Modern Rheumatology

, Volume 21, Issue 1, pp 16–23

Prevalence of reactivation of hepatitis B virus replication in rheumatoid arthritis patients

Authors

    • Department of RheumatologySeihoku Chuo Hospital
  • Ryoko Uesato
    • Department of Orthopaedic SurgerySeihoku Chuo Hospital
  • Dai Tanaka
    • Department of Orthopaedic SurgerySeihoku Chuo Hospital
  • Kenji Kowatari
    • Department of Orthopaedic SurgerySeihoku Chuo Hospital
  • Taisuke Nitobe
    • Department of Orthopaedic SurgerySeihoku Chuo Hospital
  • Yoshihide Nakamura
    • Department of Orthopaedic SurgeryHirosaki University Graduate School of Medicine
  • Shigeru Motomura
    • Department of PharmacologyHirosaki University Graduate School of Medicine
Original Article

DOI: 10.1007/s10165-010-0337-z

Cite this article as:
Urata, Y., Uesato, R., Tanaka, D. et al. Mod Rheumatol (2011) 21: 16. doi:10.1007/s10165-010-0337-z

Abstract

Reactivation of hepatitis B involves the reappearance of active necroinflammatory liver disease after an inactive hepatitis B surface antigen (HBsAg) carrier state or resolved hepatitis B, occurring during or after immunosuppression therapy or chemotherapy. We prospectively investigated the reactivation rate for hepatitis B virus (HBV) DNA replication in cases of rheumatoid arthritis (RA) with resolved hepatitis B. HBV markers were evaluated in 428 RA patients. Patients with positive findings of HBsAg or HBV DNA at enrolment were excluded. The study population comprised 422 RA patients, with resolved hepatitis B diagnosed in 135 patients based on HBsAg-negative and antihepatitis B core antibody/antihepatitis B surface antibody-positive results. HBV DNA was measured every 3 months in this group, and if HBV DNA became positive after enrolment, measurement was repeated every month. HBV DNA became positive (≥3.64 log copies/mL) in 7 of 135 patients for 12 months. Use of biologic agents was significantly more frequent in patients who developed reactivation of HBV DNA replication (85.7%) than in patients who did not (36.0%, p = 0.008). Hazard ratios for use of biologic agents and etanercept were 10.9 (p = 0.008) and 6.9 (p = 0.001), respectively. RA patients with resolved hepatitis B need careful monitoring when receiving biologic agents, regardless of HBV DNA levels.

Keywords

BiologicHepatitis B virusReactivation of hepatitis BRheumatoid arthritis

Introduction

More than one third of the population worldwide has been infected with hepatitis B virus (HBV), and 350 million individuals have chronic HBV infection [1], with 75% living in the Southeast Asia and western Pacific regions. HBV infection is a leading cause of cirrhosis and hepatocellular carcinoma (HCC) [2] and is estimated to be responsible for 500,000–700,000 deaths annually. Reactivation of hepatitis B in patients undergoing immunosuppressive therapy is considered to be a complication of considerable clinical importance [35]. Reactivation of hepatitis B can be transient and clinically silent, but is often severe, resulting in acute hepatic failure. Two clinical scenarios contribute to the reactivation of hepatitis B. The first occurs in patients who have chronic hepatitis B. Fulminant HBV has been reported in hepatitis B surface antigen (HBsAg)-positive patients with rheumatoid arthritis (RA) taking tumor necrosis factor agents (TNFA) [6, 7]. In the second scenario, reactivation of hepatitis B occurs in patients with resolved hepatitis B. In these patients, low levels of HBV replication have been shown to persist in the liver and in peripheral blood mononuclear cells for decades [810], and reactivation of hepatitis B has been described after transplantation, immunosuppressive therapy, and allogeneic and autologous hematopoietic stem-cell transplantation, with the reappearance of HBsAg [1115]. Reactivation of hepatitis B sometimes occurs in RA patients with resolved hepatitis B on immunosuppressive therapy, including corticosteroids (CS), methotrexate (MTX) [16], and TNFA [17, 18], and can result in fulminant or lethal hepatitis [4]. Optimal management of this group of patients is unclear [9]. This study aimed to determine the rate of reactivation of HBV DNA replication in RA patients with resolved hepatitis B.

Materials and methods

Patients and methods

In our departments, 428 patients were treated for RA between January 2008 and March 2009 who fulfilled the American College of Rheumatology (ACR) 1987 revised criteria for RA. All patients were evaluated for HBV markers, including HBsAg, antihepatitis B surface antibody (anti-HBs), and antihepatitis B core antibody (anti-HBc). After all, 422 patients entered the study, and 6 patients were excluded by HBsAg-positive at baseline. HBV markers were detected using commercial enzyme immunoassays (HBsAg: ARCHITECT HBsAg QT; anti-HBs: ARCHITECT Anti-HBs; anti-HBc: ARCHITECT Anti-HBc, Abbott Laboratories, Wiesbaden, Germany). If patients were HBsAg-positive, or HBsAg-negative and anti-HBs- and/or anti-HBc-positive, HBV DNA levels were assessed. Sensitivity was 2 log copies/mL. When negative results were obtained for HBV DNA, measurements were repeated every 3 months, and if HBV DNA became positive, measurements were repeated every month. Medications including biologic agents were generally not discontinued, irrespective of HBV DNA levels. All study protocols were approved by the ethics committees of the participating centers, and all patients provided written informed consent prior to enrolment.

Quantification of HBV DNA in blood by real-time PCR

HBV DNA levels were quantified using the automated COBAS TaqMan HBV Test version 2.0. Samples were pretreated with the COBAS AmpliPrep System for amplification and quantification by real-time polymerase chain reaction (PCR) and were analyzed using the COBAS TaqMan gene analyzer [19].

Statistical analysis

Fisher’s exact test, Student’s t test, and Mann–Whitney U test were used to compare baseline patient characteristics between subgroups. Two-tailed values of p ≤ 0.05 were regarded as significant. Cox regression hazard analyses were used to separately investigate the influence of biologic agents, MTX, CS, and disease-modifying antirheumatic drugs (DMARDs) on reactivation of HBV DNA replication. All analyses were performed using JMP version 6.0 software (JMP Japan, Tokyo, Japan).

Results

Background characteristics of the 422 patients are listed in Table 1. Six patients were HBsAg-positive, whereas 135 were HBsAg-negative and anti-HBs- and/or anti-HBc-positive (32.0%). Ninety-seven patients (71.9%) were anti-HBs-positive, 38 (28.1%) were hepatitis B surface antibody (HBsAb)-negative/hepatitis B core antibody (HBcAb)-positive, and 12 (8.9%) were HBsAb-positive/HBcAb-negative (Table 2). When comparing resolved hepatitis B patients to anti-HBs- and anti-HBc-negative patients, significant differences in age (65.6 ± 11.8 vs. 61.8 ± 14.0 years, respectively, p = 0.0169) and erythrocyte sedimentation rate (ESR) (25.0 ± 25.6 vs. 21.0 ± 20.6, respectively, p = 0.0471) at baseline were identified. No significant differences in other background characteristics were seen. No resolved hepatitis B patients were positive for HBV DNA at baseline.
Table 1

Baseline demographic and clinical and laboratory characteristics for the patient cohort

 

Values

Number of patients

422

Age (years) (mean)

62.3 ± 13.5 (63.6)

Female (n)

349 (82.7%)

RA duration (years)

8.0 ± 9.4 (4.4)

CRP (mg/dL)

0.83 ± 1.79 (0.16)

ESR (mm/h)

22.3 ± 22.4 (14.0)

IgM RF (IU/mL)

85.4 ± 194.8 (25.0)

AST (U/L)

27.8 ± 15.2 (23.0)

ALT (U/L)

26.8 ± 20.7 (20.0)

IgG (mg/dL)

1,356.5 ± 415.0 (1,306.5)

Neutrophil count

4,083 ± 1,907 (3,610)

Lymphocyte count

1,628 ± 648 (1,559)

Values are given as the mean ± standard deviation (median)

RA rheumatoid arthritis, CRP C-reactive protein, ESR erythrocyte sedimentation rate, Ig immunoglobulin, RF rheumatoid factor, AST aspartate aminotransferase, ALT alanine aminotransferase

Table 2

Distribution of hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) results among hepatitis B surface antigen (HBsAg)-negative and HBsAg-positive patients

 

HBsAg-negative

HBsAg-positive

HBsAb-positive

HBsAb-negative

HBsAb-positive

HBsAb-negative

HBcAb-positive

85

38

3

3

HBcAb-negative

12

0

0

0

Patients were followed for 12 months, and HBV DNA became positive (3.64 log copies/mL) in 7 of 135 patients (5.2%), whereas hepatic function remained normal in all cases (Table 3). Details of the patients who developed reactivation of HBV DNA replication are listed in Table 4; six patients showed HBV DNA replication during biologic-agent therapy [etanercept (ETN), n = 5; tocilizumab (TCZ), n = 1], whereas one patient showed replication without biologic-agent therapy. The types of DMARDs and immunosuppressants used for RA treatment during the study and numbers of patients on each pharmacotherapy are shown in Tables 5 and 6. In two of the seven patients, HBV DNA became negative without any therapy. In the remaining five, HBV DNA became negative with entecavir therapy (mean 1.7 months).
Table 3

Comparison of hepatitis B virus (HBV) replication-positive and HBV replication-negative patients for baseline demographic, clinical, and laboratory characteristics

Baseline demographic, clinical, and laboratory characteristics

HBV replication (+)

HBV replication (−)

P value

Number of patients

7

128

 

Age (years) (mean)

63.3 ± 12.9 (64.7)

65.8 ± 11.8 (66.8)

0.695

Female (n)

5 (71.4%)

105 (82.0%)

0.505

RA duration (years)

3.8 ± 2.6 (3.0)

7.8 ± 9.0 (4.6)

0.439

CRP (mg/dL)

0.57 ± 0.63 (0.40)

1.03 ± 2.00 (0.19)

0.924

ESR (mm/h)

17.6 ± 8.4 (16.0)

25.5 ± 26.3 (15.0)

0.979

IgM RF (IU/mL)

56.2 ± 64.8 (28.2)

73.9 ± 117.9 (28.1)

0.835

AST (U/L)

23.0 ± 3.8 (23.0)

27.5 ± 17.8 (22.0)

0.103

ALT (U/L)

23.1 ± 5.4 (25.0)

25.8 ± 20.1 (20.0)

0.419

IgG (mg/dL)

1,228 ± 401.5 (1,106)

1,435 ± 470.7 (1,369)

0.361

Neutrophil count

2,680 ± 1,449 (2,094)

4,389 ± 2,227 (3,843)

0.186

Lymphocyte count

1,367 ± 483 (1,450)

1,698 ± 809 (1,534)

0.349

Values are given as mean ± standard deviation (median)

RA rheumatoid arthritis, CRP C-reactive protein, ESR erythrocyte sedimentation rate, Ig immunoglobulin, RF rheumatoid factor, AST aspartate aminotransferase, ALT alanine aminotransferase

Table 4

Demographic, clinical, and laboratory characteristics of patients with hepatitis B virus (HBV) replication

Case

Age (years)

RA disease duration (months)

Biologic agent

MTX (mg/week)

DMARDs

Prednisolone (mg/day)

HBV (log copies/mL)

Entecavir

Final status of HBV DNA

Time between emergence of HBV DNA and its disappearance (months)

ALT (U/L)

1

77

35

Tocilizmuba

6

None

None

2.0

None

DNA-negative

1

27

2

65

53

Etanercept

None

None

2

5

Yes

DNA-negative

5

20

3

46

120

Etanercept

8

Tacrolimus (1 mg/day)

None

3.7

Yes

DNA-negative

1

30

4

49

60

Etanercept

None

Bucillamin (200 mg/day)

None

7.4

Yes

DNA-negative

18

20

5

60

36

Etanercept

None

Leflunomide (10 mg/day)

 

2

None

DNA-negative

1

25

6

75

18

Etanercept

8

None

6

2.4

Yes

DNA-negative

2

26

7

74

19

None

7.5

None

5

3

Yes

DNA-negative

2

14

RA rheumatoid arthritis, MTX methotrexate, DMARDs disease-modifying antirheumatic drugs, ALT alanine aminotransferase

aThis patient had received three biologic agents: infliximab, etanercept, and tocilizumab, sequentially

Table 5

Number of patients using concomitant drugs related to rheumatoid arthritis during the study [comparing patients with resolved hepatitis B and patients with HBsAg(−)/HBcAb(−)/HBsAb(−)]

Variables

Number of patientsa

P value

Resolved hepatitis B

HBsAg(−)/HBcAb(−)/HBsAb(−)

Total

135

287

 

Biologic agent

52 (38.5%)

118 (41.1%)

0.615

 Adalimumab

7 (5.2%)

21 (7.3%)

0.402

 Etanercept

38 (28.2%)

94 (32.8%)

0.339

 Infliximab

15 (16.5%)

29 (10.1%)

0.332

 Tocilizumab

4 (3.0%)

14 (4.9%)

0.349

 Rituximab

1 (1.1%)

0 (0%)

0.131

Methotrexate

65 (48.2%)

158 (55.1%)

0.185

 Mean dose

6.7 ± 1.9 mg/week

6.7 ± 1.8 mg/week

0.987

Corticosteroids

52 (38.5%)

201 (70.0%)

0.080

 Mean dose

5.1 ± 4.3 mg/day

4.2 ± 2.8 mg/day

0.197

Sulfasalazine

28 (20.7%)

58 (20.2%)

0.900

Bucillamine

27 (20.0%)

49 (17.1%)

0.469

Tacrolimus hydrate

9 (6.7%)

12 (4.2%)

0.285

Sodium aurothiomalate

2 (1.5%)

8 (2.8%)

0.391

Leflunomide

3 (2.2%)

4 (1.4%)

0.544

d-Penicillamine

2 (1.5%)

1 (0.4%)

0.217

Actarit

1 (0.7%)

0

0.131

Auranofin

3 (2.2)

0

0.009

Cyclosporine

1 (0.1%)

0

0.131

Minocycline hydrochloride

2 (1.5%)

0

0.032

Mizoribine

0

1 (0.4%)

0.380

Cyclophosphamide

1 (0.7%)

0

0.131

HBsAg hepatitis B surface antigen, HBcAb hepatitis B core antibody, HBsAb hepatitis B surface antibody

aValues are given as the number of patients taking a drug; patients can take more than one drug and can switch to another biologic agent

Table 6

Number of patients using concomitant drugs related to rheumatoid arthritis during the study [comparing hepatitis B virus (HBV)-replication-positive patients with HBV-replication-negative patients]

Variables

Number of patientsa

P value

HR (95% CI)

HBV replication (+)

HBV replication (−)

Total

7

128

  

Biologic agent

6 (85.7%)

46 (36.0%)

0.008

10.9 (1.4–87.7)

 Adalimumab

0

7 (5.5%)

0.382

 

 Etanercept

6 (85.7%)

32 (25.0%)

0.001

6.9 (1.4–33.9)

 Infliximab

1 (14.3%)

17 (13.3%)

0.940

1.08 (0.2–8.5)

 Tocilizumab

1 (14.3%)

3 (2.3%)

0.175

5.5 (0.8–35.4)

Methotrexate

5 (71.4%)

60 (46.9%)

0.200

2.7 (0.5–13.4)

 Mean dose

6.3 ± 2.5 mg/week

6.7 ± 1.9 mg/week

0.980

 

Corticosteroids

5 (71.4%)

47 (36.7%)

0.070

4.0 (0.8–19.8)

 Mean dose

3.4 ± 2.1 mg/day

5.2 ± 4.4 mg/day

0.380

 

Sulfasalazine

0

28 (21.9%)

0.067

 

Bucillamine

2 (28.6%)

25 (19.5%)

0.577

1.6 (0.3–7.8)

Tacrolimus hydrate

1 (14.3%)

8 (6.3%)

0.463

2.3 (0.3–17.3)

Sodium aurothiomalate

0

2 (1.6%)

0.643

 

Leflunomide

1 (2.2%)

2 (1.6%)

0.119

7.3 (1.2–43.5)

d-Penicillamine

0

2 (1.6%)

0.643

 

Actarit

0

1 (0.8%)

0.743

 

Auranofin

0

3 (2.3%)

0.570

 

Cyclosporine

0

1 (0.8%)

0.744

 

Minocycline hydrochloride

0

2 (1.6%)

0.643

 

Cyclophosphamide

0

1 (0.8%)

0.743

 

HR hazard ratio, 95% CI 95% confidence interval

aValues are given as the number of patients taking a drug; patients can take more than one drug and can switch to another biologic agent

Exploratory analysis was conducted on factors potentially associated with development of HBV replication (Table 6). Among resolved hepatitis B patients who did and did not develop reactivation of HBV DNA replication, a significant difference was noted between the use of biologic agent (85.7 vs. 36.0%, respectively; p = 0.008) and use of ETN (85.7 vs. 25.0%, respectively; p = 0.001). Cox regression hazard analysis also revealed use of a biologic agent and ETN as predictors for reactivation of HBV DNA replication. The hazard ratios (HR) for use of a biologic agent and ETN were 10.9 (p = 0.008) and 6.9 (p = 0.001), respectively. Age at presentation, RA duration, male gender, use of MTX and CS, dose of MTX and CS, and levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), immunoglobulin (Ig)G, neutrophil counts and lymphoid cell counts were not associated with reactivation of HBV DNA replication.

Discussion

HBV may persist in HBsAg-negative individuals after infection. HBsAg negativity may occasionally be due to the presence of mutant viruses missed by the commonly used HBsAg assays. In most other cases, negative results are due to suppressed viral replication and gene expression [20]. Such individuals are typically labeled as having occult HBV infection if HBV DNA is detectable in peripheral blood mononuclear cells and the liver [8].

The activity of chronic hepatitis B infection depends on host immune response to the virus; immunosuppressive therapy is known to alter this response [20, 21]. Acute reactivation of hepatitis B following immunosuppression has been observed in patients with resolved hepatitis B [13]. The timing of reactivation of HBV DNA replication may vary but occurs most frequently following cessation of immunosuppression or during chemotherapy. The median interval between initiation of chemotherapy and onset of reactivation is about 4 months (range 4–36 months) [22, 23]. Although HBV DNA and liver transaminase levels may rise at the same time, increasing HBV DNA levels tend to precede elevations of liver transaminases [23] by days or even weeks [11, 24]. HBV DNA levels may also already be declining when liver enzyme levels start rising [11]. Development of reactivation of hepatitis B appears to be a result of immune-mediated liver injury following restoration of host immune response [25].

A recent study investigated 244 HBsAg-negative lymphoma patients receiving cytotoxic chemotherapy [13]. Reactivation of hepatitis B developed following therapy in eight of these 244 patients (3.3%). They appeared to have a higher tendency to develop fulminant hepatic failure (3 of 8 patients, 37.5%). Direct DNA sequencing results confirmed that all eight patients showed reactivation of hepatitis B from resolved hepatitis B. These patients were initially HBsAg-negative, and HBsAb- and/or HBcAb-positive, and serum liver enzyme levels were not elevated. At the time of hepatitis B reactivation, these patients became HBsAg-positive. This was associated with a more than 100-fold increase in serum HBV DNA levels, which occurred before elevation of serum transaminases [13].

Management of patients with RA and HBV infection is a complex issue that deserves particular care and cooperation between different specialists. An unrecognized HBV infection may expose patients with rheumatic diseases to an increased risk of complications when receiving low doses of CS or long-term use of MTX. CS has been shown to have direct stimulatory effects on HBV replication in addition to indirect effects mediated via generalized suppression of the immune system [4].

TNF is a proinflammatory cytokine that plays a key role in host responses to several types of infection and other stimuli [26]. Various observations have strongly implicated TNF in the pathogenesis of RA and ankylosing spondylitis (AS), and increased TNF production propagates rheumatoid synovitis, promotes osteoclast formation, and results in characteristic bone and joint destruction [27]. TNFA has greatly affected the current treatment of RA and AS [28] but is associated with adverse reactions such as reactivation of tuberculosis [29]. The literature regarding the safety of TNFA with chronic viral infection remains limited. Several theories have been put forward regarding how TNF inhibitors might reactivate hepatitis B. Elevated levels of TNF are seen in both the serum and hepatocytes of patients with chronic hepatitis B [30] and are secreted by HBV-specific cytotoxic T lymphocytes (CTL) [31]. TNF has biological activity and an amino acid sequence similar to lymphotoxin, which inhibits HBV replication [32]. Infected cells are also reported to be selectively killed by TNF [33]. TNF acts to suppress HBV DNA replication by reducing intracellular HBV transcription [33]. Animal studies have shown that TNF-knockout mice have defects in the proliferative capacity of HBV-specific CTL [34], suggesting that TNF plays a role in clearing or controlling HBV [3436]. Moreover, HBV-specific CTL inhibit HBV gene expression by secreting antiviral cytokines such as interferon γ and TNF and inducing apoptosis in HBV-infected hepatocytes [37, 38].

To date, several case reports have shown that inhibition of TNF facilitates reactivation of HBV DNA replication and can cause fulminant hepatic failure or fatal outcomes [6, 3944]. According to the 2009 recommendations of the Japan College of Rheumatology, biologic agents are contraindicated in chronic hepatitis B only in active HBsAg carriers. However, as shown in our study, reactivation of HBV DNA replication can occur in resolved hepatitis B, and this finding supports the conclusion that careful monitoring should be used if patients with resolved hepatitis B are receiving TNFA, regardless of HBV DNA levels.

In our study, reactivation of HBV DNA replication was identified in RA patients under TCZ medication. TCZ might have influenced patient immune response to HBV, as interleukin (IL)-6 is a cytokine that has an important role in regulating immune responses, inflammation, and hematopoiesis [45]. IL-6 also induces T-cell proliferation and CTL differentiation and promotes antibody production by B cells. Host immune responses to viral antigens on infected hepatocytes represent the main cause of hepatocellular injury [35]. Furthermore, a significant correlation exists between serum IL-6 and aminotransferase levels in patients with chronic hepatitis B [46]. This suggests that IL-6 plays a role in chronic hepatitis B and may contribute to the elimination of HBV.

To the best of our knowledge, this study represents the first systematic analysis investigating the rate of reactivation of HBV DNA replication in a homogenous population of patients with resolved hepatitis B diagnosed with and treated for RA over the course of more than 1 year. This study demonstrated a high proportion of resolved hepatitis B patients in RA and an association between biologic agents and HBV DNA replication in RA patients with resolved HBV. With increasing use of biologic agents such as TNFA, anti-IL-6 receptor, anti-CD20 [47], and anti-CD28, reactivation of HBV DNA replication in patients who have resolved HBV will probably increase, particularly in endemic areas. Among patients who are scheduled to receive MTX, CS, and biologic agents, patients who are HBsAg-negative should be further screened for anti-HBc and anti-HBs.

The significantly higher prevalence of ETN among cases with HBV reactivation represents a source of bias, as ETN is the first biologic agent used for RA in our institutions. Further information from controlled trials is required with regard to the relative safety of various biologic agents, risk after cessation of immunosuppression when immune reconstitution may occur, and whether the risk of emergence of entecavir resistance in patients receiving prophylactic treatment is at a level that renders this approach unsafe. What effects biologic agent therapy will have on the risk of hepatic fibrosis, cirrhosis, and HCC in this high-risk group remains to be seen, as there is strong evidence of HBV itself being a direct cause of HCC [48]. Furthermore, reactivation of hepatitis B can be misdiagnosed as superimposition of another form of liver disease (e.g., drug-induced liver disease, alcoholic liver disease) occurring against a background of previously stable, resolved hepatitis B. Greater awareness is therefore needed regarding the reactivation of hepatitis B, when and where reactivation occurs, and how this phenomenon should be prevented or managed.

Conflict of interest

None.

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© Japan College of Rheumatology 2010