Is viral hepatitis screening and HIV (Human Immunodeficiency Virus) antigen/antibody combo testing indicated before initiating infliximab (chimeric monoclonal antibody against tumor necrosis factor alpha) therapy?

From the Guidelines

Yes, hepatitis viral screening and HIV Ag/Ab combo testing are indicated before starting infliximab therapy. Prior to initiating infliximab, patients should be screened for hepatitis B virus (HBV) infection with hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs) as recommended by the most recent guidelines 1. Hepatitis C virus (HCV) antibody testing is also recommended. Additionally, HIV Ag/Ab combo testing should be performed as part of the pre-treatment screening.

These screenings are essential because infliximab, as a TNF-alpha inhibitor, can cause reactivation of latent viral infections, particularly hepatitis B, which may lead to fulminant hepatitis, liver failure, or death. For patients who test positive for hepatitis B surface antigen, antiviral prophylaxis should be considered before starting infliximab and continued for several months after discontinuation, as suggested by recent studies 1. Similarly, patients with evidence of hepatitis C or HIV should be managed in consultation with specialists in these conditions. The immunosuppressive effects of infliximab can worsen these viral infections or lead to complications if they are not properly identified and managed before treatment initiation.

Key points to consider:

• Screening for HBV infection with HBsAg, anti-HBc, and anti-HBs is crucial before starting infliximab therapy 1.
• HCV antibody testing should also be performed as part of the pre-treatment screening.
• HIV Ag/Ab combo testing is recommended to identify patients with HIV infection.
• Antiviral prophylaxis should be considered for patients with positive HBsAg results before starting infliximab and continued for several months after discontinuation 1.
• Patients with evidence of hepatitis C or HIV should be managed in consultation with specialists in these conditions.

From the Research

Hepatitis and HIV Screening before Infliximab Treatment

• Hepatitis screening is indicated before starting infliximab treatment, as infliximab has been associated with reactivation of latent hepatitis B virus (HBV) infection 2, 3, 4, 5, 6.
• HIV Ag/Ab Combo screening is also recommended before initiating anti-TNF-alpha treatment, including infliximab, as part of the overall screening for viral infections 6.
• The screening should include a history of previous viral infections, laboratory tests such as hepatitis B test and HIV test, and physical examination 6.

Risk of Reactivation and Prophylaxis

• Patients with a positive HBsAg prior to starting infliximab therapy are at risk of HBV reactivation, and prophylactic antiviral therapy is recommended 2, 3, 4.
• Antiviral treatment is mandatory for HBsAg-positive patients at the start of anti-TNF-alpha treatment, including infliximab 4, 6.
• HBsAg-negative antibody to hepatitis B core antigen (anti-HBc) seropositive patients require watchful monitoring only 4.

Pre-Treatment Evaluation and Vaccinations

• A careful medical history, Mantoux test/quantiferon-TB Gold In-tube Test, and chest-X-ray should always be performed before starting infliximab treatment 5, 6.
• Appropriate vaccinations for influenza, S. pneumoniae, and HBV should be administered to decrease the risk of infection 5, 6.
• Patients who are at high risk of herpes zoster reactivation would benefit from a second vaccination in adulthood 5, 6.