Should a patient with no immunity to hepatitis B (HBV) and negative results for hepatitis C virus (HCV) and human immunodeficiency virus (HIV) receive hepatitis B vaccination before starting Adalimumab (adalimumab) for psoriasis treatment?

Hepatitis B Vaccination Before Starting Adalimumab for Psoriasis

Yes, this patient should receive hepatitis B vaccination before starting adalimumab, with the first vaccine dose administered immediately and adalimumab initiation delayed until at least the vaccination series is underway, ideally with documented immune response.

Rationale for Pre-Treatment Vaccination

Risk of HBV Reactivation with TNF-α Inhibitors

• TNF-α inhibitors like adalimumab carry significant risk for hepatitis B reactivation in patients with chronic HBV infection, including fatal cases reported with infliximab 1
• While this patient is HBsAg-negative, the lack of immunity (negative anti-HBs) places them at risk for de novo HBV infection during immunosuppression 1
• Adalimumab-induced immunosuppression increases vulnerability to new HBV acquisition and potentially more severe acute infection 2

Vaccination Timing and Protocol

Immediate vaccination is recommended:

• The first hepatitis B vaccine dose should be administered immediately, even before completing the full series 2
• The standard 3-dose series should be given at 0,1, and 6 months 2
• Vaccination of persons who lack immunity is not harmful and does not increase adverse events 2

Optimal timing before adalimumab initiation:

• Ideally, complete the vaccination series and confirm protective antibody response (anti-HBs ≥10 mIU/mL) before starting adalimumab 2
• If clinical urgency requires earlier adalimumab initiation, begin vaccination immediately and start adalimumab after at least the first 1-2 doses of HBV vaccine 2
• Postvaccination serologic testing should be performed 1-2 months after the final vaccine dose, as this patient will be immunocompromised and requires documentation of immunity 2

Clinical Management Algorithm

Step 1: Immediate Vaccination

• Administer first dose of hepatitis B vaccine immediately 2
• Do not delay vaccination while awaiting any additional testing 2

Step 2: Complete Vaccination Series

• Continue with doses at 1 month and 6 months 2
• If psoriasis severity requires earlier biologic initiation, adalimumab can be started after the second vaccine dose, though this is suboptimal 2

Step 3: Confirm Immune Response

• Test anti-HBs levels 1-2 months after the third vaccine dose 2
• Protective level is anti-HBs ≥10 mIU/mL 2, 3
• This testing is essential because the patient will be on immunosuppressive therapy 2

Step 4: Manage Non-Responders

• If anti-HBs <10 mIU/mL after primary series, administer a second complete 3-dose series 2
• Retest 1-2 months after completing the second series 2
• Persistent non-responders should be counseled about HBV exposure risks and may require HBIG for post-exposure prophylaxis 2

Important Caveats and Pitfalls

Common Errors to Avoid

• Do not start adalimumab without initiating HBV vaccination - this leaves the patient vulnerable to new HBV infection during immunosuppression 2, 1
• Do not assume immunity without serologic confirmation - documentation of protective antibody levels is essential for patients starting immunosuppressive therapy 2, 3
• Do not skip postvaccination testing - unlike routine vaccination, patients starting biologics require confirmed immunity 2

Special Considerations for TNF-α Inhibitors

• All TNF-α antagonists carry warnings about infections, and screening for hepatitis B is essential before therapy 2, 1
• Infliximab has been associated with more HBV reactivation cases than adalimumab or etanercept, though all carry risk 1
• Even patients with isolated positive hepatitis B core antibody (anti-HBc) can experience reactivation, though this patient is completely negative 1, 4

Vaccine Response Considerations

• Immunocompetent persons who achieve anti-HBs ≥10 mIU/mL have long-term protection and do not need periodic retesting 2, 3
• However, if the patient starts adalimumab before completing vaccination, immune response may be blunted, making completion of the series before biologic initiation preferable 2

Clinical Context

While the 2011 AAD psoriasis guidelines mention screening for infections before TNF-α antagonist therapy 2, and the 2009 British guidelines discuss adalimumab efficacy 2, neither specifically addresses vaccination timing for non-immune patients. The 2025 hidradenitis suppurativa guidelines emphasize that all patients should be screened for hepatitis B before starting immunosuppressants or biologics 2, and the CDC guidelines clearly support vaccination of immunocompromised persons with documentation of response 2.

The safest approach is to complete HBV vaccination and confirm immunity before adalimumab initiation, though if disease severity is urgent, vaccination should begin immediately with adalimumab started after at least 1-2 vaccine doses.