Is secukinumab (secukinumab) contraindicated in a cancer patient with chronic hepatitis B (HBV) on nivolumab (nivolumab) with a severe psoriasis flare?

Chronic Hepatitis B is NOT an Absolute Contraindication for Secukinumab

Secukinumab can be used in patients with chronic hepatitis B, including those on nivolumab with severe psoriasis, but requires mandatory hepatitis B screening, risk stratification, antiviral prophylaxis for HBsAg-positive patients, and close monitoring for viral reactivation. 1

Risk Stratification and Management Algorithm

Pre-Treatment Assessment Required

• Screen all patients with hepatitis B surface antigen (HBsAg), anti-HBs antibody, anti-HBc antibody, and baseline HBV-DNA PCR before initiating secukinumab 1
• Obtain baseline liver function tests (complete metabolic panel) 1
• Consult with hepatology or infectious disease specialist for patients with active or chronic HBV infection 1

Treatment Decisions Based on HBV Status

For HBsAg-Positive Patients (Chronic Active HBV):

• Initiate antiviral prophylaxis (entecavir or tenofovir) before starting secukinumab 2, 3
• This represents a relative contraindication requiring specialist management, not an absolute contraindication 1
• HBV reactivation risk is 24% without prophylaxis but 0% with prophylaxis 3
• Continue antiviral therapy throughout secukinumab treatment 2, 3

For HBsAg-Negative/Anti-HBc-Positive Patients (Resolved or Occult HBV):

• Reactivation risk is lower (4.17%) but still present 3
• Monitor HBV-DNA PCR every 3 months without mandatory prophylaxis 2, 4
• Consider prophylaxis if additional immunosuppression (like nivolumab) is present 2, 3

For Patients with Resolved HBV Infection (Anti-HBc positive only):

• Do not require specialist follow-up but need monitoring for reactivation risk 1
• Serial HBV-DNA PCR monitoring every 3 months is essential 4, 5

Secukinumab-Specific Safety Profile in HBV

The evidence strongly supports secukinumab's favorable safety profile compared to other biologics:

• Real-world data from 60 patients showed only 1/60 (1.7%) hepatitis reactivation over 53.5 weeks, occurring in a patient who did not receive prophylaxis 2
• Secukinumab carries no increased risk for reactivation of hepatitis B compared to TNF-α inhibitors, which have higher reactivation rates 6
• In a Chinese cohort of 20 patients (including chronic inactive, occult, and resolved HBV), no viral reactivation occurred over 24 weeks with appropriate monitoring 5
• IL-17 inhibitors like secukinumab are less likely to cause hepatitis reactivation than anti-TNF therapies 2, 6

Ongoing Monitoring Protocol

• HBV-DNA PCR testing every 3 months during secukinumab therapy 2, 4, 5
• Liver function tests (ALT, AST) every 3 months 5, 3
• Monitor for clinical signs of hepatitis (fatigue, jaundice, right upper quadrant pain) 5, 3
• HBsAg can remain negative even with viral reactivation, making HBV-DNA PCR essential 4, 3

Critical Pitfalls to Avoid

• Never start secukinumab in HBsAg-positive patients without antiviral prophylaxis - this increases reactivation risk from 0% to 24% 3
• Do not rely solely on HBsAg testing - reactivation can occur with negative HBsAg but positive HBV-DNA PCR 4, 3
• Avoid skipping the 3-month monitoring intervals - early detection of viral reactivation allows prompt antiviral intervention 2, 4, 5
• Do not assume resolved HBV infection is risk-free - these patients still require HBV-DNA monitoring as reactivation can occur 1, 4, 5

Special Consideration for Cancer Patients on Nivolumab

While the guidelines do not specifically address the combination of secukinumab with checkpoint inhibitors like nivolumab, the general principle applies: multiple immunosuppressive agents increase infection and reactivation risk 2, 3. In this high-risk scenario:

• Mandatory hepatology consultation before initiating secukinumab 1
• Consider prophylactic antiviral therapy even for HBsAg-negative/anti-HBc-positive patients 3
• Intensify monitoring frequency if clinically indicated 5, 3