Prevention and Treatment of Hepatitis B Virus Reactivation during Immunosuppresive Therapy Guideline Patient Companion

Clinical practice guidelines are developed under the guidance of the AGA Institute Clinical Guideline Committee and provide evidence-based recommendations for clinical practice in the field of gastroenterology. The clinical practice guidelines and related Clinical Decision Support Tools support evidence-based clinical decision-making by gastroenterologists and other health-care professionals at the point of care. The below information presents important content from those guidelines in a way that will help patients better understand AGA’s recommendations for evaluating, diagnosing or managing a condition.

AGA Clinical Guideline: Prevention and Treatment of Hepatitis B Virus Reactivation during Immunosuppresive Therapy

The information provided by the AGA Institute is not medical advice and should not be considered a replacement for seeing a medical professional.

What is Hepatitis B Virus?

  • Hepatitis B (HBV) is a virus that affects the liver.
  • Not everyone with HBV will have symptoms when they are infected.
  • HBV will often go away on its own within six months (acute), but sometimes it becomes a long-term (chronic) infection.
  • The DNA of the virus can stay in the body even after the first infection goes away, and infection may be reactivated under certain conditions.
  • Drugs that weaken the immune system may raise an individual’s risk for HBV reactivation, which can cause life-threatening liver problems.
  • Your doctor can tell you whether you are at risk of reactivation, and how best to prevent it from happening.
  • HBV spreads through sexual contact and through sharing infected objects, such as needles and razors. It can also pass from mother to baby during birth.
  • Some people with HBV infection will have symptoms, but others will not. Symptoms of HBV usually occur one to six months after a person is infected. Symptoms of HBV are:
    • Feeling tired.
    • Getting sick or throwing up.
    • Stomach pain.
    • Diarrhea (loose stool).
    • Body aches.
    • Yellowing of the skin and eyes.

Acute HBV Infection

  • In an acute HBV infection, the body’s immune system naturally fights off the virus.
  • The patient should be healthy again within six months.
  • Most people with acute HBV do not need to take medicine.
  • To help fight the infection, a person with HBV should:
  • Get lots of rest.
  • Drink lots of fluids.
  • Eat a healthy diet.
  • Not drink alcohol or do drugs.
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Chronic HBV Infection

  • Sometimes, HBV turns into a long-term health issue. This means that it lasts longer than six months.
  • Five percent of adults and 95 percent of babies who are infected with HBV will develop a chronic infection.
  • Chronic HBV can cause serious liver damage and scarring. It can also lead to liver cancer or liver failure.
  • Chronic HBV can be treated with antiviral drugs that lower the amount of HBV in the blood. Sometimes, these drugs can totally remove HBV from the blood.

Managing Hepatitis B Reactivation

Hepatitis B reactivation is when the amount of HBV in a person’s blood quickly increases.

  • A few weeks after reactivation starts, the infected person’s liver will become swollen and tender, and may stop working well.
  • When the liver is affected by HBV, it gives off a chemical called alanine aminotransferase, or ALT.
  • During this time, a person’s skin and eveye may turn yellow, and their urine may turn dark. This is called jaundice (JON-diss), and it is caused by having too much a certain chemical, called bilirubin, in the blood.
  • Doctors test for reactivation by measuring the change in HBV, ALT and bilirubin levels in a person’s blood.
  • Anyone who has ever had HBV is at risk of reactivation.
  • People with chronic HBV are more likely to have reactivation.
  • A person who had acute HBV in the past is also at risk. This is because the DNA of the virus can stay in a person’s body even after they are healthy again.
  • A reactivation of HBV can be fatal.
  • Reactivation can happen when someone with past or current HBV infection takes certain medicines that can weaken the immune system.
  • Immune-weakening drugs, or immunosuppressants (imm-YOO-no-sup-RESS-uhnts), are used to treat many diseases, including:
    • Lymphoma and leukemia.
    • Solid tumor cancers, such as breast or lung cancer.
    • Rheumatoid arthritis.
    • Certain blood disorders.
    • Inflammatory bowel disease (IBD).
    • Vasculitis.
    • Other immune disorders.
  • You doctor can use the AGA Guideline to measure your risk and decide whether to prescribe antiviral drugs to help prevent reactivation.
  • If you have ever been infected with HBV, and are taking drugs for any of the conditions above, ask your doctor about your risk of reactivation. Your level of risk depends on several factors, including:
    • The type of drug you are taking.
    • How long you have been taking the drug.
    • Your type of HBV infection (acute or chronic).
    • Whether your blood was ever clear of the virus.

High Risk

  • High risk means that you are more than 10 percent likely to have reactivation while taking immunosuppressants.
  • If you are at high risk, your doctor should always test your blood to see whether you were ever infected with HBV.
  • Your doctor should also prescribe an antiviral drug to prevent reactivation.
  • High-risk patients should take antiviral drugs as long as they are taking immunosuppressants, and for six to 12 months after stopping them.

Medium Risk

  • Some drugs give you a medium risk of HBV reactivation.
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  • A medium risk would mean that you are 1 to 10 percent likely to have HBV reactivation while taking immunosuppressants.
  • All medium-risk patients need to be tested for HBV and should talk to their doctor about the pros and cons of taking antiviral drugs.
  • Some patients may choose to take antiviral drugs until six months after stopping immunosuppressants. Others may decide not to take them.

Low Risk

  • Low risk means you are less than 1 percent likely to have HBV reactivation while taking immunosuppressants.
  • Most patients at low risk would not need to be tested for HBV and generally do not need to take antiviral drugs.

Questions For Your Doctor

If You Are Taking Immunosuppressants:
  • Have I been vaccinated for HBV? If not, should I be vaccinated?
  • What is my risk of carrying HBV?
  • Should I be screened for HBV?
  • If I have HBV, what is my risk of reactivation?

If You Have a Past or Current HBV Infection:
  • Do I have any risk factors for HBV reactivation?
  • What can I do to help prevent reactivation?


Reddy, R.K., Beavers, K.L., Hammond, S.P. et al. American Gastroenterological Association Institute guideline on the prevention and treatment of hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology. 2015; 148: 215–219

American Gastroenterological Association. AGA Hepatitis B Virus Reactivation Guideline: Patient Summary. Gastroenterology 2015;149:496–497. Available at