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HBV Prophylaxis Before Biologics — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyHBV Prophylaxis Before BiologicsSCE Rheumatology

A 50-year-old man has active rheumatoid arthritis despite methotrexate, and treatment with adalimumab is planned. Pre-treatment screening shows that he is HBsAg positive and anti-HBc positive. His alanine aminotransferase is normal and serum HBV DNA is undetectable. Which is the most appropriate management before initiating adalimumab?

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Correct answer: D — Obtain hepatology input and start entecavir or tenofovir before adalimumab

HBsAg positivity indicates current HBV infection. A normal ALT and undetectable HBV DNA do not eliminate the risk of reactivation when a biologic DMARD, particularly a TNF inhibitor, is started. He should be referred for hepatology assessment and commence a high-barrier nucleos(t)ide analogue, usually entecavir or tenofovir, before immunosuppression; ALT and HBV DNA should then be monitored during and after treatment. Monitoring without prophylaxis is more appropriate for selected HBsAg-negative, anti-HBc-positive patients receiving lower-risk therapy, not an HBsAg-positive patient starting adalimumab. Switching to another TNF inhibitor does not remove the risk. Vaccination is not therapeutic in established HBV infection, and starting the biologic without HBV-directed management risks severe or potentially fatal reactivation.

Reference: Fragoulis GE et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases, hepatitis B recommendation and algorithm. Ann Rheum Dis. 2023;82:742–753. https://pubmed.ncbi.nlm.nih.gov/36328476/