Should we check for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) before starting high-dose steroid therapy?

Screening for HBV and HCV Before Starting High-Dose Steroid Therapy

Yes, screening for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) should be performed before starting high-dose steroid therapy due to the significant risk of viral reactivation that can lead to severe hepatitis, liver failure, and death. 1

Rationale for Screening

• High-dose steroid therapy (≥20 mg prednisone or equivalent) can cause reactivation of HBV in both active carriers (HBsAg-positive) and those with past/resolved infection (HBsAg-negative, anti-HBc-positive) 1
• Even low-dose steroid therapy (2.5 mg/day) has been reported to cause fatal HBV reactivation in previously inactive HBV carriers 2
• HCV reactivation, though less common than HBV reactivation, can also occur during steroid therapy 3
• The American Gastroenterological Association (AGA) strongly recommends testing for hepatitis B in all individuals at potential risk of HBV reactivation 1

Recommended Screening Tests

• Initial screening should include at minimum HBsAg and anti-HBc 1, 4
• A comprehensive screening panel should include:
  • HBsAg (to detect active infection)
  • Anti-HBc (to detect previous or ongoing infection)
  • Anti-HBs (to indicate immunity due to vaccination or resolved infection) 4
• For HCV, screening should include anti-HCV antibody testing 1
• If HBsAg and/or anti-HBc is positive, HBV DNA testing should be performed 1

Risk Stratification and Management

For HBV:

1. HBsAg-positive patients (active HBV infection):

   • High risk of reactivation with high-dose steroids (≥20 mg prednisone)
   • Prophylactic antiviral therapy is strongly recommended before starting steroid therapy 1
   • Preferred antivirals: entecavir, tenofovir DF, or tenofovir AF 1

2. HBsAg-negative, anti-HBc-positive patients (past HBV infection):

   • Moderate risk of reactivation with high-dose steroids
   • Consider monitoring ALT, HBsAg, and HBV DNA every 3-6 months during therapy 1
   • Start antiviral therapy if reactivation occurs 1
   • Time-weighted average prednisone dose >20 mg/day is associated with high risk of reactivation (HR 49.48) 5

For HCV:

• If HCV RNA is detectable, consider antiviral treatment for HCV before starting immunosuppressive therapy 1
• Monitor ALT during steroid therapy in patients with HCV 1
• Coordinate care with a hepatologist for patients with active HCV infection 1

Duration of Antiviral Prophylaxis

• Continue antiviral prophylaxis throughout steroid therapy and for at least 12 months after discontinuation of immunosuppression 1
• Longer duration may be needed for patients receiving rituximab or other B-cell depleting therapies 1

Common Pitfalls to Avoid

• Failing to screen for both HBV and HCV before starting steroid therapy 1
• Underestimating the risk of reactivation with "low-dose" steroids - even doses as low as 2.5 mg/day can cause reactivation 2
• Not monitoring liver enzymes during steroid therapy in at-risk patients 1
• Discontinuing antiviral prophylaxis too early after stopping steroid therapy 1
• Not considering the additive risk when multiple immunosuppressive agents are used concurrently 6

By implementing proper screening and prophylaxis strategies, the risk of viral hepatitis reactivation and its potentially fatal consequences can be significantly reduced in patients requiring high-dose steroid therapy.