炎症性肠病合并病毒性肝炎治疗策略

Treatment strategy of inflammatory bowel disease associated with viral hepatitis

随着免疫抑制剂及生物制剂的广泛应用,炎症性肠病(inflammatory bowel disease,IBD)的治疗方案也发生了显著改变。IBD患者中乙型肝炎病毒(hepatitis B virus,HBV)感染较为常见,接受免疫抑制治疗可能会导致HBV活跃复制,轻者出现肝酶异常,重者出现肝功能衰竭,甚至死亡。HBV的活跃复制会增加IBD患者的病死率。IBD患者应当接受HBV相关的抗原及抗体检测,对于HBs Ag阳性的IBD患者,为避免HBV的活跃复制,应当在接受免疫抑制治疗前采用抗病毒治疗,抗病毒治疗可选择耐药率低的恩替卡韦或替诺福韦。对于既往感染HBV的IBD患者,应当在接受免疫抑制治疗期间密切监测HBV DNA。与HBV感染相比,接受免疫抑制治疗的IBD患者发生HCV活跃复制的现象较为少见。干扰素联合利巴韦林抗HCV治疗并未增加IBD患者的不良反应。

Recently, treatment in inflammatory bowel disease （IBD） patients has been changed and immunosuppres- sion and biological therapies are used more frequently than before. Hepatitis B virus （HBV） infection in IBD patients is a very common infection worldwide. Its reactivation in patients receiving immunosuppression has been widely described as being associated with significant mortality. Liver dysfunction associated with HBV infection may develop from a subtle change in serum aminotransferase levels to fulminant liver failure and death. As preventive measures, all IBD patients should be screened for HBV markers at diagnosis and those who are positive for the hepatitis B surface antigen should re- ceive antiviral prophylaxis before undergoing immunosuppression in order to avoid HBV reactivation. Tenofovir or ente- cavir is preferred to lamivudine due to their better resistance profile. In patients with occult or resolved HBV, regular DNA determination is recommended during immunosuppression therapy. Compared with HBV infection, hepatitis C virus （HCV） reactivation is uncommon in patients receiving immunosuppression therapy. The efficacy and safety of HCV therapy with immunosuppression and ribavirin for patients with IBD are comparable to those of subjects without IBD.