P057 Is baseline screening enough for long term biologic treatment? Looking for hepatitis in biologic populations
Authors: Eden Alexandra , Ellis Spencer , Marianayagam Thiraupathy 
Published: April 2022

Abstract

Background/Aims
With biological agents used for inflammatory arthritis (IA) for over 20 years and the more recent addition of targeted synthetic agents, it is no surprise that pre-screening has evolved as we continually learn about these drugs. The BSR biologic guidelines (2018) recommend that we screen hepatitis B (HBV) and hepatitis C (HCV) serology prior to commencing any biologic. However, in long-term treatment, infection risks are posed from both new exposure and from reactivation of latent disease in the context of immunosuppression. The latter has been well recognised for tuberculosis, but we report a case of hepatitis B in a patient treated for 11 years, initially with anti-TNF for 2.5 years and subsequently with rituximab (RTX). We present an 80-year-old female patient diagnosed with rheumatoid arthritis (RA) in 2001, who migrated from Hong Kong in 1972. After initial treatment with gold, sulfasalazine, methotrexate, hydroxychloroquine and leflunomide, eventually etanercept (ETN) was initiated in 2010. In accordance with earlier BSR guidance (2005) we tested for HBsAg and HCV in 2009, prior to ETN, both were undetected. In early 2018, hepatology advice recommended including antibodies to hepatitis B core antigen (anti-HBc) with our screening, later specified by the current 2018 BSR guidance. Initially, this was only undertaken in new patients, however, we decided to re-check all patients on biologics to include anti-HBc in 2019. Prior to this, re-screening was not undertaken routinely at any interval or when switching biologic, unless there were relevant risk factors. The relevant guidance and recommendations, at the time, only recognised prior screening and reactivation of HBV. On re-testing our case in July 2021, anti-HBc was detected. Subsequently the patient was referred to hepatology and commenced on anti-viral treatment (tenofovir). The aim was to review all patients on biologics not previously screened for anti-HBc, especially those in high-risk groups.

Methods
A retrospective review of the hepatitis screening profiles of 71 patients. These patients were actively receiving RTX or infliximab in the preceding three years, since including anti-HBc.

Results
HBV was not detected in 55/71 (77.5%). Twelve patients (16.9%) are yet to be re-screened. HBV was detected in four individuals (5.6%). Our index patient, receiving RTX since 2012, underwent additional screen in 2021, likely delayed by the pandemic. Of the other three, one had no viral load detected and the result deemed a false positive. One patient was new to RTX in 2019, and the final patient had HBsAg detected with anti-HBc not detected.

Conclusion
For patients with IA receiving long-term biologic therapy, there is a need to standardise screening protocols for viral hepatitis and to undertake repeat testing at a reasonable interval, such as every five years and possibly more frequently in high-risk groups.

Disclosure
A. Eden: None. S. Ellis: None. T. Marianayagam: None.