Whether testing for serological immunity should be systematically performed after HBV vaccination in patients with IBD remains controversial, as does the most suitable cut-off titre for antibodies to hepatitis B surface antigen (anti-HBs). It has been suggested that a second course of HBV vaccination is recommendable in IBD patients whose first vaccination attempt fails, but the effectiveness of this rescue strategy has not been proven. We do not know how long anti-HBs antibody titres remain positive after HBV vaccination and, consequently, whether anti-HBs titres should be periodically monitored and whether booster vaccines should be considered. Finally, issues concerning the efficacy and safety of anti-viral treatment in patients with IBD have not been resolved, and more information is required on the risk of exacerbation of IBD in patients treated with interferon.
The present manuscript poses a series of questions on the relationship between IBD and HBV/HCV infection and attempts to answer them using scientific evidence to provide practical conclusions for the clinician who diagnoses and treats patients with IBD.
Bibliographical searches were performed in MEDLINE up to September 2010 using the following key words (all fields): ('inflammatory bowel disease' OR 'Crohn's disease' OR 'ulcerative colitis') AND hepatitis.
Abstract and Introduction
Abstract
Background Viral hepatitis is a very common infection.
Aim To review the prevention and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in inflammatory bowel disease (IBD).
Methods Bibliographical searches were performed in MEDLINE up to September 2010.
Results The prevalence of both HBV and HCV infection in IBD patients is now similar to that of the general population. All IBD patients should be screened for HBV markers at diagnosis. Liver dysfunction in IBD patients treated with immunosuppressants is more frequent and severe in HBV than in HCV carriers and is associated with combined immunosuppression. In patients receiving anti-TNF drugs, HBV reactivation is common unless anti-viral prophylaxis is administered. HBsAg-positive patients should receive anti-viral prophylaxis before starting immunosuppressants. As interferon might worsen underlying IBD, nucleoside/nucleotide analogues are preferred for anti-viral prophylaxis in patients with HBV (tenofovir/entecavir are preferred to lamivudine). IBD patients should be vaccinated against HBV at diagnosis. The response rate to HBV vaccination is low, mainly in those receiving anti-TNF therapy. The serological response to HBV vaccine should be confirmed, and patients with an inadequate response should receive a second full series of vaccine. Peginterferon (±ribavirin) for HCV infection is as effective and safe as in non-IBD patients.
Conclusions The present manuscript poses a series of questions on the prevention and management of HBV/HCV infection in IBD, and attempts to answer them using scientific evidence in order to provide practical conclusions for the clinician.
Introduction
Viral hepatitis is a very common infection: over 350 million people worldwide have chronic hepatitis B virus (HBV) infection and over 250 million people have chronic hepatitis C virus (HCV) infection.
In the last 10 years, the treatment of inflammatory bowel disease (IBD), which includes both Crohn's disease (CD) and ulcerative colitis (UC), has been marked by the increasing use of immunosuppressors (mainly azathioprine/mercaptopurine and methotrexate) and by the advent of biological therapies. Increasing evidence in favour of immunosuppressors means that they are being used more often and earlier in the course of the disease.
Many issues concerning the relationship between IBD and HBV/HCV infection remain unresolved. For example, the prevalence of HBV and HCV infection in IBD patients has received little attention and it is still unclear which patients should be screened for HBV/HCV and when. Such questions are particularly relevant, as immunomodulator therapy has a clear impact on the natural history of viral hepatitis, although it is not clear which factors increase the risk of HBV reactivation in IBD patients treated with immunosuppressants. Deciding on the most suitable candidates for anti-viral prophylaxis and timing of this treatment are also matters of debate, as is the type of prophylaxis to be chosen. Although a consensus exists on the need to vaccinate IBD patients against HBV infection, vaccination seems to be under-used in clinical practice. Furthermore, the efficacy of HBV vaccination, specifically in IBD patients, and the factors influencing this efficacy are unknown. Several types, doses and schedules of HBV vaccination have been recommended in the general population, and it has been suggested that modified dosing regimens might increase response rates in IBD patients. Whether testing for serological immunity should be systematically performed after HBV vaccination in patients with IBD remains controversial, as does the most suitable cut-off titre for antibodies to hepatitis B surface antigen (anti-HBs). It has been suggested that a second course of HBV vaccination is recommendable in IBD patients whose first vaccination attempt fails, but the effectiveness of this rescue strategy has not been proven. We do not know how long anti-HBs antibody titres remain positive after HBV vaccination and, consequently, whether anti-HBs titres should be periodically monitored and whether booster vaccines should be considered. Finally, issues concerning the efficacy and safety of anti-viral treatment in patients with IBD have not been resolved, and more information is required on the risk of exacerbation of IBD in patients treated with interferon.
The present manuscript poses a series of questions on the relationship between IBD and HBV/HCV infection and attempts to answer them using scientific evidence to provide practical conclusions for the clinician who diagnoses and treats patients with IBD.
Bibliographical searches were performed in MEDLINE up to September 2010 using the following key words (all fields): ('inflammatory bowel disease' OR 'Crohn's disease' OR 'ulcerative colitis') AND hepatitis.
Source...