Arthritis patients with resolved hepatitis B infection, who received disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, were unlikely to have the hepatitis B resurface. That’s one of the findings of a meta-analysis of 25 studies.
“Patients who have hepatitis B history should inform their physicians and confirm the hepatitis B status before starting DMARDs,” said Jay Lin and Daniel Solomon of Brigham and Women’s Hospital and Harvard Medical School, and two of the Arthritis Care & Research study authors.
Patients receiving non-biologic DMARDs, especially combined with steroids, should also be aware of elevated hepatitis B reactivation risk, the researchers said. Their meta-analysis found that the reactivation rate of hepatitis B was a lot higher for patients with chronic hepatitis B infection without antiviral prophylaxis. The rates were similar for those receiving tumor necrosis factor inhibitors (TNFi), non-TNF biologics, and nonbiologic DMARDs.
“Physicians should screen patients starting DMARDs for their hepatitis B status,” Lin and Solomon said. “Follow-up for hepatitis B status should be considered even for patients who are in a hepatitis B-resolved status.” For those without antiviral prophylaxis, the reactivation risk was 14.6 percent, compared to 9 percent for those with antiviral prophylaxis.
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In their research, Solomon, Lin, and colleagues found higher rates than the 2015 Gastroenterological Association guidelines would expect for risk of reactivation when combining non-biologic DMARDs and glucocorticoids (1.7 percent) and TNF inhibitors (1.4 percent). “This urges the awareness from physicians, as combination of non-biologic DMARDs and glucocorticoids is a common choice for rheumatoid arthritis patients with moderate to high disease activity,” Solomon and Lin said.
DMARDs, the two said, are the “anchor drugs” of rheumatoid arthritis, and they control disease activity. When rheumatoid arthritis patients have chronic hepatitis B, one option, Lin and Solomon said, is to stop DMARDs temporarily and treat the hepatitis B first.
“However, for patients with high rheumatoid arthritis disease activity, they may not want to wait until the hepatitis B is resolved,” the researchers said. “Antiviral prophylaxis enables the timely and concomitant use of DMARDs and control the disease activity as soon as possible.”
[Read about one patient’s experience when biologics and other drugs didn’t work.]
The nature of the study, however, makes it hard to estimate the real differences in hepatitis B reactivation risk between chronic hepatitis B patients who had or didn’t have antiviral prophylaxis.
“However, it would be unethical to conduct a study to compare the reactivation risk in chronic hepatitis B patients with and without antiviral prophylaxis,” Lin and Solomon said. “Currently, there are several newer antivirals with lower resistant rates to hepatitis B.”
“The critical point now is that low resistant antivirals are more expensive than high resistant antivirals, and in some low income regions, they are not available,” they add. “More reactivation risk information for newer non-TNF biologic DMARDs (such as abatacept and tocilizumab) is still needed; the current study did not have large enough sample size to have precise estimates.”
