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Brakenhoff SM, Hoekstra R, Honkoop P, Roomer R, den Hollander JG, Bezemer G, de Knegt RJ, Sonneveld MJ, de Man RA. Patients treated with rituximab are poorly screened for hepatitis B infection: Data from a low-incidence country. Eur J Intern Med 2023; 108:68-73. [PMID: 36462966 DOI: 10.1016/j.ejim.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND & AIMS Patients with chronic or resolved hepatitis B are at risk of hepatitis B reactivation (HBVr) when treated with high-risk immunosuppressive therapy such as rituximab. Therefore, international guidelines recommend HBV screening prior to rituximab treatment and subsequent antiviral prophylaxis among patients with a (resolved) infection. In this study, we evaluated the adherence to those recommendations. METHODS This is a retrospective multicentre study including patients treated with rituximab between 2000-2021. Performance of correct screening was assessed, defined as the measurement of hepatitis B surface antigen (HBsAg) and hepatitis B core antibodies (anti-HBc). Next, initiation of antiviral prophylaxis and HBVr rate among patients with a chronic or resolved HBV infection was studied. RESULTS We enrolled 3,176 patients of whom 1,448 (46%) were screened correctly. Screening rates differed significantly between academic and non-academic hospitals; respectively 65% vs 32% (p<0.001). In addition, screening rates differed across specialties and improved throughout the years; from 32% before 2012 to 75% after 2020 among academic prescribers, versus 1% to 60% among non-academic prescribers (both p<0.001). Antiviral prophylaxis was initiated in 58% vs 36% of the patients with a chronic or resolved HBV infection. Seven patients experienced HBVr, including one fatal liver decompensation. CONCLUSIONS Many patients treated with rituximab were not correctly screened for HBV infection and antiviral prophylaxis was often not initiated. Although screening rates improved over time, rates remain suboptimal. With the increasing number of indications for rituximab and other immunosuppressive agents these findings could raise awareness among all medical specialties prescribing these agents.
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Affiliation(s)
- Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - Roos Hoekstra
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | - Jan G den Hollander
- Department of Internal Medicine, Maasstad Medical Centre, Rotterdam, the Netherlands
| | - Geert Bezemer
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, the Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Etienne S, Vosbeck J, Bernsmeier C, Osthoff M. Prevention of Hepatitis B Reactivation in Patients Receiving Immunosuppressive Therapy: a Case Series and Appraisal of Society Guidelines. J Gen Intern Med 2023; 38:490-501. [PMID: 36138278 PMCID: PMC9905451 DOI: 10.1007/s11606-022-07806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022]
Abstract
Hepatitis B (HBV) reactivation (HBVr) is a potentially fatal complication in patients with past HBV exposure receiving immunosuppressive therapy. HBVr can occur in patients with chronic HBV infection as well as in patients with resolved HBV infection. In this article, we present the cases of four patients with resolved hepatitis B who presented with HBVr during or after immunosuppressive treatment, of whom two died as a consequence of HBVr. We then reflect on and summarize the recommendations of four major societies for the screening and management of previously HBV-exposed patients planned to receive immunosuppressive treatment. Current guidelines recommend screening for HBV in all patients planned to receive immunosuppressive therapy. Risk of HBVr is assessed based on the serological status of the patient and the planned immunosuppressive drug regimen. For patients considered to be at low risk of HBVr, management consists of serological monitoring for HBVr and immediate preemptive antiviral therapy in the case of HBVr. For patients considered to be at intermediate or high risk for HBVr, antiviral prophylaxis should be initiated concordantly with the immunosuppressive therapy and continued for up to 18 months after cessation of the immunosuppressive regimen. Areas of uncertainty include the risk of novel and emerging immunosuppressive and immune modulatory drugs and the exact duration of antiviral prophylaxis. Greater awareness is needed among clinicians regarding the risk of HBVr in patients receiving immunosuppressive therapy, especially in low-endemicity settings. Implementation of screening and management programs and decision support tools based on the presented guidelines may improve the management of these patients.
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Affiliation(s)
- Samuel Etienne
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jürg Vosbeck
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | | | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Department of Clinical Research, University of Basel, Basel, Switzerland.
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Schmajuk G, Montgomery A, Tarasovsky G, Li J, Hauser RG, Rozenberg-Ben-Dror K, Whooley MA. Screening for Latent Infections Among Users of High-Risk Immunosuppressants: A Cross-Sectional Analysis From the Veterans Health Administration Healthcare System. J Patient Saf 2023; 19:1-7. [PMID: 36395779 DOI: 10.1097/pts.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Guidelines recommend screening for latent hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) before initiating biologics or targeted synthetic disease-modifying antirheumatic drugs (b/ts DMARDs) to avoid reactivation of life-threatening infections. The extent to which such screening occurs in the national Veterans Health Administration (VA) healthcare system is unknown. METHODS Using data from the Veterans Affairs' (VA) Corporate Data Warehouse, we performed a cross-sectional analysis of veterans receiving b/ts DMARDs between October 1, 2017, and September 30, 2019. We calculated the proportion of patients with screening completed for latent HBV, HCV, and TB between October 1, 1999 and September 30, 2019. Patient characteristics associated with complete screening were evaluated using mixed-effects multivariate logistic regression models. We also examined facility-level factors associated with high versus lower performance. RESULTS A total of 51,764 unique patients from 129 VA facilities received b/ts DMARDs from 2017 to 2019. Of these, 63% had complete screening. Among the 11,006 patients identified as new users, 64% had complete screening. Higher screening rates were observed among Hispanic/Latinx and Black/African American patients, users of B-cell therapies, and patients who had seen oncology subspecialists. Substantial variation was observed across facilities, with complete screening ranging from 13% to 98% of patients. Higher screening rates were associated with highly complex, urban, and higher-volume facilities. CONCLUSIONS Approximately two-thirds of veterans taking b/ts DMARDs have received guideline-recommended screening for HBV, HCV, and TB, but substantial facility variation was observed. Performance measures, robust multidisciplinary workflows, and electronic health record-based tools to feed information back to providers may improve screening rates for low-performing facilities.
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Bozkurt I, Ozturk Cerik H, Kir S, Ustaoglu M, Turgut M, Esen S. Evaluation of Hepatitis B screening and reactivation in patients receiving rituximab containing chemotherapy: A single-centre study. Int J Clin Pract 2021; 75:e14685. [PMID: 34331726 DOI: 10.1111/ijcp.14685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/16/2021] [Accepted: 07/30/2021] [Indexed: 12/26/2022] Open
Abstract
AIMS Hepatitis B virus (HBV) infection is a worldwide distributing viral disease. Hepatitis caused by HBV reactivation may progress to chronic illness and associated with increased risk of hepatic failure and hepatocellular cancer. Rituximab (RTX) is an immunosuppressive agent, is particularly used in the treatment of non-Hodgkin's Lymphoma. Patients have significant risk for HBV reactivation following chemotherapy with a RTX-containing regimen. This study aimed to determine the HBV screening manner and reactivation rates in patients with haematological neoplasm following chemotherapy including Rituximab. METHODS This is a single-centered retrospective cohort study. A total of 331 adults with haematological disorders who received chemotherapy regimen including RTX between years of 2006 and 2016 were enrolled. Patients who experienced reactivation were evaluated. RESULTS Only 130 of 331 patients were screened appropriately for HBV infection for 10-year period. We found 18 patients were Hepatitis B surface antigen (HBsAg) (+) and 16 (88.8%) of them received antiviral prophylaxis. Among screened patients, 27 were HBsAg (-)/AntiHBc (+) and only 10 (37%) of them received HBV prophylaxis. In total, nine patients experienced reactivation, six were from screened and three were from unscreened group. CONCLUSION Incomplete screening and inappropriate prophylaxis may result in HBV reactivation in patients under RTX-based chemotherapy and related complications such as death.
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Affiliation(s)
- Ilkay Bozkurt
- Department of Infectious Diseases, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Hatun Ozturk Cerik
- Department of Infectious Diseases, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Seher Kir
- Department of Internal Medicine, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Muge Ustaoglu
- Department of Gastroenterology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Mehmet Turgut
- Department of Hematology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Saban Esen
- Department of Infectious Diseases, Ondokuz Mayis University School of Medicine, Samsun, Turkey
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Abstract
Purpose of Review We reviewed the current data on infections associated with rituximab use published over the last 5 years. Recent Findings New literature was available on rates of serious infections, Hepatitis B reactivation and screening, and infection with Severe Acute Respiratory Syndrome Coronavirus 2. Summary Rates of infection varied by study and population, however, higher risk of infection in patients with underlying rheumatologic diseases was seen in those who required a therapy switch, had a smoking history, and those undergoing retreatment who had a serious infection with their first course of therapy. With regards to HBV, the proportion of patients screened continues to be inadequate. Despite the upfront cost, HBV screening and prophylaxis were found to be cost effective. There is still limited data regarding COVID-19 severity in the setting of rituximab, however, rituximab, especially in combination with steroids, may lead to more severe disease and higher mortality.
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Aguirre A, Trupin L, Margaretten M, Goglin S, Noh JH, Yazdany J. Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic. J Rheumatol 2020; 47:1712-1720. [PMID: 32062597 PMCID: PMC7429246 DOI: 10.3899/jrheum.190472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population. METHODS The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care. RESULTS There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets. CONCLUSION Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.
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Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, Clinical Fellow, Division of Rheumatology, Department of Medicine, University of California, San Francisco;
| | - Laura Trupin
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Mary Margaretten
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Sarah Goglin
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Jung Hee Noh
- J.H. Noh, RN, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jinoos Yazdany
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
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Schmajuk G, Li J, Evans M, Anastasiou C, Izadi Z, Kay JL, Hammam N, Yazdany J. RISE registry reveals potential gaps in medication safety for new users of biologics and targeted synthetic DMARDs. Semin Arthritis Rheum 2020; 50:1542-1548. [PMID: 32234243 DOI: 10.1016/j.semarthrit.2020.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 03/13/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Immunosuppressant drugs can increase the risk of hepatitis B virus (HBV) and hepatitis C virus (HCV) and tuberculosis (TB) reactivation. Using the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry, we examined pre-treatment screening among new users of biologic or targeted synthetic disease modifying drugs (DMARDs). METHODS Data, derived from RISE, included patients ≥ 18 years old who were new users of biologic or targeted synthetic DMARDs. We developed quality measures related to pre-treatment screening for HBV, HCV, and TB in addition to a "composite" measure for all applicable tests. We assessed patient-level screening rates, practice-level variation among practices reporting on ≥ 20 patients, and the frequency of positive results. RESULTS We included 26,802 patients across 213 rheumatology practices nationwide. Patients were 58 (14) years old, 75.9% female; 59.6% had rheumatoid arthritis, and TNFi were the most common index DMARDs (64.9%). Overall, 44.8% and 40.5% patients had any documented HBV or HCV screening, respectively, prior to the index date; 29.7% had TB screening in the year prior to drug start. Only 15.5% had documentation of screening for all appropriate infections prior to drug start. Practice-level performance on the composite measure was low (range 0 to 48.3%). 2.4% of screening tests were positive. CONCLUSION We found gaps in documentation of key safety measures among practices participating in RISE. Given the small but significant number of patients with active or latent infections that pose safety risks, developing standardized and reliable strategies to capture safety screening measures is paramount.
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Affiliation(s)
- Gabriela Schmajuk
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States; Philip R. Lee Institute for Health Policy Research, University of California - San Francisco, 3333 California St San Francisco, CA 94118, United States; San Francisco VA Medical Center, 4150 Clement St 111R, San Francisco, CA 94121, United States.
| | - Jing Li
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Michael Evans
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Christine Anastasiou
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Zara Izadi
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Julia L Kay
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Nevin Hammam
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
| | - Jinoos Yazdany
- University of California - San Francisco - Division of Rheumatology, Department of Medicine, 3333 California St San Francisco, CA 94118, United States
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8
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Patterson S, Schmajuk G, Evans M, Aggarwal I, Izadi Z, Gianfrancesco M, Yazdany J. Gaps in Ambulatory Patient Safety for Immunosuppressive Specialty Medications. Jt Comm J Qual Patient Saf 2019; 45:348-357. [PMID: 30686706 PMCID: PMC7433663 DOI: 10.1016/j.jcjq.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES New specialty drugs such as biologics are now available in record numbers, presenting increased safety risks for people with immune-mediated diseases. However, comprehensive assessments of patient safety for these drugs are lacking. We examined performance on key patient safety measures, such as screening for latent tuberculosis (LTBI), hepatitis B virus (HBV), and hepatitis C virus (HCV), for new users of a broad group of specialty medications. METHODS Data were extracted via electronic health record data warehouses of a large university health system using structured queries, and extensive chart review was performed to confirm measure elements. We included all new users of immunosuppressive specialty drugs between 2013 and 2017. We assessed screening for LTBI, HBV, and HCV from 12 months before through 60 days after medication initiation, and calculated performance on a composite measure that required screening for all three infections. Multivariable logistic regression was used to assess differences in screening across specialties, adjusting for patient race, sex, age, and comorbidities. RESULTS Among 2027 patients, the most common drugs prescribed were adalimumab (32%), etanercept (24%), infliximab (19%), and ustekinumab (9%). Overall, 62% of patients were screened for LTBI, 42% for HBV, and 33% for HCV. Only 26% of patients were screened appropriately for all three infections. Screening patterns differed significantly according to treating specialty. CONCLUSIONS We found gaps in ambulatory safety for patients treated with immunosuppressive specialty drugs for diverse inflammatory conditions across all relevant treating specialties. More robust safety protocols are urgently needed to prevent serious patient safety events in this high-risk population.
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Affiliation(s)
- Sarah Patterson
- Department of Medicine, Division of Rheumatology, University of California, San Francisco.
| | - Gabriela Schmajuk
- Department of Medicine, University of California, San Francisco, and the Department of Veterans Affairs Medical Center, San Francisco, USA
| | - Michael Evans
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Ishita Aggarwal
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Zara Izadi
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Milena Gianfrancesco
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
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Schwaneck EC, Krone M, Kreissl-Kemmer S, Weißbrich B, Weiss J, Tony HP, Gadeholt O, Schmalzing M, Geier A. Management of anti-HBc-positive patients with rheumatic diseases treated with disease-modifying antirheumatic drugs-a single-center analysis of 2054 patients. Clin Rheumatol 2018; 37:2963-2970. [PMID: 30238380 DOI: 10.1007/s10067-018-4295-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 12/14/2022]
Abstract
Hepatitis B virus (HBV) reactivation is a common complication of immunosuppressive treatment in high prevalence countries. Biological disease-modifying antirheumatic drugs (bDMARDs) cause this adverse event more often than conventional immunosuppressants. The incidence of HBV reactivation during treatment for rheumatic diseases in Germany is unclear. Furthermore, it remains open how to treat and monitor patients at risk during immunosuppressive therapy with bDMARDs. We examined 2054 patients from a German tertiary rheumatology center in order to analyze the prevalence of HBc-antibody-positivity and the incidence of HBV reactivation in German rheumatology patients treated with immunosuppressants. Of 1317 patients treated with bDMARDs and 737 conventional synthetic DMARD (csDMARDs) patients between 2008 and 2017, 86 had a history of HBV infection (anti-HBc positive). Only two patients were suffering from chronic infection (HBsAg positive). Three patients were treated pre-emptively with entecavir, and eight patients after HBV DNA reappearance. No liver failure occurred due to HBV reactivation. Compared to anti-HBc-positive patients without reactivation, the reactivation group included more patients exposed to three or more classes of bDMARDs (p = 0.017). The median HBs antibody titer was significantly lower in the reactivation group (15.0 IU/l vs. 293.5 IU/l; p = 0.001). This study shows that bDMARDs and csDMARDs can safely be administered to patients with a history of HBV, provided they are closely monitored. Low titers of anti-HBs antibodies and a history of ≥ 3 classes of immunosuppressants increase the risk of HBV reactivation. These data highlight major differences to high prevalence regions.
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Affiliation(s)
- Eva C Schwaneck
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany.
| | - Manuel Krone
- Institute for Hygiene and Microbiology, University of Wuerzburg, Würzburg, Germany
| | | | - Benedikt Weißbrich
- Institute for Virology and Immunobiology, University of Wuerzburg, Würzburg, Germany
| | - Johannes Weiss
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Ottar Gadeholt
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Marc Schmalzing
- Division of Rheumatology/Immunology, University Hospital Wuerzburg, Würzburg, Germany
| | - Andreas Geier
- Division of Hepatology, University Hospital Wuerzburg, Würzburg, Germany
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Jasmine Bullard A, Cunningham FE, Volpp BD, Lowy E, Beste LA, Heron BB, Geraci M, Hammond JM, LaPlant K, Stave EA, Turner MJ, O’Leary MC, Kelley MJ, Hunt CM. Preventing Hepatitis B Reactivation During Anti-CD20 Antibody Treatment in the Veterans Health Administration. Hepatol Commun 2018; 2:1136-1146. [PMID: 30202826 PMCID: PMC6128236 DOI: 10.1002/hep4.1238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 12/29/2022] Open
Abstract
Hepatitis B virus (HBV) reactivation may occur with high risk immunosuppression, such as anti-cluster of differentiation (CD)20 antibodies (Abs). Appropriate HBV prophylaxis during anti-CD20 Ab therapy averts hepatitis, chemotherapy disruption, and death. Serologic evidence of prior HBV exposure is present in one in nine veterans in the Veterans Health Administration (VHA). In 2014, most (61%-73%) patients in the VHA who were receiving anti-CD20 Ab treatment underwent HBV testing, yet <20% of eligible patients received HBV antiviral prophylaxis. We aimed to prevent HBV reactivation by increasing HBV testing and antiviral treatment rates among anti-CD20 Ab recipients through prospective interventions. A multidisciplinary team of clinicians, pharmacists, and public health professionals developed comprehensive prevention systems, including national seminars/newsletters/websites; pharmacy criteria for HBV screening/treatment prior to anti-CD20 Ab use; changes to national formulary restrictions to expand HBV prophylaxis prescribing authority; Medication Use Evaluation Tracker to identify omissions; national e-mail alert to all VHA oncology providers detailing specific testing and HBV antiviral treatment needs; and a voluntary electronic medical record "order check" used at interested facilities (n = 11) to automatically assess pretreatment HBV testing and antiviral treatment and only generate a reminder to address deficiencies. Analysis of monthly data from June 2016 through September 2017 among anti-CD20 Ab recipients revealed pre-anti-CD20 Ab treatment HBV testing increased to 91%-96% and appropriate HBV antiviral prophylaxis to 76%-85% nationally following implementation of the intervention. Medical centers using the voluntary electronic medical record order check increased HBV testing rates to 93%-98% and HBV antiviral prophylaxis rates to 99%. Conclusion: Multimodal intervention systems to prevent HBV reactivation among VHA patients receiving anti-CD20 Ab therapies increased national rates of HBV testing to >90% and antiviral prophylaxis to >80%.
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Affiliation(s)
- A. Jasmine Bullard
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | | | - Bryan D. Volpp
- Veterans Affairs Northern California Healthcare SystemMartinezCA
| | - Elliott Lowy
- Veterans Affairs Puget Sound Health Care System, Health Services Research and DevelopmentUniversity of Washington School of Public HealthSeattleWA
| | - Lauren A. Beste
- Veterans Affairs Puget Sound Health Care System, Health Services Research and Development, Department of MedicineUniversity of WashingtonSeattleWA
| | | | - Mark Geraci
- Veterans Affairs Pharmacy Benefits Management ServicesHinesIL
| | - Julia M. Hammond
- Pharmacy DepartmentDurham Veterans Affairs Health Care SystemDurhamNC
| | - Kourtney LaPlant
- Malcom Randall Veterans Affairs Medical CenterVeterans Health SystemNorth Florida, South Georgia, GainesvilleFL
| | - Elise A. Stave
- Zucker School of Medicine at Hofstra/NorthwellHempsteadNY
| | - Marsha J. Turner
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | - Meghan C. O’Leary
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
| | - Michael J. Kelley
- Office of Patient Care Services, Department of Veterans AffairsWashingtonDC
- Hematology‐Oncology ServiceDurham Veterans Affairs Health Care SystemDurhamNC
| | - Christine M. Hunt
- Cooperative Studies Program Epidemiology Center‐DurhamDurham Veterans Affairs Health Care SystemDurhamNC
- Department of MedicineDuke University Medical CenterDurhamNC
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