Infliximab and occult Hepatitis B infection: to treat or not to treat?

The long-term effects of anti-TNF-α agents on patients with chronic viral hepatitis C and B infections

AIM

To evaluate the long-term effects of anti-tumor necrosis factor-alpha (TNF-α) therapy on patients with chronic hepatitis B and C infections.

METHODS

Rheumatoid arthritis, ankylosing spondylitis and Crohn's disease patients administered anti-TNF-α therapy for at least 36 months were retrospectively reviewed for hepatitis B or C serology, liver function tests, viral load, genotype and liver biopsy results, if performed. Nine relevant cases receiving anti-TNF-α were evaluated: six patients had chronic hepatitis C, one had chronic dual hepatitis B and C and two had chronic hepatitis B infection.

RESULTS

The patient with dual infection exhibited virologic breakthrough for hepatitis C and required treatment. Two patients with occult hepatitis B infection developed hepatitis B surface antigen (HBsAg) reversion and low-level viremia at the end of the study.

CONCLUSION

Long-term use of anti-TNF-α treatments may result in viral replication that requires anti-viral therapy. Before determining the safety of anti-TNF drugs in the treatment of autoimmune diseases in patients with hepatitis C infection, studies with large homogeneous patient groups must be performed, and the exact group of hepatitis C virus infected patients for whom anti-TNF treatment would be deemed safe should be identified. Prior to anti-TNF-α treatment, it seems logical to screen all patients for HBsAg and anti-HB core immunoglobulin G status, especially in endemic regions. These patients must be followed periodically by means of alanine aminotransferase, HBsAg and hepatitis B virus DNA to identify HBsAg reversion and active viral replication that might require anti-viral prophylaxis or treatment.