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Anti-rheumatic drug-induced hepatitis B virus reactivation and preventive strategies for hepatocellular carcinoma. Pharmacol Res 2022; 178:106181. [PMID: 35301112 DOI: 10.1016/j.phrs.2022.106181] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 12/13/2022]
Abstract
To date, an estimated 3 million people worldwide have been infected with chronic hepatitis B virus (HBV). Although anti-HBV therapies have improved the long-term survival profile of chronic carriers, viral reactivation still poses a significant challenge for preventing HBV-related hepatitis, hepatocellular carcinoma (HCC), and death. Immuno-modulating drugs, which are widely applied in managing rheumatic conditions, are commonly associated with HBV reactivation (HBVr) as a result of drug-induced immune suppression. However, there are few reports on the risk of HBVr and the medication management plan for HBV carriers, especially rheumatic patients. In this review, we summarize immuno-modulating drug-induced HBVr during rheumatoid therapy and its preventive strategies for HBVr-induced liver diseases, especially cirrhosis and HCC. These findings will assist with developing treatments for rheumatic patients, and prevent HBV-related cirrhosis and HCC.
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Huang JX, Zhang LJ. Successful treatment of tofacitinib in a case with rheumatoid arthritis who experienced hepatitis B virus reactivation induced by tocilizumab and recovered from entecavir rescue therapy. Arch Rheumatol 2021; 36:458-460. [PMID: 34870178 PMCID: PMC8612488 DOI: 10.46497/archrheumatol.2021.8230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/22/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jin-Xian Huang
- Department of Rheumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Jun Zhang
- Department of Rheumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Chen MH, Lee IC, Chen MH, Hou MC, Tsai CY, Huang YH. Abatacept is second to rituximab at risk of HBsAg reverse seroconversion in patients with rheumatic disease. Ann Rheum Dis 2021; 80:1393-1399. [PMID: 34187776 DOI: 10.1136/annrheumdis-2021-220774] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatitis B surface antigen (HBsAg) reverse seroconversion (RS) can happen in patients with rheumatoid arthritis (RA) with resolved hepatitis B (RHB) undergoing biological disease-modifying antirheumatic drugs (bDMARDs). But the incidence and risk factors need to be delineated. METHODS From 2003 to 2019, 1937 patients with RA with available HBsAg and antibody to hepatitis B virus (HBV) core antigen data were retrospectively reviewed, and 489 patients with RHB undergoing bDMARDs treatment were identified. Factors associated with HBsAg RS were analysed. RESULTS During 67 828 person-months of follow-up, 27 (5.5%) patients developed HBsAg RS after bDMARD treatment. As compared with those without HBsAg RS, patients with HBsAg RS were older, had lower frequency of antibody to HBsAg (anti-HBs), and lower baseline anti-HBs levels. In multivariate analysis, rituximab, abatacept and baseline negative for anti-HBs were the independent risk factors for HBsAg RS (adjusted HR: 87.76, 95% CI: 11.50 to 669.73, p<0.001; adjusted HR: 60.57, 95% CI: 6.99 to 525.15, p<0.001; adjusted HR: 5.15, 95% CI: 2.21 to 12.02, p<0.001, respectively). The risk of HBsAg RS was inversely related to the level of anti-HBs. Both rituximab and abatacept might result in anti-HBs loss, and abatacept had a cumulative incidence of HBsAg RS of 35.4%-62.5% in patients with low titers or negative of anti-HBs. CONCLUSIONS Not only rituximab, but also abatacept has a high risk of HBV reactivation in patient with RA with RHB. Anti-HBs positivity cannot confer HBV reactivation-free status if the anti-HBs levels are not high enough for patients with RHB on rituximab and abatacept treatment.
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Affiliation(s)
- Ming-Han Chen
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan .,Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - I-Cheng Lee
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Huang Chen
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Rodríguez S, Muñoz A, Bustos RH, Jaimes D. Pharmacovigilance of Biopharmaceuticals in Rheumatic Diseases, Adverse Events, Evolution, and Perspective: An Overview. Biomedicines 2020; 8:E303. [PMID: 32842558 PMCID: PMC7555940 DOI: 10.3390/biomedicines8090303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
Since we have gained an understanding of the immunological pathophysiology of rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, treatment based on biological drugs has become a fundamental axis. These therapies are oriented towards the regulation of cytokines such as tumour necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-1, and the modulation of cell-mediated immunity (B cells and T cells) by anti CD20 or anti CTAL-4 agents, and can increase the risk of associated infections or adverse events (AE). In this context, the entry of biotherapeutics represented a challenge for pharmacovigilance, risk management and approval by the main global regulatory agencies regarding biosimilars, where efficacy and safety are based on comparability exercises without being an exact copy in terms of molecular structure. The objective of this review is divided into three fundamental aspects: (i) to illustrate the evolution and focus of pharmacovigilance at the biopharmaceutical level, (ii) to describe the different approved recommendations of biopharmaceuticals (biological and biosimilars) and their use in rheumatic diseases (RDs) such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE) and other less frequent RD like cryopyrin-associated autoinflammatory syndromes (CAPS), and (iii) to identify the main AE reported in the post-marketing phase of RD biopharmaceuticals.
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Affiliation(s)
| | | | - Rosa-Helena Bustos
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (S.R.); (A.M.); (D.J.)
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Seo YB, Moon SJ, Jeon CH, Song JY, Sung YK, Jeong SJ, Kwon KT, Kim ES, Kim JH, Kim HA, Park DJ, Park SH, Park JK, Ahn JK, Oh JS, Yun JW, Lee JH, Lee HY, Choi MJ, Choi WS, Choi YH, Choi JH, Heo JY, Cheong HJ, Lee SS. The Practice Guideline for Vaccinating Korean Patients With Autoimmune Inflammatory Rheumatic Disease. JOURNAL OF RHEUMATIC DISEASES 2020. [DOI: 10.4078/jrd.2020.27.3.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Yu Bin Seo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eu Suk Kim
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Hoon Kim
- Department of Rheumatology, Korea University Guro Hospital, Seoul, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Dong-Jin Park
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Sung-Hoon Park
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joong Kyong Ahn
- Division of Rheumatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Won Yun
- Division of Infectious Disease Control, Korea Centers for Disease Control and Prevention, Osong, Korea
| | - Joo-Hyun Lee
- Division of Rheumatology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Joo Choi
- Division of Infectious Disease, Department of Internal Medicine, Catholic Kwandong University International St. Mary’s Hospital, Incheon, Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jung-Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St. Mary’s Hospital, Seoul, Korea
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hee Jin Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Korea
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Seo YB, Moon SJ, Jeon CH, Song JY, Sung YK, Jeong SJ, Kwon KT, Kim ES, Kim JH, Kim HA, Park DJ, Park SH, Park JK, Ahn JK, Oh JS, Yun JW, Lee JH, Lee HY, Choi MJ, Choi WS, Choi YH, Choi JH, Heo JY, Cheong HJ, Lee SS. The Practice Guideline for Vaccinating Korean Patients with Autoimmune Inflammatory Rheumatic Disease. Infect Chemother 2020; 52:252-280. [PMID: 32618150 PMCID: PMC7335656 DOI: 10.3947/ic.2020.52.2.252] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 01/03/2023] Open
Abstract
To develop a clinical practice guideline for vaccination in patients with autoimmune inflammatory rheumatic disease (AIIRD), the Korean College of Rheumatology and the Korean Society of Infectious Diseases developed a clinical practice guideline according to the clinical practice guideline development manual. Since vaccination is unlikely to cause AIIRD or worsen disease activities, required vaccinations are recommended. Once patients are diagnosed with AIIRD, treatment strategies should be established and, at the same time, monitor their vaccination history. It is recommended to administer vaccines when the disease enters the stabilized stage. Administering live attenuated vaccines in patients with AIIRD who are taking immunosuppressants should be avoided. Vaccination should be considered in patients with AIIRD, prior to initiating immunosuppressants. It is recommended to administer influenza, Streptococcus pneumoniae, hepatitis A, hepatitis B, herpes zoster, measles-mumps-rubella virus, human papillomavirus, and tetanus-diphtheria-pertussis vaccines in patients with AIIRD; such patients who planned to travel are generally recommended to be vaccinated at the recommended vaccine level of healthy adults. Those who live in a household with patients with AIIRD and their caregivers should also be vaccinated at levels that are generally recommended for healthy adults.
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Affiliation(s)
- Yu Bin Seo
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Su Jin Moon
- Division of Rheumatology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea
| | - Yoon Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Eu Suk Kim
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hoon Kim
- Department of Rheumatology, Korea University Guro Hospital, Seoul, Korea
| | - Hyoun Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Dong Jin Park
- Department of Rheumatology, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Sung Hoon Park
- Division of Rheumatology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joong Kyong Ahn
- Division of Rheumatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Won Yun
- Division of Infectious Disease Control, Korea Centers for Disease Control and Prevention, Osong, Korea
| | - Joo Hyun Lee
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Joo Choi
- Division of Infectious Disease, Department of Internal Medicine, Catholic Kwandong University, International St. Mary's Hospital, Incheon, Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Ansan Hospital, Ansan, Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea
| | - Jung Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Seoul, Korea
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea
| | - Hee Jin Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, Korea.
| | - Shin Seok Lee
- Department of Rheumatology, Chonnam National University Medical School & Hospital, Gwangju, Korea.
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Managing Psoriasis in Patients with HBV or HCV Infection: Practical Considerations. Am J Clin Dermatol 2019; 20:829-845. [PMID: 31222626 DOI: 10.1007/s40257-019-00457-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Considered more efficacious and safer than traditional systemic drugs, biologic therapies have dramatically improved the quality of life of patients with psoriasis. Recently, there has been a proliferation of new targeted treatment options, including anti-interleukin-17, anti-interleukin-12/23, as well as small-molecule drugs such as apremilast. There are nevertheless some concerns regarding their use, especially in patients with chronic infections such as hepatitis B virus (HBV) and hepatitis C virus (HCV). It has been estimated that two billion individuals are infected with HBV worldwide and approximately 240 million have chronic HBV infection. Moreover, there are approximately 71 million individuals with chronic HCV infection worldwide, with a high percentage of them unaware of being infected. As patients with HBV and HCV infections are excluded from controlled clinical trials investigating new drugs, data regarding their safety in patients with psoriasis are based almost exclusively on case reports and small retrospective cohort studies and need to be constantly updated. The risk of HBV reactivation can be defined as: high risk (≥ 10%), moderate risk (1-10%), and low risk (< 1%) depending on the type of immunosuppressive therapy stratified by the presence or absence of hepatitis B surface antigen but positivity to anti-hepatitis B core antigen. Hepatitis B surface antigen-positive patients treated with tumor necrosis factor-α inhibitors, ustekinumab, or cyclosporine carry a high or moderate risk of HBV reactivation and should be considered candidates for prophylactic anti-HBV therapy. Once therapy is commenced, it is important to check HBV DNA levels every 3 months. Hepatitis B virus reactivation typically occurs with immune reconstitution and therefore antiviral therapy should continue for 6-12 months after stopping immunosuppression. Hepatitis B surface antigen-positive patients who are prescribed methotrexate, acitretin, or apremilast have a low risk and need to be monitored for viral reactivation by determining alanine aminotransferase and HBV DNA levels every 3 months. No conclusive data are available for interleukin-17 and interleukin-23 inhibitors. Anti-hepatitis B core antigen-positive patients treated with tumor necrosis factor-α inhibitors, ustekinumab, and cyclosporine are linked to a moderate risk of reactivation, and they should preferably undergo HBV DNA or hepatitis B surface antigen and alanine aminotransferase testing rather than be subjected to routine pre-emptive therapy. Anti-hepatitis B core antigen-positive patients receiving methotrexate, acitretin, or apremilast have a low risk of reactivation and do not require anti-HBV therapy, nor should monitoring be considered mandatory. No conclusive data are available for interleukin-17 and interleukin-23 inhibitors.
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Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. ACTA ACUST UNITED AC 2019; 17:215-228. [PMID: 31103432 DOI: 10.1016/j.reuma.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/28/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.
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Fujita M, Sugiyama M, Sato Y, Nagashima K, Takahashi S, Mizokami M, Hata A. Hepatitis B virus reactivation in patients with rheumatoid arthritis: Analysis of the National Database of Japan. J Viral Hepat 2018; 25:1312-1320. [PMID: 29770539 DOI: 10.1111/jvh.12933] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/03/2018] [Indexed: 02/06/2023]
Abstract
This study aimed to determine the incidence and risk factors for hepatitis B virus (HBV) reactivation in patients with rheumatoid arthritis (RA) undergoing immunosuppressive therapy. The National Database of Japan, in which insurance claim data have been comprehensively accumulated, was utilized. The subjects were 76 641 RA patients who were plausibly initiated on immunosuppressive therapy from April 2013 to March 2014. Laboratory tests of the hepatitis B surface antigen, anti-hepatitis B virus surface antibody, and anti-hepatitis B virus core antibody were performed in 28.23%, 12.52% and 14.63% of patients, respectively, when the therapy was initiated. We found that HBV reactivation and fulminant hepatitis occurred in both the patients with and without HBV DNA monitoring, indicating insufficient monitoring in Japan during the study. The cumulative incidence of HBV reactivation over 24 months was 1.57% (95% confidence interval [CI] = 1.28%-1.92%) in the monitoring group, which consisted of those with resolved HBV infection. Glucocorticoid administration was a potent risk factor for HBV reactivation (hazard ratio [HR] = 1.70, 95% CI = 1.26-2.29, P = .001 in all subjects, and HR = 1.82, 95% CI = 1.18-2.81, P = .007 in the nonmonitoring group), although it was not statistically significant in the monitoring group (HR = 1.49, 95% CI = 0.99-2.26 and P = .057). No significant risk difference was observed between single administration of methotrexate and biological drugs.
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Affiliation(s)
- M Fujita
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba City, Japan
| | - M Sugiyama
- Genome Medical Sciences Project, National Center for Global Health and Medicine, Ichikawa City, Japan
| | - Y Sato
- Department of Global Clinical Research, Chiba University Graduate School of Medicine, Chiba City, Japan
| | - K Nagashima
- Department of Global Clinical Research, Chiba University Graduate School of Medicine, Chiba City, Japan
| | - S Takahashi
- Clinical Research Center, Chiba University Hospital, Chiba City, Japan
| | - M Mizokami
- Genome Medical Sciences Project, National Center for Global Health and Medicine, Ichikawa City, Japan
| | - A Hata
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba City, Japan
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Fukuda W, Hanyu T, Katayama M, Mizuki S, Okada A, Miyata M, Handa Y, Hayashi M, Koyama Y, Arii K, Kitaori T, Hagiyama H, Urushidani Y, Yamasaki T, Ikeno Y, Suzuki T, Omoto A, Sugitani T, Morita S, Inokuma S. Incidence of hepatitis B virus reactivation in patients with resolved infection on immunosuppressive therapy for rheumatic disease: a multicentre, prospective, observational study in Japan. Ann Rheum Dis 2016; 76:1051-1056. [PMID: 27934678 DOI: 10.1136/annrheumdis-2016-209973] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although the reactivation of hepatitis B virus (HBV) is recognised as a serious complication in patients with rheumatic disease (RD) receiving immunosuppressive drugs (ISDs), the incidence and risk factors for reactivation remain controversial. OBJECTIVES To investigate the incidence and risk factors for HBV reactivation in patients with RD. METHODS We performed a multicentre, observational, prospective study over 2 years in patients with resolved HBV infection. Patients with RD treated with a dose of ≥5 mg/day prednisolone and/or synthetic or biological ISDs with negative HB virus surface antigen and positive anti-HB virus surface antibody (HBsAb) and/or anti-HB virus core antibody (HBcAb) were enrolled. Quantitative HBV DNA results and related data were regularly recorded. RESULTS Among 1042 patients, including 959 with rheumatoid arthritis, HBV DNA was detected in 35 (1.93/100 person-years), with >2.1 log copies/mL observed in 10 patients (0.55/100 person-years). None of the reactivated patients, including seven treated with a nucleic acid analogue, showed overt hepatitis. Low HBsAb titres and advanced age seemed to be risk factors for HBV reactivation; however, reactivation was observed in three patients with positive HBsAb and negative HBcAb test results. The risk of reactivation was lower with methotrexate but higher with prednisolone among the different types of ISDs. The intervals from the start of ISD to reactivation were relatively long (3-182 months; median, 66 months). CONCLUSIONS The incidence of HBV reactivation with ISD use was 1.93/100 person-years in patients with RD with resolved HBV infection. No overt hepatitis was observed in the reactivated patients.
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Affiliation(s)
- Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tadamasa Hanyu
- Department of Rheumatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Masaki Katayama
- Department of Rheumatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichi Mizuki
- Department of Rheumatology, Matsuyama Red Cross Hospital, Ehime, Japan
| | - Akitomo Okada
- Department of Rheumatology, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Masayuki Miyata
- Department of Internal Medicine, Japanese Red Cross Fukushima Hospital, Fukushima, Japan
| | - Yuichi Handa
- Department of Rheumatology, Saitama Red Cross Hospital, Saitama, Japan
| | - Masatoshi Hayashi
- Department of Orthopedic Surgery and Rheumatology, Nagano Red Cross Hospital, Nagano, Japan
| | - Yoshinobu Koyama
- Department of Rheumatology, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Kaoru Arii
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, Kochi, Japan
| | - Toshiyuki Kitaori
- Department of Orthopedics, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | | | | | - Takahito Yamasaki
- Department of Rehabilitation, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yoshihiko Ikeno
- Department of Rheumatology, Nasu Red Cross Hospital, Tochigi, Japan
| | - Tsuyoshi Suzuki
- Division of Allergy and Rheumatology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Atsushi Omoto
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Toshifumi Sugitani
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeko Inokuma
- Department of Allergy and Rheumatology, Chiba Central Medical Center, Chiba, Japan
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11
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Koutsianas C, Thomas K, Vassilopoulos D. Hepatitis B Reactivation in Rheumatic Diseases: Screening and Prevention. Rheum Dis Clin North Am 2016; 43:133-149. [PMID: 27890170 DOI: 10.1016/j.rdc.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) reactivation (HBVr) has been an increasingly recognized and appreciated risk of immunosuppressive therapies in rheumatic patients. Despite its potential for significant morbidity and mortality, HBVr is a fully preventable complication with appropriate pretreatment screening and close monitoring of susceptible patients. Better knowledge of the risk for HBVr with the different antirheumatic agents and the establishment of the new-generation oral antivirals in clinical practice has greatly improved the design of screening and therapeutic algorithms. In this review, all available data regarding HBVr in rheumatic patients are critically presented and a screening and therapeutic algorithm is proposed.
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Affiliation(s)
- Christos Koutsianas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece; Department of Rheumatology, The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley DY1 2HQ, West Midlands, UK
| | - Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, 114 Vass, Sophias Avenue, Athens 115 27, Greece.
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12
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Katchamart W, Narongroeknawin P, Chevaisrakul P, Dechanuwong P, Mahakkanukrauh A, Kasitanon N, Pakchotanon R, Sumethkul K, Ueareewongsa P, Ukritchon S, Bhurihirun T, Duangkum K, Intapiboon P, Intongkam S, Jangsombatsiri W, Jatuworapruk K, Kositpesat N, Leungroongroj P, Lomarat W, Petcharat C, Sittivutworapant S, Suebmee P, Tantayakom P, Tipsing W, Asavatanabodee P, Chiowchanwisawakit P, Foocharoen C, Koolvisoot A, Louthrenoo W, Siripaitoon B, Totemchokchyakarn K, Kitumnuaypong T. Evidence-based recommendations for the diagnosis and management of rheumatoid arthritis for non-rheumatologists: Integrating systematic literature research and expert opinion of the Thai Rheumatism Association. Int J Rheum Dis 2016; 20:1142-1165. [DOI: 10.1111/1756-185x.12905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Wanruchada Katchamart
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | - Pongthorn Narongroeknawin
- Division of Rheumatology; Department of Medicine; Pramongkutklao and College of Medicine; Bangkok Thailand
| | - Parawee Chevaisrakul
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol; Bangkok Thailand
| | - Pornchai Dechanuwong
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Vajira Hospital; Navamindradhiraj University; Bangkok Thailand
| | - Ajanee Mahakkanukrauh
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Nuntana Kasitanon
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Rattapol Pakchotanon
- Division of Rheumatology; Department of Medicine; Pramongkutklao and College of Medicine; Bangkok Thailand
| | - Kittiwan Sumethkul
- Rheumatology Unit; Department of Internal Medicine; Rajavithi Hospital; Bangkok Thailand
| | - Parichat Ueareewongsa
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | - Sittichai Ukritchon
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Chulalongkorn University; Bangkok Thailand
| | - Thitirat Bhurihirun
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | - Kittikorn Duangkum
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Porntip Intapiboon
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | - Samanan Intongkam
- Division of Rheumatology; Department of Medicine; Pramongkutklao and College of Medicine; Bangkok Thailand
| | - Wimol Jangsombatsiri
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol; Bangkok Thailand
| | - Kanon Jatuworapruk
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Naravadee Kositpesat
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Chulalongkorn University; Bangkok Thailand
| | - Pawinee Leungroongroj
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol; Bangkok Thailand
| | - Wiyanoot Lomarat
- Division of Rheumatology; Department of Medicine; Pramongkutklao and College of Medicine; Bangkok Thailand
| | - Chonachan Petcharat
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | | | - Patcharawan Suebmee
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Pongchirat Tantayakom
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | - Worakan Tipsing
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Vajira Hospital; Navamindradhiraj University; Bangkok Thailand
| | - Paijit Asavatanabodee
- Division of Rheumatology; Department of Medicine; Pramongkutklao and College of Medicine; Bangkok Thailand
| | - Praveena Chiowchanwisawakit
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | - Chingching Foocharoen
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Ajchara Koolvisoot
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Siriraj hospital; Mahidol University; Bangkok Thailand
| | - Worawit Louthrenoo
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Chiang Mai University; Chiang Mai Thailand
| | - Boonjing Siripaitoon
- Division of Rheumatology; Department of Medicine; Faculty of Medicine; Prince of Songkla University; Songkla Thailand
| | - Kitti Totemchokchyakarn
- Division of Allergy, Immunology and Rheumatology; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol; Bangkok Thailand
| | - Tasanee Kitumnuaypong
- Rheumatology Unit; Department of Internal Medicine; Rajavithi Hospital; Bangkok Thailand
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13
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Hirano F, Mizoguchi F, Harigai M, Miyasaka N, Kohsaka H. Tacrolimus successfully used to control refractory eosinophilic granulomatosis with polyangiitis complicated by invasive aspergillosis and chronic hepatitis B. Int J Rheum Dis 2016; 22:746-749. [PMID: 27125472 DOI: 10.1111/1756-185x.12869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
While several alternatives to cyclophosphamide have been proposed for refractory eosinophilic granulomatosis with polyangiitis (EGPA), therapeutic options are limited in patients with chronic infections. We report a case of refractory EGPA complicated by invasive aspergillosis and chronic hepatitis B. Although multiple immunosuppressants, including cyclophosphamide, were not effective, tacrolimus was used successfully to control disease without exacerbating concomitant infections in the long term. Tacrolimus could be an alternative choice in the treatment of EGPA, especially when aggressive immunosuppression is unfeasible.
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Affiliation(s)
- Fumio Hirano
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Fumitaka Mizoguchi
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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14
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Akashi K, Saegusa J, Nakamachi Y, Nakazawa T, Kumagai S, Morinobu A. Hepatitis B Virus Reactivation Following Salazosulfapyridine Monotherapy in a Patient with Rheumatoid Arthritis. Intern Med 2016; 55:1371-3. [PMID: 27181550 DOI: 10.2169/internalmedicine.55.5425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 72-year-old man was diagnosed with rheumatoid arthritis (RA) and prior hepatitis B virus (HBV) infection. He began treatment with salazosulfapyridine (SASP). Several months later, his blood tests reflected a slightly elevated liver function. Serum tests were positive for hepatitis B surface antigen and HBV-DNA, and the diagnosis of de novo HBV hepatitis was made. A genetic analysis showed that he had polymorphisms of ABCG2 and NAT2, which could lead to high plasma concentrations of SASP and sulfapyridine. To the best of our knowledge, this is the first report of de novo hepatitis developing during SASP monotherapy for RA.
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Affiliation(s)
- Kengo Akashi
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Japan
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15
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Kato M, Atsumi T. Reactivation of occult hepatitis B virus infection in patients with rheumatic diseases: pathogenesis, risk assessment and prevention. Rheumatol Int 2015; 36:635-41. [PMID: 26573663 DOI: 10.1007/s00296-015-3395-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/06/2015] [Indexed: 12/20/2022]
Abstract
Over the past decade, reactivation of occult hepatitis B virus (HBV) infection has garnered much attention from rheumatologists owing to a number of reports which have indicated the potential risk of biologics in causing this previously ignored infectious complication. Hepatitis due to reactivation of occult HBV infection occurs only occasionally but with high mortality upon occurrence, placing us in a clinical dilemma "to address or not to address?" In this review, we discuss how biological and other immunosuppressive therapies increase the risk of developing reactivation of occult HBV infection and attempt to solve this clinical quandary.
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Affiliation(s)
- Masaru Kato
- Division of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Tatsuya Atsumi
- Division of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
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16
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Loechelt BJ, Green M, Gottlieb PA, Blumberg E, Weinberg A, Quinlan S, Baden LR. Screening and Monitoring for Infectious Complications When Immunosuppressive Agents Are Studied in the Treatment of Autoimmune Disorders. J Pediatric Infect Dis Soc 2015; 4:198-204. [PMID: 26336066 PMCID: PMC4554203 DOI: 10.1093/jpids/piu055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 05/11/2014] [Indexed: 01/31/2023]
Abstract
Significant progress has been made in the development, investigation, and clinical application of immunosuppressive agents to treat a variety of autoimmune disorders. The expansion of clinical applications of these new agents requires the performance of large multicenter clinical trials. These large clinical trials are particularly important as one considers these agents for the treatment of type 1 diabetes, which although autoimmune in its pathogenesis, is not classically treated as an autoimmune disorder. Although these agents hold promise for amelioration or cure of this disease, they have the potential to facilitate infectious complications. There are limited data regarding the prospective assessment of infectious risks with these agents in trials of this nature. Pediatric subjects may be at greater risk due to the higher likelihood of primary infection. A subgroup of experts associated with TrialNet (a National Institutes of Health [NIH]-funded Type 1 diabetes mellitus research network) with expertise in infectious diseases, immunology, and diagnostics developed an approach for screening and monitoring of immunosuppression-associated infections for prospective use in clinical trials. The goals of these recommendations are to provide a structured approach to monitor for infections, to identify specific laboratory testing and surveillance methods, and to consider therapies for treatment of these potential complications. Prospective evaluations of these infectious risks allow for greater scientific rigor in the evaluation of risk, which must be balanced with the potential benefits of these therapies. Our experience supports an important role for investigators with expertise in infections in immunocompromised individuals in protocol development of immunosuppressive trials in type 1diabetes and potentially other autoimmune diseases.
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Affiliation(s)
- Brett J. Loechelt
- Children's National Medical Center, Washington, District of Columbia
- The George Washington University, District of Columbia
| | | | | | - Emily Blumberg
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | | | - Scott Quinlan
- The George Washington University, District of Columbia
| | - Lindsey R. Baden
- Brigham and Women's Hospital/Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
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17
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Safety of biologic and nonbiologic disease-modifying antirheumatic drug therapy in veterans with rheumatoid arthritis and hepatitis B virus infection: a retrospective cohort study. Arthritis Res Ther 2015; 17:136. [PMID: 26001631 PMCID: PMC4489034 DOI: 10.1186/s13075-015-0628-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/16/2015] [Indexed: 02/08/2023] Open
Abstract
Introduction We evaluated the safety of current treatment regimens for patients with RA and HBV in a large US cohort. Methods We identified biologic and nonbiologic treatment episodes of RA patients using 1997 to 2011 national data from the US Veterans Health Administration. Eligible episodes had evidence of HBV infection (HBV surface antigen, HBV core antibody, HBV e-antibody and/or HBV DNA) and had a baseline alanine aminotransferase (ALT) <1.5 times the upper limit of laboratory normal within 90 days prior to initiation of a new biologic or nonbiologic DMARD. The main outcome of interest was hepatotoxicity, defined as ALT elevation >100 IU/mL. Results were reported as the cumulative incidence of treatment episodes achieving hepatotoxicity at 3, 6 and 12 months post biologic exposure. Results Five hundred sixty-six unique RA patients with HBV contributed 959 treatment episodes. Mean age was 62.1 ± 10.3 years; 91.8% were male. Hepatotoxicity was uncommon, with 26 events identified among 959 episodes (2.7%) within 12 months. Hepatotoxicity was comparable between biologic and nonbiologic DMARDs (2.6% vs. 2.8%, P = 0.87). The median time between HBV screening and starting a new RA drug was 504 days (IQR 144, 1,163). Follow-up HBV testing occurred among 14 hepatotoxicity episodes (53.8%) at a median of 202 days (IQR 82, 716) from the date of ALT elevation. A total of 146 (15.2%) treatment episodes received at least one test for HBV DNA at any point in the observation period. Conclusions Among US veterans with RA and HBV the risk of hepatotoxicity is low (2.7%), and comparable between biologic and nonbiologic DMARDS (2.8% vs. 2.6%, P = 0.87). HBV testing associated with DMARD initiation or hepatotoxicity was infrequent. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0628-z) contains supplementary material, which is available to authorized users.
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