title: Safety of Corticosteroid Treatment in Rheumatologic Patients With Markers of Hepatitis B Viral Infection: Pilot Evaluation Study.
abstract: BACKGROUND
  Immunosuppressive agents may induce hepatitis B flares. The minimal corticosteroid dose and duration of therapy leading to HBV reactivation is unknown.
  
  
  OBJECTIVE
  To assess whether short-term corticosteroid therapy for rheumatologic diseases induces HBV reactivation.
  
  
  METHODS
  The records of all HBsAg or HBcore antibodies positive, anti-HBs negative patients who were hospitalized in the rheumatology department during 2001-2014 and treated with corticosteroids were reviewed. Alanine aminotransferase (ALT), HBV serology, and serum HBV DNA at baseline and 1-3 months after discharge were recorded.
  
  
  RESULTS
  Complete data were found for 23 patients who were hospitalized 73 times for 7 days of treatment with IV corticosteroids. Eighteen patients were HBsAg positive. The mean methylprednisolone dose was 33.9 ± 24 mg/d. The concomitant therapy included DMARDs (15), low-dose corticosteroids (8), and biologicals (10). Serum HBV DNA was detected at baseline in seven patients. Three HBsAg-positive patients treated with cyclophosphamide had HBV hepatitis flare-up with elevated ALT. Two HBsAg-positive patients had reappearance of HBV DNA in serum after treatment with azathioprine and infliximab, respectively, but the ALT levels remained normal. Lamivudine therapy reduced the serum HBV DNA and improved ALT levels in all patients. Corticosteroid therapy by itself did not trigger exacerbation of HBV hepatitis. No HBV reactivation occurred in lamivudine-treated patients after recurrent exposure to biologicals or cyclophosphamide.
  
  
  CONCLUSIONS
  Short episodes of corticosteroids seem to be safe in HBV carriers, even in the presence of DMARDs, but lamivudine prophylaxis should be considered for patients exposed to biologicals or cyclophosphamide. Larger prospective trials are needed to establish guidelines.
authors.affiliation: From the *B. Shine Rheumatology Unit, Rambam Health Care Campus, B. Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa; †Liver Institute, Beilinson Hospital, Petah Tikva; and ‡Liver Unit, Rambam Health Care Campus, Haifa, Israel.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Braun-Moscovici
authors.forename: Marius
authors.initials: M
authors.lastname: Braun
authors.forename: Tarek
authors.initials: T
authors.lastname: Saadi
authors.forename: Doron
authors.initials: D
authors.lastname: Markovits
authors.forename: Menahem A
authors.initials: MA
authors.lastname: Nahir
authors.forename: Alexandra
authors.initials: A
authors.lastname: Balbir-Gurman
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000410:Alanine Transaminase / Q000097:blood*; D018501:Antirheumatic Agents / Q000627:therapeutic use; D001379:Azathioprine / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use; D004279:DNA, Viral / Q000097:blood; D005260:Female; D006514:Hepatitis B Surface Antigens / Q000097:blood; D019694:Hepatitis B, Chronic / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D000069285:Infliximab / Q000627:therapeutic use; D019259:Lamivudine / Q000627:therapeutic use; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use*; D008875:Middle Aged; D010865:Pilot Projects; D012216:Rheumatic Diseases / Q000188:drug therapy*
chemical_list: D000305:Adrenal Cortex Hormones; D018501:Antirheumatic Agents; D004279:DNA, Viral; D006514:Hepatitis B Surface Antigens; D007166:Immunosuppressive Agents; D019259:Lamivudine; D003520:Cyclophosphamide; D000069285:Infliximab; D000410:Alanine Transaminase; D001379:Azathioprine; D008775:Methylprednisolone