Emilio Suárez

Hepatobiliary manifestations in inflammatory bowel disease: The gut, the drugs and the liver

Abnormal liver biochemical tests are present in up to 30% of patients with inflammatory bowel disease (IBD), and therefore become a diagnostic challenge. Liver and biliary tract diseases are common extraintestinal manifestations for both Crohns disease and ulcerative colitis (UC), and typically do not correlate with intestinal activity. Primary sclerosing cholangitis (PSC) is the most common hepatobiliary manifestation of IBD, and is more prevalent in UC. Approximately 5% of patients with UC develop PSC, with the prevalence reaching up to 90%. Cholangiocarcinoma and colon cancer risks are increased in these patients. Less common disorders include autoimmune hepatitis/PSC overlap syndrome, IgG4-associated cholangiopathy, primary biliary cirrhosis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis, liver abscess, and non-alcoholic fatty liver disease. Hepatitis B reactivation during immunosuppressive therapy is a major concern, with screening and vaccination being recommended in serologically negative cases for patients with IBD. Reactivation prophylaxis with entecavir or tenofovir for 6 to 12 mo after the end of immunosuppressive therapy is mandatory in patients showing as hepatitis B surface antigen (HBsAg) positive, independently from viral load. HBsAg negative and anti-HBc positive patients, with or without anti-HBs, should be closely monitored, measuring alanine aminotransferase and hepatitis B virus DNA within 12 mo after the end of therapy, and should be treated if the viral load increases. On the other hand, immunosuppressive therapy does not seem to promote reactivation of hepatitis C, and hepatitis C antiviral treatment does not influence IBD natural history either. Most of the drugs used for IBD treatment may induce hepatotoxicity, although the incidence of serious adverse events is low. Abnormalities in liver biochemical tests associated with aminosalicylates are uncommon and are usually not clinically relevant. Methotrexate-related hepatotoxicity has been described in 14% of patients with IBD, in a dose-dependent manner. Liver biopsy is not routinely recommended. Biologics-related hepatotoxicity is rare, but has been shown most frequently in patients treated with infliximab. Thiopurines have been associated with veno-occlusive disease, regenerative nodular hyperplasia, and liver peliosis. Routine liver biochemical tests are recommended, especially during the first month of treatment. All these conditions should be considered in IBD patients with clinical or biochemical features suggestive of hepatobiliary involvement. Diagnosis and management of these disorders usually involve hepatologists and gastroenterologists due to its complexity.

Documento de consenso de la AEEH sobre el tratamiento de la infección por el virus de la hepatitis B (2012)

Los conocimientos sobre la historia natural, manejo y tratamiento de la hepatitis crónica B están cambiando continuamente. El documento de consenso de la Asociación Española para el Estudio del Hígado (AEEH) sobre el tratamiento de las infecciones por los virus de las hepatitis B y C se elaboró en el año 2005 y se publicó en 20061. El objetivo de este documento es actualizar estas recomendaciones para la hepatitis B, debido a la relevancia de los cambios que han tenido lugar en el tratamiento de esta enfermedad. Para ello, la Junta Directiva de la AEEH ha encargado a un panel de expertos la revisión y actualización del documento previo. El nuevo documento ha sido aprobado por la Junta Directiva de la AEEH.

Artículo especialDocumento de consenso de la AEEH sobre el tratamiento de la infección por el virus de la hepatitis B (2012)Consensus document of the spanish association for the study of the liver on the treatment of Hepatitis B infection (2012)

Los conocimientos sobre la historia natural, manejo y tratamiento de la hepatitis crónica B están cambiando continuamente. El documento de consenso de la Asociación Española para el Estudio del Hígado (AEEH) sobre el tratamiento de las infecciones por los virus de las hepatitis B y C se elaboró en el año 2005 y se publicó en 20061. El objetivo de este documento es actualizar estas recomendaciones para la hepatitis B, debido a la relevancia de los cambios que han tenido lugar en el tratamiento de esta enfermedad. Para ello, la Junta Directiva de la AEEH ha encargado a un panel de expertos la revisión y actualización del documento previo. El nuevo documento ha sido aprobado por la Junta Directiva de la AEEH.

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

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.

CS1 COST-EFFECTIVENESS ANALYSIS OF A CERVICAL CANCER VACCINE IN FIVE LATIN AMERICAN COUNTRIES

quedó limitado al caso del CASMU, y el fondo de garantía previsto con recursos del FONASA, se sustituyó con un fondo de rentas generales, que supone un incremento potencial del gasto del Estado LECCIONES APRENDIDAS: Aunque no resulta novedoso, en primer lugar la experiencia pone de relieve de qué manera las decisiones políticas no siempre se alinean con el mejor diseño técnico para la solución del problema. Por otra parte, este caso en particular puso de manifiesto debilidades históricas del sistema, que la reforma aún no ha podido modificar, relacionadas con la calidad de las decisiones del regulador, y con su diseño institucional.