Risk of hepatitis B and tuberculosis reactivation in patients with neuromyelitis optica spectrum disorder undergoing B cell depletion therapy.

INTRODUCTION: B cell-depleting agents are highly effective in preventing relapses in neuromyelitis optica spectrum disorder (NMOSD). Currently, no standardized guidelines exist for preventing hepatitis B reactivation (HBVr) or tuberculosis reactivation (TBr) during the use of B cell-depleting agents in patients with NMOSD who are at risk of HBVr or TBr. Furthermore, data on HBVr and TBr in such patients remain limited.

OBJECTIVE: This study aimed to evaluate the risk of HBVr and TBr in patients with NMOSD undergoing B cell depletion therapy and to explore the corresponding prophylactic strategy against HBVr and TBr.

METHODS: Patients with NMOSD treated with inebilizumab or rituximab at the Third Affiliated Hospital of Sun Yat-sen University between January 1, 2016, and August 31, 2024, were screened for potential risks of HBVr and TBr. The incidence of HBVr and TBr during treatment with B cell-depleting agents was analyzed.

RESULTS: Among 102 patients with NMOSD receiving B cell-depleting agents (36 patients treated with inebilizumab and 66 with rituximab), 42 were at risk of HBVr (2 HBsAg-positive and 40 HBsAg-negative and anti-HBc-positive), and 11 were at risk of TBr (2 prior TB infection and 9 latent tuberculosis infection [LTBI]). For the HBVr-risk cohort, the median follow-up duration was 11.5 months (6-21 months). Both of these two patients with HBsAg-positive received prophylactic anti-HBV treatment. One of these two patients experienced HBVr, and responsed well to continuing anti-HBV medications and polyene phosphatidylcholine capsules. Among the 40 HBsAg-negative and anti-HBc-positive patients, 11 received prophylactic anti-HBV treatment, and none of these 40 patients experienced HBVr. For the TBr-risk cohort, the median follow-up duration was 11 months (7-17 months). Two patients with prior cured TB infections did not receive prophylactic anti-TB treatment, and no TBr was observed. Similarly, nine patients with LTBI did not receive prophylactic anti-TB treatment, and no active TB was identified during follow-up.

CONCLUSION: Patients with NMOSD who were HBsAg-negative and anti-HBc-positive or had LTBI had no observed instances of HBVr/TBr while receiving B cell depletion therapy during the follow-up period, with or without prophylactic anti-HBV or anti-TB treatment.