Biologic medications have transformed the treatment of many forms of inflammatory arthritis, offering hope to patients who once struggled with persistent pain, joint damage, and limited mobility. These advanced therapies target specific components of the immune system and have significantly improved outcomes for conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis.
However, while biologics can be highly effective, they also require careful preparation before treatment begins. One of the most important safety measures is screening for hepatitis B—and, in some cases, hepatitis C—before starting therapy. Despite well-established clinical recommendations, research has found that more than 75% of arthritis patients may not receive appropriate hepatitis screening before initiating a biologic medication.
This gap in preventive care raises important concerns because biologics suppress parts of the immune system, which can allow previously inactive hepatitis viruses to reactivate. Reactivation can lead to serious liver complications, hospitalization, and, in severe cases, liver failure. Fortunately, these risks can often be reduced through timely screening, appropriate monitoring, and preventive treatment when indicated.
Understanding why hepatitis screening matters, who should be tested, and how patients can advocate for their own care is essential for anyone considering biologic therapy.
What Are Biologic Medications?
Biologic drugs are medications derived from living cells that target specific parts of the immune system involved in inflammation.
Unlike traditional disease-modifying antirheumatic drugs (DMARDs), which broadly suppress immune activity, biologics focus on particular proteins or immune cells that contribute to autoimmune disease.
Common biologic medications used to treat inflammatory arthritis include:
- Adalimumab
- Etanercept
- Infliximab
- Golimumab
- Certolizumab pegol
- Abatacept
- Rituximab
- Tocilizumab
- Sarilumab
- Secukinumab
- Ixekizumab
- Ustekinumab
These medications may reduce:
- Joint pain
- Swelling
- Morning stiffness
- Disease progression
- Long-term joint damage
For many patients, biologics significantly improve mobility, physical function, and overall quality of life.
Why Screening Is Necessary Before Starting a Biologic
Because biologic medications suppress specific aspects of the immune system, they may reduce the body’s ability to keep certain viral infections under control.
One of the greatest concerns involves hepatitis B virus (HBV).
Some people have an active hepatitis B infection, while others were infected years earlier and recovered. Even after recovery, traces of the virus can remain dormant in the liver.
When immune function is suppressed, dormant hepatitis B may become active again.
This process is known as hepatitis B reactivation.
Reactivation can range from mild increases in liver enzymes to severe hepatitis, liver failure, and, in rare cases, death.
Early identification of hepatitis B allows healthcare providers to take preventive steps before biologic therapy begins.
Understanding Hepatitis B
Hepatitis B is a viral infection that affects the liver.
Many people who become infected recover completely.
Others develop chronic hepatitis B, in which the virus remains in the body for years.
Some individuals may not realize they were ever infected because they experienced few or no symptoms.
Potential symptoms of active hepatitis B include:
- Fatigue
- Fever
- Loss of appetite
- Nausea
- Abdominal discomfort
- Dark urine
- Yellowing of the skin or eyes (jaundice)
However, many infections remain silent until liver damage has already occurred.
This is one reason screening is so valuable.
Hepatitis C and Other Viral Infections
Although hepatitis B receives the greatest attention before biologic therapy, hepatitis C screening may also be appropriate for some patients based on clinical guidelines, risk factors, or local practice recommendations.
Unlike hepatitis B, hepatitis C reactivation during biologic therapy appears to be less common, but identifying chronic infection remains important because highly effective antiviral treatments are now available.
Healthcare providers may also evaluate patients for:
- Tuberculosis
- HIV in appropriate situations
- Current infections
- Vaccination status
These assessments help reduce treatment-related complications.
What Research Has Found
Several studies examining real-world clinical practice have identified concerning gaps in hepatitis screening before biologic therapy.
Research has shown that a substantial proportion of patients beginning biologic medications either:
- Receive incomplete hepatitis testing
- Are screened after treatment has already started
- Are not screened at all
Some analyses have estimated that more than 75% of patients do not undergo all recommended hepatitis screening before initiating certain biologic therapies.
While screening rates have improved over time in some healthcare systems, significant opportunities for improvement remain.
The reasons behind these gaps are complex and may include variations in clinical practice, differences in healthcare systems, lack of awareness, incomplete medical records, or inconsistent implementation of screening protocols.
Which Tests Are Commonly Recommended?
Healthcare providers often use a combination of blood tests to evaluate hepatitis B status before initiating biologic therapy.
Common tests include:
Hepatitis B Surface Antigen (HBsAg)
This test helps identify current hepatitis B infection.
A positive result indicates that the virus is present.
Hepatitis B Surface Antibody (Anti-HBs)
This test determines whether a person has immunity from either vaccination or previous infection.
Hepatitis B Core Antibody (Anti-HBc)
This marker indicates previous exposure to hepatitis B.
Even if someone no longer has an active infection, a positive core antibody may suggest a risk of viral reactivation during immunosuppressive therapy.
Together, these tests provide a more complete picture than any single test alone.
Depending on the results, additional laboratory testing may be necessary.
Who Is Most at Risk for Hepatitis B Reactivation?
Although any patient with current or previous hepatitis B infection deserves careful evaluation, certain factors increase the likelihood of reactivation.
These include:
- Chronic hepatitis B infection
- Previous hepatitis B infection
- Potent immunosuppressive therapy
- Rituximab treatment
- High-dose corticosteroids
- Certain chemotherapy medications
- Stem cell transplantation
The level of risk varies depending on both the patient’s infection status and the specific medication being used.
What Happens If Screening Finds Hepatitis B?
A positive hepatitis test does not necessarily mean biologic treatment cannot proceed.
Instead, healthcare providers may recommend several strategies.
These may include:
Referral to a Liver Specialist
Some patients benefit from evaluation by a hepatologist or infectious disease specialist before beginning immunosuppressive therapy.
Antiviral Medication
Preventive antiviral therapy can greatly reduce the risk of hepatitis B reactivation in eligible patients.
The timing and duration of treatment depend on individual circumstances and the type of immunosuppressive medication being used.
Ongoing Monitoring
Patients may undergo periodic blood tests to monitor:
- Liver enzymes
- Viral activity
- Overall liver function
Regular follow-up helps identify potential problems early.
Why Screening Is Sometimes Missed
Although recommendations are clear, several practical challenges may contribute to missed screening.
Multiple Healthcare Providers
Patients often receive care from:
- Rheumatologists
- Primary care physicians
- Specialists
- Infusion centers
When responsibilities are unclear, important tests may inadvertently be overlooked.
Time Pressures
Severe arthritis symptoms sometimes create urgency to begin treatment quickly.
Without standardized checklists, screening may be delayed or forgotten.
Incomplete Medical Histories
Patients may not remember previous hepatitis infections or vaccinations.
Electronic health records may also lack complete information if testing occurred elsewhere.
Variability in Clinical Practice
Healthcare systems differ in how consistently they implement pre-biologic screening protocols.
Some institutions use automated reminders, while others rely solely on individual clinician judgment.
The Importance of Vaccination
For patients who have never been infected with hepatitis B and are not immune, vaccination may be recommended.
The hepatitis B vaccine helps protect against future infection.
Ideally, vaccination is completed before significant immunosuppression begins, as the immune response to vaccines may be less robust after biologic therapy has started.
Patients should discuss their vaccination history with their healthcare provider.
Other Safety Evaluations Before Starting a Biologic
Hepatitis screening is only one part of a comprehensive safety assessment.
Before beginning biologic therapy, healthcare providers may also evaluate:
- Tuberculosis risk
- Current infections
- Recent vaccinations
- Pregnancy considerations
- Liver function
- Kidney function
- Complete blood counts
- Heart failure history for certain medications
- Neurological conditions in specific situations
Each biologic medication has its own safety profile, making individualized evaluation essential.
Questions Patients Can Ask Their Healthcare Provider
Patients play an important role in their own healthcare.
Before starting a biologic, consider asking questions such as:
- Have I been screened for hepatitis B?
- Do I also need hepatitis C testing?
- Have I been tested for tuberculosis?
- Are my vaccinations up to date?
- Should I receive any vaccines before treatment begins?
- What symptoms should I report after starting therapy?
- How often will I need blood tests?
Open communication helps ensure that important preventive measures are not overlooked.
The Role of Shared Decision-Making
Modern arthritis care emphasizes shared decision-making between patients and healthcare professionals.
Rather than simply prescribing medication, clinicians work with patients to discuss:
- Benefits
- Risks
- Alternatives
- Monitoring requirements
- Personal preferences
This collaborative approach helps patients better understand their treatment plan and encourages active participation in ongoing care.
Improving Screening Rates
Healthcare organizations continue working to improve hepatitis screening before biologic therapy.
Potential strategies include:
- Electronic medical record alerts
- Standardized pre-treatment checklists
- Staff education
- Patient education
- Automated laboratory ordering systems
- Quality improvement initiatives
Many experts believe these interventions can substantially increase screening rates while reducing preventable complications.
Living Safely With Biologic Therapy
For most patients, biologic medications provide substantial benefits that outweigh their potential risks when appropriate screening and monitoring are performed.
Successful treatment often includes:
- Taking medications as prescribed
- Attending regular follow-up appointments
- Completing recommended laboratory testing
- Reporting signs of infection promptly
- Maintaining open communication with the healthcare team
With careful planning, many patients experience significant improvements in pain, physical function, and daily activities.
Looking Ahead
As biologic therapies continue to evolve, safety protocols are also becoming more refined. Advances in electronic health records, standardized screening pathways, and increased awareness among healthcare professionals are helping to close existing gaps in preventive care.
Researchers are also studying ways to personalize treatment decisions based on individual risk factors, allowing clinicians to better identify patients who may benefit from enhanced monitoring or preventive antiviral therapy.
These ongoing improvements aim to maximize the benefits of biologic medications while minimizing avoidable complications.
Final Thoughts
Biologic medications have revolutionized the treatment of inflammatory arthritis, offering many patients the opportunity to control disease activity, reduce pain, and preserve joint function. However, because these therapies alter the immune system, careful screening before treatment begins is an essential part of safe and effective care.
Research indicating that more than 75% of arthritis patients may not receive appropriate hepatitis screening before starting a biologic highlights an important opportunity for improvement. Screening for hepatitis B—and, when appropriate, hepatitis C—can identify individuals at risk for viral reactivation and allow preventive measures to be put in place before complications occur.
Patients should feel empowered to ask their healthcare providers about recommended screening tests, vaccination status, and ongoing monitoring. Working together, patients and healthcare teams can ensure that biologic therapy is both effective and as safe as possible, allowing individuals with inflammatory arthritis to benefit from these life-changing treatments while reducing preventable health risks.
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