Hepatitis B and immunosuppressive therapies for chronic inflammatory diseases： When and how to apply prophylaxis,with a special focus on corticosteroid therapy

Currently immunosuppressive and biological agentsare used in a more extensive and earlier way inpatients with inflammatory bowel disease, rheumaticor dermatologic diseases. Although these drugs haveshown a significant clinical benefit, the safety of thesetreatments is a challenge. Hepatitis B virus （HBV）reactivations have been reported widely, even includingliver failure and death, and it represents a deep concernin these patients. Current guidelines recommend to preemptivetherapy in patients with immunosuppressantsin general, but preventive measures focused in patientswith corticosteroids and inflammatory diseases arescarce. Screening for HBV infection should be done atdiagnosis. The patients who test positive for hepatitisB surface antigen, but do not meet criteria for antiviraltreatment must receive prophylaxis before undergoingimmunosuppression, including corticosteroids at higherdoses than prednisone 20 mg/d during more than twoweeks. Tenofovir and entecavir are preferred thanlamivudine because of their better resistance profile inlong-term immunosuppressant treatments. There is nota strong evidence, to make a general recommendationon the necessity of prophylaxis therapy in patientswith inflammatory diseases that are taking low dosesof corticosteroids in short term basis or low systemicbioavailability corticosteroids such as budesonide orbeclomethasone dipropionate. In these cases regularlyHBV DNA monitoring is recommended, starting earlyantiviral therapy if DNA levels begin to rise. In patientswith occult or resolved hepatitis the risk of reactivationis much lower, and excepting for Rituximab treatment,the prophylaxis is not necessary.