Hepatitis B reactivation prophylaxis in immune-suppressed patients

In their letter “Hepatitis B virus-related liver disease in isolated anti-hepatitis b-core positive lymphoma patients receiving chemo- or chemo-immune therapy” Targhetta et al. conclude that in the case of occult HBV infection in lymphoma patients close monitoring is mandatory, whereas there is no clearcut indication to chemoprophylaxis (e.g. Lamivudine).1

We think that this statement is to be argued in that: they did not mention if they measured HBV DNA levels before and during treatment and later on during follow-up. In the face of normal liver function tests, this simple and widely available laboratory tool allows a better definition of the real infectious status of the patients Other more sophisticated investigations such as determination of covalently closed circular DNA (cccDNA) of HBV virus in the liver remain in the realm of research laboratories and clinical trials, and are as yet beyond daily routine practice.2

In any case, we strongly support the implementation of HBV reactivation prophylaxis even in HBV DNA negative subjects who are to receive prolonged and efficient immune suppressive interventions of any kind, since we have no means to predict who will remain negative and who will reactivate.3

Even after recovering and attaining normalization of liver function, reactivated patients often revert indefinitely to HbsAg positivity, as reported in the authors’ experience, which complicates their further management should they require other courses of chemo-immune therapy or transplantation. To be effective lamivudine prophylaxis must be initiated before treatment and protracted well beyond the cessation of immune suppressive therapy, due to the effects of rebounds in immune competence upon the latent infection (as the late reactivation cited by the authors underline).

Lamivudine is quite a safe drug and its administration is cost effective, given the high costs, both clinical and economic, enthralled by a reactivation of HBV infection in individuals who are not able to cope.

Moreover, in times of hugely increased litigation, a feasible prophylaxis to prevent a potentially life threatening event4 subsequent to a medical act is an option to be highly recommended.