Infectious Disease

PCP submission

45 yo M, incarcerated male. I am beginning treatment for Hep C, genotype 3, with no RAS with Epclusa.

Fibrosure is F4, Alb = 4.1, platelets = 94, INR = 1.07, and TBili is 0.5. The patient is also coinfected with Hep B – He is sAg (+), sAb (-), cAb (+),Hep B DNA – ND, Hep Be Ag (-) and Hep D RNA (-). Also HIV (-).

Generally, when coinfected persons are started, I would initiate treatment for Hep B treatment first; however, this person has ND detected DNA so treatment not indicated. With Hep C cAb(+), I generally monitor sAg and CMP q4 weeks. Since this person is already sAg (+), what should monitoring look like? Should I monitor Hep B DNA q4 weeks?

Specialist response

Indeed, in HCV/HBV coinfection (with pos. HBsAg, as here), initiation of HCV antiviral therapy can lead to exacerbation of hepatitis B. The general approach to this risk is to first start patients on anti-HBV therapy, when they would have an indication for it without HCV coinfection. In your patient with undetectable HBV DNA, there is no indication for anti-HBV therapy ‘per se’. In this case, monitoring of ALT every four weeks is recommended with reflex to HBV DNA if there is any rise of ALT rather than decline. You could also add HBV DNA to the routine q 4 week labs, but it does offer any advantage to the reflex testing in terms of overlie detection of HBV exacerbation. If HBV DNA rise is found, then anti-HBV therapy should be added to anti-HCV therapy at that time. Given the patient has cirrhosis (F4) with portal hypertension (plt 94k), you may want to monitor his ALT more frequently in the beginning, say every 2 weeks.

Reference: Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance Norah A. Terrault, Anna S.F. Lok, Brian J. McMahon, et al. HEPATOLOGY, VOL. 67, NO. 4, 2018 link: file:///C:/Users/brau-/Downloads/Update_on_prevention,_diagnosis,_and_treatment_of.34.pdf