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Resolved HBV Rituximab Risk — RACP Adult Medicine MCQ

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HardInfectious DiseasesResolved HBV Rituximab RiskRACP Adult Medicine

A 55-year-old man with resolved hepatitis B (HBsAg negative, anti-HBc positive, anti-HBs positive) is about to commence rituximab for RA. HBV DNA is undetectable. He has no liver disease. What HBV management is appropriate?

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Correct answer: C — Monitor HBV DNA every 1-3 months during and after rituximab

Resolved HBV (anti-HBc positive ± anti-HBs) patients receiving rituximab can have HBV reactivation from cccDNA reservoir in hepatocytes (~5-10% risk). Two strategies: (1) prophylactic antivirals (entecavir or tenofovir) from start of rituximab, or (2) monitoring approach — serial HBV DNA every 1-3 months with pre-emptive antiviral if DNA becomes detectable. AASLD/EASL 2024 recommend prophylactic antivirals for anti-HBc positive patients receiving anti-CD20 therapy (rituximab, obinutuzumab). Anti-HBs does NOT fully protect against reactivation.

Reference: GESA – 2022 – HBV Reactivation; AASLD 2024; EASL 2024