How I Select First-line HBV Therapy in Patients With Abnormal Bone Health

Norah Terrault, MD, MPH

Professor of Medicine and Surgery
Director, Viral Hepatitis Center
Division of Gastroenterology
University of California, San Francisco
San Francisco, California


Norah Terrault, MD, MPH, has disclosed that she has received consulting fees from Dynavax Technologies, Gilead Sciences, and Novartis and funds for research support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, and Merck.


View ClinicalThoughts from this Author

Released: July 23, 2018

The most recent AASLD/IDSA guidance recommends entecavir, TAF, or TDF as preferred first-line therapies for HBV infection. Although the updated guidance now advocates for consideration of bone health when selecting an initial therapy, it offers limited specifics on how to do so. How can we choose among these recommended options for our HBV-infected patients with poor bone health?

Selecting HBV Therapy in Settings of Poor Bone Health
Bone health is an important consideration because studies show that there is a greater impact of TDF vs TAF on bone health. Although the absolute change in bone mineral density with TDF vs TAF exposure is small, we want to be mindful of any potentially deleterious effect when managing patients with osteopenia or osteoporosis.

The good news is that we have excellent options for our patients with poor bone health or at risk of worsening bone health. Now that TAF is approved by the FDA for chronic HBV infection, many clinicians—and many experts in Clinical Care Option’s decision support tool for first-line HBV therapy—would choose either entecavir or TAF over TDF when there are concerns about bone health. Neither entecavir nor TAF is associated with adverse events on bone. Thus, deciding between entecavir vs TAF in your patients with poor bone health comes down to other factors, such as HIV coinfection, prior treatment experience, or copays and other cost factors. 

If considering TDF, it is important to take into account both the patient’s current bone health and whether the patient is at risk for developing osteoporosis or osteopenia. Well-recognized risk groups include postmenopausal women and individuals with older age, low body weight, history of excess alcohol, or glucocorticoid exposure.

In my practice, when I am considering TDF for a patient, I perform a FRAX score calculation and I consider a baseline DXA scan to help determine whether the patient has or is at risk for osteopenia or osteoporosis.

To Switch or Not to Switch? Bone Health Considerations
How should we approach our patients who initiated TDF but later develop poor bone health? In my practice, I would consider switching a patient doing well on long-term TDF after documentation of osteopenia and certainly after documentation of osteoporosis. In that setting, I try to do everything to optimize the patient’s bone health. Therefore, if possible, I would switch the patient to entecavir or TAF, which do not influence bone health. I would also check the patient’s vitamin D levels and ensure that the patient’s primary care doctor or endocrinologist is onboard in managing the osteoporosis.

Among the much larger group of patients who are doing well on TDF and whose bone health is not at risk, I see no strong reason to switch these patients. However, we should monitor these patients annually to assess whether they are acquiring risk factors for osteopenia and osteoporosis and to and ensure that, if they are older, they receive DXA scans per the osteoporosis screening guidelines.

Experts’ Selection of HBV Therapy
In Clinical Care Option’s decision support tool for first-line HBV therapy, you can see how other experts and I selected first-line HBV therapy for patients with or at risk for poor bone health and for a variety of patient scenarios.

Your Thoughts?
Do you consider bone health when starting a patient on HBV therapy? How do you assess a patient’s risk factors for bone disease? Please share your experiences below.

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