Closing the Knowledge Gap: Hepatitis B Reactivation in Immunosuppression

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Yassir M Daghistani, MD, MPH
Fergus To, MD, FRCPC
Eric M Yoshida, OBC, MD, MHSc, FRCPC, FACP
Patrick Doyle, MD, MHSc, FRCPC
Hin Hin Ko, MD, FRCPC
Mel Krajden, MD, FRCPC
Jason Kur, MD, FRCPC
Alnoor Ramji, MD, FRCPC
Kam Shojania, MD, FRCPC
Edward Tam, MD, FRCPC
John Wade, MD, FRCPC
Graham Reid, MD, FRCPC
Siegfried Erb, MD, FRCPC
Mollie Carruthers, MD, FRCPC




The usage of immunosuppressive medications (ISMs), and specifically disease modifying anti-rheumatic drugs (DMARDs), in a wide range of internal medicine subspecialties has increased the risk of hepatitis B virus re-activation (HBVr). We assessed the understanding of HBVr using a Canada-wide survey.


An electronic survey was sent to 521 members of the Canadian Rheumatology Association (CRA). The questions focused on the knowledge of screening, monitoring and management of patients with chronic or past infection with HBV in the setting of starting ISMs.The results were compared to the American Gastroenterology Association (AGA) guidelines. 


A total of142 respondents were included in the analysis (response rate = 27.3%). Over 50% of the respondents would order unnecessary tests such as anti-HBs or anti-HBc for monitoring a HBsAg positive patient on an ISMs. There were 43% of responders who answered incorrectly to starting anti-viral prophylaxis for HBsAg positive patients on synthetic DMARDs (sDMARDs).


There are some knowledge gaps amongst physicians managing rheumatology patients with chronic or past infection with HBV in the setting of ISMs. The AGA guidelines were summarized and incorporated into a user-friendly guide.

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