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Kridin K, Zirpel H, Mruwat N, Ludwig RJ, Thaci D. Evaluating the risk of infections under interleukin 23 and interleukin 17 inhibitors relative to tumour necrosis factor inhibitors - A population-based study. J Eur Acad Dermatol Venereol 2023; 37:2319-2326. [PMID: 37466275 DOI: 10.1111/jdv.19328] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 06/26/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND The risk of infections among patients with psoriasis undergoing interleukin (IL)-23 inhibitors (IL-23i) and IL-17 inhibitors (IL-17i) is yet to be exhaustively determined. OBJECTIVE To assess the risk of infectious complications in patients with psoriasis managed by IL-23i and IL-17i with tumour necrosis factor inhibitors (TNFi) as a comparator. METHODS A global cohort study comprised two distinct analyses comparing patients with psoriasis under different therapeutic modalities; (i) new users of IL-23i (n = 5272) versus TNFi (n = 5272) and (ii) new users of IL-17i (n = 15,160) versus TNFi (n = 15,160). Study groups were compared regarding the risk of 26 different infections. Propensity score matching was conducted to optimize between-group comparability. RESULTS Patients under IL-23i had a lower risk of otitis media (HR, 0.66; 95% CI, 0.44-0.97), encephalitis (HR, 0.18; 95% CI, 0.04-0.78), herpes zoster (HZ; HR, 0.58; 95% CI, 0.41-0.82), hepatitis B virus (HBV) reactivation (HR, 0.24; 95% CI, 0.12-0.47), cytomegalovirus (HR, 0.25; 95% CI, 0.07-0.86), influenza (HR, 0.52; 95% CI, 0.38-0.71) and parasitic diseases (HR, 0.78; 95% CI, 0.64-0.95). IL-17i was associated with a decreased risk of pneumonia (HR, 0.76; 95% CI, 0.68-0.85), septicaemia (HR, 0.84; 95% CI, 0.72-0.97), upper respiratory tract infection (HR, 0.84; 95% CI, 0.77-0.92), HZ (HR, 0.79; 95% CI, 0.67-0.92), HBV (HR, 0.59; 95% CI, 0.46-0.76) and hepatitis C virus (HR, 0.71; 95% CI, 0.57-0.88) reactivation, cytomegalovirus (HR, 0.58; 95% CI, 0.36-0.93), Epstein-Barr virus (HR, 0.38; 95% CI, 0.19-0.75), influenza (HR, 0.70; 95% CI, 0.61-0.81) and parasitic diseases (HR, 0.80; 95% CI, 0.72-0.88). CONCLUSION Compared with TNFi, IL-23i and IL-17i are associated with decreased risk of several infectious diseases. These agents might be preferred in patients with susceptibility to infections.
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Affiliation(s)
- Khalaf Kridin
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Unit of Dermatology and Skin Research Laboratory, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Henner Zirpel
- Comprehensive Center for Inflammation Medicine, University-Hospital Schleswig-Holstein, Lübeck, Germany
| | - Noor Mruwat
- Unit of Dermatology and Skin Research Laboratory, Galilee Medical Center, Nahariya, Israel
| | - Ralf J Ludwig
- Lűbeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Diamant Thaci
- Comprehensive Center for Inflammation Medicine, University-Hospital Schleswig-Holstein, Lübeck, Germany
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Grillo TG, Silveira CFDSMP, Quaglio AEV, Dutra RDM, Baima JP, Bazan SGZ, Sassaki LY. Acute heart failure as an adverse event of tumor necrosis factor inhibitor therapy in inflammatory bowel disease: A review of the literature. World J Cardiol 2023; 15:217-228. [PMID: 37274378 PMCID: PMC10237008 DOI: 10.4330/wjc.v15.i5.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/09/2023] [Accepted: 04/12/2023] [Indexed: 05/19/2023] Open
Abstract
Tumor necrosis factor inhibitors (anti-TNFs) are widely used therapies for the treatment of inflammatory bowel diseases (IBD); however, their administration is not risk-free. Heart failure (HF), although rare, is a potential adverse event related to administration of these medications. However, the exact mechanism of development of HF remains obscure. TNFα is found in both healthy and damaged hearts. Its effects are concentration- and receptor-dependent, promoting either cardio-protection or cardiomyocyte apoptosis. Experimental rat models with TNFα receptor knockout showed increased survival rates, less reactive oxygen species formation, and improved diastolic left ventricle pressure. However, clinical trials employing anti-TNF therapy to treat HF had disappointing results, suggesting abolishment of the cardioprotective properties of TNFα, making cardiomyocytes susceptible to apoptosis and oxidation. Thus, patients with IBD who have risk factors should be screened for HF before initiating anti-TNF therapy. This review aims to discuss adverse events associated with the administration of anti-TNF therapy, with a focus on HF, and propose some approaches to avoid cardiac adverse events in patients with IBD.
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Affiliation(s)
- Thais Gagno Grillo
- Department of Internal Medicine, Medical School, São Paulo State University, Botucatu, Botucatu 18618686, Brazil
| | | | - Ana Elisa Valencise Quaglio
- Department of Biophysics and Pharmacology, Institute of Biosciences, São Paulo State University, Botucatu, Botucatu 18618689, Brazil
| | - Renata de Medeiros Dutra
- Department of Internal Medicine, Medical School, São Paulo State University, Botucatu, Botucatu 18618686, Brazil
| | - Julio Pinheiro Baima
- Department of Internal Medicine, Medical School, São Paulo State University, Botucatu, Botucatu 18618686, Brazil
| | - Silmeia Garcia Zanati Bazan
- Department of Internal Medicine, Medical School, São Paulo State University, Botucatu, Botucatu 18618686, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, Medical School, São Paulo State University, Botucatu, Botucatu 18618686, Brazil
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Shivaji UN, Sharratt CL, Thomas T, Smith SCL, Iacucci M, Moran GW, Ghosh S, Bhala N. Review article: managing the adverse events caused by anti-TNF therapy in inflammatory bowel disease. Aliment Pharmacol Ther 2019; 49:664-680. [PMID: 30735257 DOI: 10.1111/apt.15097] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/12/2018] [Accepted: 11/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biological therapy is currently widely used to treat IBD. Infliximab, adalimumab and golimumab are currently licensed anti-TNF therapies. Biosimilar anti-TNF monoclonal antibodies are increasingly used. Anti-TNF therapies are widely used and their adverse effects are well characterised, and may cause significant morbidity and mortality in a small proportion of exposed patients. Gastroenterologists need to understand the mechanisms for these effects, recognise these swiftly and manage such events appropriately. AIM To cover the range of potential adverse reactions as a result of biologic therapy and specifically management of these events. METHODS A Medline and Pubmed search was undertaken. Search terms included were "anti-TNF," "infliximab" or "adalimumab" or "golimumab" combined with the keywords "ulcerative colitis" or "Crohn's disease" or "inflammatory bowel disease" and then narrowed to articles containing the keywords "complications," "side effects" or "adverse events" or "safety profile." International guidelines were also reviewed where relevant. RESULTS Adverse events discussed in this review include infusion reactions, blood disorders and infections (including bacterial, viral, fungal and opportunistic infections) as well as autoimmune, dermatological disorders, cardiac and neurological conditions. Malignancies including solid organ, haematological and those linked to viral disease are discussed. CONCLUSIONS Anti-TNF therapy has wide-ranging effects on the immune system resulting in a spectrum of potential adverse events in a small proportion of patients. Research advances are improving the understanding, recognition and management of these adverse events.
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Affiliation(s)
- Uday N Shivaji
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Caroline L Sharratt
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham University Hospitals, Nottingham, UK
| | - Tom Thomas
- Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK
| | | | - Marietta Iacucci
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Institute of Translational Medicine, Edgbaston, UK
| | - Gordon W Moran
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham, UK.,Nottingham Digestive Diseases Centre, Nottingham University Hospitals, Nottingham, UK
| | - Subrata Ghosh
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Institute of Translational Medicine, Edgbaston, UK
| | - Neeraj Bhala
- Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK.,University of Birmingham, Birmingham, UK
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ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [I]: anti-tumor necrosis factor-α agents). Clin Microbiol Infect 2018; 24 Suppl 2:S10-S20. [DOI: 10.1016/j.cmi.2017.12.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/25/2017] [Accepted: 12/30/2017] [Indexed: 12/14/2022]
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Atzeni F, Gianturco L, Talotta R, Varisco V, Ditto MC, Turiel M, Sarzi-Puttini P. Investigating the potential side effects of anti-TNF therapy for rheumatoid arthritis: cause for concern? Immunotherapy 2016; 7:353-61. [PMID: 25917627 DOI: 10.2217/imt.15.4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
There are now five anti-TNF drugs available for clinical use, and it will not be long before they are joined by biosimilar drugs. Some patients treated with selective TNF drugs may develop adverse events such as infections, malignancies, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Registry data consistently show that, particularly during the first 6 months, anti-TNF drugs slightly increase the risk of serious infections of the skin, soft tissues and joints, but it does not seem to increase the risk of cancer other than nonmelanoma skin cancers. A number of studies have shown that the administration of biological agents can lead to the formation of neutralizing and nonneutralizing antibodies. Lipid levels increase, but the atherogenic index remains stable and qualitative changes to lipid particles may reduce the risk of cardiovascular diseases. Patients treated with anti-TNF drugs therefore need to be monitored regularly.
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Sehgal VN, Pandhi D, Khurana A. Biologics in dermatology: adverse effects. Int J Dermatol 2015; 54:1442-60. [PMID: 26147909 DOI: 10.1111/ijd.12802] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 01/13/2014] [Accepted: 06/25/2014] [Indexed: 12/13/2022]
Abstract
Biologics are a group of drugs that precisely affect certain specific steps in the immune response and are an extremely useful group when used in an appropriate setting. However, their use can often be a double-edged sword. Careful patient selection and thorough knowledge of adverse effects is a key to their successful use in various disorders. The initial enthusiasm has gradually given way to a more cautious approach wherein a balance is sought between clinical usefulness and expected side effects. The adverse effects of the biologics most commonly used in dermatology have been carefully listed for ready reference. The plausible causes of the adverse reactions are succinctly outlined along with their incriminating factor(s). Besides, in brief, the attention has been focused on their management. The content should provide an essential didactic content for educating the practitioner.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences, and Associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, Dr RML hospital and PGIMER, New Delhi, India
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Huang CK, Yu T, de la Monte SM, Wands JR, Derdak Z, Kim M. Restoration of Wnt/β-catenin signaling attenuates alcoholic liver disease progression in a rat model. J Hepatol 2015; 63:191-8. [PMID: 25724365 PMCID: PMC4475483 DOI: 10.1016/j.jhep.2015.02.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/14/2015] [Accepted: 02/17/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Alcoholic liver disease (ALD) is characterized by the development of fatty liver, alcoholic hepatitis, fibrosis and cirrhosis. However, the underlying mechanism(s) associated with progression remains elusive. Pro-inflammatory cytokines have been implicated in ALD progression due to pro-apoptotic effects on hepatocytes. Wnt/β-catenin signaling recently has been shown to promote inflammation and apoptosis, suggesting that activation of this signaling pathway may modulate ALD progression. The current study was designed to test whether pharmacological activation of Wnt/β-catenin signaling altered ALD development and progression in a rat model. METHODS Adult male Long Evans rats were fed with isocaloric liquid diets containing 0% or 37% ethanol for 8 weeks, and also treated with Wnt agonist during the last 3 weeks of the feeding regimen. Liver and blood samples were subjected to histology, TUNEL assay, immunoblot analysis, real-time quantitative PCR, and alanine transaminase (ALT) assay. RESULTS Wnt/β-catenin signaling was negatively correlated with Foxo3A expression and reduced steatosis, cellular injury and apoptosis in ALD rats. Mutation experiments demonstrated that Foxo3A was critical for modulating these effects. Activation of Wnt/β-catenin signaling suppressed Foxo3A-induced apoptosis through upregulation of serum/glucocorticoid regulated kinase 1 (SGK1). Moreover, pharmacological restoration of Wnt/β-catenin signaling reduced ALD progression in vivo. CONCLUSIONS Wnt/β-catenin signaling plays a protective role in ALD progression via antagonizing Foxo3A-induced apoptosis, and activation of the Wnt/β-catenin signaling cascade attenuates ALD progression.
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Affiliation(s)
- Chiung-Kuei Huang
- Liver Research Center, Division of Gastroenterology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Tunan Yu
- Liver Research Center, Division of Gastroenterology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Suzanne M de la Monte
- Departments of Medicine and Pathology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Jack R Wands
- Liver Research Center, Division of Gastroenterology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Zoltan Derdak
- Liver Research Center, Division of Gastroenterology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Miran Kim
- Liver Research Center, Division of Gastroenterology, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
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López-Serrano P, Briongos EDLF, Alonso EC, Pérez-Calle JL, Rodríguez CF. Hepatitis B and immunosuppressive therapies for chronic inflammatory diseases: When and how to apply prophylaxis, with a special focus on corticosteroid therapy. World J Hepatol 2015; 7:539-547. [PMID: 25848477 PMCID: PMC4381176 DOI: 10.4254/wjh.v7.i3.539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 12/07/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023] Open
Abstract
Currently immunosuppressive and biological agents are used in a more extensive and earlier way in patients with inflammatory bowel disease, rheumatic or dermatologic diseases. Although these drugs have shown a significant clinical benefit, the safety of these treatments is a challenge. Hepatitis B virus (HBV) reactivations have been reported widely, even including liver failure and death, and it represents a deep concern in these patients. Current guidelines recommend to pre-emptive therapy in patients with immunosuppressants in general, but preventive measures focused in patients with corticosteroids and inflammatory diseases are scarce. Screening for HBV infection should be done at diagnosis. The patients who test positive for hepatitis B surface antigen, but do not meet criteria for antiviral treatment must receive prophylaxis before undergoing immunosuppression, including corticosteroids at higher doses than prednisone 20 mg/d during more than two weeks. Tenofovir and entecavir are preferred than lamivudine because of their better resistance profile in long-term immunosuppressant treatments. There is not a strong evidence, to make a general recommendation on the necessity of prophylaxis therapy in patients with inflammatory diseases that are taking low doses of corticosteroids in short term basis or low systemic bioavailability corticosteroids such as budesonide or beclomethasone dipropionate. In these cases regularly HBV DNA monitoring is recommended, starting early antiviral therapy if DNA levels begin to rise. In patients with occult or resolved hepatitis the risk of reactivation is much lower, and excepting for Rituximab treatment, the prophylaxis is not necessary.
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Yılmaz N, Karadağ Ö, Kimyon G, Yazıcı A, Yılmaz S, Kalyoncu U, Kaşifoğlu T, Temiz H, Baysal B, Tözün N. Prevalence of hepatitis B and C infections in rheumatoid arthritis and ankylosing spondylitis: A multicenter countrywide study. Eur J Rheumatol 2014; 1:51-54. [PMID: 27708874 DOI: 10.5152/eurjrheumatol.2014.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/02/2014] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Immunosuppressive therapies, especially tumor necrosis factor-α inhibitors, are frequently used in treatment of rheumatoid arthritis (RA) and ankylosing spondylitis (AS). These therapies can induce viral reactivation in concurrent hepatitis B virus (HBV)- or hepatitis C virus (HCV)-positive patients. On the other hand, the prevalence of HBV and HCV infections is not exactly known in RA and AS patients. The aim of this study was to investigate the prevalence of HBV and HCV infections in RA and AS patients. MATERIAL AND METHODS A group of 1517 RA and 886 AS consecutive patients followed by six different rheumatology outpatient clinics of Turkey were recruited in this study. The prevalence of HBV surface antigen (HBsAg) and HCV antibody (anti-HCV) were retrospectively investigated. RESULTS The mean age was 49.0±13.2 years in RA and 37.3±10.5 years in AS patients. HBsAg prevalence was 35 (2.3%) in RA and 27 (3%) in AS patients. Anti-HCV prevalence was 17 (1.1%) and 10 (1.1%), respectively. In the RA group, both HBsAg and anti-HCV positive patients were older than negative ones (p<0.05), and the highest prevalence was found in those 60-69 years (p<0.05). CONCLUSION In previous national data, the prevalence of HBsAg has been reported as 3.99% and shown to increase with age. In this study we have found a lower HBV infection prevalence in both RA and AS patients according to Turkish national data. This result may explain by being younger age of our patients. In another conclusion, lower prevalence could be related to, joint complaints may less consulted to Rheumatologist in HBV positive.
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Affiliation(s)
- Neslihan Yılmaz
- Department of Rheumatology, İstanbul Bilim University Faculty of Medicine, İstanbul, Turkey
| | - Ömer Karadağ
- Department of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gezmiş Kimyon
- Department of Rheumatology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Ayten Yazıcı
- Department of Rheumatology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Sema Yılmaz
- Department of Rheumatology, Selçuklu University, Faculty of Medicine, Konya, Turkey
| | - Umut Kalyoncu
- Department of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Timuçin Kaşifoğlu
- Department of Rheumatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Hakan Temiz
- Department of Microbiology, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Birol Baysal
- Department of Gastroenterology, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Nurdan Tözün
- Department of Gastroenterology, Acıbadem University Faculty of Medicine, Istanbul, Turkey
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Ruan J, Li HJ, Sun DX. Reactivation of hepatitis B virus. Shijie Huaren Xiaohua Zazhi 2014; 22:927-932. [DOI: 10.11569/wcjd.v22.i7.927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Reactivation of hepatitis B is characterized by the abrupt recurrence or the rise of hepatitis B virus (HBV) DNA in the serum of patients with previously inactive or resolved HBV infection, which frequently occurs during or after cytotoxic chemotherapy or immunosuppressive therapy; however, most of these cases are subclinical and only detected until activated liver disease. Several randomized controlled trials have shown that HBV reactivation can be prevented by antiviral prophylaxis. Thus, patients who are to receive cytotoxic chemotherapy or immunosuppressive therapy should be screened for present and previous hepatitis B infection, and hepatitis B surface antigen positive patients should receive antiviral prophylaxis.
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Atzeni F, Benucci M, Sarzi-Puttini P. Infections during treatment with biological agents and possible treatment in clinical practice. Expert Rev Clin Immunol 2014; 9:193-5. [DOI: 10.1586/eci.13.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Xuan D, Yu Y, Shao L, Wang J, Zhang W, Zou H. Hepatitis reactivation in patients with rheumatic diseases after immunosuppressive therapy--a report of long-term follow-up of serial cases and literature review. Clin Rheumatol 2013; 33:577-86. [PMID: 24343455 PMCID: PMC3962582 DOI: 10.1007/s10067-013-2450-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/24/2013] [Indexed: 12/16/2022]
Abstract
The aims of this paper are to report hepatitis B virus reactivation in 12 patients with rheumatic disease undergoing immunosuppressive therapy and to evaluate whether pre-emptive antiviral therapy is necessary in patients receiving disease-modifying anti-rheumatic drugs. From January 2008 to March 2012, a total of 12 HBV-infected patients with rheumatic diseases were consecutively enrolled in the long-term follow-up. Liver function, HBV DNA, and serum aminotransferase level were tested during the follow-up. We also reviewed the published reports and summarized the clinical characteristics of HBV reactivation during immunosuppressive therapy in patients with rheumatic diseases. The medium duration of follow-up was 41 months (range 16–48). Patients were treated with prednisone, disease-modifying anti-rheumatic drugs (DMARDs) or tumor necrosis factor-alpha-blocking agents (TNFBA). HBV reactivation was only documented in two patients treated with prednisone without pre-emptive antiviral therapy. One hundred patients from literature review were identified as having HBV reactivation; 20.8 % of the patients receiving prednisone experienced HBV reactivation compared to only 4.46 and 9.52 % of patients treated with DMARDs or TNFBA, respectively. This long-term follow-up of serial cases suggests that pre-emptive antiviral therapy should be administered in patients receiving prednisone therapy for rheumatic disease. In contrast, DMARDs and TNFBA are relatively safe to HBV-infected patients with rheumatic diseases. Close monitoring of HBV DNA and ALT levels is necessary in the management of HBV reactivation.
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Affiliation(s)
- Dandan Xuan
- Department of Rheumatology, Huashan Hospital affiliated to Fudan University, 12 Wulumuqi Zhong Rd, Shanghai, 200040, China
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Papa A, Mocci G, Bonizzi M, Felice C, Andrisani G, Papa G, Gasbarrini A. Biological therapies for inflammatory bowel disease: controversies and future options. Expert Rev Clin Pharmacol 2012; 2:391-403. [PMID: 22112183 DOI: 10.1586/ecp.09.12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Over the last few years, advances in understanding the pathogenesis of inflammatory bowel disease, together with progress in biotechnology, have led to the availability of several biological drugs that have dramatically changed the therapeutic approach to these disorders. Indeed, several molecules targeting crucial inflammatory cytokines, blocking T-cell activation/proliferation or the recruitment of inflammatory cells into the inflamed bowel, have been discovered and commercialized. However, the increasing use of biological agents has raised some concerns regarding their short- and long-term safety. This review offers a critical evaluation of the efficacy and safety of biological agents in the management of both Crohn's disease and ulcerative colitis. In addition, promising therapeutic options are discussed.
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Affiliation(s)
- Alfredo Papa
- Istituto di Medicina Interna e Geriatria, Policlinico A. Gemelli, Università Cattolica del S. Cuore, L.go A. Gemelli, 8 00168 Roma, Italy.
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Sandhu A, Alameel T, Dale CH, Levstik M, Chande N. The safety and efficacy of antitumour necrosis factor-alpha therapy for inflammatory bowel disease in patients post liver transplantation: a case series. Aliment Pharmacol Ther 2012; 36:159-65. [PMID: 22616981 DOI: 10.1111/j.1365-2036.2012.05141.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/04/2012] [Accepted: 05/01/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND The role of antitumour necrosis factor-alpha (anti-TNF) therapy for inflammatory bowel disease (IBD) among liver transplant recipients is largely unknown given the rarity of this population and the paucity of literature on the subject. AIM To investigate the safety and efficacy of anti-TNF therapy for refractory IBD in the post liver transplant population. METHODS The liver transplant database at London Health Sciences Centre was searched to identify adult patients with IBD treated with anti-TNF therapy post transplantation. RESULTS Six patients (five men, one woman) were identified, aged 28-65. All patients had cadaveric orthotopic liver transplants. Four patients required transplantation due to primary sclerosing cholangitis, one due to autoimmune hepatitis, and one due to biliary atresia. Five patients suffered from Crohn's disease and the remaining patient from indeterminate colitis. All patients were treated with infliximab 5 mg/kg every 8 weeks after undergoing induction at weeks 0, 2 and 6, with the exception of one patient. The duration of infliximab therapy ranged from 8 weeks to 4 years. Four patients treated with infliximab experienced sustained improvement of their IBD symptoms post transplantation, as documented by Harvey-Bradshaw Index scores demonstrating clinical remission. Of the remaining two patients, neither had sustained improvement of their IBD with infliximab or subsequent adalimumab. One patient was diagnosed with systemic lupus erythematosus and another with colorectal adenocarcinoma following anti-TNF therapy. Otherwise, no side effects were attributed to anti-TNF therapy. CONCLUSIONS Based on this case series, anti-TNF therapy appears to be safe and effective for treating refractory IBD in patients post liver transplantation. These patients respond to anti-TNF therapy similar to those who have not been previously transplanted.
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Affiliation(s)
- A Sandhu
- Department of Medicine, Division of Gastroenterology, The University of Western Ontario, London, ON, Canada.
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Biologics and infections: lessons from tumor necrosis factor blocking agents. Infect Dis Clin North Am 2012; 25:895-910. [PMID: 22054762 DOI: 10.1016/j.idc.2011.08.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In the decade since tumor necrosis factor α (TNF-α) antagonists were first approved for clinical use, they have proven invaluable for the treatment of specific types of chronic inflammation. Currently licensed TNF blockers fall into two classes, monoclonal antibody (or antibody fragments) and soluble receptor. Although they are equally effective in rheumatoid arthritis and psoriasis, important differences have emerged with regard to efficacy in granulomatous inflammation and risks of granulomatous infections, particularly tuberculosis. This article focuses on recent studies that inform prevention and management of infections in this susceptible patient population.
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Hepatitis B immunity and response to booster vaccination in children with inflammatory bowel disease treated with infliximab. Am J Gastroenterol 2012; 107:133-8. [PMID: 21876562 DOI: 10.1038/ajg.2011.295] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Hepatitis B virus (HBV) reactivation has been described in patients treated with infliximab for inflammatory bowel disease (IBD). This has resulted in a "black box" warning. Although universal vaccination against hepatitis B was implemented in the United States in 1991, up to 10% of vaccine recipients fail to respond with adequate anti-hepatitis B surface antibodies (anti-HBs) levels after a primary series of vaccinations. In addition, anti-HBs levels are expected to decline with time. The objectives of this study were to determine HBV immunity in children with IBD on infliximab therapy and to determine response to a booster dose of the HBV vaccine in patients who were found to be non-immune. METHODS This was a prospective cross-sectional, single-center study that included 100 pediatric IBD patients on infliximab. Serologic specimens were tested for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and anti-HBs. Patients with an anti-HBs level ≥10 mIU/ml were considered to be immune. One booster dose was given to non-immune patients and a serum sample was collected after 4 weeks to assess the presence of anamnestic response (anti-HBs level ≥10 mIU/ml after booster). RESULTS The mean age of the patients was 17.9 (±4.0) years. None of the patients were positive for HBsAg or anti-HBc. In all, 87 patients were vaccinated against HBV and 49/87 (56%) had immunity to HBV as defined by anti-HBs level ≥10 mIU/ml. The mean concentration of anti-HBs levels in immune patients was 295.6 (±350.6) mIU/ml. Older age, lower albumin levels, and the presence of pancolitis were associated with the absence of protective antibodies; however, infliximab dose, frequency, duration, and the concurrent use of immunomodulators were not significantly different between immune and non-immune patients. Thirty-four patients received booster immunization and 26/34 (76%) had an anamnestic response. Interestingly, non-responders were given infliximab with higher frequency (every 5.9 ± 1.2 weeks vs. every 7.1 ± 1.8 weeks, P=0.01). Overall, 75/87 (86%) of previously immunized patients were considered immune against HBV infection. CONCLUSIONS In pediatric IBD patients seen at a large, urban tertiary care facility in the United States, a significant minority (13%) have not been vaccinated against HBV. Nearly one-half of all patients (and 44% of previously vaccinated patients) did not have protective anti-HBs levels. Moreover, of those previously vaccinated, a significant minority (14%) appear at risk for HBV because protective anti-HBs levels were absent and could not be elicited through booster immunization. Given the high risk for severe HBV infection in this group, efforts should be made to screen for HBV immunity at the time of IBD diagnosis. Booster immunization should be considered in patients without protective antibodies.
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Viganò M, Degasperi E, Aghemo A, Lampertico P, Colombo M. Anti-TNF drugs in patients with hepatitis B or C virus infection: safety and clinical management. Expert Opin Biol Ther 2011; 12:193-207. [DOI: 10.1517/14712598.2012.646986] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cho YT, Chen CH, Chiu HY, Tsai TF. Use of anti-tumor necrosis factor-α therapy in hepatitis B virus carriers with psoriasis or psoriatic arthritis: a case series in Taiwan. J Dermatol 2011; 39:269-73. [PMID: 22077677 DOI: 10.1111/j.1346-8138.2011.01434.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of anti-tumor necrosis factor (TNF)-α therapy in patients with psoriasis who are hepatitis B virus (HBV) carriers is usually not recommended, and routine antiviral prophylaxis is suggested for those who need the treatment. We report our experience on the safety of anti-TNF-α therapy in patients with psoriasis who are HBV carriers in our clinic using HBV viral load as a guide for HBV treatment. Between 2007 and 2011, seven HBV carriers receiving TNF-α inhibitors for psoriasis in our clinic were collected retrospectively. The HBV viral load and aminotransferase levels were regularly monitored. Two of the seven patients were inactive HBV carriers, and the other five patients had chronic hepatitis B. Only one patient received antiviral agents before the anti-TNF-α treatment. The mean duration of the anti-TNF-α treatment was 26.6 months (range, 14-45 months). These patients were followed up from the start of the anti-TNF-α therapy for a mean duration of 28.9 months (range, 14-45 months). HBV reactivation was observed in three patients, one of whom required antiviral treatment. No HBV reactivation-related hepatitis was observed. In conclusion, prevention of HBV reactivation by monitoring of HBV viral load is cost-effective and may decrease the risk of developing drug resistance from routine anti-HBV prophylaxis treatment. It can be considered as an alternative in psoriasis patients treated by TNF-α inhibitors, especially in areas with a high HBV burden and in hepatitis B e-antigen-negative patients who have a lower risk of viral reactivation.
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Affiliation(s)
- Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
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Pérez-Alvarez R, Díaz-Lagares C, García-Hernández F, Lopez-Roses L, Brito-Zerón P, Pérez-de-Lis M, Retamozo S, Bové A, Bosch X, Sanchez-Tapias JM, Forns X, Ramos-Casals M. Hepatitis B virus (HBV) reactivation in patients receiving tumor necrosis factor (TNF)-targeted therapy: analysis of 257 cases. Medicine (Baltimore) 2011; 90:359-371. [PMID: 22033451 DOI: 10.1097/md.0b013e3182380a76] [Citation(s) in RCA: 199] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The emergence of tumor necrosis factor-α (TNF-α)-targeted therapies as a key therapeutic option for patients with rheumatic, digestive, and dermatologic autoimmune diseases has been associated with increasing reports of liver damage in patients with hepatitis B virus (HBV) infection. We studied the current evidence on the use of anti-TNF agents in patients with HBV through a systematic analysis of cases reported in the MEDLINE and EMBASE databases using the MeSH term "hepatitis B virus" combined with the terms "infliximab," "etanercept," "adalimumab," "certolizumab," "golimumab," and "anti-TNF agents," and summarize the results here. We analyzed 257 patients with positive HBV markers who received anti-TNF therapy (255 identified in the search strategy and 2 new cases), 89 HBsAg+ carriers, and 168 anti-HBc+ persons. HBV reactivation was reported in 35 (39%) HBsAg+ carriers. The percentage of reactivation was higher in patients previously treated with immunosuppressive agents (96% vs. 70%, p=0.033) and lower in those who received antiviral prophylaxis (23% vs. 62%, p=0.003). Acute liver failure was reported in 5 patients, 4 of whom died. Infliximab was associated with a higher rate of induced liver disease (raised transaminase levels, clinical signs, viral reactivation, and acute liver failure) compared with etanercept. In anti-HBc+ persons, reactivation was reported in 9 (5%) cases, including 1 patient who died due to fulminant liver failure.In summary, our search of the current evidence identified 257 reported HBV+ patients treated with anti-TNF agents, with a significant percentage of liver damage in HBsAg+ carriers, including raised transaminase levels (42%), signs and symptoms of liver disease (16%), reappearance of serum HBV-DNA (39%), and death related to liver failure (5%). The rate of reactivation in anti-HBc+ persons was 7-fold lower than in HBsAg+ carriers. The increasing number of reported cases of HBV reactivation following TNF-targeted therapies and the associated morbidity and mortality demand specific preventive strategies.
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Affiliation(s)
- Roberto Pérez-Alvarez
- From Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases (RP-A, CD-L, PB-Z, MP-d-L, SR, AB, MR-C), Department of Internal Medicine, ICMiD (XB), and Liver Unit, Ciberehd, IDIBAPS (J-MS-T, XF), Hospital Clínic, Barcelona; Department of Internal Medicine (RP-A, MP-d-L), Hospital do Meixoeiro, Vigo; Department of Internal Medicine, Collagenosis and Pulmonary Hypertension Unit (FG-H), Hospital Virgen del Rocío, Sevilla; and Department of Gastroenterology and Hepatology (LL-R), Hospital Xeral-Calde, Lugo, Spain
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Consensus Statement of the Spanish Society of Rheumatology on Risk Management of Biologic Therapy in Rheumatic Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.reumae.2011.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Rubin DT, Panaccione R, Chao J, Robinson AM. A practical, evidence-based guide to the use of adalimumab in Crohn's disease. Curr Med Res Opin 2011; 27:1803-13. [PMID: 21809894 DOI: 10.1185/03007995.2011.604672] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor (anti-TNF) agents are important therapies for treating Crohn's disease (CD) because they may induce and maintain remission, reduce the need for corticosteroids, decrease hospitalizations and surgeries, and heal the mucosa. Here we provide a practical, evidence-based guide to help clinicians optimize the use of adalimumab in patients with CD. SCOPE A literature search in the MEDLINE, EMBASE, and BIOSIS databases was performed for articles published between 1996 and 2010 describing adalimumab use in CD. Abstracts presented at the ACG, DDW, UEGW, ECCO, and SGNA congresses, references from review articles and published randomized clinical trials, and the manufacturer's prescribing information also were reviewed. FINDINGS When selecting an anti-TNF agent, factors such as efficacy, safety, immunogenicity, patient preference, and the timing and sequencing of therapies should be considered. Important considerations for patient management include dosage selection, use of combination therapy, timing of monitoring treatment response, and evaluation of recurrent CD symptoms in a previously responding patient. We recommend that patients initiating adalimumab receive a loading dose of 160/80 mg subcutaneously at Week 0/Week 2, followed by up to 8 weeks of 40 mg every-other-week maintenance therapy prior to determining if there is non-response. During therapy, recurrent or new symptoms should be fully evaluated to ensure that they are indeed related to underlying inflammation versus other causes (e.g., intercurrent infection, bile acid diarrhea, or irritable bowel). Patients experiencing attenuation of response or inflammatory-mediated symptoms during maintenance therapy may benefit from dosage intensification to weekly adalimumab. CONCLUSION Considerations for the use of anti-TNF agents in CD, with an emphasis on adalimumab, are reviewed and practical patient management recommendations are presented.
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Affiliation(s)
- David T Rubin
- University of Chicago Medical Center, Chicago, IL 60637, USA.
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Reino JG, Loza E, Andreu JL, Balsa A, Batlle E, Cañete JD, Collantes Estévez E, Fernández Carballido C, Fernández Sueiro JL, García de Vicuña R, González-Álvaro I, González Fernández C, Juanola X, Linares LF, Marenco JL, Martín Mola E, Moreno Ramos M, Mulero Mendoza J, Muñoz Fernández S, Queiro R, Richi Alberti P, Sanz J, Tornero Molina J, Zarco Montejo P, Carmona L. Consenso SER sobre la gestión de riesgo del tratamiento con terapias biológicas en pacientes con enfermedades reumáticas. ACTA ACUST UNITED AC 2011; 7:284-98. [DOI: 10.1016/j.reuma.2011.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/04/2011] [Accepted: 05/04/2011] [Indexed: 12/16/2022]
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Liu CJ, Chen PJ, Chen DS, Kao JH. Hepatitis B virus reactivation in patients receiving cancer chemotherapy: natural history, pathogenesis, and management. Hepatol Int 2011; 7:316-26. [DOI: 10.1007/s12072-011-9279-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 05/27/2011] [Indexed: 12/13/2022]
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A patient with rheumatoid arthritis treated with tocilizumab together with lamivudine prophylaxis after remission of infliximab-reactivated hepatitis B. Mod Rheumatol 2011; 21:701-5. [PMID: 21626075 DOI: 10.1007/s10165-011-0470-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 05/06/2011] [Indexed: 12/16/2022]
Abstract
A 59-year-old woman with rheumatoid arthritis was treated quite successfully with infliximab, but her serum aminotransferase levels were markedly elevated; this was diagnosed as acute exacerbation of hepatitis B and she was treated with lamivudine, and infliximab was discontinued. The rheumatoid arthritis disease activity was uncontrollable after the discontinuation of infliximab, and we therefore initiated tocilizumab treatment (after obtaining the patient's informed consent) together with lamivudine prophylaxis. After tocilizumab administration her rheumatoid arthritis disease activity was significantly attenuated, and the activity has remained low, without re-exacerbation of the hepatitis, for more than 2 years since the initiation of the tocilizumab.
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Rosenblum H, Amital H. Anti-TNF therapy: safety aspects of taking the risk. Autoimmun Rev 2011; 10:563-8. [PMID: 21570495 DOI: 10.1016/j.autrev.2011.04.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 04/14/2011] [Indexed: 12/17/2022]
Abstract
Rheumatoid arthritis (RA) therapy has been revolutionized in recent years following the introduction of three main anti-tumor necrosis factor-alpha inhibitors (anti-TNF) agents, infliximab, adalimumab and etanercept. Evidence in the literature indicates that patients treated with anti-TNF agents are at increased risk for bacterial infections, but it is not clear if this is a result of the treatment or of disease severity. The treatment has been recognized as a clear risk factor for reactivation of latent TB infections. So far, observational studies have not indicated any increased overall risk of cancer in RA patients treated with anti-TNF. The overall risk of lymphoma in these patients does not appear to differ greatly from that recorded among untreated patients, but rather is associated with the degree of disease activity rather than the type of therapy. There is a consensus in the literature that the likelihood of drug survival with infliximab is inferior to both adalimumab and etanercept, mostly due to increased risk of infection or allergic reactions. Due to the lack of head to head studies, there is no agreement as to which agent has the highest rates of treatment response and disease remission.
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Affiliation(s)
- Hemda Rosenblum
- Department of Medicine D, Meir Medical Center, Kfar Saba, Israel
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Kavanaugh AF, Mayer LF, Cush JJ, Hanauer SB. Shared experiences and best practices in the management of rheumatoid arthritis and Crohn's disease. Am J Med 2011; 124:e1-18. [PMID: 21531240 DOI: 10.1016/j.amjmed.2011.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Arthur F Kavanaugh
- Center for Innovative Therapy, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, San Diego, California, USA
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Manzano-Alonso ML, Castellano-Tortajada G. Reactivation of hepatitis B virus infection after cytotoxic chemotherapy or immunosuppressive therapy. World J Gastroenterol 2011; 17:1531-7. [PMID: 21472116 PMCID: PMC3070121 DOI: 10.3748/wjg.v17.i12.1531] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 09/13/2010] [Accepted: 09/20/2010] [Indexed: 02/06/2023] Open
Abstract
Reactivation of hepatitis B is defined as the recurrence or an abrupt rise in hepatitis B virus (HBV) replication, often accompanied by an increase in serum transaminase levels, and both events occurring in a patient with a previous inactive hepatitis B infection. This reactivation can occur in situations in which the ratio of HBV replication and immune response is altered. It can happen during the treatment of hemato-oncological malignancies with chemotherapy and in immunosuppression of autoimmune diseases. Clinical manifestations of hepatitis B reactivation are variable and can range from asymptomatic to acute hepatitis, which are sometimes serious and result in acute liver failure with risk of death, and usually occur in the periods between cycles or at the end of chemotherapy. Immunosuppressive drugs such as corticosteroids or azathioprine can induce HBV reactivation in patients carrying hepatitis B virus surface antigen (HBsAg) or anti-HBc, but much less frequently than chemotherapy treatments. The tumor necrosis factor α inhibitors infliximab, etanercept and adalimumab may cause reactivation of hepatitis B, and the overall frequency with infliximab may be similar (50%-66%) to that caused by chemotherapy. Baseline HBV serology is recommended for all patients receiving chemotherapy and immunosuppressive drugs, and HBsAg positive patients should receive anti-HBV prophylaxis to decrease virus reactivation and death rates.
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Gisbert JP, Chaparro M, Esteve M. Review article: prevention and management of hepatitis B and C infection in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:619-33. [PMID: 21416659 DOI: 10.1111/j.1365-2036.2010.04570.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Viral hepatitis is a very common infection. AIM To review the prevention and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in inflammatory bowel disease (IBD). METHODS Bibliographical searches were performed in MEDLINE up to September 2010. RESULTS The prevalence of both HBV and HCV infection in IBD patients is now similar to that of the general population. All IBD patients should be screened for HBV markers at diagnosis. Liver dysfunction in IBD patients treated with immunosuppressants is more frequent and severe in HBV than in HCV carriers and is associated with combined immunosuppression. Inpatients receiving anti-TNF drugs, HBV reactivation is common unless anti-viral prophylaxis is administered. HBsAg-positive patients should receive anti-viral prophylaxis before starting immunosuppressants. As interferon might worsen underlying IBD, nucleoside ⁄ nucleotide analogues are preferred for anti-viral prophylaxis in patients with HBV (tenofovir ⁄ entecavir are preferred to lamivudine). IBD patients should be vaccinated against HBV at diagnosis. The response rate to HBV vaccination is low, mainly in those receiving anti-TNF therapy. The serological response to HBV vaccine should be confirmed, and patients with an inadequate response should receive a second full series of vaccine. Peginterferon (ribavirin) for HCV infection is as effective and safe as in non-IBD patients. CONCLUSIONS The present manuscript poses a series of questions on the prevention and management of HBV/HCV infection in IBD, and attempts to answer them using scientific evidence in order to provide practical conclusions for the clinician.
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Affiliation(s)
- J P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria, Princesa (IP), Madrid, Spain.
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Coffin CS, Fraser HF, Panaccione R, Ghosh S. Liver diseases associated with anti-tumor necrosis factor-alpha (TNF-α) use for inflammatory bowel disease. Inflamm Bowel Dis 2011; 17:479-84. [PMID: 20848520 DOI: 10.1002/ibd.21336] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The conventional treatment of inflammatory bowel disease (IBD) has focused on nonspecifically targeting mucosal inflammation. In the last decade, with the advent of novel biological agents that directly inhibit proinflammatory cytokines, such as tumor necrosis factor alpha (TNF-α), rapid progress has been made in clinical management of complex and challenging patients with IBD. However, there remain many unanswered questions about the short and long-term side effects; this article focuses on hepatic complications. This review aims to provide a concise update to gastroenterologists on the well-known, as well as the potential rare consequences of anti-TNFα therapy on the liver and recommendations for clinical management. We performed a focused literature review for reports of the effect of anti-TNF therapy on preexisting liver disease as well as de novo hepatitis and drug-induced hepatotoxicity. Search terms used included anti-TNF therapy, biologics, liver disease, inflammatory bowel disease, hepatitis, hepatotoxicity, opportunistic infections,, and hepatitis virus reactivation. There are multiple potential effects of anti-TNF therapy on the liver during treatment of patients with IBD. Often treatment may be complicated by preexisting chronic liver disease. Clinicians should be aware of potential hepatic side effects and appropriate management options.
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Affiliation(s)
- Carla S Coffin
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Meyer-Olson D, Hoeper K, Schmidt RE. [Infectious complications of biologic therapy in patients with rheumatoid arthritis]. Z Rheumatol 2010; 69:879-88. [PMID: 21128049 DOI: 10.1007/s00393-010-0677-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The introduction of biological disease-modifying drugs (DMARDs) has substantially improved the treatment options for patients with rheumatoid arthritis. However, infectious complications represent the most common side effects of these drugs, including severe infections as well as rare opportunistic infections. Treating patients on biological DMARDs is therefore one of the biggest challenges in rheumatology care. The present review describes the current state of knowledge regarding frequency and type of infectious complications associated with biological DMARDs. The article focuses mainly on risk management, in particular on diagnosis and recurrence prevention of tuberculosis and reactivation of hepatitis B virus infection. Furthermore, we discuss the importance of vaccinations in primary disease prevention in patients with rheumatoid arthritis.
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Affiliation(s)
- D Meyer-Olson
- Klinik für Immunologie und Rheumatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, Hannover, Germany.
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Bordas X, Martín-Sala S. [Etanercept and chronic infection by HCV and HBV]. ACTAS DERMO-SIFILIOGRAFICAS 2010; 101 Suppl 1:82-7. [PMID: 20492886 DOI: 10.1016/s0001-7310(10)70014-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Both psoriasis and chronic infections by HBV and HCV have high prevalence. Thus, it is relatively easy for them to coincide in the same patient. If the psoriasis requires systemic treatment, the dermatologist should consider the hepatic comorbidity when selecting an appropriate treatment. Cyclosporine, in addition to other well-known side effects, is an immunosuppressant that may condition worse evolution of the viral hepatitis. On the other hand, retinoids, psoralens and, above all, methotrexate may worsen the liver function. The anti-TNF-|A biological agents are not hepatotoxic and their theoretical contraindication in this context would be because of their action on the immune response and risk of reactivation of the hepatic infection. However, several studies have demonstrated that neither the viral load nor the hepatic inflammation parameters are generally modified negatively when they are used in hepatitis due to HCV. Their use in this context, with correct monitoring, seems, therefore, very reasonable. On the contrary, in chronic hepatitis B virus, there are cases of worsening, even with fatal outcome in some cases, and the use of these biological agents should be reserved for cases having greater need, and always be associated to antiviral treatment and strict monitoring. The review of the recent literature seems to allow the conclusion that the concomitant use of lamivudine would greatly reduce the risk of viral reactivation and, with this condition, the use of etanercept in some HBV+ patients may also be contemplated.
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Affiliation(s)
- X Bordas
- Servicio de Dermatología, Hospital de Bellvitge, Barcelona, España.
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Katsanos KH, Tsianos VE, Zois CD, Zioga H, Vagias I, Zervou E, Christodoulou DK, Tsianos EV. Inflammatory bowel disease and hepatitis B and C in Western Balkans: a referral centre study and review of the literature. J Crohns Colitis 2010; 4:450-65. [PMID: 21122543 DOI: 10.1016/j.crohns.2010.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 02/28/2010] [Accepted: 03/01/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS There is limited data on IBD patients diagnosed with viral hepatitis B and C. The aim of the study was to assess the prevalence of chronic HBV or HCV infection in IBD patients followed by our centre and to describe and review the course of bowel and liver disease during therapy. METHODS Single centre retrospective study on 482 consecutive IBD patients. Laboratory investigation for HBV and HCV was performed with routine methods. Treatment protocols for HBV included IFNa and nucleot(s)ide administration and for HCV combined IFNa and ribavirin. RESULTS We diagnosed 15 patients (15/482, 3.1%) with HBV or HCV. Of these, 11 were HBV (11/482, 2.3%) and 4 were HCV (4/482, 0.8%). Nine of eleven HBV patients received antiviral therapy (8 lamivudine, 1 IFNa). Five lamivudine patients were switched to tenofovir and in another one adefovir dipivoxil were added. Bowel disease was in remission in ten of the eleven HBV patients. One patient was diagnosed with carcinoid tumor. Two HCV patients received IFNa that was well tolerated. One HCV patient denied therapy and one died from hepatocellular cancer. Of the seven patients on azathioprine only one achieved sustained response. Four patients on Infliximab achieved bowel disease remission but experienced biochemical or virological flare. CONCLUSIONS This study demonstrates that prevalence of HBV and HCV infection in a large IBD cohort from Western Balkans is compared to that of the background population. IBD patients under immunosuppressants may apparently be treated with safety if preventive antiviral treatment is administered.
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Affiliation(s)
- Konstantinos H Katsanos
- Hepato-Gastroenterology Unit & Laboratory of Immunology, 1st Division of Internal Medicine, Medical School of Ioannina, Greece
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Abstract
PURPOSE OF REVIEW To evaluate the recent published data on the safety of biological agents, mainly anti-TNFalpha and rituximab, and diagnostic difficulties in the setting of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and inflammatory arthritides. RECENT FINDINGS There are important differences between HBV and HCV carriers; however, clinical observations suggest that hepatotropic virus infection should not preclude the treatment with biologic agents in rheumatic diseases. Retrospective reports on limited series of HBV-infected patients with concomitant chronic arthritis convey that careful patients' clinico-virological assessment, in collaboration with the hepatologist, is necessary before starting immunosuppressive treatments, especially biological agents. Preemptive or combined antiviral treatment is mandatory, mainly in active and inactive HBV carriers. Occult HBV infection should be also carefully evaluated due to potential virus reactivation. In HCV-infected patients without chronic active hepatitis the treatment with biological agents, anti-TNFalpha or rituximab, is generally useful and well tolerated. Preliminary data suggest the possible synergic effects of combined antivirals (alpha-interferon and ribavirin) and anti-TNFalpha (or rituximab) in patients with chronic arthritis and active hepatitis C. SUMMARY In all patients with chronic arthritis requiring immunomodulating treatments both HBV and HCV infection along with liver conditions should be evaluated before any therapeutic decisions, including differential diagnosis among virus-related autoimmune disease and simple comorbidity. Patients with HBV infection should be referred to the hepatologist and correctly classified into active, inactive, and occult carriers. Similarly, rheumatic patients with active chronic hepatitis C must be treated with sequential or combined treatment with antiviral and biological agents.
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Emer JJ, Frankel A, Zeichner JA. A practical approach to monitoring patients on biological agents for the treatment of psoriasis. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2010; 3:20-6. [PMID: 20877538 PMCID: PMC2945861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Psoriasis is a chronic, systemic, inflammatory skin condition that manifests predominantly as well-demarcated, erythematous, scaly plaques on the elbows, knees, and scalp. While mild cases (minimal body surface) often respond to various topical treatments and light therapy, patients with extensive disease (larger body surface and possibly joint involvement) may require systemic medications for remission. The development of biological agents provides dermatologists valuable ways to help treat psoriatic disease quite efficiently, but literature regarding the monitoring of patients on biological treatments is sparse. Clinical practice varies widely since there is modest strong evidence to recommend or refute most tests currently recommended by the United States Food and Drug Administration. The purpose of this article is to present a practical approach to monitoring patients on biological therapy based on the most up-to-date literature.
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Affiliation(s)
- Jason J Emer
- Mount Sinai School of Medicine, Department of Dermatology, New York, New York
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Urata Y, Uesato R, Tanaka D, Kowatari K, Nitobe T, Nakamura Y, Motomura S. Prevalence of reactivation of hepatitis B virus replication in rheumatoid arthritis patients. Mod Rheumatol 2010; 21:16-23. [PMID: 20668905 DOI: 10.1007/s10165-010-0337-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 06/28/2010] [Indexed: 12/16/2022]
Abstract
Reactivation of hepatitis B involves the reappearance of active necroinflammatory liver disease after an inactive hepatitis B surface antigen (HBsAg) carrier state or resolved hepatitis B, occurring during or after immunosuppression therapy or chemotherapy. We prospectively investigated the reactivation rate for hepatitis B virus (HBV) DNA replication in cases of rheumatoid arthritis (RA) with resolved hepatitis B. HBV markers were evaluated in 428 RA patients. Patients with positive findings of HBsAg or HBV DNA at enrolment were excluded. The study population comprised 422 RA patients, with resolved hepatitis B diagnosed in 135 patients based on HBsAg-negative and antihepatitis B core antibody/antihepatitis B surface antibody-positive results. HBV DNA was measured every 3 months in this group, and if HBV DNA became positive after enrolment, measurement was repeated every month. HBV DNA became positive (≥3.64 log copies/mL) in 7 of 135 patients for 12 months. Use of biologic agents was significantly more frequent in patients who developed reactivation of HBV DNA replication (85.7%) than in patients who did not (36.0%, p = 0.008). Hazard ratios for use of biologic agents and etanercept were 10.9 (p = 0.008) and 6.9 (p = 0.001), respectively. RA patients with resolved hepatitis B need careful monitoring when receiving biologic agents, regardless of HBV DNA levels.
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Affiliation(s)
- Yukitomo Urata
- Department of Rheumatology, Seihoku Chuo Hospital, 41 Nunoyacho, Gosyogawara, 037-0053, Japan.
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Caporali R, Bobbio-Pallavicini F, Atzeni F, Sakellariou G, Caprioli M, Montecucco C, Sarzi-Puttini P. Safety of tumor necrosis factor alpha blockers in hepatitis B virus occult carriers (hepatitis B surface antigen negative/anti-hepatitis B core antigen positive) with rheumatic diseases. Arthritis Care Res (Hoboken) 2010; 62:749-54. [PMID: 20535784 DOI: 10.1002/acr.20130] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the safety of anti-tumor necrosis factor alpha (anti-TNFalpha) therapy on the course of hepatitis B virus (HBV) infection in carriers of antibodies to hepatitis B core antigen (anti-HBc) affected by chronic inflammatory arthropathies. METHODS From January 2001 to December 2008, HBV markers were determined before the first administration of anti-TNFalpha agents in all 732 patients affected by inflammatory arthropathies treated with anti-TNFalpha at 2 outpatient rheumatologic clinics in Northern Italy. Anti-HBc-positive patients were prospectively evaluated and HBV markers and HBV DNA were assessed every 6 months, in case of aminotransferase elevation, and at the end of the study. RESULTS At the time of recruitment, 72 patients were anti-HBc carriers, 5 of whom were positive for hepatitis B surface antigen (HBsAg) and not included in the study. The ratio of men:women was 26:41 and the mean +/- SD followup was 42.52 +/- 21.33 months. Of the patients, 25 were treated with infliximab, 23 with etanercept, and 19 with adalimumab. Fifty-one patients were treated also with methotrexate, 52 with nonsteroidal antiinflammatory drugs, and 43 with prednisone (3 with a dosage >7.5 mg/day). All anti-HBc patients were HBV DNA negative at the first observation. During followup, no patient presented HBV reactivation with viral load increase and no patient became HBsAg positive. CONCLUSION Anti-HBc positivity in HBsAg-negative patients is a sign of previous HBV infection and does not indicate chronic hepatitis. In these patients, anti-TNFalpha therapy appears to be quite safe, as no HBV reactivation was found in our study. Nevertheless, careful monitoring is necessary.
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Affiliation(s)
- R Caporali
- University of Pavia, IRCCS S Matteo Foundation, Pavia, Italy.
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Use of tumor necrosis factor alpha inhibitors in hepatitis B surface antigen-positive patients: a literature review and potential mechanisms of action. Clin Rheumatol 2010; 29:1021-9. [PMID: 20556450 DOI: 10.1007/s10067-010-1523-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 06/01/2010] [Accepted: 06/04/2010] [Indexed: 12/14/2022]
Abstract
As a class, tumor necrosis factor (TNF)-alpha inhibitors have provided clinicians significant control over chronic inflammatory diseases. With their widespread use has come the emergence of new side effects such as the reactivation of latent infections. One such infection that may reactivate is the hepatitis B virus (HBV). It is currently unknown if HBV reactivation is a class effect or attributable to a particular TNF-alpha inhibitor. To answer this question, a comprehensive literature review to identify trends in related cases was performed. A systemic literature review was performed using the PubMed and Medline databases (1996 to January 2010) searching for the index term "Hepatitis B" combined with the terms "tumor necrosis factor," "TNF-alpha inhibitors," "etanercept," "adalimumab," "certolizumab," and "golimumab." All relevant articles in English were reviewed, and secondary references of interest were also retrieved. Thirty-five cases with hepatitis B surface antigen (HBsAg) positivity known prior to initiation of TNF-alpha inhibitors were identified. Infliximab was used in 17 cases, etanercept in 12 cases, and adalimumab in 6 cases. All six cases of clinically symptomatic hepatitis were associated with infliximab therapy. Infliximab was associated with the most cases of greater than 2-fold increase in alanine aminotransferase (six of nine cases) and greater than 1,000-fold increase in HBV DNA load (three of four). The two deaths reported occurred with infliximab therapy. Potential mechanisms of action for the reported observations include differences in molecular design, route of administration, and potency in clearing TNF-alpha. In patients with a positive HBsAg prior to starting a TNF-alpha inhibitor, infliximab has the most reported cases associated with HBV reactivation. While such reactivation may be due to a variety of reasons, clinicians prescribing TNF-alpha inhibitors to HBsAg-positive patients should consider prophylactic antiviral therapy and close monitoring for any clinical or serological evidence of hepatitis.
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Chemoprevention of Patients with Hepatitis B Receiving Chemotherapy or Bone Marrow Transplant. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s11901-010-0048-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Yazdany J, Calabrese L. Preventing hepatitis B reactivation in immunosuppressed patients: is it time to revisit the guidelines? Arthritis Care Res (Hoboken) 2010; 62:585-9. [PMID: 20191573 DOI: 10.1002/acr.20167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Stine JG, Khokhar OS, Charalambopoulos J, Shanmugam VK, Lewis JH. Rheumatologists' awareness of and screening practices for hepatitis B virus infection prior to initiating immunomodulatory therapy. Arthritis Care Res (Hoboken) 2010; 62:704-11. [PMID: 20461789 DOI: 10.1002/acr.20209] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the degree of awareness of the American College of Rheumatology (ACR) guidelines and package insert information on the screening for and management of hepatitis B virus (HBV) infection by rheumatologists in patients receiving immunomodulation drug therapies. METHOD A questionnaire survey was administered to a nationwide sample of 1,000 members of the ACR. Each participating physician answered questions regarding their awareness of the risk of HBV reactivation, familiarity with published guidelines regarding HBV reactivation, their decision process in screening patients for HBV, knowledge of antiviral treatments for HBV, personal experience with HBV reactivation, and preferred approach to prophylaxis and subsequent monitoring of those patients. RESULTS Responses were highly variable with regard to awareness, screening, and treatment options. The overall response rate was 15.3%. Of those surveyed, 7.4% had seen HBV reactivation. Depending on the agent, 19-53% were aware of manufacturers' warnings for HBV reactivation within drug package inserts. Nearly three-quarters (72%) would screen for HBV reactivation regardless of the presence/absence of manufacturers' warnings. Only 69% reported performing universal screening prior to initiating therapy with biologic disease-modifying antirheumatic drugs. The majority (81%) would defer to a gastroenterologist/hepatologist to determine prophylactic therapy for HBV. Only 22% had managed patients who were given prophylaxis against HBV reactivation while receiving immunosuppressants. CONCLUSION Based on this survey, improving education among rheumatologists regarding the risks of HBV reactivation and its prevention for patients receiving immunosuppressants seems warranted. More specific consensus guidelines are recommended to achieve universal screening as the standard of care in these patients, especially with the increasing prevalence of HBV infection estimated in the US.
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Lubel JS, Angus PW. Hepatitis B reactivation in patients receiving cytotoxic chemotherapy: diagnosis and management. J Gastroenterol Hepatol 2010; 25:864-71. [PMID: 20546439 DOI: 10.1111/j.1440-1746.2010.06243.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nearly one third of the world's population have been infected with hepatitis B and the virus is endemic in many Asian countries. With increasing life expectancy and the expected global increase in cancer, chemotherapy induced reactivation of hepatitis B is likely to become an increasing problem. Patients with significant levels of hepatitis B virus (HBV) DNA in serum prior to chemotherapy and patients receiving intensive chemotherapy for hematological malignancies appear particularly at risk. Most patients who suffer reactivation of hepatitis B are positive for hepatitis B surface antigen (HBsAg) prior to chemotherapy and are therefore easily identifiable by routine screening. In addition, the very large population of patients who have been exposed to the virus and have apparently cleared the virus as assessed by serological testing (HBsAg negative/hepatitis B core antibody [HBcAb] positive) may also be at risk of reactivation. These patients should be monitored and in some cases receive prophylaxis during chemotherapy. Published experience with antiviral prophylaxis has largely been limited to the nucleoside analogue, lamivudine. The commencement of antiviral prophylaxis prior to chemotherapy and its continuation until restitution of normal host immunity is the cornerstone to effective prevention of hepatitis B reactivation. This review summarizes the important issues related to HBV reactivation and suggests an algorithm for managing these patients in the clinical setting.
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Affiliation(s)
- John S Lubel
- Department of Hepatology, Box Hill Hospital, Box Hill, Melbourne, Victoria, Australia.
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Chevaux JB, Bigard MA, Bensenane M, Oussalah A, Jarlot S, Belle A, Nani A, Bronowicki JP, Peyrin-Biroulet L. Inflammatory bowel disease and hepatitis B and C. ACTA ACUST UNITED AC 2010; 33:1082-93. [PMID: 19896313 DOI: 10.1016/j.gcb.2009.03.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 03/11/2009] [Accepted: 03/17/2009] [Indexed: 12/13/2022]
Abstract
The risk of viral B and C hepatitis has long been considered to be increased in patients with inflammatory bowel disease (IBD). Blood transfusion and surgery have been identified as the two main risk factors, suggesting nosocomial transmission could be involved. However, recent epidemiologic surveys have found that prevalence in IBD patients is similar to or even lower than that in the general population. Part of the explanation of these recent data may lie in the application of protective measures against viral infection (hepatitis B virus [HBV] vaccination and hepatitis C virus [HCV]-free blood transfusions). Sometimes fatal viral reactivations have been reported in patients on immunosuppressive therapy. Two periods can be distinguished: a) during therapy, a rise in viremia associated with a decrease of immune-mediated hepatic lesions; b) after cessation of therapy, an immune rebound with a destruction of virus-infected hepatocytes. For HBV, preemptive strategy consisting of an antiviral analog is efficient in chronic HBs antigen carriers. For HCV, the impact of immunosuppressive drugs on the natural history is unclear. Most studies report improved comfort although no biopsies were performed before and after immunosuppressive treatment. Physicians managing IBD patients should be aware of the need for screening and institute preventive measures against B and C hepatitis.
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Affiliation(s)
- J-B Chevaux
- INSERM U724, CHU de Nancy, Vandoeuvre, France
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Kuwabara H, Fukuda A, Tsuda Y, Shibayama Y. Precore mutant hepatitis B virus-associated fulminant hepatitis during infliximab therapy for rheumatoid arthritis. Clin Rheumatol 2010; 32 Suppl 1:S47-9. [PMID: 20379839 PMCID: PMC3594820 DOI: 10.1007/s10067-010-1438-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 03/15/2010] [Indexed: 12/16/2022]
Abstract
A 73-year-old female, who suffered from rheumatoid arthritis for 10 years, developed precore mutant hepatitis B virus-associated fulminant hepatitis after 1 year of infliximab therapy and subsequent methotrexate withdrawal. We emphasize the importance of preemptive antiviral therapy before starting infliximab administration and withdrawing immunosuppressive drugs.
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Affiliation(s)
- Hiroko Kuwabara
- Department of Pathology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
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Subfulminant hepatitis B during treatment with adalimumab in a patient with rheumatoid arthritis and chronic hepatitis B. Eur J Gastroenterol Hepatol 2010; 22:494-9. [PMID: 20306568 DOI: 10.1097/meg.0b013e3283329d13] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We report a case of reactivation of hepatitis B virus (HBV) infection with subacute liver failure during administration of adalimumab, followed by a literature review of all 19 published cases, with a focus on the effect of antiviral prophylaxis. Eight patients were given prophylaxis and had a good outcome. Of the 11 patients without prophylaxis, six patients developed a reactivation and needed to stop anti-TNFalpha therapy (P = 0.017). One patient developed an acute liver failure, necessitating urgent liver transplantation. One patient died. Administration of anti-TNFalpha therapy can lead to HBV reactivation, with a possible lethal outcome. High-risk patients and possibly all patients should be screened for hepatitis B surface antigen and anti-HBV core antibody before starting anti-TNFalpha therapy. Administration of antiviral prophylaxis proves beneficial in prevention of reactivation in hepatitis B surface antigen positive patients.
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Shale MJ, Seow CH, Coffin CS, Kaplan GG, Panaccione R, Ghosh S. Review article: chronic viral infection in the anti-tumour necrosis factor therapy era in inflammatory bowel disease. Aliment Pharmacol Ther 2010; 31:20-34. [PMID: 19681818 DOI: 10.1111/j.1365-2036.2009.04112.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor (TNF) therapy is now well established in the treatment of inflammatory bowel disease and the risk of opportunistic infection is recognized. However, specific considerations regarding screening, detection, prevention and treatment of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease are not widely adopted in practice. AIM To provide a detailed and comprehensive review of the relevance of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease. METHODS Literature search was conducted using Medline, Pubmed and Embase using the terms viral infection, hepatitis, herpes, CMV, EBV, HPV, anti-TNF, infliximab, adalimumab, certolizumab pegol and etanercept. Hepatitis B and C and HIV had the largest literature associated and these have been summarized in Tables. RESULTS Particular risks are associated with the use of anti-TNF drugs in patients with hepatitis B infection, in whom reactivation is common unless anti-viral prophylaxis is used. Reactivation of herpes zoster is the most common viral problem associated with anti-TNF treatment, and may be particularly severe. Primary varicella infection may present with atypical features in patients on anti-TNF. CONCLUSION Appreciation of risks of chronic viral disease associated with anti-TNF therapy may permit early recognition, prophylaxis and treatment.
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Affiliation(s)
- M J Shale
- GI Section, Imperial College London, London, UK
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Charpin C, Guis S, Colson P, Borentain P, Mattéi JP, Alcaraz P, Balandraud N, Thomachot B, Roudier J, Gérolami R. Safety of TNF-blocking agents in rheumatic patients with serology suggesting past hepatitis B state: results from a cohort of 21 patients. Arthritis Res Ther 2009; 11:R179. [PMID: 19941642 PMCID: PMC3003507 DOI: 10.1186/ar2868] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Revised: 09/18/2009] [Accepted: 11/26/2009] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Reactivation of hepatitis B virus (HBV) infection in patients with past infection has been described in 5% to 10% of individuals undergoing immunosuppressive therapies. No data are available to date on the outcome of patients treated by tumour necrosis factor-alpha (TNFalpha) inhibitors for chronic arthritis with a serological pattern of past HBV infection. The aim of our study was to monitor HBV markers in HBV surface antigen (HBsAg)-negative/anti-HBcAb-positive patients treated with a TNFalpha inhibitor for inflammatory arthritides. METHODS Twenty-one HBsAg-negative/anti-HBcAb-positive patients were included. HBV serological patterns were compared with those determined before starting TNFalpha inhibitors. Serum HBV DNA testing by polymerase chain reaction was additionally performed. Spearman correlation analysis was used and P < 0.05 was chosen as the significance threshold. RESULTS Before starting therapy, mean anti-HBsAb titre was 725 IU/L, no patient had an anti-HBsAb titre <10 IU/L, and 18 patients had an anti-HBsAb >100 IU/L. At a mean time of 27.2 months following therapy introduction, mean anti-HBsAb titre was 675 IU/L and anti-HBsAb titre remained >100 IU/L in 17 patients. There was a strong correlation between the first and second anti-HBsAb titres (r = 0.98, P = 0.013). Moreover, no patient had an anti-HBsAb titre below 10 IU/L or HBV reactivation (HBsAg seroreversion or positive HBV DNA detection). However, the anti-HBsAb titre decreased by more than 30% in 6 patients. The mean anti-HBsAb titre at baseline was significantly lower (P = 0.006) and the mean duration of anti-TNFalpha therapy, although non-significant (P = 0.09), was longer in these six patients as compared to patients without a decrease in anti-HBsAb titre. CONCLUSIONS Anti-TNFalpha treatments are likely to be safe in patients with past hepatitis B serological pattern. However, the significant decrease of anti-HBsAb titre observed in a proportion of patients deserves HBV virological follow-up in these patients, especially in those with a low anti-HBsAb titre at baseline.
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Affiliation(s)
- Caroline Charpin
- Service de Rhumatologie, Centre Hospitalier Universitaire Conception, 147 Boulevard Baille, 13385 Marseille, France.
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Chung SJ, Kim JK, Park MC, Park YB, Lee SK. Reactivation of hepatitis B viral infection in inactive HBsAg carriers following anti-tumor necrosis factor-alpha therapy. J Rheumatol 2009; 36:2416-20. [PMID: 19797507 DOI: 10.3899/jrheum.081324] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate whether anti-tumor necrosis factor-alpha (TNF-alpha) therapy can influence the reactivation of hepatitis B virus (HBV) infection in inactive HBsAg carriers. METHODS The medical records of 103 patients [59 with ankylosing spondylitis (AS), 41 with rheumatoid arthritis (RA), 2 with juvenile RA, and 1 with psoriatic arthritis] who had been treated with anti-TNF-alpha therapy were reviewed retrospectively. Data on seropositivity of HBV, HBV load, and serum aminotransferases prior to and after initiation of anti-TNF-alpha therapy were obtained. RESULTS Eight patients were inactive HBsAg carriers, and all of them had normal liver function and undetectable HBV load prior to anti-TNF-alpha therapy. Reactivation of hepatitis B occurred in 1 patient during the course of anti-TNF-alpha therapy. After the third infusion of infliximab 5 mg/kg at Week 6, a blood test showed that the patient had normal liver function. When the patient returned for the fourth infusion of infliximab at Week 14, a blood test showed markedly elevated aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels (457 and 1054 IU/l, respectively) and increased viral DNA by HBV polymerase chain reaction (PCR). The fourth infliximab infusion was canceled, and entecavir 0.5 mg/day was prescribed. Then AST/ALT levels began to decrease and returned to normal range after 3 months. Followup HBV PCR showed negative results. CONCLUSION We found 1 HBV reactivation case among 8 inactive HBsAg carriers following anti-TNF-alpha therapy. This finding supports the prophylactic use of antiviral agents in HBV carriers, even if they have normal liver function or an undetectable viral load.
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Affiliation(s)
- Soo-Jin Chung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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