Use of tumor necrosis factor-α (TNF-α) antagonists infliximab, etanercept, and adalimumab in patients with concurrent rheumatoid arthritis and hepatitis B or hepatitis C: a retrospective record review of 11 patients

Abstract

An understanding of the cytokine cascade in a rheumatoid joint has led to the development of new therapeutic options, including drugs targeting tumor necrosis factor-alpha (TNF-alpha). The safety profile of these agents in patients with hepatitis-induced liver disease, however, remains a concern because of risks associated with immune suppression. To examine the effect of three different TNF-alpha antagonists, infliximab, etanercept, and adalimumab, on serum transaminases and hepatitis viral load in patients with rheumatoid arthritis (RA) and concurrent hepatitis B (HBV) or hepatitis C (HCV). Medical records of 11 patients with diagnosis of RA and documented seropositivity for hepatitis B or hepatitis C were retrospectively reviewed for worsening of hepatic inflammation and viral proliferation as measured by a rise in aspartate aminotransferase (AST) or alanine aminotransferase (ALT) and viral load while using these agents. Three patients had RA with concurrent chronic HBV and eight patients had RA with concurrent chronic HCV. Seven patients remained on a single anti-TNF-alpha agent and four patients switched to a second anti-TNF-alpha agent due to treatment failure. Two patients showed a transient elevation in AST and/or ALT from normal, but in all 11 patients, AST and ALT levels were within one time the upper range of normal at the conclusion of the study. No significant increase in viral load was seen except one patient who showed a fourfold increase from baseline. Our case series supports results obtained from previous studies examining the safety of anti-TNF-alpha agents in patients with underlying hepatic disease. Use of these agents in patients with HBV or HCV may be associated with a transient transaminitis but appears to be safe overall. In both groups, frequent monitoring of serum transaminase levels and viral load is essential.

Liver diseases associated with anti-tumor necrosis factor-alpha (TNF-α) use for inflammatory bowel disease

“…Overall, most published reports indicate that anti-TNF agents are safe in patients infected with hepatitis C, 19,[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] as recently reviewed. 1 However, the safety of anti-TNF agents in patients with advanced HCV-related fibrosis is unknown.…”

Safety of tumor necrosis factor α blockers in hepatitis B virus occult carriers (hepatitis B surface antigen negative/anti–hepatitis B core antigen positive) with rheumatic diseases

“…A recent retrospective study showed 1 case of viral reactivation among 8 HBsAg carriers treated with anti-TNF␣ therapy (24). On the other hand, many cases have been described in which TNF blockade, either in association with lamivudine prophylactic therapy or not, did not lead to HBV reactivation (6,(25)(26)(27)(28)(29)(30), and recently a retrospective study showed no reactivation during anti-TNF␣ therapy (31). The use of lamivudine to prevent HBV reactivation is recommended in HBsAg-positive patients undergoing immunosuppressive therapies, including anti-TNF␣ drugs (4,32), but its use can lead to viral resistance (33).…”

Effect of etanercept and entecavil in a patient with rheumatoid arthritis who is a hepatitis B carrier: a review of the literature

“…However, in clinical practice, it is necessary to use anti-TNF-a in these patients. Table 1 summarizes the course of nine patients who received etanercept according to our literature search [16,[22][23][24][25][26]. Nine of four patients were women.…”