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HBV Reactivation with Rituximab — RACP Adult Medicine MCQ

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ModerateInfectious DiseasesHBV Reactivation with RituximabRACP Adult Medicine

A 55-year-old man with chronic hepatitis B on entecavir requires chemotherapy with rituximab-containing regimen for DLBCL. What is the critical risk and management?

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Correct answer: D — HBV reactivation – continue entecavir throughout and for 12 months after rituximab cessation

Rituximab (and other anti-CD20 agents) causes profound B-cell depletion, creating a very high risk of HBV reactivation (up to 50–80% without prophylaxis), which can be fatal. Entecavir (or tenofovir) MUST be continued throughout chemotherapy and for at least 12 months after the last rituximab dose. HBV DNA should be monitored every 3 months. This applies to HBsAg-positive patients. Even HBsAg-negative/anti-HBc-positive patients (occult HBV) are at risk with rituximab and should receive antiviral prophylaxis.

Reference: eTG – 2025 – Antibiotic Guidelines; AASLD – 2018 – HBV Reactivation Guidance