Introduction: The aim of this study was to ascertain the outcomes of chronic hepatitis B (CHB) infection following immunosuppressive therapy in 38 consecutive oriental patients with systemic rheumatic diseases. Materials and Methods: This is a retrospective consecutive, non-comparative study. Results: The majority of patients were female (26, 68.4%), predominantly Chinese (92.1%), with a mean age 54 ± 14 years (range, 16 to 87). The mean duration of rheumatic disease was 9 ± 11 years (range, 0.1 to 48), with rheumatoid arthritis (52.6%) and systemic lupus erythematosus (23.7%) being the most common. The mean duration of CHB infection was 6 ± 5 years (range, 0.1 to 17), with the majority diagnosed during pre-methotrexate screening (50.0%) and asymptomatic transaminitis following initiation of immunosuppressive therapy (23.7%). Upon diagnosis of rheumatic disease, all patients had normal alanine aminotransferase (ALT). Of these, 18.2% were positive for hepatitis B e antigen (HBeAg) and 78.1% were positive for antiHBe antibody. Twenty (52.6%) developed ALT elevation, which was more than twice the upper limit of normal in 12 patients. ALT normalised spontaneously in 12 patients without hepatic decompensation or change in therapy. Seven (18.4%) patients received lamivudine for 18 ± 22 months (range, 2 to 61). Two patients developed YMDD mutation subsequently treated with adefovir (1) and adefovir/lamivudine (1). There were 3 (7.9%) hepatitis B virus (HBV)-unrelated deaths [infection (2), genitourinary malignancy (1)], and 1 from HBV-reactivation complicated by septicaemia. None have developed hepatocellular carcinoma. Conclusion: Elevated ALT occurred in 52.6% of patients, with only 18.4% requiring anti-viral therapy for HBV reactivation. HBV-related mortality was low. With the appropriate precautionary measures, prednisolone and immunosuppressants (except methotrexate and leflunomide) may be used safely in patients where clinically indicated.
More than 75% of patients with chronic hepatitis B virus (HBV) infection are found in Asia, where hepatitis B is the leading cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma (HCC).1 A hepatitis B seroprevalence survey conducted in 1999 showed that the overall prevalence of chronic hepatitis B (CHB) virus infection was 4.1% among Singapore residents aged between 18 and 69 years.2 The level of immunity to HBV virus was also lowest in the 18 to 29 years age group. Up to 50% of patients with chronic HBV infection in Singapore have chronic hepatitis, with raised serum alanine aminotransferase (ALT) and histologic changes, and about 20% have cirrhosis.3
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