Management of psoriasis patients with hepatitis B or hepatitis C virus infection

The systemic therapies available for the management of Psoriasis (PsO) patients who cannot be treated with more conservative options, such as topical agents and/or phototherapy, with the exception of acitretin, can worsen or reactivate a chronic infection. Therefore, before administering immunosuppressive therapies with either conventional disease-modifying drugs (cDMARDs) or biological ones (bDMARDs) it is mandatory to screen patients for some infections, including hepatitis B virus (HBV) and hepatitis C virus (HCV). In particular, the patients eligible to receive an immunosuppressive drug must be screened for the following markers: antibody to hepatitis B core, antibody to hepatitis B surface antigen (anti-HBsAg), HBsAg, and antibody to HCV (anti-HCV). In case HBV or HCV infection is diagnosed, a close collaboration with a consultant hepatologist is needed before and during an immunosuppressive therapy. Concerning therapy with immunosuppressive drugs in PsO patients with HBV or HCV infection, data exist mainly for cyclosporine a (CyA) or bDMARDs (etanercept, adalimumab, infliximab, ustekinumab). The natural history of HBV and HCV infection differs significantly as well as the effect of immunosuppression on the aforementioned infectious diseases. As a rule, in the case of active HBV infection, systemic immunosuppressive antipsoriatic therapies must be deferred until the infection is controlled with an adequate antiviral treatment. Inactive carriers need to receive antiviral prophylaxis 2-4 wk before starting immunosuppressive therapy, to be continued after 6-12 mo from its suspension. Due to the risk of HBV reactivation, these patients should be monitored monthly for the first 3 mo and then every 3 mo for HBV DNA load together with transaminases levels. Concerning the patients who are occult HBV carriers, the risk of HBV reactivation is very low. Therefore, these patients generally do not need antiviral prophylaxis and the sera HBsAg and transaminases dosing can be monitored every 3 mo. Concerning PsO patients with chronic HCV infection their management with immunosuppressive drugs is less problematic as compared to those infected by HBV. In fact, HCV reactivation is an extremely rare event after administration of drugs such as CyA or tumor necrosis factor-α inhibitors. As a rule, these patients can be monitored measuring HCV RNA load, and ALT, aspartate transaminase, gamma-glutamyl-transferase, bilirubin, alkaline phosphatase, albumin and platelet every 3-6 mo. The present article provides an updated overview based on more recently reported data on monitoring and managing PsO patients who need systemic antipsoriatic treatment and have HBV or HCV infection as comorbidity.

Efficacy,safety,and cost-effectiveness of triple therapy in preventing relapse in rheumatoid arthritis:A randomized controlled trial(ESCoRT study)

Background:Biological agents,such as tumor necrosis factor inhibitors(TNFi),have been widely used in rheumatoid arthritis(RA)patients and greatly improved goal achievement.The aim of this study was to investigate whether conventional synthetic diseasemodifying anti-rheumatic drugs(csDMARDs)combination was better in reducing relapse than methotrexate(MTX)monotherapy,and more cost-effective than continuing TNFi plus MTX in RA patients who achieved low disease activity(LDA)with TNFi and MTX therapy.Methods:RA patients who failed to csDMARDs received an induction therapy of MTX plus TNFi for maximally 12 weeks.Those achieving LDA in 12 weeks were randomly assigned at a 1:1:1 ratio into three groups:(A)adding hydroxychloroquine and sulfasalazine for the first 12 weeks and then discontinuing TNFi for the following 48 weeks;(B)maintaining TNFi and MTX for 60 weeks;and(C)maintaining TNFi and MTX for the first 12 weeks and then discontinuing TNFi for the following 48 weeks.The primary outcome was relapse.Results:A total of 117 patients were enrolled for induction therapy and 67 patients who achieved LDA within 12 weeks were randomized,with 24,21,and 22 patients in groups A,B,and C,respectively.The relapse rates of groups A and B during the entire 60 weeks were comparable[10/22(45.5%)vs.7/20(35.0%),χ^(2)=0.475,P=0.491],however,significantly lower than that of group C[10/22(45.5%)vs.17/20(85.0%),χ^(2)=5.517,P=0.019;7/20(35.0%)vs.17/20(85.0%),χ^(2)=11.035,P=0.004,respectively].Taking RMB 100,000 Yuan as the threshold of willingness to pay,compared to MTX monotherapy(group C),both TNFi maintenance and triple csDMARDs therapies were cost-effective,but triple csDMARDs therapy was better.Conclusion:For RA patients who have achieved LDA with TNFi and MTX,csDMARDs triple therapy was a cost-effective option in favor of reducing relapse.Trial registration:ClinicalTrials.gov,NCT02320630.