Rituximab and risk of HBV re-activation

[DrMetal]

[you guys probably give way more rituximab than I do.]

You know how you're supposed to get a hepatitis panel before starting rituximab, so what if the panel is positive for the inactive chronic charier state of HBV? (+HBsAg , +HBcAb , but undetectable viral load, normal liver enzymes).

Could you still give the rituximab? Or is even the inactive carrier state of HBV (negative PCR, negative LAEs) a contraindication?

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[DoctorDontStop]

[you guys probably give way more rituximab than I do.]

You know how you're supposed to get a hepatitis panel before starting rituximab, so what if the panel is positive for the inactive chronic charier state of HBV? (+HBsAg , +HBcAb , but undetectable viral load, normal liver enzymes).

Could you still give the rituximab? Or is even the inactive carrier state of HBV (negative PCR, negative LAEs) a contraindication?

Conventional wisdom is that you weigh the pros and cons, prior infection vs vaccination. Some patients do end up getting Hepatitis B viral prophylaxis while on anti CD20 therapy. Hope this helps.

 

[HOIV]

[you guys probably give way more rituximab than I do.]

You know how you're supposed to get a hepatitis panel before starting rituximab, so what if the panel is positive for the inactive chronic charier state of HBV? (+HBsAg , +HBcAb , but undetectable viral load, normal liver enzymes).

Could you still give the rituximab? Or is even the inactive carrier state of HBV (negative PCR, negative LAEs) a contraindication?

If they have core ab + they are getting viread from me. The anti cd20 drugs are the most likely agents to allow reactivation and lead to acute liver failure. Not worth the risk. I start at positive core finding and continue x 1 year after completion of antibody therapy.

 

[DrMetal]

If they have core ab + they are getting viread from me. The anti cd20 drugs are the most likely agents to allow reactivation and lead to acute liver failure. Not worth the risk. I start at positive core finding and continue x 1 year after completion of antibody therapy.

Makes sense to me, even in the absence of a viral load and normal LAEs, right? Why is this not standard of care?

 

[bobow98]

Makes sense to me, even in the absence of a viral load and normal LAEs, right? Why is this not standard of care?

Agreed. We have some lymphoma peeps that will say "PCR neg, no need to ppx", but I am on the side of treating through all of therapy plus a minimum of 3 - 6 months. Anyone have higher level evidence of how long to continue for?

 

[gutonc]

Makes sense to me, even in the absence of a viral load and normal LAEs, right? Why is this not standard of care?

Not sure what you mean not standard of care. It's in the PI for rituximab. Not screening, and treating if HBC+ (or other evidence of infection other than vaccination) is malpractice...full stop.

And now ASCO recommends HBV screening and treatment for anybody getting anti-cancer systemic therapy.

 

[DrMetal]

Not sure what you mean not standard of care. It's in the PI for rituximab. Not screening, and treating if HBC+ (or other evidence of infection other than vaccination) is malpractice...full stop.

And now ASCO recommends HBV screening and treatment for anybody getting anti-cancer systemic therapy.

well, apparently not all are practicing that way. I had a patient with a reactivation of HBV . . .previous notes said something about forgoing ppx b/c her initial PCR was negative. I thought that didn't sound right.

good discussion, so definitely ppx if hbc+ (irrespective of a normal PCR and normal LAEs).

 

[HemeOncHopeful19]

well, apparently not all are practicing that way. I had a patient with a reactivation of HBV . . .previous notes said something about forgoing ppx b/c her initial PCR was negative. I thought that didn't sound right.

good discussion, so definitely ppx if hbc+ (irrespective of a normal PCR and normal LAEs).

My understanding as a noob fellow is for Rituximab either Core Ab or Antigen needs Viread (and consider delaying if PCR positive).

For most other chemo it is Surface Ag only but lots of people will treat the Core Ab for CYA/“why not” reasons.

Viread (if indicated) is continued for 1 year after completing chemo/Rituximab (NOT 1 year from starting)