Screening for HBV and HCV Before Starting High-Dose Steroid Therapy

Rationale for Screening

High-dose steroid therapy can cause reactivation of HBV in both active carriers and those with past/resolved infection, leading to severe hepatitis, liver failure, and death, according to the American Gastroenterological Association (AGA) 1, 2
The American Gastroenterological Association (AGA) strongly recommends testing for hepatitis B in all individuals at potential risk of HBV reactivation 2

Initial screening should include at minimum HBsAg and anti-HBc, as recommended by the American Gastroenterological Association (AGA) 2, 3
A comprehensive screening panel should include HBsAg, anti-HBc, and anti-HBs, to detect active infection, previous or ongoing infection, and immunity due to vaccination or resolved infection, respectively 3
For HCV, screening should include anti-HCV antibody testing, as recommended by the American Academy of Dermatology 4, 5

HBsAg-positive patients are at high risk of reactivation with high-dose steroids and should receive prophylactic antiviral therapy before starting steroid therapy, according to the Clinical and Molecular Hepatology guidelines 1, 5, 6
HBsAg-negative, anti-HBc-positive patients are at moderate risk of reactivation and should be monitored for ALT, HBsAg, and HBV DNA every 3-6 months during therapy, as recommended by the American Academy of Dermatology 5, 6
If HCV RNA is detectable, consider antiviral treatment for HCV before starting immunosuppressive therapy, as recommended by the Clinical and Molecular Hepatology guidelines 7

Antiviral prophylaxis should be continued throughout steroid therapy and for at least 12 months after discontinuation of immunosuppression, as recommended by the Journal of Clinical Oncology 8, 9

Failing to screen for both HBV and HCV before starting steroid therapy can lead to severe consequences, as highlighted by the Journal of the American Academy of Dermatology 4, 5
Not monitoring liver enzymes during steroid therapy in at-risk patients can lead to delayed detection of reactivation, according to the Clinical and Molecular Hepatology guidelines 7
Discontinuing antiviral prophylaxis too early after stopping steroid therapy can increase the risk of reactivation, as warned by the Journal of Clinical Oncology 8