Prevention and Treatment of Hepatitis B Virus Reactivation (HBVr) in At-Risk Individuals
2025 Guideline from the American Gastroenterological Association for Hepatits B Virus Reactivation.
HBVr Risk
High Risk
For individuals at high risk of HBVr, the AGA recommends antiviral prophylaxis over monitoring alone.
1. This recommendation assumes the use of antivirals with a high barrier to resistance.
2. Antiviral prophylaxis should be started before start of medications that impose risk of HBVr and should be continued for at least 6 months after discontinuation of risk-imposing therapy (at least 12 months for B cell–depleting agents).
1. This recommendation assumes the use of antivirals with a high barrier to resistance.
2. Antiviral prophylaxis should be started before start of medications that impose risk of HBVr and should be continued for at least 6 months after discontinuation of risk-imposing therapy (at least 12 months for B cell–depleting agents).
Strong recommendation
Moderate quality evidence
Moderate Risk
For individuals at moderate risk of HBVr, the AGA suggests antiviral prophylaxis over monitoring alone.
1. This recommendation assumes the use of antivirals with a high barrier to resistance.
2. Patients who place a higher value on avoiding long-term use of antiviral therapy and the cost associated with its use, and a lower value on avoiding the small risk of reactivation (particularly in those who are HBsAg-negative) may reasonably select active monitoring over antiviral prophylaxis, with careful consideration of feasibility and likelihood of adherence to long-term monitoring. Monitoring should be performed at 1- to 3-month intervals, and must include assessment of hepatitis B viral load in addition to assessment of alanine aminotransferase.
1. This recommendation assumes the use of antivirals with a high barrier to resistance.
2. Patients who place a higher value on avoiding long-term use of antiviral therapy and the cost associated with its use, and a lower value on avoiding the small risk of reactivation (particularly in those who are HBsAg-negative) may reasonably select active monitoring over antiviral prophylaxis, with careful consideration of feasibility and likelihood of adherence to long-term monitoring. Monitoring should be performed at 1- to 3-month intervals, and must include assessment of hepatitis B viral load in addition to assessment of alanine aminotransferase.
Conditional recommendation
Moderate quality evidence
Low Risk
For individual at low risk of HBVr, the AGA suggests monitoring alone over using antiviral prophylaxis.
1. This recommendation assumes regular and sufficient follow-up that ensures continued monitoring.
2. Patients who place a higher value on avoiding the small risk of reactivation (particularly those who may be on more than 1 low-risk immunosuppressive medication) and a lower value on the burden and cost of antiviral therapy may reasonably select antiviral therapy.
1. This recommendation assumes regular and sufficient follow-up that ensures continued monitoring.
2. Patients who place a higher value on avoiding the small risk of reactivation (particularly those who may be on more than 1 low-risk immunosuppressive medication) and a lower value on the burden and cost of antiviral therapy may reasonably select antiviral therapy.
Conditional recommendation
Moderate quality evidence
All Risk
For individuals at risk of HBVr, the AGA recommends testing for hepatitis B.
1. Given universal Centers for Disease Control and Prevention (CDC) screening guidance for hepatitis B for all adults aged 18 years by testing for HBsAg, anti-HBs, and total anti-HBc, stratifying screening practices by magnitude of HBVr risk is no longer needed.
2. It is reasonable to test initially for serologic markers alone (at minimum for HBsAg, anti-HBc) followed by viral load testing (HBV-DNA) if HBsAg and/or anti-HBc is positive.
1. Given universal Centers for Disease Control and Prevention (CDC) screening guidance for hepatitis B for all adults aged 18 years by testing for HBsAg, anti-HBs, and total anti-HBc, stratifying screening practices by magnitude of HBVr risk is no longer needed.
2. It is reasonable to test initially for serologic markers alone (at minimum for HBsAg, anti-HBc) followed by viral load testing (HBV-DNA) if HBsAg and/or anti-HBc is positive.
Strong recommendation
Moderate quality evidence
What do the icons mean?
How strong is the AGA's recommendation?
Strong recommendation
Most individuals in this situation would want the recommended course of action, and only a small proportion would not.Conditional recommendation
The majority of individuals in this situation would want the suggested course of action, but many would not.Moderate quality evidence
We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.Literature
Original/Primary Reference
