P061  Prophylaxis of hepatitis B reactivation and inflammatory bowel disease: a case report.

P061  Prophylaxis of hepatitis B reactivation and inflammatory bowel disease: a case report.

Basílio Fabiana1, Amorim Cesar1, Carvalho Márcio1, Martins Carolina1, Fonseca Isabel1, Breves Joana1, Zaltman Cyrla1
1 Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

BACKGROUND: The risk of opportunistic infections is increasing with the progressive use of immunosuppressants and biological therapy in IBD treatment. In this scenario, screening for hepatitis B vírus (HBV) is important in order to prevent viral reactivation.
 

METHODS: CASE REPORT: A 48 year old female with longstanding ulcerative proctitis (diagnosed in 2008) using mesalazine 3g /day presented with three bowel movements a day with mucus and blood,  diffuse abdominal pain, tenesmus, and urgent evacuation. Laboratory tests showed leukocytosis without left shift, normal platelets and liver tests. Flexible sigmoidoscopy showed a severe disease activity (Mayo score 3) in the rectum and sigmoid. The patient was admitted to our hospital and received IV corticosteroids without response and was then started Azathioprine and Infliximab. HBsAg and anti-HBc Ag were positive at admission. HBV DNA was detected (225 IU / ml -low). Other labs were consistent with chronic hepatitis B (Anti-HBeAg positive, HBe-Ag negative, Anti-HBsAg positive). Abdominal elastography and ultrasound were normal. Considering the serological profile and the use of high-dose corticosteroids, infliximab, and azathioprine, Entecavir 0.5 mg / day was initiated.

RESULTS: HBV produces stable cccDNA mini-chromosome in infected hepatocytes, that can be present even after the loss of the HBs antigen and seroconversion to anti-HBs. cccDNA serves as a matrix for reactivation even in patients with a remote history of hepatitis B. This fact explains the impossibility of HBV infection eradication. Viral reactivation in chronic inactive patients is defined as a 2 log increase in HBV-DNA. The use of prophylaxis must be based on the patient's serological profile and the risk of drugs used and their potential for viral reactivation (table 1). Higher doses than 20 mg / day of prednisone for 4 weeks or more are considered of moderate risk but the use of immunosuppressants or biological therapy increase this risk (high risk). Azathioprine monotherapy is not associated with viral reactivation, unlike what occurs with the sole use of infliximab.  Antiviral prophylaxis should be done with nucleotide analogues (NAs) with high potency (Entecavir, Tenofovir Disoproxil Fumarate or Tenofovir Alafenamide). Lamivudine and other NAs are not recommended because of the risk of selection of resistant strains, but it can be used if it is the only option. Prophylaxis should be maintained for 6 to 12 months after the suspension of the immunobiological agent. Pre-emptive therapy with an antiviral can be performed in moderate risk patients with easy access to serial viral load dosage, transaminases and serology. 
 

CONCLUSION(S): Screening for HBV infection should be a routine in IBD patients mainly at diagnosis, as HBV reactivation can occur in the context of immunosuppressive therapy. As this risk depends on host factors, virological factors, and type and degree of immunosuppression, therapeutic / prophylactic strategies must be individualized.