Anti-TNF drugs in patients with hepatitis B or C virus infection: safety and clinical management

Introduction: Drugs targeting TNF-alpha biological activity are increasingly used for the treatment of immune-mediated diseases, like rheumatoid arthritis, inflammatory bowel diseases and psoriasis. Since TNF-alpha is a mediator of the immune response against viral infections, use of TNF-alpha inhibitors in patients with concurrent HBV or HCV infection can promote viral reactivation and potentially fatal liver failure. Areas covered: This paper reviews TNF mechanisms of action in viral hepatitis B and C, recommendations for managing HBV and HCV-infected patients receiving treatment with anti-TNF drugs, safety and anti-TNF hepatotoxicity. Expert opinion: In hepatitis B surface antigen (HBsAg) carriers undergoing anti-TNF therapy, either anti-HBV treatment or prophylaxis is mandatory to prevent hepatitis reactivation, whereas HBsAg-negative antibody to hepatitis B core antigen (anti-HBc) seropositive patients require watchful monitoring, only. Conversely, in HCV-infected patients, TNF-alpha inhibition by specific drugs is safe and could be even beneficial, as TNF-alpha pathways are involved in perpetuating liver inflammation and fibrosis progression in HCV. HBV- or HCV-infected patients should be referred to a hepatologist for expert clinical management whenever antiviral therapy is deemed necessary or hepatitis reactivation occurs.