Clinical Manual for Management of the HIV-Infected ... - myCME.com

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Some patients treated with ART may experience
worsening of HBV symptoms and laboratory
markers in the weeks after ART initiation, because
of immune reconstitution. Hepatic decompensation
due to immune reconstitution must be distinguished
from other causes, such as medication toxicity,
or other infection. Liver function tests should be
monitored closely in patients starting ART.
Some antiretroviral medications are hepatotoxic and
should be avoided or used cautiously. These include
nevirapine, tipranavir, and high-dose ritonavir.
Numerous other medications (eg, fluconazole and
isoniazid) are known to be hepatotoxic and can pose
problems for people with impaired liver function.
For patients with treatment failure, consult an HBV
specialist.
Caution: Discontinuation of HBV medications in
patients with HIV/HBV coinfection may cause
a flare of liver disease. If this occurs, consider
reinstating HBV therapy as soon as possible. Be
very cautious when discontinuing HBV-active
medications from an HIV ART regimen. In this
scenario, consider continuing or substituting the
HBV-active medications to avoid rebound liver
inflammation and decompensation. For example, if
it is decided to discontinue HIV treatment for an
HIV/HBV-coinfected patient taking lamivudine
+ tenofovir + lopinavir/ritonavir, consider starting
adefovir or entecavir to maintain activity against
HPV.
Other care issues
Acute hepatitis A virus (HAV) or HCV in persons
with chronic HBV infection can cause decompensated
liver disease. All patients with HBV infection should
be tested for immunity to HAV and HCV. Patients
who are not immune to HAV should be vaccinated
and patients who are not immune to HCV should be
counseled about how to avoid the acquisition of HCV.
All HBV-infected individuals should be taught how
to reduce the risk of HBV transmission to others. As
appropriate, patients should be counseled to adopt
“safer sex” approaches, avoid blood exposures (eg, from
sharing razors or tattoo equipment), and practice safe
drug injection techniques. Persons with HBV infection
should be counseled to avoid exposure to hepatotoxins,
including alcohol and hepatotoxic medications
(eg, acetaminophen in large doses, fluconazole, and
isoniazid).
Section 6—Disease-Specific Treatment | 6–39
Table 2. Hepatitis B Treatment Regimens
Medication Treatment
Regimen
Interferon-alfa
2a or 2b
Pegylated
interferon-alfa
2a (Pegasys)
Lamivudine
(Epivir, 3TC) #
Tenofovir
(Viread) #
Emtricitabine
(Emtriva) #
Adefovir
(Hepsera)
Entecavir
(Baraclude)
5 million units (MU)
daily or 10 MU 3
times weekly for 4-6
months*
180 micrograms per
week for 4-6 months*
150 mg twice daily or
300 mg daily (dosage
as part of ART
regimen) for 1 year or
more*
300 mg daily:
treatment duration
unknown*
200 mg daily:
treatment duration
unknown*
10 mg daily:
treatment duration
unknown*
0.5-1.0 mg daily:
treatment duration
unknown*
Comments
• Interferon is contraindicated
in patients with
decompensated cirrhosis.
• Expect the CD4 count to
drop by 100-150 cells/µL
or more during treatment
with interferon or pegylated
interferon. (The CD4
percentage usually remains
stable.
•
•
•
•
•
•
•
•
•
Use only as part of an
effective HIV ART regimen.
High rate of HBV resistance
occurs after 1-2 years of
treatment. Lamivudineresistant
HBV is also
resistant to emtricitabine.
Most specialists recommend
combination with a second
agent (eg, tenofovir or
emtricitabine).
Use only as part of an
effective HIV ART regimen.
Active against lamivudineresistant
strains of HBV.
Most specialists recommend
combination with a second
agent (eg, lamivudine or
emtricitabine).
Use only as part of an
effective HIV ART regimen.
Emtricitabine-resistant
HBV also is resistant to
lamivudine.
Most specialists recommend
combination with a second
agent (eg, tenofovir or
lamivudine)
• Active against lamivudineresistant
strains of HBV.
• Active against lamivudineresistant
strains of HBV.
• May have activity against
HIV; pending further
studies, should not be used
in patients who are not on
effective HIV ART regimen.
# Agents are active against both HIV and HBV.
* The duration and expected efficacy of treatment vary according to the treatment strategy and the
individual patient characteristics.