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Resolved hepatitis B infection before rituximab therapy — SCE Rheumatology MCQ

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ModerateProphylaxisResolved hepatitis B infection before rituximab therapySCE Rheumatology

A 61-year-old woman with seropositive rheumatoid arthritis has persistent high disease activity despite methotrexate and two tumour necrosis factor inhibitors. Rituximab has been selected as her next treatment. Pre-treatment screening shows hepatitis B surface antigen negative, hepatitis B core antibody positive and hepatitis B surface antibody positive at 112 IU/L. Serum hepatitis B virus DNA is undetectable, alanine aminotransferase is normal and HIV and hepatitis C serology are negative. She has no known history of liver disease. Which is the most appropriate strategy to prevent hepatitis B reactivation?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Start lamivudine before rituximab and continue it for at least 6 months after B-cell-depleting therapy ends

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

This patient has resolved previous HBV infection: she is HBsAg negative and anti-HBc positive, with undetectable HBV DNA. Despite anti-HBs positivity, rituximab confers a clinically important risk of HBV reactivation through B-cell depletion. Current NICE guidance specifies lamivudine prophylaxis for HBsAg-negative, anti-HBc-positive patients starting rituximab or another B-cell-depleting therapy, regardless of anti-HBs status. It should begin before immunosuppression and continue for at least 6 months after it stops. A is incorrect because anti-HBs positivity removes the indication for prophylaxis only when the patient is not receiving rituximab or another B-cell-depleting agent. C uses an antiviral recommended by NICE in other HBV categories and stops it too early; completion of the infusions does not end the period of reactivation risk. D resembles the monitoring strategy for an HBsAg-negative, anti-HBc-positive, anti-HBs-negative patient who is not receiving B-cell-depleting therapy. E provides the correct drug and post-treatment duration but starts prophylaxis too late: it should be established before the first rituximab exposure.

Reference: Hepatitis B (chronic): diagnosis and management — Recommendations (Published 26 June 2013; updated 20 October 2017) — https://www.nice.org.uk/guidance/cg165/chapter/Recommendations Hepatitis B (chronic): diagnosis and management — Overview (Last reviewed 14 October 2025) — https://www.nice.org.uk/Guidance/CG165