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HBV testing rates remain low among patients with RA
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Despite gradual increases throughout the past decade, rates of hepatitis B virus testing among patients with rheumatoid arthritis remain low in both the United States and Taiwan, according to findings published in Arthritis Care and Research.
“There is general agreement that hepatitis B testing should be pursued,” Tzu-Chieh Lin, PhD, and Daniel H. Solomon, MD, MPH, both of Brigham and Women’s Hospital and Harvard Medical School, in Boston, told Healio Rheumatology. “However, there are several different guidelines from the CDC, the European Association for the Study of the Liver, and the American Association for the Study of Liver Diseases, that have slightly different recommendations.”
According to Lin and Solomon, the American College of Rheumatology treatment guideline for RA have drawn criticism for not emphasizing hepatitis B virus (HBV) testing.”
“Therefore, it is crucial to update current practice patterns of HBV testing in RA patients, both in nonendemic and endemic regions, to facilitate more specific guideline recommendations,” Lin and Solomon noted.
To analyze the patterns of HBV testing among patients with RA in both the United States and Taiwan, the researchers conducted a retrospective cohort study including 14,568 U.S. patients and 46,265 patients in Taiwan. In both countries, the participants had started treatment with disease-modifying antirheumatic drugs (DMARDs).
The researchers defined baseline as the 1-year period before the first day of any DMARD treatment. They defined HBV testing as any of the following within 1 year before or after the first day of DMARD treatment: hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody, hepatitis B envelope antigen, hepatitis B envelope antibody or HBV DNA. They then calculated the HBV testing rate by year, and used Poisson regression to calculate the testing rate ratio.
According to the researchers, there were only small differences in the HBV testing rates across both populations. The overall testing rate among patients with RA in the United States was 20.3%, and 24.5% among those in Taiwan. However, these figures gradually increased during the study period, from 13.1% to 23% in the United States, and from 16.8% to 30% in Taiwan.
In the United States, 43.4% of patients with RA received more than one type of HBV test, as did 16.3% of patients in Taiwan. Following Poisson regression, the researchers found that the patients in Taiwan had a 17% higher testing rate compared with the U.S. patients during the follow-up period (RR = 1.17; 95% CI, 1.12–1.22).
“We found the HBV testing rates were low in the U.S. as well as in Taiwan,” Lin and Solomon said. “The uncertainty of universal or risk-based testing strategies may be one of the reasons for nonspecific ACR recommendations, leading to low testing rates. Risk-based testing may not be effective in typical practice if risk factors are not easily defined by providers. Future updates from RA guideline as well as quality improvement interventions and aimed at endemic and nonendemic regions should be considered.” – by Jason Laday
Disclosure: Lin reports no relevant financial disclosures. Solomon reports research support from Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lily, Pfizer, and Genentech. See the full study for additional authors’ disclosures.
Perspective
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Elizabeth Kirchner, CNP, RN-BC
The study by Lin and colleagues is just one more reminder that rheumatology practitioners are missing an opportunity to protect patients. The 2015 ACR guidelines for screening patients prior to starting biologic and non-biologic DMARDs have, as the Healio authors point out, met with criticism for being in discordance with black box warnings and obvious best practices. The risk of HBV reactivation is real: With rituximab and prednisone at doses of 20 mg per day or higher the risk is >10%, whereas, with anti-TNFs and cytokine inhibitors the risk is 1-10%.
Patients with autoimmune inflammatory diseases are getting better treatment and having better outcomes thanks to the advances made in our field. However, we have to do a better job of actively finding our patients who are at risk for hepatitis B reactivation before we begin treatment. Worldwide, 240 million people are chronically infected with hepatitis B — it is not difficult to imagine that some of them are going to be walking through our doors, unaware of their HBV status. We must use Lin’s study as a wakeup call to provide patients with the protection they deserve.
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