Reactivation of hepatitis B virus (HBV) and de novo HBV
hepatitis in patients with
rheumatic diseases given intensive and long-term immunosuppressive therapy with or without biological
disease-modifying antirheumatic drugs is of great concern, especially in regions where the virus is endemic, including Japan. To ascertain a better benefit-risk balance for immunosuppressive therapy for patients with
rheumatic diseases, the Japan College of Rheumatology developed this proposal. All patients with
rheumatic diseases commencing immunosuppressive therapy should be screened for
hepatitis B surface antigen (
HBsAg); those who are negative for
HBsAg should be screened for
hepatitis B core antibody (HBcAb) and
hepatitis B surface antibody (HBsAb) as well. HBV carriers and serum HBV
DNA positive patients with resolved
infection should receive
nucleoside analog as soon as possible, prior to commencing immunosuppressive therapy. For serum HBV
DNA negative patients with resolved
infection, careful monthly monitoring using serum levels of
aspartate and
alanine aminotransferases and HBV
DNA is recommended during and at least 12 months after withdrawal of immunosuppressive therapy. If serum HBV
DNA becomes positive, patients should receive
nucleoside analog treatment as soon as possible, while ongoing immunosuppressive therapy should be continued to avoid severe or
fulminant hepatitis development. To facilitate proper management of patients with HBV
infection, collaboration between rheumatologists and hepatologists is strongly encouraged.