Before you start taking a biologic drug or one of the new targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs), several screening tests are recommended. These include tests to see whether you have hepatitis B or C in your body that isn’t causing symptoms but might be reactivated after you start these powerful immune-suppressing drugs.
But there’s a big gap between what’s recommended and what’s really happening, as a new study reveals that fewer than one in four patients in a national registry received hepatitis screening before starting these medications.
“I think that we all believe that we are doing an excellent job taking care of our patients, but what we found is that there is a gap of care around screening for these infections,” Gabriela Schmajuk, MD, of the University of California, San Francisco, told Healio Rheumatology. Dr. Schmajuk was senior author of the new study, which was presented at the 2019 American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting in Atlanta.
The researchers looked at electronic health records from 23,597 patients (average age 57, 72 percent female) being treated at 196 different practices participating in the Rheumatology Informatics System for Effectiveness national registry. Each received their first prescription for a biologic or new synthetic DMARD in 2017, with the majority (63 percent) starting a tumor necrosis factor inhibitor.
Prior to the first prescription, 77 percent were not screened for hepatitis B virus (HBV) and 86 percent were not screened for hepatitis C virus (HCV). Only 6 percent of patients were fully screened for HBV, including both HBV surface antigen and HBV core antibody, prior to their first prescription. Another 17 percent had received one of the tests. Only 14 percent of patients received complete testing for HCV prior to their first prescription.
Of the patients who were fully screened, 83% had screening completed before receiving their first prescription, and a total of 97% had completed screening within 60 days of receiving their prescription.
“We actually looked to see, among the patients who were screened, how many had a positive test, and we found a rate of about 2 to 3 percent, so it is not insignificant,” Dr. Schmajuk told Healio Rheumatology. “If we can prevent one of those people from reactivating, that is going to save all of the money that we spent in screening them.”
Reactivation of HBV may lead to a hepatitis flare, liver failure, and sometimes even death, so patients who screen positive for the virus are often treated with an antiviral medication to prevent reactivation and its complications. HCV reactivation can also lead to hepatitis, but it may not be as severe as that caused by HBV reactivation.
The researchers acknowledge that their data, which can only capture screening entered into electronic health records at the rheumatology practices, could be missing hepatitis screening that was only noted in writing in the patient chart or conducted elsewhere and faxed to the practice, not making it into the electronic record.
Pre-medication screening percentages differed wildly between practices, with 0 percent to 63 percent of patients screened for HBV and 0 percent to 80 percent of patients screened for HCV.
If you’re not sure whether you have been screened for hepatitis B or C and you’re starting a biologic medication make sure you ask your health care provider.
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