HBV Reactivation Risk — SCE Rheumatology MCQ

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HardRheumatology PharmacologyHBV Reactivation RiskSCE Rheumatology

A 58-year-old woman with active seropositive rheumatoid arthritis requires a biological DMARD. Hepatitis B screening shows HBsAg negative, total anti-HBc positive, anti-HBs negative and HBV DNA undetectable. Assuming equivalent rheumatological indications and before antiviral risk-mitigation measures are applied, which biologic is associated with the highest risk of hepatitis B virus reactivation?

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Correct answer: C — Rituximab

Rituximab is correct. CD20-positive B-cell depletion substantially impairs immune control of persistent HBV. In RA patients with HBsAg-negative/anti-HBc-positive serology, a meta-analysis found the highest pooled reactivation rate with rituximab (9%), followed by abatacept (6%); absence of anti-HBs further increases risk. Adalimumab, etanercept and tocilizumab can also permit reactivation and do not remove the need for HBV assessment and monitoring, but their reported risk is lower. Abatacept is the strongest distractor because its risk is appreciable, although it remains below that of rituximab. EULAR recommends HBV-status-based antiviral management, while the UK rituximab SmPC mandates screening and liver-specialist management for positive HBV serology.

Reference: Hong X et al. Risk of hepatitis B reactivation in HBsAg-/HBcAb+ patients after biologic or JAK inhibitor therapy for rheumatoid arthritis: A meta-analysis. Immunity, Inflammation and Disease. 2023;11:e780. https://pubmed.ncbi.nlm.nih.gov/25765930/