Patients with psoriasis often have more than one comorbidity, which may or may not complicate their treatment plan. During the session “Management of Immunosuppressants and Biologics in Patients With Chronic Viral Infections Such as Hepatitis B & C,” Erin Amerson, MD, discussed what dermatologists need to know about prescribing and managing biologics in patients with immune-mediated inflammatory diseases and hepatitis B (HBV) or hepatitis C (HCV).
HBV is a serious health concern. Its sequelae include fulminant liver failure, cirrhosis, hepatocellular carcinoma, and extrahepatic manifestations. Most patients who have HBV acquire it in the perinatal period, either developing chronic HBV (HBsAg+) or occult/resolved infection (HBsAg-). Testing can be confusing since the markers are dynamic and there are more than one option, including:
- Core antibody HBcAb, which detects infection (both active or prior)
- Surface antigen HBsAg, which detects active infection
- Surface antibody HBsAb, which detects vaccination if the results show core antibody or resolved infection
- HBV DNA by PCR, which can detect the level of viral replication
Therefore, with the number of tests, it is helpful to understand the five different clinical scenarios for HBV:
- Vaccinated/immune: HBsAb+, HBsAg-, HBcAb-
- Chronic infection; HBsAb-, HBsAg+, HBcAb+
- Past infection “occult”: HBsAb-, HBsAg-, HBcAb+
- Past infection “resolved”: HBsAb+, HBsAg-, HBcAb+
- Never infected/no vaccination: HBsAb-, HBsAg-, HBcAb-
“True or false: there are clear evidence-based guidelines for choosing a biologic and lab monitoring in HBV-infected patients?” asked Dr Amerson. The answer is false. Patients with HBV and HCV are often excluded from clinical trials, so data on the efficacy of biologics in this patient group are lacking despite good evidence out of Taiwan.
For patients who have a past infection, Dr Amerson shared a proposed adapted treatment algorithm from a review of hepatology guidelines. For biologic agents and drugs with a moderate risk of immunosuppression (eg, TNF, IL-12/IL-23, or IL-17 inhibitors), dermatologists should either (1) start an antiviral prophylaxis and monitor HBV DNA every 3 months or (2) monitor HBsAg, liver function, HBV DNA every 1 to 3 months; in either option, if reactivation is detected, then the patient should be referred to hepatology. In high-risk immunosuppressants (eg, rituximab or >20mg of prednisone per day for longer than 1 month), dermatologists should automatically refer to hepatology, begin antiviral prophylaxis, and monitor HBV DNA every 3 months. Following withdrawal of the immunosuppressant, patients should continue their antiviral prophylaxis and have routine laboratory monitoring for 12 months after reconstitution.
For patients with a chronic HBV infection, Dr Amerson shared another proposed treatment algorithm. These patients should be referred to hepatology and be tested for HBV DNA, HBeAb, HBeAg, HDV, HCV, and HIV. Whether the agent is considered moderate or high risk, patients with chronic HBV infection should be started on antiviral prophylaxis and monitor HBV DNA every 3 months.
The risk of reactivation without antiviral prophylaxis in chronic infection is thought to be up to 60% with high-risk therapies and up to 62% in moderate-risk therapies based on Taiwanese literature.
Similarly to HBV, HCV causes hepatologic disease. However, HCV and biologics are less of a concern than its double-stranded counterpart. The risk of reactivation on biologics is very low overall, except for rituximab, which is slightly higher than other options. Dermatologists should test for HCV prior to initiating treatment, and if positive, refer for treatment with one of the excellent options available for HCV. —Lauren Mateja
Reference
Amerson EH. Management of immunosuppressants and biologics in patients with chronic viral infections such as hepatitis B & C. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.
