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Resolved hepatitis B infection before rituximab — SCE Rheumatology MCQ

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ModerateInfectious DiseaseResolved hepatitis B infection before rituximabSCE Rheumatology

A 61-year-old woman with granulomatosis with polyangiitis has a pulmonary–renal relapse requiring rituximab induction. Intravenous methylprednisolone has been given, and the first rituximab infusion is planned within 48 hours. Pretreatment infection screening shows: hepatitis B surface antigen negative, total hepatitis B core antibody positive, hepatitis B surface antibody 126 IU/L and hepatitis B virus DNA undetectable. Alanine aminotransferase, bilirubin and albumin are normal. A hepatologist confirms previous resolved hepatitis B infection with no evidence of active hepatitis or cirrhosis. Which strategy is most appropriate to reduce her risk of hepatitis B reactivation?

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Correct answer: E — Start lamivudine before the first rituximab infusion and continue it for at least 6 months after the final dose

This is resolved hepatitis B infection: HBsAg is negative, anti-HBc is positive and HBV DNA is undetectable. The positive anti-HBs titre does not eliminate reactivation risk. Rituximab causes prolonged B-cell depletion and is specifically associated with potentially severe HBV reactivation in HBsAg-negative, anti-HBc-positive patients. NICE recommends lamivudine prophylaxis for such patients, regardless of anti-HBs status, beginning before rituximab or another B-cell-depleting therapy and continuing for a minimum of 6 months after immunosuppression stops. Therefore D is the best answer. A is a plausible pre-emptive strategy for some anti-HBc-positive patients receiving lower-risk immunosuppression, but monitoring alone is insufficient for rituximab. B starts prophylaxis too late: reactivation prevention should be established before B-cell depletion. C stops treatment when the induction infusions finish, despite persistent biological immunosuppression and the risk of delayed reactivation. E incorrectly treats anti-HBs positivity as protective enough to avoid prophylaxis; NICE explicitly applies its recommendation regardless of anti-HBs status. Her urgent vasculitis treatment need not be deferred once appropriate antiviral prophylaxis and specialist oversight are arranged.

Reference: Hepatitis B (chronic): diagnosis and management — Recommendations (Published 26 June 2013; last 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; article date December 2013) — https://www.gov.uk/drug-safety-update/rituximab-screen-for-hepatitis-b-virus-before-treatment