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Resolved hepatitis B infection before rituximab therapy — SCE Rheumatology MCQ

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ModerateGastroenterologyResolved hepatitis B infection before rituximab therapySCE Rheumatology

A 62-year-old woman with seropositive rheumatoid arthritis has persistent synovitis despite methotrexate and two tumour necrosis factor inhibitors. Treatment with rituximab is planned. She was born in mainland China and has no known liver disease. Screening shows normal alanine aminotransferase and bilirubin, negative hepatitis B surface antigen, positive total hepatitis B core antibody, positive hepatitis B surface antibody at 84 mIU/mL, and undetectable serum hepatitis B virus DNA. Which strategy is most appropriate to minimise the risk of hepatitis B reactivation?

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Correct answer: A — Refer to a liver specialist, start lamivudine before rituximab, and continue it for at least 6 months after immunosuppressive therapy stops

Explanation lettering: D = shown as A · C = shown as B · A = shown as C · E = shown as D · B = shown as E

Negative HBsAg with positive anti-HBc and anti-HBs, together with undetectable HBV DNA, indicates previous hepatitis B infection rather than active disease. Nevertheless, replication-competent virus may persist, and rituximab-induced B-cell depletion carries a clinically important risk of reactivation. The positive anti-HBs titre does not remove this risk. NICE recommends lamivudine prophylaxis for HBsAg-negative, anti-HBc-positive patients starting rituximab or another B-cell-depleting therapy, regardless of anti-HBs status. It should be started before immunosuppression and continued for a minimum of 6 months after immunosuppressive therapy stops. MHRA advice additionally supports referral of patients with positive HBV serology to a liver specialist before rituximab. A recognises the need for prophylaxis but starts it too late and stops it while the biological effects of rituximab persist. B is a pre-emptive monitoring strategy applicable to some anti-HBc-positive patients receiving non-B-cell-depleting immunosuppression, but it is insufficient for rituximab. C would accord with NICE for an anti-HBs-positive patient not receiving B-cell-depleting therapy, but not in this case. E is unnecessarily restrictive: resolved HBV infection is not an absolute contraindication when specialist assessment and prophylaxis are provided. Active hepatitis B disease, by contrast, should preclude rituximab until appropriately managed.

Reference: Hepatitis B (chronic): diagnosis and management — Recommendations (Published 26 June 2013; updated 20 October 2017; reviewed 14 October 2025) — https://www.nice.org.uk/Guidance/CG165/chapter/recommendations Rituximab: screen for hepatitis B virus before treatment (11 December 2014) — https://www.gov.uk/drug-safety-update/rituximab-screen-for-hepatitis-b-virus-before-treatment