Surveillance and Treatment Protocols to Detect and Treat Hepatitis B Virus Reactivation in Hepatitis B Surface Antigen–Negative/Antibody to Hepatitis B Core Antigen–Positive Patients Receiving Chemotherapy for Onco-Hematologic Malignancies

Abstract

TO THE EDITOR: We read with interest the article by Niitsu et al, and we compliment the authors for having focused their attention on the group of hepatitis B surface antigen–negative/antibody to hepatitis B core antigen–positive patients who are undergoing chemotherapy for onco-hematologic malignancies and who are at high risk for hepatitis B reactivation, especially if receiving rituximab-based protocols. In this setting, the risks of hepatitis B virus (HBV) reactivation and development of difficult-to-treat acute hepatitis characterized by high mortality rates need to be clarified, and appropriate screening and managing protocols should be developed. However, some specific questions regarding the article do arise. What is the cost of monthly dosing of HBV-DNA and the antibody to the hepatitis B surface antigen titer? Has the cost-effectiveness profile of this approach been addressed or compared with alternative strategies? What HBV-DNA levels were detected at reactivation? It would be interesting to provide this information, given that the decision to use a high-potency/high-genetic barrier antiviral such as entecavir to treat low-level HBV-DNA reactivation might be excessive. Actually, in patients with reactivation that is characterized by low levels of HBVDNA, lamivudine still presents an attractive treatment solution, given its relative availability, effectiveness, and low cost. The use of other, more potent antivirals such as entecavir could be considered for the management of patients with higher levels of HBV-DNA or acute hepatitis that develops as a result of HBV reactivation. In addition, the strategy of lamivudine prophylaxis in selected high-risk groups may present an additional option to be considered in the setting of immunosuppression during the treatment of onco-hematologic malignancies. Answers to these questions are crucial to define the applicability of the authors’ findings to everyday practice, especially in countries in which the availability of high-cost medications and surveillance protocols might hamper the feasibility of this approach. Definition of surveillance strategies for isolated patients with an antibody to the hepatitis B core antigen who are undergoing chemotherapy and are at risk for HBV reactivation, and how to manage the manifestations of reactivation, which range from isolated increases of HBV-DNA to severe acute hepatitis and liver failure, still remain debated issues.