Article Search
검색
검색 팝업 닫기

Metrics

Help

  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
  • 3. Editorial Office
  • 4. Articles
  • 5. Instructions for Authors
  • 6. File Download (PDF version)
  • 7. Ethical Standards
  • 8. Peer Review

    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
    The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.

    The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.

Search

Search

Year

to

Article Type

Editorial

Split Viewer

Antiviral Prophylaxis Against Hepatitis B Virus in Patients Treated with Anti-Tumor Necrosis Factor α Agents for Inflammatory Bowel Disease

Eun Ae Kang , Jae Hee Cheon

Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

Correspondence to:Jae Hee Cheon
ORCID https://orcid.org/0000-0002-2282-8904
E-mail geniushee@yuhs.ac

See “Clinical Course of Hepatitis B Viral Infection in Patients Undergoing Anti-Tumor Necrosis Factor α Therapy for Inflammatory Bowel Disease” by Ji Min Lee, et al. on page 396, Vol. 16, No. 3, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2022; 16(4): 501-502

Published online July 15, 2022 https://doi.org/10.5009/gnl220186

Copyright © Gut and Liver.

Hepatitis B virus (HBV) infection is common in East Asia including Korea and Taiwan. Korea is an intermediate endemic country for HBV infection.1 For this reason, HBV vaccination is recommended as a mandatory vaccination for infants in Korea. Liver cirrhosis and hepatocellular carcinoma (HCC) can develop from chronic HBV infection. HCC is the sixth most common cancer and second leading cause of cancer mortality in Korea.2 Approximately 70% of HCC is associated with chronic HBV infection.3 Chronic HBV infection is defined as the positive result of HBV surface antigen. Inactive HBV carrier state is defined as hepatitis B envelope antigen-negative state, low levels of HBV DNA, and normal liver function. Resolved HBV infection is defined as a seroconverted state with anti-hepatitis B core antigen-positive. HBV can be reactivated when immunosuppressed in inactive HBV carriers or in those with resolved hepatitis. Chemotherapy or use of immunomodulators, anti-tumor necrosis factor α (anti-TNF-α) agents, or corticosteroids are known to be related to reactivation of HBV. Therefore, a preemptive use of antiviral agents in case of anti-TNF-α therapy is recommended.

As the prevalence of inflammatory bowel disease (IBD) increases in Korea, the rate of anti-TNF-α therapy in patients with IBD is also increasing.4-6 Prophylactic antiviral therapy is recommended for patients with IBD and chronic HBV infection treated with anti-TNF-α therapy in the guidelines.7-9 However, the level of evidence of recommendation of antiviral prophylaxis of HBV is relatively low. There have been insufficient studies on whether HBV prophylaxis should be implemented in patients with IBD and particularly in those with chronic HBV infection receiving anti-TNF therapy.

Regarding the last issue, Lee et al.10 reported the clinical courses of HBV infection in patients with IBD who had anti-TNF-α treatment. The authors aimed to investigate the risk of HBV reactivation in IBD patients receiving anti-TNF-α therapy. Patients with IBD with either chronic or resolved HBV infection and underwent anti-TNF-α therapy were included. Given results of the liver function test of the study population, enrolled patients were considered inactive carriers or at the stage of immune tolerance. A total of 191 patients with IBD were included. Of them, 87 patients (46%) were diagnosed as having chronic HBV infection. Fifty-four of the 87 patients (28.3%) were treated with a prophylactic antiviral agent. Fifty-two of the 54 patients (96%) had chronic HBV infection. This retrospective multinational study showed that 7.3% of patients (14/191) had liver dysfunction due to HBV reactivation during anti-TNF therapy. Most of the patients who experienced HBV reactivation were chronic HBV-infected state and had no prophylactic antiviral agents (non-prophylaxis group [26%] vs prophylaxis group [8%], p=0.02). Antiviral prophylaxis significantly reduced the risk of liver dysfunction due to HBV reactivation in chronic HBV-infected patients (odds ratio, 0.16; 95% confidence interval, 0.04 to 0.66; p=0.01). However, there was no significant prophylactic effect of antiviral therapy in the group with resolved infection. There was no further increased risk of reactivation of HBV when anti-TNF-α therapy was combined with immunomodulatory agents. Moreover, antiviral prophylaxis did not affect the clinical course of IBD including cumulative disease flare, hospitalization, or surgery rates.

HBV reactivation in patients with chronic HBV infection can be fatal in cases of liver failure. Liver dysfunction due to HBV reactivation leads to discontinuation of anti-TNF-α therapy, which may affect the disease courses of IBD. Antiviral prophylaxis suggested by the existing guidelines is justified. However, it is not helpful for patients with resolved HBV infection. There were several limitations in this study in terms of the nature of the retrospective study and the small sample size. Data of preferred biologics, duration of treatment, and follow-up plans were also lacking. More research is needed on how to effectively prevent and manage chronic HBV infection in endemic countries including Korea and Taiwan. Studies on the relationship between the risk of hepatitis A or C and anti-TNF-α therapy are also needed. Randomized controlled trials are usually difficult to conduct because several studies have already shown beneficial effects of antiviral prophylaxis. Furthermore, studies are needed to investigate the effects of antiviral prophylaxis in patients with both IBD and chronic HBV infection undergoing other biologics and small molecules, such as ustekinumab, vedolizumab, or tofacitinib.

No potential conflict of interest relevant to this article was reported.

  1. Yim SY, Kim JH. The epidemiology of hepatitis B virus infection in Korea. Korean J Intern Med 2019;34:945-953.
    Pubmed KoreaMed CrossRef
  2. Kim BH, Park JW. Epidemiology of liver cancer in South Korea. Clin Mol Hepatol 2018;24:1-9.
    Pubmed KoreaMed CrossRef
  3. Lee YS, Seo YS, Kim JH, et al. Can more aggressive treatment improve prognosis in patients with hepatocellular carcinoma? A direct comparison of the Hong Kong Liver Cancer and Barcelona Clinic Liver Cancer Algorithms. Gut Liver 2018;12:94-101.
    Pubmed KoreaMed CrossRef
  4. Song EM, Yang SK. Natural history of inflammatory bowel disease: a comparison between the East and the West. Intest Res. Epub. Epub 2021 Dec 2; https://doi.org/10.5217/ir.2021.00104.
    Pubmed CrossRef
  5. Song JH, Kang EA, Park SK, et al. Long-term outcomes after the discontinuation of anti-tumor necrosis factor-α therapy in patients with inflammatory bowel disease under clinical remission: a Korean Association for the Study of Intestinal Disease Multicenter Study. Gut Liver 2021;15:752-762.
    Pubmed KoreaMed CrossRef
  6. Park SH. Update on the epidemiology of inflammatory bowel disease in Asia: where are we now? Intest Res 2022;20:159-164.
    Pubmed KoreaMed CrossRef
  7. Degasperi E, Caprioli F, El Sherif O, Back D, Colombo M, Aghemo A. Challenges in treating patients with inflammatory bowel disease and concurrent viral hepatitis infection. Expert Rev Gastroenterol Hepatol 2016;10:1373-1383.
    Pubmed CrossRef
  8. Park SK, Choi CH, Chun J, et al. Prevention and management of viral hepatitis in inflammatory bowel disease: a clinical practice guideline by the Korean Association for the Study of Intestinal Diseases. Intest Res 2020;18:18-33.
    Pubmed KoreaMed CrossRef
  9. Ooi CJ, Hilmi I, Banerjee R, et al. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. Intest Res 2019;17:285-310.
    Pubmed KoreaMed CrossRef
  10. Lee JM, Wei SC, Lee KM, et al. Clinical course of hepatitis B viral infection in patients undergoing anti-tumor necrosis factor α therapy for inflammatory bowel disease. Gut Liver 2022;16:396-403.
    Pubmed KoreaMed CrossRef

Article

Editorial

Gut and Liver 2022; 16(4): 501-502

Published online July 15, 2022 https://doi.org/10.5009/gnl220186

Copyright © Gut and Liver.

Antiviral Prophylaxis Against Hepatitis B Virus in Patients Treated with Anti-Tumor Necrosis Factor α Agents for Inflammatory Bowel Disease

Eun Ae Kang , Jae Hee Cheon

Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

Correspondence to:Jae Hee Cheon
ORCID https://orcid.org/0000-0002-2282-8904
E-mail geniushee@yuhs.ac

See “Clinical Course of Hepatitis B Viral Infection in Patients Undergoing Anti-Tumor Necrosis Factor α Therapy for Inflammatory Bowel Disease” by Ji Min Lee, et al. on page 396, Vol. 16, No. 3, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Hepatitis B virus (HBV) infection is common in East Asia including Korea and Taiwan. Korea is an intermediate endemic country for HBV infection.1 For this reason, HBV vaccination is recommended as a mandatory vaccination for infants in Korea. Liver cirrhosis and hepatocellular carcinoma (HCC) can develop from chronic HBV infection. HCC is the sixth most common cancer and second leading cause of cancer mortality in Korea.2 Approximately 70% of HCC is associated with chronic HBV infection.3 Chronic HBV infection is defined as the positive result of HBV surface antigen. Inactive HBV carrier state is defined as hepatitis B envelope antigen-negative state, low levels of HBV DNA, and normal liver function. Resolved HBV infection is defined as a seroconverted state with anti-hepatitis B core antigen-positive. HBV can be reactivated when immunosuppressed in inactive HBV carriers or in those with resolved hepatitis. Chemotherapy or use of immunomodulators, anti-tumor necrosis factor α (anti-TNF-α) agents, or corticosteroids are known to be related to reactivation of HBV. Therefore, a preemptive use of antiviral agents in case of anti-TNF-α therapy is recommended.

As the prevalence of inflammatory bowel disease (IBD) increases in Korea, the rate of anti-TNF-α therapy in patients with IBD is also increasing.4-6 Prophylactic antiviral therapy is recommended for patients with IBD and chronic HBV infection treated with anti-TNF-α therapy in the guidelines.7-9 However, the level of evidence of recommendation of antiviral prophylaxis of HBV is relatively low. There have been insufficient studies on whether HBV prophylaxis should be implemented in patients with IBD and particularly in those with chronic HBV infection receiving anti-TNF therapy.

Regarding the last issue, Lee et al.10 reported the clinical courses of HBV infection in patients with IBD who had anti-TNF-α treatment. The authors aimed to investigate the risk of HBV reactivation in IBD patients receiving anti-TNF-α therapy. Patients with IBD with either chronic or resolved HBV infection and underwent anti-TNF-α therapy were included. Given results of the liver function test of the study population, enrolled patients were considered inactive carriers or at the stage of immune tolerance. A total of 191 patients with IBD were included. Of them, 87 patients (46%) were diagnosed as having chronic HBV infection. Fifty-four of the 87 patients (28.3%) were treated with a prophylactic antiviral agent. Fifty-two of the 54 patients (96%) had chronic HBV infection. This retrospective multinational study showed that 7.3% of patients (14/191) had liver dysfunction due to HBV reactivation during anti-TNF therapy. Most of the patients who experienced HBV reactivation were chronic HBV-infected state and had no prophylactic antiviral agents (non-prophylaxis group [26%] vs prophylaxis group [8%], p=0.02). Antiviral prophylaxis significantly reduced the risk of liver dysfunction due to HBV reactivation in chronic HBV-infected patients (odds ratio, 0.16; 95% confidence interval, 0.04 to 0.66; p=0.01). However, there was no significant prophylactic effect of antiviral therapy in the group with resolved infection. There was no further increased risk of reactivation of HBV when anti-TNF-α therapy was combined with immunomodulatory agents. Moreover, antiviral prophylaxis did not affect the clinical course of IBD including cumulative disease flare, hospitalization, or surgery rates.

HBV reactivation in patients with chronic HBV infection can be fatal in cases of liver failure. Liver dysfunction due to HBV reactivation leads to discontinuation of anti-TNF-α therapy, which may affect the disease courses of IBD. Antiviral prophylaxis suggested by the existing guidelines is justified. However, it is not helpful for patients with resolved HBV infection. There were several limitations in this study in terms of the nature of the retrospective study and the small sample size. Data of preferred biologics, duration of treatment, and follow-up plans were also lacking. More research is needed on how to effectively prevent and manage chronic HBV infection in endemic countries including Korea and Taiwan. Studies on the relationship between the risk of hepatitis A or C and anti-TNF-α therapy are also needed. Randomized controlled trials are usually difficult to conduct because several studies have already shown beneficial effects of antiviral prophylaxis. Furthermore, studies are needed to investigate the effects of antiviral prophylaxis in patients with both IBD and chronic HBV infection undergoing other biologics and small molecules, such as ustekinumab, vedolizumab, or tofacitinib.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Yim SY, Kim JH. The epidemiology of hepatitis B virus infection in Korea. Korean J Intern Med 2019;34:945-953.
    Pubmed KoreaMed CrossRef
  2. Kim BH, Park JW. Epidemiology of liver cancer in South Korea. Clin Mol Hepatol 2018;24:1-9.
    Pubmed KoreaMed CrossRef
  3. Lee YS, Seo YS, Kim JH, et al. Can more aggressive treatment improve prognosis in patients with hepatocellular carcinoma? A direct comparison of the Hong Kong Liver Cancer and Barcelona Clinic Liver Cancer Algorithms. Gut Liver 2018;12:94-101.
    Pubmed KoreaMed CrossRef
  4. Song EM, Yang SK. Natural history of inflammatory bowel disease: a comparison between the East and the West. Intest Res. Epub. Epub 2021 Dec 2; https://doi.org/10.5217/ir.2021.00104.
    Pubmed CrossRef
  5. Song JH, Kang EA, Park SK, et al. Long-term outcomes after the discontinuation of anti-tumor necrosis factor-α therapy in patients with inflammatory bowel disease under clinical remission: a Korean Association for the Study of Intestinal Disease Multicenter Study. Gut Liver 2021;15:752-762.
    Pubmed KoreaMed CrossRef
  6. Park SH. Update on the epidemiology of inflammatory bowel disease in Asia: where are we now? Intest Res 2022;20:159-164.
    Pubmed KoreaMed CrossRef
  7. Degasperi E, Caprioli F, El Sherif O, Back D, Colombo M, Aghemo A. Challenges in treating patients with inflammatory bowel disease and concurrent viral hepatitis infection. Expert Rev Gastroenterol Hepatol 2016;10:1373-1383.
    Pubmed CrossRef
  8. Park SK, Choi CH, Chun J, et al. Prevention and management of viral hepatitis in inflammatory bowel disease: a clinical practice guideline by the Korean Association for the Study of Intestinal Diseases. Intest Res 2020;18:18-33.
    Pubmed KoreaMed CrossRef
  9. Ooi CJ, Hilmi I, Banerjee R, et al. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. Intest Res 2019;17:285-310.
    Pubmed KoreaMed CrossRef
  10. Lee JM, Wei SC, Lee KM, et al. Clinical course of hepatitis B viral infection in patients undergoing anti-tumor necrosis factor α therapy for inflammatory bowel disease. Gut Liver 2022;16:396-403.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.16 No.4
July, 2022

pISSN 1976-2283
eISSN 2005-1212

qrcode
qrcode

Share this article on :

  • line

Popular Keywords

Gut and LiverQR code Download
qr-code

Editorial Office