Reactivation of hepatitis B virus infection in rheumatic diseases: risk and management considerations

Abstract

In patients with rheumatic diseases undergoing immunosuppressive treatment, hepatitis B virus reactivation (HBVr) has been long recognized as a major treatment-related adverse event with substantial morbidity and mortality. Because HBVr is easily preventable with appropriate screening and monitoring strategies, and, when indicated, prophylactic antiviral treatment, awareness of this complication is of the utmost importance, especially in the era of biologic treatments. As a condition, it continues to be topical, in view of the emergence of novel classes of immunosuppressive drugs (i.e. Janus kinase inhibitors) acquiring licenses for a variety of rheumatic diseases. The class-specific risk of these agents for HBVr has not yet been determined. Moreover, ambiguity still exists for the management of patients planned to be treated with traditional agents, such as cyclophosphamide and glucocorticoids, particularly in the setting of resolved HBV infection. Clinicians in the field of rheumatic diseases should be tailoring their practice according to the host’s profile and treatment-specific risk for HBVr. In this review, the authors attempt to critically review the existing literature and provide practical advice on these issues.

Infections in Patients with Rheumatoid Arthritis in the Era of Targeted Synthetic Therapies

“…Hepatitis B virus (HBV) remains the most common chronic viral infection worldwide. 55 Its prevalence worldwide has been estimated at 3.6%, 55 , 56 with a similar prevalence among RA patients, as it was shown recently in the International COMORA study (estimated prevalence: 3%). 57 …”

“… 60 Cases of HBV reactivation has been reported with all immunosuppressive agents used in the treatment of RA, including GCs, b- and ts-DMARDs. 56 …”

“…Currently, all RA patients starting DMARD therapy should be screened for HBV infection with HBsAg, anti-HBc and anti-HBs antibodies ( Table 2 ). 47 , 56 Such screening offers the opportunity of identifying susceptible patients, while vaccination should be offered in HBV negative patients (HBsAg-, anti-HBc-, anti-HBs-) who are at high risk for HBV exposure. 56 …”

“…Patients who are HBsAg+ (chronic infection) should receive appropriate chronic antiviral prophylaxis with the newer generation of oral antivirals (entecavir, tenofovir disoproxil fumarate or alafenamide). 56 For those with past or resolved HBV infection (HBsAg-, anti-HBc+, anti-HBs±), close monitoring of HBsAg, HBV DNA and ALT levels is recommended (especially for patients who are treated with B cell depleting agents) 56 with antiviral prophylaxis initiation in case of HBV reactivation (HBsAg or HBV DNA+).…”

Regarding the problem of viral hepatitis reactivation in rheumatic diseases: risks and curation issues

“…Эти данные следует интерпретировать с осторожностью применительно к ИВРЗ, при лечении которых выраженность иммуносупрессии ниже, а продолжительность терапии больше (годы). К тому же разработка и внедрение новых препаратов для лечения ИВРЗ в последние годы требуют дополнительных пояснений в отношении рекомендаций по курации и мониторингу HBV-р [9].…”