Hepatitis B screening, prophylaxis and re-activation in the era of rituximab-based chemotherapy

Hepatitis B re-activation is a well-described complication in patients with inactive chronic hepatitis B receiving chemotherapy. Screening for HBV and pre-emptive therapy are recommended. However, the rates of HBV screening, prophylaxis and re-activation during rituximab-containing chemotherapy are unknown.

We performed a retrospective study of patients with non-Hodgkin lymphoma (NHL) who received rituximab between August 1997 and September 2009. We evaluated patients for hepatitis B serologies, antiviral prophylaxis and hepatitis B re-activation during or up to 6 months after chemotherapy.

One thousand four hundred and twenty-nine patients underwent rituximab-containing chemotherapy for NHL. Hepatitis B serologies were documented in 524 (36.6%) patients. Of these, 20 (3.8%) were HBsAg positive and 10 (50%) experienced HBV re-activation. Only half (5/10) had HBV serology documented before re-activation. Only 3/8 (37.5%) of patients with newly documented HBsAg positivity received antiviral prophylaxis. Virological breakthrough occurred in two of the patients on chronic therapy, in one of three inactive carriers on prophylaxis and in two of five patients not receiving prophylaxis. Re-activation developed in another five patients not screened previously for hepatitis B. One patient developed ALF and died. Re-activation did not occur in 25 patients with isolated positive core antibody.

At tertiary care institutions hepatitis B serologies are infrequently assessed before rituximab-based chemotherapy and prophylaxis is uncommon. Greater adherence to recommendations for screening and prophylaxis is necessary. This suboptimal screening rate could be even lower in community hospitals and could result in significant harm to unscreened and unprophylaxed patients.