Patients who are HBV core antibody positive with an undetectable HBV DNA should be serially monitored with liver profile every two to three months during the at-risk period (during therapy and 6–12 months after therapy). Patients with more substantive risks for HBV reactivation (detectable HBV DNA, absence of protective HBsAb levels) may benefit from monitoring with HBV DNA every two to three months, although the cost benefit of this approach has not been established. If an abrupt increase in HBV DNA and/or abnormal liver profile is observed, all immunosuppressive medications should be discontinued and consultation with a hepatitis specialist is advised. There are insufficient data to recommend resumption of rituximab in patients with previous HBV reactivation.
Other Safety Concerns
Given the limited existing data regarding safety of rituximab in rheumatoid arthritis patients receiving treatment for HBV, use of other agents should be considered. Tumor necrosis factor antagonists (TNFs) are contraindicated in Child-Turcotte-Pugh (CTP) Class B-C, but not CTP Class A cirrhosis. HBV antiviral prophylaxis prior to TNF initiation appears to reduce the risk of HBV reactivation in HBV surface antigen-positive patients.2 Provided frequent monitoring for HBV reactivation occurs, TNFs are likely safe to use in CPT Class A HBV surface antigen-positive patients receiving appropriate HBV antivirals.
Treatment of RA in Patients with Chronic Hepatitis C
The risk of hepatitis reactivation appears to be greater among RA patients infected with HBV than those with hepatitis C virus (HCV). Although immunosuppression has been associated with a more rapid progression to HCV-associated cirrhosis, rituximab has been used in HCV-associated cryoglobulinemia with no worsening of HCV-associated liver disease.3 In addition, TNFs appear relatively safe in patients with RA and HCV.4
Mary Jane Burton, MD, is an associate professor of infectious diseases at the University of Mississippi Medical Center. Her research interests include improving outcomes in viral hepatitis. She actively treats hepatitis B and C in her clinics at the Jackson (Miss.) VA Medical Center.
John W. Baddley, MD, MSPH, is professor of medicine in the Division of Infectious Diseases at the University of Alabama at Birmingham. He is also chief of infectious diseases at the Birmingham VA Medical Center.
Kevin L. Winthrop, MD, MPH, is an associate professor of infectious diseases, public health and preventive medicine at Oregon Health and Sciences University in Portland. His research interests include drug safety, and he collaborates closely with rheumatologists in the prevention and treatment of infectious diseases that occur in the setting of biologic therapy.
