Review: prevention of chemotherapy/ immuno-suppressive therapy (CH/ISTH) related flare up of hepatitis B (HepB) with lamivudine (LAM)

Background: Hepatitis B virus (HBV) can exist as an inactive chronic infection in a high percentage of infected patients. Accumulating experience suggests that accelerated viral replication during Ch/IsTh and/or discontinuation of such therapies may lead to flare up of HepB. Objectives: With systematic review of available literature and our own seven patients we evaluated the rationale of LAM prophylaxis in HBV carrier patients during Ch/IsTh.

Results: No systematic prospective studies, but numerous cases with severe reactivation of HBV in such situations are reported in the literature. Reported cases include bone marrow, kidney and lung transplant patients as well as patients with different hematological malignancies. Some of these patients with HBc-IgG antibodies re-converted from negative HBsAg status to positive during Ch/IsTh. Three out of our patients who received no LAM prophylaxis suffered severe/fulminant HBV flare up with one fatal outcome (despite of subsequent LAM treatment). Consistent with pre-core mutants, two of these patients remained negative for HBeAg during their flare ups, with detectable HBV DNA levels. In contrast, out of our four patients on LAM prophylaxis, two developed only mild/moderate transaminase elevations, while liver functions remained normal in the others. Conclusion: Literature review as well as our experience suggest that lamivudine prophylaxis seems to be a feasible strategy to prevent severe/fatal HBV flare up related to Ch/IsTh. Screening for HBsAg is mandatory prior to such therapies (but it might be insufficient without HBc-IgG).