Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Mar 27, 2015; 7(3): 539-547
Published online Mar 27, 2015. doi: 10.4254/wjh.v7.i3.539
Hepatitis B and immunosuppressive therapies for chronic inflammatory diseases: When and how to apply prophylaxis, with a special focus on corticosteroid therapy
Pilar López-Serrano, Elsa de la Fuente Briongos, Elisa Carrera Alonso, Jose Lázaro Pérez-Calle, Conrado Fernández Rodríguez
Pilar López-Serrano, Elsa de la Fuente Briongos, Jose Lázaro Pérez-Calle, Conrado Fernández Rodríguez, Department of Gastroenterology, University Hospital Fundación Alcorcón, 28922 Madrid, Spain
Elisa Carrera Alonso, Department of Gastroenterology, University Hospital of Guadalajara, 19002 Guadalajara, Spain
Author contributions: López-Serrano P, de la Fuente Briongos E, Carrera Alonso E, Pérez-Calle JL and Fernandez Rodríguez C contributed equally to this work; all authors had approved the final version of the manuscript.
Conflict-of-interest: Dr. Conrado Fernández Rodríguez is a advisory board member, panel reviewer and consultant for Bristol Myers Squibb. The rest of the authors whose names are listed certify that they have NO affiliations or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Pilar López-Serrano, Department of Gastroenterology, University Hospital Fundación Alcorcón, Calle Budapest 1, 28922 Madrid, Spain.
Telephone: +34-91-6219400 Fax: +34-91-6219890
Received: August 28, 2014
Peer-review started: August 30, 2014
First decision: November 14, 2014
Revised: December 28, 2014
Accepted: January 9, 2015
Article in press: January 9, 2015
Published online: March 27, 2015

Currently immunosuppressive and biological agents are used in a more extensive and earlier way in patients with inflammatory bowel disease, rheumatic or dermatologic diseases. Although these drugs have shown a significant clinical benefit, the safety of these treatments is a challenge. Hepatitis B virus (HBV) reactivations have been reported widely, even including liver failure and death, and it represents a deep concern in these patients. Current guidelines recommend to pre-emptive therapy in patients with immunosuppressants in general, but preventive measures focused in patients with corticosteroids and inflammatory diseases are scarce. Screening for HBV infection should be done at diagnosis. The patients who test positive for hepatitis B surface antigen, but do not meet criteria for antiviral treatment must receive prophylaxis before undergoing immunosuppression, including corticosteroids at higher doses than prednisone 20 mg/d during more than two weeks. Tenofovir and entecavir are preferred than lamivudine because of their better resistance profile in long-term immunosuppressant treatments. There is not a strong evidence, to make a general recommendation on the necessity of prophylaxis therapy in patients with inflammatory diseases that are taking low doses of corticosteroids in short term basis or low systemic bioavailability corticosteroids such as budesonide or beclomethasone dipropionate. In these cases regularly HBV DNA monitoring is recommended, starting early antiviral therapy if DNA levels begin to rise. In patients with occult or resolved hepatitis the risk of reactivation is much lower, and excepting for Rituximab treatment, the prophylaxis is not necessary.

Keywords: Hepatitis B virus, Inflammatory bowel disease, Rheumatic disease. Dermatologic diseases, Corticosteroids, Anti-tumor necrosis factor, Prophylaxis, Immunosuppressants

Core tip: Few reviews have been published including data of the three more common inflammatory diseases that require immunosuppressive therapy: inflammatory bowel disease, rheumatic and dermatologic diseases. This paper is focused on the risk of reactivation of hepatitis B virus under immunosuppressants, and particularly corticosteroids. Although most of the guidelines do not specify the necessity of prophylaxis in case of monotherapy with corticosteroids, the specialists responsible of these patients are usually concerned about this issue. Moreover, the risk with low systemic bioavailability new corticosteroids has not been evaluated in previous reviews. This work summarizes the evidence of VHB reactivation in patients with inflammatory diseases: when and how to apply prophylaxis, with a special focus on “new” and “old” steroids.