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Inflammatory Bowel Disease Patients Prior to Starting on Anti-TNF Are Over 5 Times More Likely to Be Screened for Hepatitis B Infection Compared to Those Starting High Dose Corticosteroids


Ho, Edith Y. MD, FACG1; Marshall, Vanessa PhD2; Alsamman, Yasser MD3; Chung, Grace MSCS, RHIA, VHA-CM4; Burant, Christopher PhD1; Dave, Maneesh MD, MPH5; Falck-Ytter, Yngve MD1

doi: 10.14309/01.ajg.0000592604.58240.5f

1Case Western Reserve University/Cleveland VA Medical Center, Cleveland, OH;

2Louis Stokes Cleveland VA Medical Center, Cleveland, OH;

3University of Texas Southwestern Medical Center, Dallas, TX;

4Cleveland VA Medical Center, Cleveland, OH;

5University of California Davis, Davis, CA.

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Screening for hepatitis B virus (HBV) infection in inflammatory bowel disease (IBD) patients prior to initiating anti-tumor necrosis factor alpha (anti-TNF) therapy has significantly improved over the past decade. HBV screening prior to initiating high dose corticosteroids (HDC) is largely unknown despite potentially greater risks of HBV reactivation compared to anti-TNF. This study aims to determine the factors associated with HBV screening and whether the type of immunosuppression affects screening practices.

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This retrospective chart review included Veterans with diagnostic codes for Crohn's Disease (CD: ICD-9-CM 555.x and ICD-10-CM K50.x) and ulcerative colitis (UC: ICD-9-CM 556.x and ICD-10-CM K51.x) first recorded between 01/2013 to 08/2016 at the Cleveland Veterans Affairs Medical Center. IBD patients who were started on anti-TNF or HDC were assessed whether HBV screening was conducted within 12 months of initiating therapy. HDC was defined as ≥10 mg for ≥4 consecutive weeks. Patient factors including gender, age, race, service connectivity (SC), and type of immunosuppression were assessed as independent predictors for screening.

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Among 571 Veterans, 56 started immunosuppression with 17 on anti-TNF and 39 on HDC. A total of 31/56 (56%) were screened: 90% male, mean age 49, 32% mean SC, 45% on anti-TNF and 55% on HDC. A total of 25/56 (44%) were not screened: 96% male, mean age 58,17% mean SC, 12% on anti-TNF and 88% on HDC. In those on anti-TNF, 88% were screened compared to 44% on HDC (P = 0.007). In multivariate analysis, immunosuppression type was significantly associated with screening where patients initiated on anti-TNF were 5.5 times more likely to be screened compared to those on HDC (OR 0.18, P = 0.025). Age, gender, race, and service connectivity did not have any impact on screening.

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Overall, 56% of IBD patients receiving immunosuppression were screened for HBV. 88% were screened prior to anti-TNF compared to 44% prior to HDC. Patients initiated on anti-TNF were over 5 times more likely to be screened compared to those on HDC. Importance of HBV screening prior to high dose corticosteroids in IBD patients should be emphasized in societal guidelines and clinical practice, given that HDC poses a potentially greater risk of HBV reactivation compared to a biologic.

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