Prevention and treatment of hepatitis B reactivation

AGA published the first guideline on preventing and managing HBVr among individuals on immunosuppressive therapy in 2014. Since that publication, multiple novel classes of immunosuppressive therapies have been developed and approved for clinical use. Additionally, interventional therapies, such as transcatheter arterial chemoembolization (TACE), that can induce an immunosuppressed state and thus are relevant to potential HBVr, have also been recognized. This 2025 guideline aims to address the wide range of exposures that are suspected to increase the risk of HBVr and for which guideline recommendations currently do not exist. In particular, the 2025 guideline sought to provide guidance on the prevention and management of HBVr in individuals taking immune checkpoint inhibitors, anti-interleukin therapies, chimeric antigen receptor T (CAR-T) cell therapies, cytokine/intergrin inhibitor therapies, tyrosine kinase inhibitors (TKIs), anti–T-cell therapies, Janus kinase (JAK) inhibitors, and update the guidance provided for anti-TNF therapies in light of new evidence. The 2025 guideline also sought to provide guidance on the prevention and management of HBVr among individuals undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and individuals who are co-infected with hepatitis C virus (HCV) and undergoing a direct-acting antiviral (DAA) treatment. These recommendations are not intended to dictate medical decision-making but are intended to provide evidence-based guidance to inform medical decision-making. No single guideline can encompass the nuance of medical decision-making that requires clinical judgment and contextualization of medical knowledge by individual values and preferences. Within this context, this guideline aims to provide guidance on the benefits and harms of antiviral prophylaxis and monitoring for HBVr as alternative strategies.