How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?

Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anything-I would discuss DMARD timing with hepatology or ID. I would also check a liver US to evaluate for parenchymal disease/cirrhosis. If no parenchymal disease, I would still consider a conventional DMARD and escalate to biologics as needed.

Patients that are hepatitis B core positive and surface antigen-positive, but DNA negative, are felt to be at a higher risk for viral reactivation so I generally refer them for antiviral prophylaxis prior to ...

The 2021 ACR guidelines (Fraenkel et al., PMID 34101387) are helpful but I would expand on Dr. @Dr. First Last’s comments. Since many patients with chronic hepatitis B require treatment for 12 months or longer, I would consider initiation of hydroxychloroquine, sulfasalazine as cDMARD early if no significant hepatic dysfunction by transaminases or markers of synthetic function. The use of ultrasound elastography(fibroscan) has greatly aided as a noninvasive assessment of cirrhosis without biopsy so in those individuals with preserved function, close monitoring for adverse effects does not preclude agents with low risk of impact on viral clearance. Following an adequate decrease in viral load on antiviral therapy, consideration for amplified...