Wednesday, 16 Jan 2019

You are here

Prevention of HBV Infection: How Are We Doing?

Hepatitis B virus (HBV) infection remains a large cause of morbidity and mortality in worldwide despite it being preventable through screening and vaccination.

In 2016, WHO set out to eliminate HBV infection as a public health threat by 2030. We are far from this goal. Vaccine implementation has been suboptimal in a number of important patient populations, including patients with rheumatologic diseases, as well as other immunocompromising diseases like HIV.

Screening and vaccinating such populations is of utmost importance because hepatitis B surface antigen (HBsAg – chronic infection) and even core antibody (HBcAb – resolved infection) positive patients are at risk of reactivating infection in the setting of immunosuppression, in particular rituximab.

In 2010, survey data was published in Arthritis Care and Research authors queried 1,000 rheumatologists nationwide about familiarity with published guidelines for hepatitis B screening and their awareness of risk of HBV reactivation. While response rate was low they found that depending on the drug 19-53% of physicians were aware of the package insert warning re: HBV reactivation, 42% routinely screened for HBV reactivation prior to starting DMARDs and 69% before biologics. This article is 7 years old but I do not doubt that these low numbers still ring true. (https://buff.ly/2mJ6ftw)

A study published in the Annals of Internal medicine in December 2017 sought to estimate the prevalence of hepatitis B vaccination among U.S. patients with HIV in 2009 through 2012. Out of 18,000 they found that over 1/3 of these patients had missed opportunities to initiation the vaccine series. (https://buff.ly/2DKiPkr)

The current CDC/ACP recommendations state that clinicians should vaccinate all unvaccinated adults at risk including at risk by sexual exposure, percutaneous or mucosal exposure (e.g. healthcare workers), chronic liver disease, ESRD and HIV infection.

While patients requiring immunosuppression are not included here, they are recommended for screening (with HBsAg, HBcAb and HBsAb). What are the ACR guidelines for screening for HBV? They are not exactly clear.

They recommend screening “high-risk” patients receiving leflunomide or methotrexate, and that appropriate evaluation “might include” HBsAg, HBsAb and HbcAb. They mention no recommendation to screen before starting biologics. 

With the growing use of immunosuppression, in particular biologics, we must be aware of the risk of HBV reactivation, which can lead to interruption of treatment and adverse liver consequences, all of which are largely preventable by timely screening and vaccination.

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Best of 2018: The Safety of Paternal Exposure to DMARDs and Biologics

Pregnancy and drug safety is a complex issue, often with limited information about maternal drug exposure on the offspring. Greater uncertainty exists when considering whether paternal exposure may also influence fetal outcomes.

A systematic review examined the effect of disease modifying anti-rheumatic drugs (DMARDs) on male fertility and if peri-conception (within 3 months) paternal exposure was detrimental to fetal outcomes.

Best of 2018: Hydroxychloroquine Being Over-Dosed with New Guidelines?

Hydroxychloroquine retinopathy prevention guidelines have revised from ideal body weight-based dosing to actual body weight-based dosing; the question remains whether these have been adopted in clinical practice. A database of nearly 21,000 new HCQ users from a UK general population database studied HCQ dosing and use between 2007 and 2016. Specifically they examined whether users were subjected to excess HCQ dosing per ophthalmology guidelines (defined by exceeding 6.5 mg/kg of IBW and 5.0 mg/kg of ABW).

CDC Top 15 Most Common Opioid Overdose Drugs

The Dec. 12 issue of the National Vital Statistics Reports from the U.S. Centers for Disease Control and Prevention reports that the most commonly abused drugs causing drug overdose deaths (between 2011-2016) include fentanyl, heroin, oxycodone, and cocaine.

Trazodone High Risk of Falls and Fractures

The CMAJ (Canadian Medical Association Journal) has reported that trazadone use in the elderly may be associated with a risk of falls and major fractures. 

Using claims data from ICES, researchers compared 6588 seniors given trazadone to 2875 receiving another atypical antipsychotic.

Musculoskeletal Events with Statin Use

Analysis of the FDA Adverse Event Reporting System data examined the association between statins' musculoskeletal adverse events (MAEs).

Review of the data shows that atorvastatin and rosuvastatin (with strong low‐density lipoprotein cholesterol‐lowering effects) had a higher risk and a faster onset of MAEs when compared with simvastatin.

They could not detect whether concomitant drugs shifted the onset timing of MAEs.