Preventing Hepatitis B reactivation in immunosuppressed patients: Is it time to revisit the guidelines?

Hepatitis B virus (HBV) infection remains a serious global health concern. Approximately one third of the world's population has evidence of previous HBV infection, and 350 million people are chronic HBV carriers.1 In the United States, the rate of new HBV infections has declined by approximately 82% since 1991, when a national strategy to eliminate HBV infection was implemented.2 The greatest decline has been among those born since 1991, when universal vaccination of children was first recommended.2 Despite these improvements, HBV remains prevalent in the United States; 800,000 to 1.4 million individuals are estimated to be chronic carriers.2 Although intravenous drug users and homosexual men are at high risk for chronic HBV, most cases in the United States are in those emigrating from high prevalence areas (e.g. Asia or Africa), where early life horizontal and vertical transmission is common.3 Reactivation of HBV in immunosuppressed individuals has been well-documented in the literature for several decades. Reactivation can occur either at the cessation of therapy when immune reconstitution occurs, or with prolonged immunosuppression that can result in an accelerated course of HBV infection.4-6 Most cases occur in individuals with cancer undergoing chemotherapy, where reactivation among HBV positive patients is common (e.g. >50% in some lymphoma series) and sometimes fatal.7-18 In rheumatology, HBV reactivation has been reported with a number of disease modifying anti-rheumatic drugs (DMARDs), although the lack of large studies makes it hard to ascertain the exact risk for most drugs. However, it is increasingly apparent that newer biologic therapies, such as TNF-α inhibitors and rituximab, may pose a significant risk of HBV reactivation. Therefore, it is especially timely to take stock of how rheumatologists approach HBV in clinical practice. In this issue of Arthritis Care & Research, Stine et al. report the results of a national survey of rheumatologists regarding screening for and management of HBV infection in patients initiating immunosuppressive therapies. Although only 15% of the over 1000 rheumatologists approached completed the survey, the authors' findings are nonetheless interesting and provide a useful starting place for evaluating rheumatologists' awareness of HBV and their practice patterns regarding screening and management. The study highlights areas of significant practice variation among rheumatologists, especially pertaining to screening (e.g. who is screened and which laboratory tests are used for screening), prophylaxis against reactivation, and monitoring intervals for HBV laboratories in chronic carriers receiving immunosuppressive therapies. This observed variation in physician practice patterns likely reflects a number of factors, including the lack of a strong evidence-base in some of these areas, heterogeneity among patient populations, and the absence of clear and specific guidelines regarding HBV screening and management in patients with rheumatic disease. The study also highlights several areas where quality improvement efforts should be targeted.