Background Clinicians generally prescribe antiviral agents to patients with chronic hepatitis B (CHB) or to inactive carriers of the virus until 6–12 months after the cessation of biologic agents. However, the current antiviral prophylaxis regimen, in addition to biological therapy, is expensive and poses an economic burden to both patients and societies. We have had patients in our medical center quit or reduce antiviral prophylaxis due to economic reasons.

Objectives To assess the outcome of tapering or discontinuation of antiviral agents in patients who were infected with hepatitis B virus (HBV) during biologic therapy.

Methods We identified 45 patients who were infected with HBV and treated with biologic agents concomitantly from January 2005 to December 2016. They were diagnosed with rheumatoid arthritis (n=20), Crohn's disease (n=13), ankylosing spondylitis (n=8), ulcerative colitis (n=3), and psoriatic arthritis (n=1). The criteria of HBV reactivation was a 10-fold rise in HBV DNA compared with previous HBV DNA titers, resulting in HBV DNA of greater than 20,000 IU/ml (HBeAg-positive patients) or 2,000 IU/ml (HBeAg-negative patients), and an increase in AST or ALT to more than twice the upper normal limit (40 IU/l).

Results Sixteen CHB patients and 29 inactive carriers were treated with biologic agent for 4.1±2.7 years. No reactivation case was observed in 23 patients (10 of CHB and 13 of inactive carrier) who maintained antiviral prophylaxis for 4.0±2.3 years. Among them, 4 patients (3 treated with infliximab and 1 with adalimumab) taking antiviral prophylaxis regimen on alternate days did not experience HBV reactivation for 28–42 months of follow-up period. In the discontinuation group (n=9), no reactivation case was observed in all inactive carrier patients (2 treated with etanercept, 1 with infliximab, and 1 with rituximab) after discontinuation of antiviral prophylaxis for 6–33 months of follow-up period. In contrast, 3 patients (2 treated with etanercept and 1 with adalimumab) among the 5 patients with CHB experienced reactivation after discontinuation of antiviral prophylaxis for 3–29 months of follow-up period.

Conclusions During biologic therapy, HBV reactivations were frequently found in CHB patients who ceased to take antiviral prophylaxis. However, no reactivation after the cessation of prophylaxis was found in inactive carrier patients who were previously treated with prophylaxis. Based on our experience, tapering or discontinuation of antiviral agent in inactive carriers with economic problem undergoing concomitant biologic agent therapy could be considered viable, albeit with caution.

References

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2. Mori S, Fujiyama S. Hepatitis B virus reactivation associated with antirheumatic therapy: Risk and prophylaxis recommendations. World J Gastroenterol. 2015;21(36):10274–89.

3. Ryu HH, Lee EY, Shin K, Choi IA, Lee YJ, Yoo B, et al. Hepatitis B virus reactivation in rheumatoid arthritis and ankylosing spondylitis patients treated with anti-TNFalpha agents: a retrospective analysis of 49 cases. Clin Rheumatol. 2012;31(6):931–6.

References

Disclosure of Interest None declared