Risk of HBV reactivation in psoriasis vulgaris patients receiving biological agent therapy.

Abstract

Objective: In recent years, the frequency of use of biological agents in the treatment of many dermatological diseases has been increasing. While effective, these treatments may carry the risk of hepatitis B virus (HBV) reactivation, particularly in patients with underlying or resolved HBV infection. Data on the risk of reactivation—especially with newer IL-23 antagonists that treat psoriasis vulgaris such as risankizumab and guselkumab, and IL-17 antagonists such as ixekizumab and secukinumab—remain limited. The aim of this study was to investigate HBV seroprevalence in patients with psoriasis using biological drug therapy and to investigate the frequency of reactivation and the importance of prophylactic treatment in this patient group at risk of HBV reactivation.

Methods: This retrospective study included 219 patients (aged 18-92) with psoriasis vulgaris who were treated with at least one biological drug treatment for at least 3 months at Dicle University Dermatology Clinic between 1 January 2018 and 30 June 2024. HBV serological markers (HBsAg, anti-HBcIgG, anti-HBs) and laboratory test results were evaluated. Patients were divided into five groups based on HBV serological: natural immune, chronic HBV infection, isolated anti-HBcIgG positivity, vaccinated and susceptible. These serological tests were repeated every 6 months during follow-up. Patients who did not meet the above-mentioned criteria or had incomplete test results were excluded from the study. Screening for hepatitis B reactivation was performed only in those with a positive anti-HBc IgG test who were at risk of reactivation. This was defined as either: Those who had a positive HBV DNA test prior to biological treatment and had an increase of >1 log10İU/mL in HBV DNA titre during biological treatment use; or those who initially tested negative for HBV DNA prior to starting biological treatment but became HBV DNA–positive during treatment were considered to have HBV reactivation.

Results: Of the 219 psoriasis vulgaris patients, 102 (46.6%) females and 117 (53.4%) males. The distribution biological agents uses was as follows: 87 (39.7%) secucinumab, 29 (13.2%) ixekizumab, 47 (21.5%), guselkizumab, and 56 (25.6%) risankizumab. Patients were categorized into five (5) groups based on HBV serology and among these groups, 46 (21%) patients (10 with secucinumab and risakizumab, 12 with ixekizumab, and 14 with guselkizumab) were found to be at risk of hepatitis B reactivation (anti-HBc IgG test positive). It was observed that 40 (86.96%) of these 46 patients at risk of hepatitis B reactivation used prophylaxis, and no reactivation developed. No significant ALT or AST elevation was detected in all patients during their biological treatment

Conclusion: IL-23 antagonist such as rizankizumab and guzelkumab, as well as IL-17 antagonists like secukinumab and ixekizumab, have been reported to carry a risk of hepatitis B reactivation during their use in the treatment of psoriasis vulgaris. Although published data on reactivation of HBV with the use of these newer and increasingly used treatments, particularly IL-23 antagonists, remains limited, our findings support their safe use when appropriate screening and prophylactic measures are implemented. The findings in this study highlight the importance of the use of prophylaxis treatment as a key measure to prevent hepatitis B reactivation in at-risk patients. Additionlly, HBV screening should be performed prior to initiating biological therapy, with antiviral prophylaxis provided when necessary. Regular hepatitis screening every six months is also recommended to minimize potential complications, enable early detection and intervention, and ensure patient safety througout treatment.