Hepatitis B and immunosuppressive therapies for chronic inflammatory diseases: When and how to apply prophylaxis, with a special focus on corticosteroid therapy

Abstract

Currently immunosuppressive and biological agents are used in a more extensive and earlier way in patients with inflammatory bowel disease, rheumatic or dermatologic diseases. Although these drugs have shown a significant clinical benefit, the safety of these treatments is a challenge. Hepatitis B virus (HBV) reactivations have been reported widely, even including liver failure and death, and it represents a deep concern in these patients. Current guidelines recommend to pre-emptive therapy in patients with immunosuppressants in general, but preventive measures focused in patients with corticosteroids and inflammatory diseases are scarce. Screening for HBV infection should be done at diagnosis. The patients who test positive for hepatitis B surface antigen, but do not meet criteria for antiviral treatment must receive prophylaxis before undergoing immunosuppression, including corticosteroids at higher doses than prednisone 20 mg/d during more than two weeks. Tenofovir and entecavir are preferred than lamivudine because of their better resistance profile in long-term immunosuppressant treatments. There is not a strong evidence, to make a general recommendation on the necessity of prophylaxis therapy in patients with inflammatory diseases that are taking low doses of corticosteroids in short term basis or low systemic bioavailability corticosteroids such as budesonide or beclomethasone dipropionate. In these cases regularly HBV DNA monitoring is recommended, starting early antiviral therapy if DNA levels begin to rise. In patients with occult or resolved hepatitis the risk of reactivation is much lower, and excepting for Rituximab treatment, the prophylaxis is not necessary.

Keywords: Hepatitis B virus; Inflammatory bowel disease; Rheumatic disease. Dermatologic diseases; Corticosteroids; Anti-tumor necrosis factor; Prophylaxis; Immunosuppressants

Core tip: Few reviews have been published including data of the three more common inflammatory diseases that require immunosuppressive therapy: inflammatory bowel disease, rheumatic and dermatologic diseases. This paper is focused on the risk of reactivation of hepatitis B virus under immunosuppressants, and particularly corticosteroids. Although most of the guidelines do not specify the necessity of prophylaxis in case of monotherapy with corticosteroids, the specialists responsible of these patients are usually concerned about this issue. Moreover, the risk with low systemic bioavailability new corticosteroids has not been evaluated in previous reviews. This work summarizes the evidence of VHB reactivation in patients with inflammatory diseases: when and how to apply prophylaxis, with a special focus on “new” and “old” steroids.