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Villacis-Nunez DS, Orenstein E, Selvaggio P, Rouster-Stevens K, Wang CS, Thakral A. Improving Hepatitis B Screening Prior to Rituximab: A Quality Improvement Project. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1142. [PMID: 37508639 PMCID: PMC10378200 DOI: 10.3390/children10071142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/25/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023]
Abstract
Rituximab, used in the treatment of some rheumatic and kidney diseases, can lead to hepatitis B virus (HBV) reactivation; HBV screening is recommended for those starting this medication. We aimed to improve by 50% the proportion of patients undergoing HBV screening by implementing multimodal interventions to support clinicians in this evidence-based practice. We conducted a quality improvement project from November 2020 to June 2022 at a tertiary care pediatric hospital system, including patients with rheumatic and/or kidney diseases starting rituximab. Multimodal interventions targeting clinicians included electronic health tools (dot phrase, display of screening recommendations and screening results in rituximab order sets/therapy plans), educational meetings, and e-mail/paper reminders. The primary outcome was the proportion of patients with complete HBV screening, while the secondary outcome was utilization of each laboratory component, tracked using statistical process control charts. Pre- and post-intervention data were compared using Fisher's test. One hundred eighty-two patients who had been prescribed rituximab were included, of which 98 (54%) were post-intervention. The proportions of patients undergoing complete HBV screening (6% vs. 44%; p < 0.001), HBsAg collection (60% vs. 79%; p = 0.006), anti-HBsAb collection (14% vs. 54%; p < 0.001), and total anti-HBcAb collection (8% vs. 52%; p < 0.001) were significantly higher in the post-intervention period. Improvement was sustained over 18 months, with shifts and/or data points above the control limits in all measures. Forty-five patients were HBV-non-immune. In this study, multimodal interventions including electronic health tools and education of the provider significantly increased the proportion of patients screened for HBV prior to rituximab and identified immunization opportunities.
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Affiliation(s)
- D Sofia Villacis-Nunez
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children's Healthcare of Atlanta, Atlanta, GA 30329, USA
| | - Evan Orenstein
- Children's Healthcare of Atlanta, Atlanta, GA 30329, USA
- Division of Hospital Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | - Kelly Rouster-Stevens
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children's Healthcare of Atlanta, Atlanta, GA 30329, USA
| | - Chia-Shi Wang
- Children's Healthcare of Atlanta, Atlanta, GA 30329, USA
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Amit Thakral
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children's Healthcare of Atlanta, Atlanta, GA 30329, USA
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Baker H, Fine R, Suter F, Allore H, Hsiao B, Chowdhary V, Lavelle E, Chen P, Hintz R, Suter LG, Danve A. Implementation of a Best Practice Advisory to Improve Infection Screening Prior to New Prescriptions of Biologics and Targeted Synthetic Drugs. Arthritis Care Res (Hoboken) 2023. [PMID: 37382043 DOI: 10.1002/acr.25181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Use of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with preexisting tuberculosis (TB), hepatitis B virus (HBV), or hepatitis C virus (HCV) infection can have serious consequences. Although various society guidelines recommend routine screening for these infections before initiating certain b/tsDMARDs, adherence to these recommendations varies widely. This quality improvement initiative evaluated local compliance with screening and assessed whether an automated computerized decision support system in the form of a best practice advisory (BPA) in the electronic health record could improve patient screening. METHODS Established patients with autoimmune rheumatic disease (ARD) aged 18 years or older with at least one visit to our rheumatology practice between October 1, 2017, and March 3, 2022, were included. When prescribing a new b/tsDMARD, clinicians were alerted via a BPA that showed the most recent results for TB, HBV, and HCV. Screening proportions for TB, HBV, and HCV before BPA initiation were compared with those of eligible patients after the BPA implementation. RESULTS A total of 711 patients pre-BPA and 257 patients post-BPA implementation were included in the study. The BPA implementation was associated with statistically significant improvement in screening for TB from 66% to 82% (P ≤ 0.001), HCV from 60% to 79% (P ≤ 0.001), hepatitis B core antibody 32% to 51% (P ≤ 0.001), and hepatitis B surface antigen from 51% to 70% (P ≤ 0.001). CONCLUSION Implementation of a BPA can improve infectious disease screening for patients with ARD who are started on b/tsDMARDs and has potential to improve patient safety.
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Affiliation(s)
- Hailey Baker
- Yale New Haven Health System, New Haven, Connecticut
| | - Rebecca Fine
- Yale New Haven Health System, New Haven, Connecticut
| | | | | | | | | | | | - Ping Chen
- Yale New Haven Hospital, New Haven, Connecticut
| | | | - Lisa G Suter
- Yale University and West Haven Veterans Affairs Medical Center, New Haven, Connecticut
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Hwang JP, Artz AS, Shah P, Symington B, Feld JJ, Hammond SP, Ludwig E, Pai A, Ramsey SD, Schlam I, Suga JM, Wang SH, Somerfield MR. Practical Implementation of Universal Hepatitis B Virus Screening for Patients With Cancer. JCO Oncol Pract 2022; 18:636-644. [DOI: 10.1200/op.22.00074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Andy S. Artz
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Parth Shah
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Banu Symington
- Memorial Hospital of Sweetwater County, Rock Springs, WY
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sarah P. Hammond
- Massachusetts General Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - Emmy Ludwig
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amy Pai
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Su H. Wang
- Saint Barnabas Medical Center, Florham Park, NJ
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Aceituno L, Bañares J, Ruiz-Ortega L, Callejo-Pérez A, Muñoz-Couselo E, Ortiz-Velez C, Díaz-Mejía N, Barreira-Díaz A, Carreras MJ, Farriols A, Buti M, Riveiro-Barciela M. The Low Incidence of Viral Hepatitis Reactivation Among Subjects on Immunotherapy Reduces the Impact of Suboptimal Screening Rate. Front Med (Lausanne) 2022; 9:916213. [PMID: 35911389 PMCID: PMC9335294 DOI: 10.3389/fmed.2022.916213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/30/2022] [Indexed: 11/21/2022] Open
Abstract
Background and Aims Immunotherapy with immune checkpoint inhibitors (ICIs) is a pillar of many advanced tumors. However, there is scarce data concerning the rate of viral hepatitis screening in this population or the risk of viral reactivation. Methods Retrospective–prospective study that includes all patients who began ICIs between January/2019 and December/2020 in a University Hospital. Data on viral hepatitis screening prior to the beginning of ICIs were collected. In subjects lacking information, serological tests were requested prospectively. Among HBsAg, anti-HBc, or anti-HCV positive subjects, reactivation was prospectively assessed. Results During the 2-year period of study, 595 subjects received ICIs (61.2% male, mean age 63 years). The most prevalent cancers found were 35.5% lung cancer, 12.1% melanoma, and 8.2% head and neck; ICIs schemes were mainly anti-PD1 (65.7%), followed by anti-PD-L1 (19.2%), and combined therapy (13.6%). Prior to immunotherapy, anti-HCV screening was performed in 462 (77.6%) subjects, HBsAg in 462 (77.6%), anti-HBc in 335 (56.3%), and the complete screening in 328 (55.1%). The anti-HBc screening was more frequently ordered among patients treated with concomitant systemic therapy (p = 0.003), especially in the case of chemotherapy (p = 0.015), though HCV screening was more commonly performed in concomitant therapies different from chemotherapy (p = 0.001). Serological tests were completed prospectively in those alive, leading to an overall prevalence for anti-HCV of 3.5%, HBsAg at 1.3%, and anti-HBc of 15.2%. HCV-RNA was detected in 2/19 (both patients with hepatocellular carcinoma), HBV-DNA in 4/7 HBsAg positive, and in 1/75 anti-HBc positive subject. Five out of the 7 HBsAg carriers and 1/75 anti-HBc+ subjects (due to concomitant antiretroviral therapy) received antiviral prophylaxis. Neither cases of HBV reactivation nor changes in HCV viral load were observed. Discussion HBV and HCV screening prior to immunotherapy is suboptimal. Though the rate of viral hepatitis reactivation seems extremely low, efforts should be made to optimize viral hepatitis screening prior to immunotherapy for the selection of candidates for either antiviral prophylaxis or periodical follow-up.
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Affiliation(s)
- Laia Aceituno
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Juan Bañares
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | | | - Ana Callejo-Pérez
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Eva Muñoz-Couselo
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Carolina Ortiz-Velez
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Nely Díaz-Mejía
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | | | | | - Anna Farriols
- Pharmacy Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - María Buti
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
- Centro de Investigaciones Biomédicas de la Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
- Centro de Investigaciones Biomédicas de la Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
- *Correspondence: Mar Riveiro-Barciela
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Aguirre A, Yazdany J. Hepatitis B Screening Before Biologic or Targeted Synthetic Disease-modifying Antirheumatic Drug Therapy: Many Roads to Improvement. J Rheumatol 2021; 49:1-4. [PMID: 34725177 DOI: 10.3899/jrheum.211000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, Clinical Fellow, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, University of California, San Francisco, California, USA.
| | - Jinoos Yazdany
- A. Aguirre, MD, Clinical Fellow, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, University of California, San Francisco, California, USA
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Fidan S, Capkın E, Arıca DA, Durak S, Okatan IE. Risk of hepatitis B reactivation in patients receiving anti-tumor necrosis factor-α therapy. Int J Rheum Dis 2020; 24:254-259. [PMID: 33244900 DOI: 10.1111/1756-185x.14034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to determine hepatitis B virus (HBV) screening rates in patients receiving anti-tumor necrosis factor (TNF)-α therapy and the frequency of HBV reactivation in patients with resolved hepatitis B virus infection (hepatitis B surface antigen [HBsAg] negative, hepatitis B core antibody [Anti-HBc] positive). PATIENTS AND METHODS Data from 1834 patients who underwent anti-TNF-α therapy in the Rheumatology, Gastroenterology and Dermatology Departments of our hospital between 2010 and 2020 were retrospectively analyzed. Within 6 months before the initial anti-TNF-α therapy, performing a HBsAg and/or anti-HBc test is defined as HBV screening. HBV reactivation is defined as the presence of detectable serum HBV DNA or HBsAg seroconversion from negative to positive. RESULTS The overall HBV screening rate was 82.3% before starting anti-TNF-α therapy. There was an increasing trend in HBV screening rates during the years analyzed (64% in 2010, 87.4% in 2019) (P < .001). Before anti-TNF-α therapy was initiated, 272 patients were HBsAg negative and anti-HBc positive. Among these patients, HBV reactivation did not occur in 31 patients who received antiviral prophylaxis, whereas HBV reactivation occurred in only 1 (0.4%) of the 241 patients who did not receive antiviral prophylaxis. CONCLUSION Hepatitis B virus screening rates prior to starting anti-TNF-α therapy were relatively high, and its trend was increased by year. HBV reactivation because of anti-TNF-α use rarely occurred in patients with resolved HBV infection. Further studies are needed on whether routine anti-HBc screening and/or HBV DNA follow-up are necessary in these patients aside from HBsAg.
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Affiliation(s)
- Sami Fidan
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erhan Capkın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Deniz Aksu Arıca
- Department of Dermatology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serdar Durak
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ilyas Ercan Okatan
- Department of Rheumatology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Koutsianas C, Thomas K, Vassilopoulos D. Reactivation of hepatitis B virus infection in rheumatic diseases: risk and management considerations. Ther Adv Musculoskelet Dis 2020; 12:1759720X20912646. [PMID: 32206094 PMCID: PMC7076579 DOI: 10.1177/1759720x20912646] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
In patients with rheumatic diseases undergoing immunosuppressive treatment, hepatitis B virus reactivation (HBVr) has been long recognized as a major treatment-related adverse event with substantial morbidity and mortality. Because HBVr is easily preventable with appropriate screening and monitoring strategies, and, when indicated, prophylactic antiviral treatment, awareness of this complication is of the utmost importance, especially in the era of biologic treatments. As a condition, it continues to be topical, in view of the emergence of novel classes of immunosuppressive drugs (i.e. Janus kinase inhibitors) acquiring licenses for a variety of rheumatic diseases. The class-specific risk of these agents for HBVr has not yet been determined. Moreover, ambiguity still exists for the management of patients planned to be treated with traditional agents, such as cyclophosphamide and glucocorticoids, particularly in the setting of resolved HBV infection. Clinicians in the field of rheumatic diseases should be tailoring their practice according to the host's profile and treatment-specific risk for HBVr. In this review, the authors attempt to critically review the existing literature and provide practical advice on these issues.
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Affiliation(s)
- Christos Koutsianas
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Thomas
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Ave., Athens, 115 27, Greece
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8
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Patients with suboptimal hepatitis B virus diagnostic characterization are at risk of liver fibrosis progression. Eur J Gastroenterol Hepatol 2020; 32:426-432. [PMID: 31490418 DOI: 10.1097/meg.0000000000001527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with chronic hepatitis B virus infection remain infradiagnosed and untreated. In a national health system with unrestricted access to treatment, our aims were to assess the level of compliance with clinical guidelines and the characteristics and risk of fibrosis progression in patients with suboptimal diagnosis. METHODS In a cohort of patients with positive hepatitis B surface antigen from January 2011 to December 2013, data were registered to assess characteristics and compliance with guidelines. For assessing the risk of liver fibrosis, positive hepatitis B surface antigen patients from January 2008 to December 2013 were grouped depending on DNA request. Liver fibrosis was estimated by serological scores. RESULTS Of 41 158 subjects with hepatitis B surface antigen request, 351 (0.9%) tested positive, and DNA was not available from 110 patients (66.4% male, mean 42.4 ± 14.5 years) after a median of 25.6 months (range 12.0-43.5). Most of these patients (76%) were assessed by primary care. Half of the patients (47.2%) showed hypertransaminasemia, at least significant fibrosis, or both conditions. After long follow-up (mean 90.1 ± 45.2 months), these patients had a higher risk of achieving at least significant fibrosis during follow-up (log-rank 8.73; P = 0.003). CONCLUSION In more than one-third of patients with positive hepatitis B surface antigen, DNA was not requested despite showing hypertransaminasemia and significant fibrosis. Patients without DNA request are at high risk of liver fibrosis progression. Thus, educational measures and other strategies are necessary, especially targeting primary care, to improve access to treatment.
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Riveiro-Barciela M, Gubern P, Roade L, Abrisqueta P, Carreras MJ, Farriols A, Bosch F, Esteban R, Buti M. An electronic alert system increases screening for hepatitis B and C and improves management of patients with haematological disorders. Sci Rep 2020; 10:3038. [PMID: 32080253 PMCID: PMC7033156 DOI: 10.1038/s41598-020-59476-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/15/2020] [Indexed: 01/18/2023] Open
Abstract
Treatment of haematological disorders in patients with chronic hepatitis B or resolved infection (anti-HBc-positive) is associated with a risk of hepatitis B reactivation. Moreover, patients with chronic hepatitis C have a higher risk of haematological malignancies than general population. An electronic alert system was developed to promote screening of hepatitis B (HBV) and C (HCV) in patients starting haematological therapies. The system included screening and linkage to care and a request for testing in those without data. From March, 2017 to March, 2018 data from 420 consecutive patients with haematological diseases were included. At first prescription before the alerts, the HCV and HBV screening rate was 60.5%. Following the alerts, an additional 115 were screened, increasing the overall screening rate to 87.9%. Anti-HBc alone was detected in 57, anti-HCV in 13, and HBsAg in 2 patients. Overall, 68% of patients with any viral hepatitis markers were previously not know, and the impact was particularly important for anti-HBc detection (47/57 unknown). Nucleoside analogues were prescribed in 28 (49.1%) anti-HBc-positive and the 2 HBsAg-positive patients. Prospective follow-up with HBV DNA and HBsAg testing showed no cases of HBV reactivation. An estimated 1.2 HBV reactivations were avoided as consequence of the alert system. In summary, an electronic alert system increased viral hepatitis screening in patients receiving haematological treatment and led to improvements in the management of these patients, including avoided HBV reactivation.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Paula Gubern
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Luisa Roade
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Farriols
- Pharmacy Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - María Buti
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
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Toka B, Eminler AT, Gönüllü E, Tozlu M, Uslan MI, Parlak E, Karabay O, Koksal AS. Rheumatologists’ awareness of hepatitis B reactivation before immunosuppressive therapy. Rheumatol Int 2019; 39:2077-2085. [DOI: 10.1007/s00296-019-04437-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/28/2019] [Indexed: 12/19/2022]
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Morales-Arraez D, Alonso-Larruga A, Diaz-Flores F, García Dopico JA, de Vera A, Quintero E, Hernández-Guerra M. Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert. J Viral Hepat 2019; 26:1117-1123. [PMID: 31077515 DOI: 10.1111/jvh.13122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 12/18/2022]
Abstract
The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0 months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.
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Affiliation(s)
- Dalia Morales-Arraez
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
| | - Ana Alonso-Larruga
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Jose A García Dopico
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Antonia de Vera
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Enrique Quintero
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
| | - Manuel Hernández-Guerra
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
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Morillas RM, López Sisamón D. Reactivación de la hepatitis B asociada a agentes inmunodepresores y a quimioterapia. Historia natural, factores de riesgo y recomendaciones para prevenirla. Med Clin (Barc) 2019; 152:107-114. [DOI: 10.1016/j.medcli.2018.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023]
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13
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Risk of HBV reactivation in patients with B-cell lymphomas receiving obinutuzumab or rituximab immunochemotherapy. Blood 2018; 133:137-146. [PMID: 30341058 DOI: 10.1182/blood-2018-04-848044] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 10/02/2018] [Indexed: 02/06/2023] Open
Abstract
Risk of hepatitis B virus (HBV) reactivation was assessed in B-cell non-Hodgkin lymphoma (NHL) patients with resolved HBV infection (hepatitis B surface antigen negative, hepatitis B core antibody positive) who received obinutuzumab- or rituximab-containing immunochemotherapy in the phase 3 GOYA and GALLIUM studies. HBV DNA monitoring was undertaken monthly to 1 year after the last dose of study drug. In case of HBV reactivation (confirmed, HBV DNA ≥29 IU/mL), immunochemotherapy was withheld and nucleos(t)ide analog treatment (preemptive NAT) started. Immunochemotherapy was restarted if HBV DNA became undetectable or reactivation was not confirmed, and discontinued if HBV DNA exceeded 100 IU/mL on NAT. Prophylactic NAT was allowed by investigator discretion. Among 326 patients with resolved HBV infection, 27 (8.2%) had HBV reactivation, occurring a median of 125 days (interquartile range, 85-331 days) after the first dose. In 232 patients without prophylactic NAT, 25 (10.8%) had HBV reactivation; all received preemptive NAT. Ninety-four patients received prophylactic NAT; 2 (2.1%) had HBV reactivation. No patients developed HBV-related hepatitis. On multivariate Cox analysis, detectable HBV DNA at baseline was strongly associated with an increased risk of reactivation (adjusted hazard ratio [HR], 18.22; 95% confidence interval [CI], 6.04-54.93; P < .0001). Prophylactic NAT was strongly associated with a reduced risk (adjusted HR, 0.09; 95% CI, 0.02-0.41; P = .0018). HBV DNA monitoring-guided preemptive NAT was effective in preventing HBV-related hepatitis during anti-CD20-containing immunochemotherapy in B-cell NHL patients with resolved HBV infection. Antiviral prophylaxis was also effective and may be appropriate for high-risk patients. These trials were registered at www.clinicaltrials.gov as NCT01287741 (GOYA) and NCT01332968 (GALLIUM).
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Jasmine Bullard A, Cunningham FE, Volpp BD, Lowy E, Beste LA, Heron BB, Geraci M, Hammond JM, LaPlant K, Stave EA, Turner MJ, O’Leary MC, Kelley MJ, Hunt CM. Preventing Hepatitis B Reactivation During Anti-CD20 Antibody Treatment in the Veterans Health Administration. Hepatol Commun 2018; 2:1136-1146. [PMID: 30202826 PMCID: PMC6128236 DOI: 10.1002/hep4.1238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 12/29/2022] Open
Abstract
Hepatitis B virus (HBV) reactivation may occur with high risk immunosuppression, such as anti-cluster of differentiation (CD)20 antibodies (Abs). Appropriate HBV prophylaxis during anti-CD20 Ab therapy averts hepatitis, chemotherapy disruption, and death. Serologic evidence of prior HBV exposure is present in one in nine veterans in the Veterans Health Administration (VHA). In 2014, most (61%-73%) patients in the VHA who were receiving anti-CD20 Ab treatment underwent HBV testing, yet <20% of eligible patients received HBV antiviral prophylaxis. We aimed to prevent HBV reactivation by increasing HBV testing and antiviral treatment rates among anti-CD20 Ab recipients through prospective interventions. A multidisciplinary team of clinicians, pharmacists, and public health professionals developed comprehensive prevention systems, including national seminars/newsletters/websites; pharmacy criteria for HBV screening/treatment prior to anti-CD20 Ab use; changes to national formulary restrictions to expand HBV prophylaxis prescribing authority; Medication Use Evaluation Tracker to identify omissions; national e-mail alert to all VHA oncology providers detailing specific testing and HBV antiviral treatment needs; and a voluntary electronic medical record "order check" used at interested facilities (n = 11) to automatically assess pretreatment HBV testing and antiviral treatment and only generate a reminder to address deficiencies. Analysis of monthly data from June 2016 through September 2017 among anti-CD20 Ab recipients revealed pre-anti-CD20 Ab treatment HBV testing increased to 91%-96% and appropriate HBV antiviral prophylaxis to 76%-85% nationally following implementation of the intervention. Medical centers using the voluntary electronic medical record order check increased HBV testing rates to 93%-98% and HBV antiviral prophylaxis rates to 99%. Conclusion: Multimodal intervention systems to prevent HBV reactivation among VHA patients receiving anti-CD20 Ab therapies increased national rates of HBV testing to >90% and antiviral prophylaxis to >80%.
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Affiliation(s)
- A. Jasmine Bullard
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | | | - Bryan D. Volpp
- Veterans Affairs Northern California Healthcare SystemMartinezCA
| | - Elliott Lowy
- Veterans Affairs Puget Sound Health Care System, Health Services Research and DevelopmentUniversity of Washington School of Public HealthSeattleWA
| | - Lauren A. Beste
- Veterans Affairs Puget Sound Health Care System, Health Services Research and Development, Department of MedicineUniversity of WashingtonSeattleWA
| | | | - Mark Geraci
- Veterans Affairs Pharmacy Benefits Management ServicesHinesIL
| | - Julia M. Hammond
- Pharmacy DepartmentDurham Veterans Affairs Health Care SystemDurhamNC
| | - Kourtney LaPlant
- Malcom Randall Veterans Affairs Medical CenterVeterans Health SystemNorth Florida, South Georgia, GainesvilleFL
| | - Elise A. Stave
- Zucker School of Medicine at Hofstra/NorthwellHempsteadNY
| | - Marsha J. Turner
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | - Meghan C. O’Leary
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | - Michael J. Kelley
- Office of Patient Care Services, Department of Veterans AffairsWashingtonDC
- Hematology‐Oncology ServiceDurham Veterans Affairs Health Care SystemDurhamNC
| | - Christine M. Hunt
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
- Department of MedicineDuke University Medical CenterDurhamNC
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15
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Buti M, Manzano ML, Morillas RM, García-Retortillo M, Martín L, Prieto M, Gutiérrez ML, Suárez E, Gómez Rubio M, López J, Castillo P, Rodríguez M, Zozaya JM, Simón MA, Morano LE, Calleja JL, Yébenes M, Esteban R. Randomized prospective study evaluating tenofovir disoproxil fumarate prophylaxis against hepatitis B virus reactivation in anti-HBc-positive patients with rituximab-based regimens to treat hematologic malignancies: The Preblin study. PLoS One 2017; 12:e0184550. [PMID: 28898281 PMCID: PMC5595327 DOI: 10.1371/journal.pone.0184550] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hepatitis B virus (HBV) reactivation in patients with resolved HBV infection (HBsAg negative, antiHBc positive) is uncommon, but potentially fatal. The role of HBV prophylaxis in this setting is uncertain. The aim of this study was to compare the efficacy of tenofovir disoproxil fumarate (TDF) prophylaxis versus close monitoring in antiHBc-positive, HBsAg-negative patients under treatment with rituximab (RTX)-based regimens for hematologic malignancy. METHODS PREBLIN is a phase IV, randomized, prospective, open-label, multicenter, parallel-group trial conducted in 17 hospitals throughout Spain. Anti-HBc-positive, HBsAg-negative patients with undetectable HBV DNA were randomized to receive TDF 300 mg once daily (Group I) or observation (Group II). The primary endpoint was the percentage of patients showing HBV reactivation during 18 months following initiation of RTX treatment. Patients with detectable HBV DNA (Group III) received the same dose of TDF and were analyzed together with Group I to investigate TDF safety. RESULTS Sixty-one patients were enrolled in the study, 33 in the TDF treatment group and 28 in the observation group. By ITT analysis, HBV reactivation was 0% (0/33) in the study group and 10.7% (3/28) in the observation group (p = 0.091). None of the patients in either group showed significant differences in liver function parameters between baseline and the last follow-up sample. TDF was generally well tolerated and there were no severe treatment-related adverse events. CONCLUSION In patients with hematological malignancy and resolved hepatitis B infection receiving RTX-based regimens, HBV reactivation did not occur in patients given TDF prophylaxis.
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Affiliation(s)
- María Buti
- Liver Unit, Hospital Vall Hebron and CIBEREHD del Instituto Carlos III, Barcelona, Spain
| | - María L. Manzano
- Department of Hepatology, Hospital Doce de Octubre, Madrid, Spain
| | - Rosa M. Morillas
- Department of Hepatology, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Leticia Martín
- Department of Hepatology, Hospital de Donostia, San Sebastián, Spain
| | - Martín Prieto
- Department of Hepatology, Hospital Universitario i Politécnico La Fe, Valencia, Spain
| | | | - Emilio Suárez
- Department of Hepatology, Hospital Nuestra Señora de Valme, Seville, Spain
| | | | - Javier López
- Department of Hematology, Hospital Ramón y Cajal, Madrid, Spain
| | - Pilar Castillo
- Department of Hepatology, Hospital La Paz, Madrid, Spain
| | - Manuel Rodríguez
- Department of Hepatology, Hospital Central de Asturias, Oviedo, Spain
| | - José M. Zozaya
- Department of Gastroenterology, Hospital de Navarra, Pamplona, Spain
| | - Miguel A. Simón
- Department of Hepatology, Hospital Clínico Lozano Blesa, Zaragoza, Spain
| | - Luis E. Morano
- Department of Infectious Diseases, Hospital do Meixoeiro, Vigo, Spain
| | - José L. Calleja
- Department of Gastroenterology, Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - María Yébenes
- Pharmacoeconomics & Outcomes Research Iberia, Madrid, Spain
| | - Rafael Esteban
- Liver Unit, Hospital Vall Hebron and CIBEREHD del Instituto Carlos III, Barcelona, Spain
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16
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Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and Patient Involvement in Decision Support Systems: Current Trends. Yearb Med Inform 2017; 10:106-18. [PMID: 26293857 DOI: 10.15265/iy-2015-015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. METHODS We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. RESULTS We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. CONCLUSIONS Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.
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Affiliation(s)
- S Quaglini
- Silvana Quaglini, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Via Ferrata 5, 27100 Pavia, Italy, Tel: +39 0382 985058, Fax: +39 0382 985060, E-mail:
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17
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Koutsianas C, Thomas K, Vassilopoulos D. Hepatitis B Reactivation in Rheumatic Diseases: Screening and Prevention. Rheum Dis Clin North Am 2016; 43:133-149. [PMID: 27890170 DOI: 10.1016/j.rdc.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) reactivation (HBVr) has been an increasingly recognized and appreciated risk of immunosuppressive therapies in rheumatic patients. Despite its potential for significant morbidity and mortality, HBVr is a fully preventable complication with appropriate pretreatment screening and close monitoring of susceptible patients. Better knowledge of the risk for HBVr with the different antirheumatic agents and the establishment of the new-generation oral antivirals in clinical practice has greatly improved the design of screening and therapeutic algorithms. In this review, all available data regarding HBVr in rheumatic patients are critically presented and a screening and therapeutic algorithm is proposed.
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Affiliation(s)
- Christos Koutsianas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece; Department of Rheumatology, The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley DY1 2HQ, West Midlands, UK
| | - Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece.
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18
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Ozoya OO, Sokol L, Dalia S. Hepatitis B Reactivation with Novel Agents in Non-Hodgkin's Lymphoma and Prevention Strategies. J Clin Transl Hepatol 2016; 4:143-50. [PMID: 27350944 PMCID: PMC4913070 DOI: 10.14218/jcth.2016.00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/12/2022] Open
Abstract
Hepatitis B virus (HBV) infection remains an endemic disease in most parts of the world despite available prophylactic vaccines. Non-Hodgkin's lymphoma is the most common hematological malignancy, and certain patients undergoing therapy are at increased risk of HBV reactivation. Rituximab, a monoclonal antibody, is well studied in HBV reactivation, but newer agents have been implicated as well. Here, we review novel agents suspected in HBV reactivation and effective strategies to prevent HBV reactivation. Fifteen years of literature were reviewed in order to better understand the reactivation rates of hepatitis B in patients with non-Hodgkin's lymphoma. Anti-CD20 antibodies continue to be the main medications that can lead to HBV reactivation, and HBV reactivation rates have decreased with increased awareness. HBV reactivation is uncommon when using other novel agents. Entecavir and lamivudine remain the agents of choice to prevent HBV reactivation in high risk patients. In conclusion, the immunosuppressive effect of NHL and its therapy provide a pathway for HBV reactivation, especially in patients treated with anti-CD20 antibody. Since many HBV positive patients are often excluded from clinical trials of novel agents in NHL, more aggressive post-market surveillance of new agents, well-designed best practice advisories, and timely case reports are needed to reduce the incidence of HBV reactivation. Lastly, large prospective investigations coupled with well-utilized best practice advisories need to be conducted to understand the impact of more potent novel NHL therapy on HBV reactivation.
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Affiliation(s)
| | - Lubomir Sokol
- Department of Hematological Malignancies, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Samir Dalia
- Oncology and Hematology, Mercy Clinic Joplin, Joplin, MO, USA
- *Correspondence to: Samir Dalia, Oncology and Hematology, Mercy Clinic Joplin, 100 Mercy Way, Joplin, MO 64804, USA. Tel: +1-417-782-7722, Fax: +1-417-556-3063, E-mail: or
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19
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Hunt CM, Beste LA, Lowy E, Suzuki A, Moylan CA, Tillmann HL, Ioannou GN, Lim JK, Kelley MJ, Provenzale D. Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration. World J Gastroenterol 2016; 22:4732-4740. [PMID: 27217704 PMCID: PMC4870079 DOI: 10.3748/wjg.v22.i19.4732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/16/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate pretreatment hepatitis B virus (HBV) testing, vaccination, and antiviral treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement.
METHODS: We performed a retrospective cohort study using a national repository of Veterans Health Administration (VHA) electronic health record data. We identified all patients receiving anti-CD20 Ab treatment (2002-2014). We ascertained patient demographics, laboratory results, HBV vaccination status (from vaccination records), pharmacy data, and vital status. The high risk period for HBV reactivation is during anti-CD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment serologic tests were used to categorize chronic HBV (hepatitis B surface antigen positive or HBsAg+), past HBV (HBsAg-, hepatitis B core antibody positive or HBcAb+), resolved HBV (HBsAg-, HBcAb+, hepatitis B surface antibody positive or HBsAb+), likely prior vaccination (isolated HBsAb+), HBV negative (HBsAg-, HBcAb-), or unknown. Acute hepatitis B was defined by the appearance of HBsAg+ in the high risk period in patients who were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis, liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease categories and differences compared using the χ2 test. Mean time to hepatitis peak alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration and follow-up were also compared by HBV disease group.
RESULTS: Among 19304 VHA patients who received anti-CD20 Ab, 10224 (53%) had pretreatment HBsAg testing during the study period, with 49% and 43% tested for HBsAg and HBcAb, respectively within 6 mo pretreatment in 2014. Of those tested, 2% (167/10224) had chronic HBV, 4% (326/7903) past HBV, 5% (427/8110) resolved HBV, 8% (628/8110) likely prior HBV vaccination, and 76% (6022/7903) were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral treatment during the high risk period while 21% to 23% of those with past or resolved HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20 Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative (P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31% in hepatitis B negative. In those pretreatment HBV negative, 16 (0.3%) developed acute hepatitis B of 4947 tested during anti-CD20Ab treatment and follow-up.
CONCLUSION: While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients received HBV antivirals, suggesting electronic health record algorithms may enhance health outcomes.
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20
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Bessone F, Dirchwolf M. Management of hepatitis B reactivation in immunosuppressed patients: An update on current recommendations. World J Hepatol 2016; 8:385-94. [PMID: 27004086 PMCID: PMC4794528 DOI: 10.4254/wjh.v8.i8.385] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 01/15/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
The proportion of hepatitis B virus (HBV) previously exposed patients who receive immunosuppressive treatment is usually very small. However, if these individuals are exposed to potent immunosuppressive compounds, the risk of HBV reactivation (HBVr) increases with the presence of hepatitis B surface antigen (HBsAg) in the serum. Chronic HBsAg carriers have a higher risk than those who have a total IgG anticore as the only marker of resolved/occult HBV disease. The loss of immune control in these patients may results in the reactivation of HBV replication within hepatocytes. Upon reconstitution of the immune system, infected hepatocytes are once again targeted and damaged by immune surveillance in an effort to clear the virus. There are different virological scenarios, and a wide spectrum of associated drugs with specific and stratified risk for the development of HBVr. Some of this agents can trigger a severe degree of hepatocellular damage, including hepatitis, acute liver failure, and even death despite employment of effective antiviral therapies. Currently, HBVr incidence seems to be increasing around the world; a fact mainly related to the incessant appearance of more powerful immunosuppressive drugs launched to the market. Moreover, there is no consensus on the length of prophylactic treatment before the patients are treated with immunosuppressive therapy, and for how long this therapy should be extended once treatment is completed. Therefore, this review article will focus on when to treat, when to monitor, what patients should receive HBV therapy, and what drugs should be selected for each scenario. Lastly, we will update the definition, risk factors, screening, and treatment recommendations based on both current and different HBV management guidelines.
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Affiliation(s)
- Fernando Bessone
- Fernando Bessone, Department of Gastroenterology and Hepatology, School of Medicine, University of Rosario, Rosario 2000, Argentina
| | - Melisa Dirchwolf
- Fernando Bessone, Department of Gastroenterology and Hepatology, School of Medicine, University of Rosario, Rosario 2000, Argentina
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21
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Cabezas J, Sampedro B, Hernández C, Crespo J. Computerized Physician Order Entry-Based System Improves Hepatitis B Virus Screening in Patients Undergoing Chemotherapy. J Clin Oncol 2016; 34:290. [PMID: 26644539 DOI: 10.1200/jco.2015.63.6779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Joaquín Cabezas
- University Hospital Marqués de Valdecilla and Instituto de Investigacíon Valdecilla, Santander, Spain
| | - Blanca Sampedro
- University Hospital Marqués de Valdecilla and Instituto de Investigacíon Valdecilla, Santander, Spain
| | - Cándido Hernández
- Autonomous University of Barcelona, Sabadell, Barcelona, and Gilead Sciences, Madrid, Spain
| | - Javier Crespo
- University Hospital Marqués de Valdecilla and Instituto de Investigacíon Valdecilla, Santander, Spain
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22
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Sanagawa A, Kuroda J, Shiota A, Kito N, Takemoto M, Kawade Y, Esaki T, Kimura K. Outcomes of the implementation of the computer-assisted HBView system for the prevention of hepatitis B virus reactivation in chemotherapy patients: a retrospective analysis. J Pharm Health Care Sci 2015; 1:29. [PMID: 26819740 PMCID: PMC4729173 DOI: 10.1186/s40780-015-0030-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/22/2015] [Indexed: 12/16/2022] Open
Abstract
Background Screening for hepatitis B virus (HBV) infection is recommended worldwide for patients receiving systemic chemotherapy in accordance with clinical guidelines, but compliance varies by country and facility. Alert systems may be useful for promoting screening, but it is unclear how effective such systems are. In this study, we investigated HBV screening procedures and their incorporation into treatment regimens following the implementation of an alert system. Methods An alert system was introduced at our hospital in April 2012. The rates of HBV screening in the periods before and after the introduction of the alert system (September 2010 to March 2012 and April 2012 to October 2013, respectively) were investigated. We collected data on hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb), and HBV-DNA testing in patients. As a result of this analysis, we developed a system in which pharmacists would intervene to check and confirm whether HBV screening had occurred in patients scheduled to begin treatment with chemotherapy. We named our project the “HBView” project, and the rate of HBV screening and the number of times pharmacists intervened was studied during specific time periods before and after the HBView project commenced (July 2013 to December 2013 and January 2014 to June 2014, respectively). Results After introducing the alert system, the percentage of patients tested for HBsAb/HBcAb and HBV-DNA increased significantly, from 71.6 % to 84.9 % and from 44.5 % to 69.7 %, respectively. However, the rate of compliance with HBV testing guidelines was not 100 % after interventions. The numbers of patients who were not screened but should have been before and after the introduction of HBView were 6 and 17, respectively. Two patients at risk of HBV reactivation were identified after intervention by pharmacists; their intervention thus prevented HBV reactivation. Conclusions Compliance with clinical HBV screening guidelines was not sufficiently improved after the introduction of the automatic alert system; however, the HBView project proved useful in reinforcing the automatic alert system.
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Affiliation(s)
- Akimasa Sanagawa
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan
| | - Junko Kuroda
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Arufumi Shiota
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Noriko Kito
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Masashi Takemoto
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Yoshihiro Kawade
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan
| | - Tetsuo Esaki
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Kazunori Kimura
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
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23
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Perrillo R. Invited Commentary: Screening for hepatitis B in the immigrant population and individuals who are in need of immunosuppressive drug therapy. Proc AMIA Symp 2015; 28:443-4. [PMID: 26424936 PMCID: PMC4569219 DOI: 10.1080/08998280.2015.11929302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic hepatitis B (CHB) afflicts approximately 300 million people in the world. Hepatitis B virus (HBV) is a known carcinogenic virus and continues to be the leading cause of hepatocellular carcinoma (HCC) (1). Approximately 70% of hepatitis B surface antigen (HBsAg) carriers reside in intermediate (>2% prevalence) to high-risk (>8% prevalence) areas such as Asia, the Pacific Islands, Africa, India, and parts of Southern Europe (1). There is a common misperception that this disorder is not very common in the United States. However, 63% of the nearly 28 million immigrants who entered the US between 1974 and 2008 were born in countries of intermediate or high prevalence (2). The Immigrant Refugee and Migrant Health Branch of the Centers for Disease Control and Prevention (CDC) estimated that an average of 53,000 CHB cases were imported to the US yearly from 2004 to 2008. Forty percent of these cases originated from China, Vietnam, and the Philippines (2). The CDC has recently revised its prevalence estimates and concluded that 2.2 million US residents are likely to have chronic HBV infection, of which 1.3 million are judged to be foreign-born individuals. Even these figures are likely to be too low, however, because the estimates do not take into account illegal immigrants and other socially disadvantaged patients. Importantly, HBsAg testing is not required as part of the process of immigrating into the United States (3). This lack of a requirement for HBV screening is an important missed opportunity to programmatically diagnose this condition.
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Affiliation(s)
- Robert Perrillo
- Hepatology Division, Baylor University Medical Center at Dallas
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24
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Hsu PI, Lai KH, Cheng JS, Kao SS, Li YR, Sun WC, Chen WC, Lin KH, Shin CA, Chiang PH, Li YD, Ou WT, Chen HC, Yu HC. Prevention of acute exacerbation of chronic hepatitis B infection in cancer patients receiving chemotherapy in a hepatitis B virus endemic area. Hepatology 2015; 62:387-96. [PMID: 26041578 DOI: 10.1002/hep.27843] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 04/07/2015] [Indexed: 12/20/2022]
Abstract
UNLABELLED Reactivation of hepatitis B viral (HBV) infection in cancer patients undergoing chemotherapy may cause interruption of chemotherapy and lead to liver failure and death. In our institute, a computerized order entry-based alert system was introduced in September 2011 to remind healthcare providers of HBV testing when prescribing chemotherapy. Since August 2012, an order entry-based therapeutic control system has been applied to ensure HBV prophylaxis during chemotherapy. This retrospective cohort study included cancer patients receiving chemotherapy in the Kaohsiung Veterans General Hospital from November 2009 to June 2013. The prechemotherapy HBV screening rate, HBV prophylactic rate, and severe HBV acute exacerbation rate were compared between stages with different order systems. Newly diagnosed cancer patients (n = 2512) were included. The HBV testing rate in the screening reminder stage was higher than that in the educational stage (93.5% versus 40.2%, P < 0.001), whereas the adequate HBV prophylactic rates in the two order entry-based stages were comparable (41.1% versus 39.2%). Patients in the order entry-based therapeutic control stage had a higher HBV screening rate (99.3% versus 40.2%, P < 0.001) and a higher HBV prophylactic rate (95.8% versus 39.2%, P < 0.001) than those in the educational stage. Additionally, the severe HBV acute exacerbation rate in the therapeutic control stage was lower than those in the educational and screening reminder stages (0% versus 1.2% and 1.2%, respectively; both P < 0.01). CONCLUSION A computerized order entry-based therapeutic control system can provide excellent prechemotherapy HBV screening for cancer patients undergoing chemotherapy and can effectively prevent severe acute exacerbation of HBV infection in hospitals among HBV endemic areas.
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Affiliation(s)
- Ping-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Kwok-Hung Lai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Jin-Shiung Cheng
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Sung-Shuo Kao
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Yuan-Rung Li
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wei-Chih Sun
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Kung-Hung Lin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Chih-An Shin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Po-Hung Chiang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Yun-Da Li
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wei-Ting Ou
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Hui-Chun Chen
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
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Riveiro-Barciela M, Artaza G, Abrisqueta P, Bosch F, Buti M. [Importance of hepatitis B virus screening in hematological patients]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:563-4. [PMID: 25888287 DOI: 10.1016/j.gastrohep.2015.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/04/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Mar Riveiro-Barciela
- Servicio de Hepatología-Medicina Interna, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Gonzalo Artaza
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Pau Abrisqueta
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Francesc Bosch
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - María Buti
- Servicio de Hepatología-Medicina Interna, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, España.
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26
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Etzion O, Ghany MG. Screening for hepatitis B virus to prevent viral reactivation - who and when? Clin Liver Dis (Hoboken) 2015; 5:47-50. [PMID: 31040948 PMCID: PMC6490454 DOI: 10.1002/cld.458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/20/2015] [Accepted: 01/24/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ohad Etzion
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Marc G. Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
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