接受化疗的乙肝病毒感染者应接受预防性治疗

张医生

乙肝病毒（HBV）感染者患恶性肿瘤尤其是淋巴瘤时，在接受化疗期间，有病毒再激活的危险。既往研究显示，如果不进行抗病毒预防治疗，乙肝病毒再激活的发生率高达50%，其相关死亡率为5%。美国Saab等学者比较了这类患者接受拉米夫定预防用药与HBV再激活后再接受拉米夫定治疗的疗效及效价比。结果显示，拉米夫定预防治疗可有效预防HBV感染者接受化疗期间的病毒再激活，且可获得较好的效价比。

在研究者设定的决策分析模型中，预防治疗组患者在化疗前开始接受拉米夫定治疗，并在化疗结束后继续服用拉米夫定6个月。如在接受了拉米夫定治疗后仍发生HBV再激活，则联合阿德福韦继续治疗。在无预防治疗组（对照组）中，仅当发生HBV再激活时，患者才接受拉米夫定治疗。比较两组患者1年内的花费及患者的健康状态，健康状态用生存年限进行比较。当相关的医疗费用随着患者的健康状态改变而发生改变时，计算其增加的效价比。

结果显示，虽然预防治疗比需要时才给予药物治疗的花费多（分别为18707美元和17177美元），但预防治疗能使HBV再激活明显减少（分别为48例和219例）。在预防治疗组中，无一例患者发生肝源性死亡，而在对照中，20例患者发生肝源性死亡。此外，预防治疗组中肿瘤相关死亡率亦比对照组低。研究者考虑其原因为前者因HBV再激活导致的化疗方案停止或改变情况相对较少。

Hepatology. 2007 Oct;46(4):1049-56.

Hepatitis B prophylaxis in patients undergoing chemotherapy for lymphoma: a decision analysis model.

Saab S, Dong MH, Joseph TA, Tong MJ.

Department of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.

Hepatitis B reactivation is a major cause of morbidity and mortality in patients undergoing chemotherapy for lymphomas. These patients may experience direct liver-related complications or reduced cancer survival because of interruptions in chemotherapy. Our aim was to compare the costs and outcomes of 2 different chronic hepatitis B management strategies. In hepatitis B carriers undergoing chemotherapy, we pursued a decision analysis model to compare the costs and clinical outcomes of using lamivudine prophylaxis versus initiating lamivudine only when clinically overt hepatitis occurred. Our results indicate that the use of lamivudine prophylaxis is cost-effective. Even though the use of lamivudine prophylaxis was associated with an incremental cost of $1530 per patient ($18,707 versus $17,177), both the number and severity of hepatitis B reactivations were reduced. None of the patients in the prophylaxis group had liver-related deaths versus 20 who died in the no-prophylaxis group. Cancer deaths were also reduced from 47-39 with lamivudine prophylaxis, presumably because of the increased need for cessation or modification of chemotherapy in patients who had severe hepatitis B virus flares. The incremental cost-effectiveness ratio of using lamivudine prophylaxis was $33,514 per life year saved. CONCLUSION: Our results provide pharmacoeconomic support for the use of lamivudine prophylaxis in patients undergoing chemotherapy for lymphoma treatment.