Background Reactivation of hepatitis in hepatitis B virus (HBV) carrier receiving cytotoxic chemotherapy or immunosuppressive therapy often occur (20-50%), so prophylactic treatment by antiviral agent is recommended with chemotherapy or immunosuppressive therapy (ref.1). However, patients often does not recognize that they are HBV carrier. We reported the case of reactivated hepatitis B by infliximab in rheumatoid arthritis (RA) and under-recognized HBV carrier (ref.2). Recently, reactivation of resolved hepatitis B under immunosuppressive treatment is a popular topic, so all of RA patients who undertake immunosuppressive therapy from now on are taken HBV related examination, but RA patients who had already taken immunosuppressive treatment might not be taken HBV related examination.
Objectives To investigate the prevalence and clinical course of RA patients with HBV infection
Methods We cross-sectionally examined serum HBs-Ag, HBs-Ab, HBc-Ab, HBV-DNA in 370 RA outpatients who regularly visited Osaka Rosai Hospital at intervals of less than 3months and selected RA patients with chronic hepatitis B virus (HBV) infection (HBs-Ag positive). HBV-DNA, AST, ALT were examined every 1-3months for HBs-Ag positive carrier and resolved HBV patients (HBs-Ag negative, HBcAb positive and/or HBsAb positive) and elevation of ALT and HBV-DNA was regarded as reactivation of hepatitis B. Patient characteristics, medication including immunosuppressive agents, time point when HBV infection had been detected, occurrence of HBV reactivation, and outcome were examined.
Results Nine patients (2.4%) were HBsAg-positive carrier and 101 patients (27.3%) were resolved HBV patients. HBV-DNA was negative in all 101 resolved HBV patients by cross-sectional examination, and reactivation of resolved hepatitis (de novo hepatitis) was not observed within 6 months. HBV-DNA was positive in all HBsAg-positive nine patients before antiviral therapy. Six patients took predonizolone, 8 patients took methotrexate, two patients took tacrolimus, one patient took infliximab, and two patients took tocilizumab. Four patients were detected as HBV carrier before undergoing immunosuppressive therapy, 3 patients were detected after immunosuppressive therapy, and 2 patients after reactivation of hepatitis caused by immunosuppressive therapy. Two patients had not recognized they were HBV carrier. Hepatitis reactivated patients were resolved with appropriate antiviral therapy (lamivudine 1, entecavir 1). All HBs-Ag positive patients can be treated with immunosuppressive therapy consecutively without reactivation of hepatitis by treating with prophylactic antiviral agent (lamivudine 1, entecavir 8).
Conclusions To check HBV related markers is important before immunosuppressive therapy. By cross-sectional examination, we could treat chronic hepatitis B infected RA patients without reactivation of hepatitis by using immunosuppressive agent and antiviral agent concomitantly.
Calabreese LH. Hepatitis B virus (HBV) reactivation with immunosuppressive theray in rheumatic disease: asessment and preventive strategies. Ann Rheum Dis 65: 983-9, 2006.
Tsuboi H. A patient with rheumatoid arthritis treated with tocilizumab together with lamivudine prophylaxis after remission of infliximab-reactivated hepatitis B. Mod rheumatol 21: 701-5, 2011.
Disclosure of Interest None Declared
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