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No antiviral drugs Know both mechanisms and clinical uses Good Review Sources: First Aid, Hi-Yield Pharm, Katzung Review (drug list.
Analgesics, including acetominophen and non-steroidal anti-inflammatory drugs (NSAID): aspirin, ibuprofen, naproxen, and others available only by prescription. Heartburn drugs of the proton pump inhibitor class, including omeprazole (brand name Prilosec), lansoprazole (brand name Prevacid), pantoprazole (brand name Protonix), rabeprazol (brand names Rabecid, Aciphex), esomeprazole (brand names Nexium, Esotrex). Antiviral drugs, including acyclovir (brand name Zovirax) used to treat herpes infection, and indinavir and tenofovir, both used to treat HIV. Rheumatoid arthritis drugs, including infliximab (brand name Remicade); chloroquine and hydroxychloroquine, which are used to treat malaria and systemic lupus erythematosus as well as rheumatoid arthritis. Anticonvulsants, including phenytoin (brand name Dilantin) and trimethadione (brand name Tridione), used to treat seizures and other conditions. Chemotherapy drugs, including interferons, pamidronate, cisplatin, carboplatin, cyclosporine, tacrolimus, quinine, mitomycin C, bevacizumab; and anti-thyroid drugs, including propylthiouracil, used to treat overactive thyroid. This information is typically 10 – 30 pages long, and includes detailed precautions, warnings, and adverse effects. Keep your doctor informed of what you’re taking, especially if you have risk factors for kidney disease (see Ref.
Not just for the people that have it, but for you – the people that stick with them – while they’re going through it. Two drugs in this class have been withdrawn from the market because of cardiovascular toxicity: rofecoxib (brand name Vioxx), and valdecoxib (brand name Bextra). This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractObjective.
These drugs are a special class of NSAID that were developed to be safer for the stomach, but have the same risk as other NSAIDs for kidney damage. To describe the antiviral treatment patterns for chronic hepatitis B (CHB) among pregnant and nonpregnant women. Using 2011 MarketScan claims, we calculated the rates of antiviral treatment among women (aged 10–50 years) with CHB.
Sasadeusz, “Chronic hepatitis B infection and pregnancy,” Obstetrical and Gynecological Survey, vol.
We described the pattern of antiviral treatment during pregnancy and ≥1 month after delivery. These data provide a baseline for assessing changes in treatment patterns with anticipated increased use of antivirals to prevent breakthrough perinatal hepatitis B virus infection.1. IntroductionAn estimated 350 million individuals worldwide are chronically infected with hepatitis B virus (HBV) [1].
Perinatal HBV infection leads to chronic hepatitis B (CHB) in up to 90% of infants [2, 3]. Postexposure immunoprophylaxis consisting of hepatitis B vaccination and hepatitis B immune globulin (HBIG) can prevent up to 95% of perinatal HBV transmissions [2, 6]. Arevalo, “Prevention of hepatitis B virus transmission by immunization: an economic analysis of current recommendations,” The Journal of the American Medical Association, vol. The use of antivirals during pregnancy solely for prophylaxis of perinatal HBV transmission requires careful evaluation of potential risks and benefits among infants and pregnant women. Animal studies showed severe growth restriction and reduced bone mineral density among fetuses [9]. The development of drug resistance (particularly with lamivudine) and postpartum flare have been a concern for pregnant women receiving antiviral treatment during pregnancy. The major potential benefit of antiviral prophylaxis during pregnancy is to reduce viremia and decrease breakthrough perinatal HBV infections [10–13]. Of five oral antiviral agents available for treatment of CHB, telbivudine and tenofovir are classified as FDA Pregnancy Category B (animal studies indicate no fetal risk, but no humans studies exist, or adverse effects in animals but not in humans), and lamivudine, adefovir dipivoxil (adefovir), and entecavir are classified as Pregnancy Category C (no adequate human or animal studies; benefit may outweigh risk) [14, 17]. Information on the use of antivirals for CHB during pregnancy in the United States of America (USA) is scarce. The objective of this study was to describe antiviral treatment among pregnant and nonpregnant women with CHB in 2011 using claims data from MarketScan, with a focus on treatment patterns among the pregnant women.2.


The MarketScan claims databases capture the full continuum of care in all settings including outpatient and inpatient visits. Goetzl, “Cost-effectiveness of maternal treatment to prevent perinatal hepatitis B virus transmission,” Obstetrics and Gynecology, vol.
Study PopulationWe restricted the study sample to women aged 10–50 years to capture a broad range of ages when women might have been pregnant in the USA. We classified women as having CHB when the ICD-9 code was 07022, 07023, 07032, or 07033 (Table 1). Because the antiviral drugs for human immunodeficiency virus (HIV) can overlap with antivirals used to treat HBV, we also identified women who might be coinfected with HIV. We classified women as coinfected with HIV when the ICD-9 code was 042, V08, 79571, or 07953 (Table 1).
For women with CHB, we extracted data on age in 2011, on residence by metropolitan or nonmetropolitan area, and by region of the USA (Northeast, North Central, South, and West). We identified pregnant women among women with CHB if they had a delivery code in 2011 (Table 1).
We defined antiviral treatment for CHB by having national drug codes for one or more of the 5 oral antiviral drugs for CHB.
Pregnant women without a delivery date were excluded from evaluation of treatment patterns.
Wang, “Estimating the number of births to hepatitis B virus-infected women in 22 states, 2006,” Pediatric Infectious Disease Journal, vol.
We looked for prescriptions of antiviral drugs for up to 300 days before the delivery date and extracted the antiviral drug prescription dates and supply. We assumed if a prescription for an antiviral was filled, the woman was receiving antiviral treatment. AnalysesWe calculated the frequencies of pregnant women with CHB who were prescribed antiviral treatment and the frequencies with which various antiviral drugs were prescribed. Using Pearson chi-square test and logistic regression, we assessed the association between antiviral treatment and age and between antiviral treatment and pregnancy status. We further determined whether the choice of antiviral differed among pregnant and nonpregnant women with CHB, and if there was regional variation (by metropolitan status and by the USA census region) in antiviral treatment. Among pregnant women, no significant difference was found between treated and untreated women by age, residence in a metropolitan area, or region of residence in the USA (Table 2). Thung, “Antenatal lamivudine to reduce perinatal hepatitis B transmission: a cost-effectiveness analysis,” The American Journal of Obstetrics and Gynecology, vol.
The proportion of women with CHB who received lamivudine and tenofovir was higher for pregnant than nonpregnant women, and the proportion who received entecavir was lower for pregnant than nonpregnant women (). Antiviral treatment prior to pregnancy was terminated for 8 women who became pregnant (Table 4). Three of the women were prescribed tenofovir and two women were prescribed adefovir dipivoxil.4. DiscussionAn increasing number of reports provide guidance on treating pregnant women with CHB [16, 18], and many cite the accumulating evidence for the efficacy of antivirals to enhance prevention of perinatal HBV transmission among pregnant women with high viral load [11–13, 16, 18]. Gluud, “Effect of hepatitis B immunisation in newborn infants of mothers positive for hepatitis B surface antigen: systematic review and meta-analysis,” British Medical Journal, vol. The significantly lower use of antiviral treatment among pregnant compared to nonpregnant women was consistent with safety concerns for use of antiviral drugs during pregnancy [1, 8, 14, 16]. About one-third of the pregnant women receiving antiviral treatment for CHB had been receiving treatment before pregnancy. Pregnant women with significant liver disease and viremia are recommended to receive close monitoring for postpartum hepatic flare, which is most often manifested by an elevation of serum alanine aminotransferase [1, 16]. Tenofovir was FDA-approved for treatment of CHB in 2008 and has shown very low or no resistance by hepatitis B virus after prolonged use [11, 23]. Lamivudine was FDA-approved for treatment of CHB in 1998 and is the most studied antiviral agent in pregnancy [1].
We found a higher proportion of pregnant women were prescribed lamivudine compared to nonpregnant women. Pan, “Virologic factors associated with failure to passive-active immunoprophylaxis in infants born to HBsAg-positive mothers,” Journal of Viral Hepatitis, vol. Short-term use of lamivudine in the last trimester is reported to be safe and is accompanied by a low risk of developing drug resistance [5, 13]. Long-term use of lamivudine is associated with development of HBV resistance [3, 11, 14, 23].Some experts recommend deferring antiviral treatment for women who are planning a pregnancy unless they have active or advanced liver disease [8, 16].
If a patient with CHB becomes pregnant during treatment, the treatment indications can be reevaluated and the choice of antiviral agent reconsidered.


If an antiviral agent is continued during pregnancy, tenofovir generally has been the agent of choice because of its effectiveness, low resistance rate, and safety profile during pregnancy. Reports include use of lamivudine, telbivudine, and tenofovir for maternal prophylaxis [11–13].
Although concerns have been raised about the safety of antiviral treatment or prophylaxis during pregnancy, increasing evidence suggests that the incidences of adverse events among pregnant women and infants receiving antiviral treatment for CHB initiated during the last trimester are comparable to those of women and infants without antiviral treatment [9, 11–14, 16, 24]. Lok, “Management of hepatitis B: our practice and how it relates to the guidelines,” Clinical Gastroenterology and Hepatology, vol. In practice, when prevention of perinatal transmission of HBV is the purpose of prescribing antivirals, prophylaxis is initiated during the last trimester and stopped soon after delivery [1, 14, 25, 26].Previous studies have shown the economic value of antiviral treatment for CHB during pregnancy, if used selectively to reduce the risk of perinatal HBV [3, 5, 27]. We compared the cost-effectiveness of five strategies and showed that antiviral treatment during the last trimester for women with high viral load, either after positive HBeAg screening or viral load testing, was cost-effective compared to the current active-passive immunoprophylaxis strategy alone [27].
Given the increasing evidence for the efficacy, safety, and economic value of antiviral prophylaxis during pregnancy, in 2012 the European Association for the Study of the Liver (EASL) and the Asian Pacific Association for the Study of the Liver (APASL) recommended considering a prophylactic antiviral in the third trimester for pregnant women with high viral load.
Notably, this strategy is not a replacement for active-passive immunoprophylaxis for infants known to be at risk for perinatal HBV transmission, and universal infant hepatitis B vaccination, which should be continued. The results from our study indicate that antiviral prophylaxis during pregnancy to prevent perinatal transmission was uncommon in 2011 among women with employer-sponsored health insurance.Although clinical and laboratory data are important to define disease severity and the need for treatment, our MarketScan database lacked this information [8, 15, 17, 20]. Without clinical and laboratory data, we were unable to examine for differences in the indications for antiviral treatment among pregnant and nonpregnant women. A limitation of using MarketScan medical claims data for insurance reimbursement is that these data are not representative of the USA population. MarketScan consists of a convenience sample of individuals with private employer insurance. Patients with CHB who did not receive private employer insurance and patients with CHB who did not have a billable medical intervention would not have been identified in the analysis. Bulterys, “Safety of tenofovir during pregnancy for the mother and fetus: a systematic review,” Clinical Infectious Diseases, vol.
Patients with insurance who purchased antiviral drugs would have drug claims data indicating CHB and, therefore, the treatment patterns likely were representative of the population that was covered by private insurance. We found that a lower proportion of pregnant than nonpregnant women received antiviral treatment in 2011, and differences existed in the type of prescribed antivirals between pregnant and nonpregnant women. The most commonly prescribed antiviral for both pregnant and nonpregnant women was tenofovir in this population of employer sponsored insurance participants. These data provide a baseline evaluation of the use of antivirals in pregnant women with severe CHB disease.
Wright et al., “Lamivudine as initial treatment for chronic hepatitis B in the United States,” The New England Journal of Medicine, vol.
Jiang et al., “Telbivudine prevents vertical transmission from HBeAg-Positive women with chronic hepatitis B,” Clinical Gastroenterology and Hepatology, vol.
Shah, “Hepatitis B in pregnancy: challenges and treatment,” Gastroenterology Clinics of North America, vol.
View at Publisher · View at Google Scholar · View at Scopus European Association for the Study of the Liver, “EASL clinical practice guidelines: management of chronic hepatitis B virus infection,” Journal of Hepatology, vol. Hann et al., “The management of chronic hepatitis B in Asian Americans,” Digestive Diseases and Sciences, vol. Hirnschall, “The 2013 WHO guidelines for antiretroviral therapy: evidence-based recommendations to face new epidemic realities,” Current Opinion in HIV and AIDS, vol. View at Publisher · View at Google Scholar · View at Scopus Thomson Reuters, MarketScan Databases User Guide and Database Dictionary, Thomson Reuters, Ann Arbor, Mich, USA, 2011. Cohen, “Evaluation and management of hepatitis B in pregnancy: a survey of current practices,” Gastroenterology and Hepatology, vol.
Miao, “Prevention of vertical hepatitis B transmission by hepatitis B immunoglobulin in the third trimester of pregnancy,” International Journal of Gynecology and Obstetrics, vol. Schalm, “Acute exacerbation of chronic hepatitis B virus infection after withdrawal of lamivudine therapy,” Hepatology, vol.
Janssen, “Exacerbation of chronic hepatitis B infection after delivery,” Journal of Viral Hepatitis, vol. Murphy, “Cost-effectiveness of testing Hepatitis B-positive pregnant women for Hepatitis B e antigen or viral load,” Obstetrics and Gynecology, vol. Kuhnert et al., “The prevalence of hepatitis B virus infection in the United States in the era of vaccination,” Journal of Infectious Diseases, vol.




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