DMARDs for Ankylosing Spondylitis With Inactive HBV

Robert Terkeltaub, MD


January 08, 2003


I have a patient who has been diagnosed with ankylosing spondylitis (AS). On further investigation, I have found that she has inactive hepatitis B. Her sulfasalazine therapy was discontinued. At present, she is only receiving painkillers such as diclofenac and physiotherapy. Can disease-modifying antirheumatic drugs (DMARDs) be used for AS with inactive hepatitis B?

Divyesh Bhagat, MBBS, MD

Response from Robert Terkeltaub, MD

Current accepted guidelines that exist for the initiation of DMARDs, such as methotrexate in rheumatoid arthritis (RA), may not apply to AS, where there is a lack of evidence-based studies to indicate that methotrexate is truly disease-modifying at the structural level. Indeed, no medication regimen currently available has demonstrated convincingly to be disease-modifying at the structural level in AS. But the results of ongoing long-term trials with biologics to address this question will be of great interest.

In the case you cite, a well-reasoned trial of sulfasalazine appears to have failed. It should be noted that TNF-alpha inhibition is an increasingly employed therapeutic strategy for psoriatic arthritis and also has been reported recently to be beneficial for pain, disease activity, and function in AS in several interesting clinical trials.[1,2,3] Long-term efficacy and safety of TNF-alpha inhibitors in AS and their potential to slow or prevent structural damage such as spinal ankylosis in AS remain to be determined.

Chronic hepatitis B virus infection is a highly prevalent problem worldwide, and thus the questions posed are important. A critical issue the clinician must address in a clinical situation such as the one described is how active or inactive is the hepatitis B infection. Some patients with viral hepatitis have normal transaminase levels yet have histologic evidence of chronic persistent hepatitis that would preclude use of methotrexate. In a patient with RA and clinical evidence for chronic viral hepatitis B or C infection, standard guidelines call for consideration of liver biopsy prior to methotrexate use and for closer monitoring than usual for methotrexate toxicity.[4] But there is insufficient knowledge from long-term surveillance of methotrexate-treated patients with inflammatory joint disease and latent viral hepatitis to completely answer your last question.[5] Furthermore, the long-term safety of TNF-alpha inhibitors with respect to possible reactivation of latent viral hepatitis is not known.


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