Hepatitis B virus and hepatitis C virus treatment and management in patients receiving immune-modifying agents

To increase awareness and review the management of chronic viral hepatitis in individuals treated with immune-modifying agents to avoid potentially severe consequences.

Hepatitis B virus (HBV) reactivation has been reported with a wide variety of immunosuppressive regimens ranging from corticosteroids to cytotoxic chemotherapy. In the rheumatology field, reactivation is best studied with anti-tumor necrosis factor-alpha agents and may occur even in individuals with 'resolved' HBV infection. These complications can be prevented with the use of well tolerated pre-emptive antiviral agents. Treatment of reactivation after it occurs is much less effective. Unlike HBV, acute deterioration is rare with immunosuppression in patients with hepatitis C virus (HCV) and prophylactic therapy is not indicated in these patients. However, patients should undergo evaluation for staging of liver disease preferably before immunosuppression because of the risk of drug-induced liver injury and also rheumatological complications, such as cryoglobulinemia.

HBV and HCV remain enormous global health problems with over 500 million people infected worldwide. Neither virus is cytopathic with liver damage and control of viral replication caused by the host immune response. With the increasing number and types of immunomodulatory therapies, HBV reactivation is becoming an increasingly recognized issue in many areas of medicine, particularly rheumatology. Unfortunately, screening rates are low, partially because of unclear clinical guidelines. HCV may also complicate immunomodulatory therapy, particularly if cirrhosis is present. The management of rheumatology patients with HBV and HCV infection is discussed with a focus on whom to screen and whom to treat to prevent consequences of these often unrecognized conditions.