The A, B, Cs of viral hepatitis in the biologic era

To evaluate the recent published data on the safety of biological agents, mainly anti-TNFalpha and rituximab, and diagnostic difficulties in the setting of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and inflammatory arthritides.

There are important differences between HBV and HCV carriers; however, clinical observations suggest that hepatotropic virus infection should not preclude the treatment with biologic agents in rheumatic diseases. Retrospective reports on limited series of HBV-infected patients with concomitant chronic arthritis convey that careful patients' clinico-virological assessment, in collaboration with the hepatologist, is necessary before starting immunosuppressive treatments, especially biological agents. Preemptive or combined antiviral treatment is mandatory, mainly in active and inactive HBV carriers. Occult HBV infection should be also carefully evaluated due to potential virus reactivation. In HCV-infected patients without chronic active hepatitis the treatment with biological agents, anti-TNFalpha or rituximab, is generally useful and well tolerated. Preliminary data suggest the possible synergic effects of combined antivirals (alpha-interferon and ribavirin) and anti-TNFalpha (or rituximab) in patients with chronic arthritis and active hepatitis C.

In all patients with chronic arthritis requiring immunomodulating treatments both HBV and HCV infection along with liver conditions should be evaluated before any therapeutic decisions, including differential diagnosis among virus-related autoimmune disease and simple comorbidity. Patients with HBV infection should be referred to the hepatologist and correctly classified into active, inactive, and occult carriers. Similarly, rheumatic patients with active chronic hepatitis C must be treated with sequential or combined treatment with antiviral and biological agents.