The American Gastroenterological Association has released updated clinical practice guidelines for preventing and treating hepatitis B virus reactivation in at-risk patients. 

These guidelines, published in Gastroenterology, provide evidence-based recommendations for risk stratification, newer immunotherapies, and updated treatment scenarios. The panel was led by Faisal S. Ali of the Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Havard Medical School, Boston, Massachusetts.

Key Recommendations

• Antiviral Prophylaxis: The expert panel made a strong recommendation for high-risk patients (baseline hepatitis B virus (HBV) reactivation risk over 10%) and a conditional recommendation for moderate-risk (1% to 10%) and low-risk patients (under 1%). Prophylaxis should begin before initiating risk-imposing therapy and continue for at least 6 months after therapy completion (12 months for B cell–depleting agents).

• HBV Testing: Universal testing for HBsAg, anti-HBc, and anti-HBs is strongly recommended for all adults aged 18 and older, following the CDC’s updated screening guidelines. Stratified screening based on HBVr risk is no longer recommended by the panel.

Risk Categorization

The panel categorized HBVr risk based on serological status and exposure:

• High-Risk: Includes HBsAg-positive patients undergoing B cell–depleting therapy (eg, rituximab), anti-TNF agents, or HCV treatment with direct-acting antivirals.
• Moderate-Risk: Includes HBsAg-negative/anti-HBc-positive individuals exposed to anthracycline derivatives, cytokine/integrin inhibitors, or CAR-T cell therapy.

Monitoring is recommended at 1-to 3-month intervals for low-risk patients, focusing on HBV viral load and ALT levels.

Antiviral Prophylaxis: Benefits and Risks

Antiviral prophylaxis reduces HBVr risk by 82% and decreases hepatitis flare rates by 72%. Despite these benefits, the panel noted potential adverse effects such as renal or bone complications associated with tenofovir disoproxil fumarate and financial barriers to accessing therapy.

Addressing Knowledge Gaps

The panel highlighted limitations in evidence for therapies, such as tyrosine kinase inhibitors and anti-IL6 agents, and noted the need for robust, real-world data to refine risk stratification and recommendations. Maintenance of registries and periodic updates have been proposed to bridge these gaps.

Implementation and Future Updates

These updated recommendations underwent a rigorous review process, including systematic evidence synthesis, peer review, and public comment. The guideline panel anticipates further updates in 5 years to incorporate emerging therapies and data.