HBV Reactivation: Are Your Immunosuppressants to Blame?
"A new study highlights the risk of Hepatitis B virus reactivation in patients undergoing immunosuppressant therapy."
For individuals managing chronic conditions such as psoriasis and rheumatoid arthritis, immunosuppressant medications like adalimumab, infliximab, prednisone, and ustekinumab offer a beacon of hope. These drugs work by suppressing the immune system, reducing inflammation, and alleviating debilitating symptoms. However, this immune suppression can sometimes lead to unintended consequences, such as the reactivation of dormant viruses.
A recent study published in the Turkish Journal of Gastroenterology sheds light on a concerning trend: Hepatitis B virus (HBV) reactivation in patients undergoing immunosuppressant therapy. The study, conducted in December 2017, examined five cases where patients developed HBV reactivation following the administration of these commonly prescribed medications. This raises critical questions about patient safety and the need for vigilant monitoring.
Understanding the link between immunosuppressants and HBV reactivation is crucial for both patients and healthcare providers. This article delves into the findings of the study, explores the underlying mechanisms, and provides practical guidance on how to mitigate the risk of HBV reactivation while effectively managing chronic inflammatory conditions.
Measuring HBV Reactivation
A study retrospectively collected data from 2014 to 2022 on patients with resolved HBV infection receiving immunosuppressants. It compared reactivation rates among patients receiving rituximab and non-rituximab therapies and used logistic regression to identify risk factors. The supplied study summary does not report the rates or specific risk factors, while a separate review emphasizes that timely management is important to prevent fatalities.
Prevention and Guidance
The American Gastroenterological Association updated its recommendations for preventing and managing HBV reactivation in January 2025, addressing the growing number of patients receiving immunosuppressive drugs. A 2022 systematic review and meta-analysis examined reactivation risk with newer immunosuppressive and immunomodulatory therapies and developed guidance on nucleos(t)ide analogue (NA) prophylaxis. Its summary states that HBV reactivation can be prevented with NAs; the supplied material does not specify limitations of these approaches.
A Growing At-Risk Population
A February 2019 review described increasing use of chemotherapy and potent immunosuppressants in patients with neoplastic conditions and in non-neoplastic care across specialties. It linked this growing use to an expanding population at risk of HBV reactivation. The supplied source does not identify a specific discovery or milestone, but highlights this shift in treatment exposure as relevant context.
The Study: Unveiling the Link Between Immunosuppressants and HBV Reactivation
The study focused on five patients who had a history of HBV infection and were being treated for either psoriasis or rheumatoid arthritis. Among these patients, four had psoriasis, and one had rheumatoid arthritis. The medications they were receiving included:
- Adalimumab (3 patients)
- Ustekinumab (1 patient)
- Infliximab and prednisone 4 mg/day (1 patient)
Therapies Linked to Reactivation
The APASL clinical practice guideline reports HBV reactivation with immunosuppressive therapy in solid organ transplantation and with traditional chemotherapy, including trans-arterial chemo-embolisation for hepatocellular carcinoma. It also describes reports involving newer tyrosine kinase inhibitors, tumor necrosis factor antagonists, and proteasome inhibitors used for malignancies and autoimmune diseases. A 2024 review focuses on biologics linked to reactivation risk, emphasizing newer immunosuppressive and immunomodulator therapies.
Limits of the Evidence
A systematic review and meta-analysis of biological therapies in patients with psoriasis and HBV, HCV, or HIV said that viral reactivation might occur, but characterized the evidence as potentially weak and noted limitations. A separate meta-analysis in rheumatoid arthritis patients who were HBsAg-negative and HBcAb-positive reported highly variable incidence in the literature. It nevertheless described a possible risk of HBV reactivation with biologic or targeted synthetic DMARD treatment in this group.
Rates Across Different Cohorts
A systematic review and meta-analysis reported a pooled HBV reactivation rate of 1.8% (95% CI 0.0–5.6%) among patients with psoriasis and hepatitis B treated with biological agents. In a prospective study of rheumatoid arthritis patients receiving immunosuppressive therapy, reactivation occurred in 2 of 5 HBsAg-positive patients and 1 of 45 patients without HBsAg. These figures come from different diseases and study designs, so they describe their respective cohorts rather than a direct comparison.
Staying Informed and Proactive About HBV Reactivation
The possibility of HBV reactivation during immunosuppressant therapy may be unnerving, but it is critical to remain proactive and well-informed. Consistent communication with healthcare providers, routine monitoring, and immediate management of any concerning symptoms are necessary. You can properly manage your chronic illness while minimizing the risk of HBV reactivation with constant attention. As research develops and medical procedures advance, people will be able to live longer, healthier lives while receiving the care they require.
Risk Beyond Fixed Categories
A July 2026 editorial discusses new real-world evidence on HBV reactivation during immunosuppressive therapy. It notes that current guidelines classify patients into high-, moderate-, and low-risk categories. The editorial suggests that reactivation risk may be more dynamic than those categories imply; the supplied summary gives no specific data or revised classification.