임신부에서 만성B형 항바이러스제 사용, Antiviral agent in women who are pregnent

항바이러스제를 복용 중인 만성B형간염 임신부가 약 복용을 지속하기로 결정한 경우, 기존 약제가 entecavir, adefovir, TAF라면 TDF로 변경하여 치료를 지속합니다. TDF는 임신부에서 안전한 것 같으며 안전 데이터도 더 많습니다.

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임신부에서 항바이러스제 사용 시작 여부 결정은 임신부가 아닌 경우, 즉 일반적인 적응증과 비슷합니다. 그러나 다음과 같은 경우에도 항바이러스 치료가 권고됩니다.

ALT 수치가 정상 상한보다 2배 보다 높고 1. HBeAg-positive 환자에서 HBV DNA >20,000 IU 2. HBeAg-negative 환자에서 HBV DNA ≥2000 IU

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그러나 간경변증이 없는 임신부에서 몇 가지 시나리오는 다를 수 있습니다.

예를 들면,

1. ALT가 정상 상한보다 바로 윗 수치 정도만 상승한 것 같은 경한 질병 활동성의 증거만 보이는 경우 출산까지 치료를 연기할 수 있습니다. ​ 2. 반대로 바이러스 load가 >2 x 10 ^5 (20만) IU인 경우 3rd trimester일 때 ALT 수치가 정상일지라도 치료를 바로 시작해야 합니다. 이 경우에 치료 목표는 수직감염 예방입니다.

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TDF is preferred if antiviral therapy is contemplated in pregnant women because of its potency, safety profile, and low risk of resistance.

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REF. UpToDate 2020.09.13

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참고) Recommendations for initial treatment of chronic hepatitis B in nonpregnant adults

HBeAg	HBV DNA (PCR)	ALT	Treatment strategy
Patients without cirrhosis*
+	>20,000 international units/mL	≤2 x ULN¶	Treatment is not recommended, because current treatment has low efficacy in inducing HBeAg seroconversion. Treatment may be considered in older patients (>40 years) and in those with family history of HCC.
			Patients should be monitoredΔ and treatment considered if ALT becomes elevated >2 x ULN, liver biopsy shows moderate/severe inflammation or fibrosis◊ (eg, METAVIR score ≥F2), and/or noninvasive testing suggests moderate/severe fibrosis.
+	>20,000 international units/mL	>2 x ULN¶	Observe for 3 to 6 months if compensated and treat if no spontaneous HBeAg loss.
			Immediate treatment if severe hepatitis flare (eg, icteric or clinical decompensation).
			ETV, TAF, TDF, or PegIFN alfa are preferred for initial therapy.§¥
			End-point of treatment – Seroconversion from HBeAg to anti-HBe.‡
			Duration of therapy:
			PegIFN alfa: 48 weeks.
			ETV, TAF, or TDF: Continue for at least 12 months after HBeAg seroconversion.
–	>2000 international units/mL	>2 x ULN¶ OR 1 to 2 x ULN¶ if liver biopsy shows moderate/severe necroinflammation or significant fibrosis◊ (eg, METAVIR score ≥F2) or non-invasive testing shows significant fibrosis	ETV, TAF, TDF, or PegIFN alfa are preferred for initial therapy.§¥
			End-point of treatment – HBsAg loss.
			Duration of therapy:
			PegIFN alfa: One year.
			ETV, TAF, or TDF: Several years or indefinite.†
–	≤2000 international units/mL	≤ULN¶	Monitor and treat if HBV DNA and ALT increase as described above.
Patients with cirrhosis*
+/–	Detectable	Any ALT	Compensated:
			HBV DNA >2000 international units/mL – Treat with ETV, TAF, or TDF.§¥ Treatment should be continued indefinitely.**
			HBV DNA <2000 international units/mL – Consider treatment particularly if ALT elevated; close monitoring if treatment is not initiated.
			Decompensated:
			Treat immediately, regardless of ALT or HBV DNA levels. ETV preferred.§¥ TDF may be used with close monitoring of renal function. Refer for liver transplant.
+/–	Undetectable	Any ALT	Compensated: Observe, recheck HBV DNA during follow-up, evaluate for other causes of cirrhosis if HBV DNA remains undetectable.
			Decompensated: Refer for liver transplant, recheck HBV DNA during follow-up, evaluate for other causes of cirrhosis.