Risk of hepatitis B reactivation following baricitinib or tocilizumab for treatment of COVID-19

Hepatitis B Reactivation and Liver Failure Because of COVID-19 Infection

Coronavirus disease 2019 (COVID-19) has been associated with liver injury incidence reported between 15% and 53%. Viral binding to ACE2 receptors in hepatobiliary cells is believed to cause liver inflammation. The relationship between hepatitis B and COVID-19 is poorly understood, but patients treated with immunosuppressive therapy for COVID-19 are at higher risk of hepatitis B reactivation (HBVr). We present a case of a patient with HBVr because of COVID-19, in the absence of any immunosuppressive treatment, leading to fulminant liver failure and subsequent requiring liver transplantation. Given low incidence, limited data, and no current guidelines, further studies are needed to evaluate the benefit and cost-effectiveness of anti-HBV prophylaxis in a patient with chronic hepatitis B (CHB) and COVID-19. Meanwhile, the American Association for the Study of Liver Diseases guidelines for patients with CHB and immunosuppressant use can be considered for anti-HBV prophylaxis for patients with CHB and COVID-19 to prevent HBVr on a case-by-case basis.

[Chronic hepatitis B in rheumatic diseases: issues of screening and reactivation of infection: A review]

Patients with rheumatic diseases infected with hepatitis B virus (HBV) are difficult to manage not only due to the presence of risk factors for the development and rapid progression of liver cirrhosis, but also due to the likelihood of reactivation of this infection. Despite the successes achieved in the fight against HBV, the virus cannot be completely defeated due to the presence of hidden forms of the disease, escaping the field of vision of a rheumatologist and an infectionist. Based on the results of the analysis of current publications, the paper presents the rationale for a complete immunological screening of patients with rheumatic diseases when prescribing antirheumatic therapy. The issues of the role of COVID-19 in the exacerbation of chronic viral hepatitis B, antiviral prevention and monitoring are discussed, the classification of antirheumatic drugs according to the risk of HBV reactivation is presented.

The Risk of Hepatitis B Virus Reactivation in Rheumatoid Arthritis Patients Receiving Tocilizumab: A Systematic Review and Meta-Analysis

BACKGROUND

Tocilizumab has demonstrated optimal efficacy and safety in patients with rheumatoid arthritis (RA) from clinical trials. However, the risk of hepatitis B virus reactivation (HBVr) in these patients remains uncertain because patients with underlying HBV have been excluded in phase III studies.

METHODS

Systematical reviews were conducted on PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to 21 February 2023. Random-effects meta-analysis was performed to calculate the pooled incidence of HBV reactivation.

RESULTS

We included 0 clinical trials and 11 observational studies with a total of 25 HBsAg+ and 322 HBsAg-/anti-HBc+ RA patients. Among the HBsAg+ patients without antiviral prophylaxis, the pooled rate was 69.4% (95% CI, 32.9-91.3), with a median time of 4 months (range, 1-8 months) from tocilizumab initiated. Half of these patients with HBVr experienced hepatitis flare-up but no deaths. HBVr was eliminated with prophylaxis in this population. Among HBsAg-/anti-HBc+ patients, the pooled incidence of reactivation was 3.3% (95% CI, 1.6-6.7), with a median time of 10 months (range, 2-43 months) from tocilizumab initiated. HBVr was not associated with hepatitis flare-up and death. HBsAg-/anti-HBc+ patients without anti-HBs antibodies had a significantly higher risk of HBVr (Odds ratio, 12.20; 95% CI, 1.16-128.06).

CONCLUSIONS

This systematic review indicated that the risk of HBVr in RA patients with anti-HBs-, HBsAg+, or HBsAg-/anti-HBc+ cannot be ignored but may be avoided. Clinicians should consider implementing appropriate antiviral prophylaxis and monitoring policies for RA patients to avoid unnecessary hepatic side effects from tocilizumab treatment.