Management of psoriasis patients with hepatitis B or hepatitis C virus infection

Abstract

The systemic therapies available for the management of Psoriasis (PsO) patients who cannot be treated with more conservative options, such as topical agents and/or phototherapy, with the exception of acitretin, can worsen or reactivate a chronic infection. Therefore, before administering immunosuppressive therapies with either conventional disease-modifying drugs (cDMARDs) or biological ones (bDMARDs) it is mandatory to screen patients for some infections, including hepatitis B virus (HBV) and hepatitis C virus (HCV). In particular, the patients eligible to receive an immunosuppressive drug must be screened for the following markers: antibody to hepatitis B core, antibody to hepatitis B surface antigen (anti-HBsAg), HBsAg, and antibody to HCV (anti-HCV). In case HBV or HCV infection is diagnosed, a close collaboration with a consultant hepatologist is needed before and during an immunosuppressive therapy. Concerning therapy with immunosuppressive drugs in PsO patients with HBV or HCV infection, data exist mainly for cyclosporine a (CyA) or bDMARDs (etanercept, adalimumab, infliximab, ustekinumab). The natural history of HBV and HCV infection differs significantly as well as the effect of immunosuppression on the aforementioned infectious diseases. As a rule, in the case of active HBV infection, systemic immunosuppressive antipsoriatic therapies must be deferred until the infection is controlled with an adequate antiviral treatment. Inactive carriers need to receive antiviral prophylaxis 2-4 wk before starting immunosuppressive therapy, to be continued after 6-12 mo from its suspension. Due to the risk of HBV reactivation, these patients should be monitored monthly for the first 3 mo and then every 3 mo for HBV DNA load together with transaminases levels. Concerning the patients who are occult HBV carriers, the risk of HBV reactivation is very low. Therefore, these patients generally do not need antiviral prophylaxis and the sera HBsAg and transaminases dosing can be monitored every 3 mo. Concerning PsO patients with chronic HCV infection their management with immunosuppressive drugs is less problematic as compared to those infected by HBV. In fact, HCV reactivation is an extremely rare event after administration of drugs such as CyA or tumor necrosis factor-α inhibitors. As a rule, these patients can be monitored measuring HCV RNA load, and ALT, aspartate transaminase, gamma-glutamyl-transferase, bilirubin, alkaline phosphatase, albumin and platelet every 3-6 mo. The present article provides an updated overview based on more recently reported data on monitoring and managing PsO patients who need systemic antipsoriatic treatment and have HBV or HCV infection as comorbidity.

Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis

“…If HBV‐DNA levels are detectable, it is recommended to start antiviral therapy first until HBV‐DNA levels are undetectable, and it is also recommended that inactive HBV carriers and those with resolved HBV infections should receive prophylactic antiviral treatment; however, due to the high cost of antivirals such as entecavir, prophylaxis is generally given only after the detection of serum HBV‐DNA or HBV surface antigen (HBsAg) seroconversion . Once csDMARD/biologic treatment is begun, serum HBV‐DNA and liver transaminase levels should be monitored every month for the first 3 months, and then once every 3 months, so that reactivation can be managed in a timely fashion …”

Practical recommendations for systemic treatment in psoriasis in case of coexisting inflammatory, neurologic, infectious or malignant disorders (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis; part 2)

“…46,53 The only reports from reactivation of hepatitis B with cyclosporin are from severe immunosuppressed patients. 54 Reactivation of hepatitis B occurred in 39% of HBsAg+ patients treated with TFN-a-blockers for autoimmune diseases but not in HBsAg-/anti-HBc+ patients. 55 We note that methotrexate is contra-indicated in these patients, due to significant risk of reactivation of hepatitis B with a potentially fatal outcome and so advise against its use.…”

INASL Guidelines on Management of Hepatitis B Virus Infection in Patients receiving Chemotherapy, Biologicals, Immunosupressants, or Corticosteroids

“…The proposed guidelines for managing monitoring and managing HBV reactivation in patients with rheumatologic and dermatologic diseases receiving biologics are similar as proposed for inflammatory bowel diseases. 84,87,99,101 It is felt that there is a need to serologically monitor all patients being treated with biologics for possible de novo HBV hepatitis and to promptly manage reactivation.…”