Screening for hepatitis B virus prior to initiating tocilizumab and tofacitinib in patients with rheumatologic diseases: a cross-sectional study.

Objective Hepatitis B virus (HBV) can reactivate among rheumatology patients initiating tocilizumab or tofacitinib. HBV screening is recommended by the Centers for Disease Control and Prevention (CDC), the American Association for the Study of Liver Diseases (AASLD), and the Canadian Rheumatology Association but is not explicitly recommended by the American College of Rheumatology. Methods We conducted a cross-sectional study to characterize HBV screening practices for adult rheumatology patients initiating tocilizumab or tofacitinib before December 31, 2018, in the Greater Boston area. We classified appropriate HBV screening patterns prior to tocilizumab or tofacitinib (i.e., HBV surface antigen [HBsAg], total core antibody [anti- HBcAb], and surface antibody [HBsAb]) as: complete (all 3 tested), partial (any 1 or 2 tests), or none. We determined the frequency of inappropriate HBV testing (HBeAg, anti-HBcAb IgM, or HBV DNA without a positive HBsAg or total anti-HBcAb) and used multivariable regression to assess factors associated with complete HBV screening. Results Among 678 subjects initiating tocilizumab, 194 (29%) completed appropriate HBV screening, 307 (45%) had partial screening, and 177 (26%) had none. Among 391 subjects initiating tofacitinib, 94 (24%) completed appropriate HBV screening, 195 (50%) had partial screening, and 102 (26%) had none. Inappropriate testing was performed in 22% of subjects. Race was associated with complete HBV screening (white versus non-white, OR 0.74; 95%CI: 0.57-0.95) while prior immunosuppression was not (csDMARDs, OR 1.05, 95%CI: 0.72-1.55; bDMARDs, OR 0.73, 95%CI: 0.48- 1.12). Conclusion Patients initiating tocilizumab or tofacitinib are infrequently screened for HBV despite recommendations from AASLD and CDC.