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Resolved hepatitis B infection before rituximab therapy — SCE Rheumatology MCQ

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ModerateImmunosuppressionResolved hepatitis B infection before rituximab therapySCE Rheumatology

A 58-year-old woman with seropositive rheumatoid arthritis has persistent high disease activity despite methotrexate and two tumour necrosis factor inhibitors. Following multidisciplinary review, rituximab is planned in 2 weeks. Pre-treatment screening shows hepatitis B surface antigen negative, total hepatitis B core antibody positive and hepatitis B surface antibody 4 mIU/mL. Serum hepatitis B virus DNA is undetectable. Alanine aminotransferase, bilirubin, albumin and platelet count are normal, and there is no clinical or imaging evidence of chronic liver disease. Which hepatitis B management strategy is most appropriate?

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Reveal the answer and explanation

Correct answer: D — Refer to hepatology and start antiviral prophylaxis before or at rituximab, with specialist-directed continuation after rituximab

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

She has resolved hepatitis B infection, defined by negative HBsAg with positive anti-HBc, and is about to receive an anti-CD20 regimen. Undetectable baseline HBV DNA does not eliminate reactivation risk because rituximab causes prolonged B-cell depletion. Her low anti-HBs titre further increases concern. EULAR therefore advises hepatology referral and consideration of prophylaxis irrespective of baseline HBV DNA in patients receiving rituximab. Current hepatitis literature supports starting a high-resistance-barrier nucleos(t)ide analogue, usually entecavir or tenofovir, before or no later than initiation of immunosuppression and continuing it beyond rituximab according to specialist advice. A provides no protection against a recognised potentially fatal complication. B is inappropriate because anti-HBc positivity indicates previous infection rather than vaccine-naive susceptibility; vaccination does not eradicate latent intrahepatic HBV or replace prophylaxis. C is inadequate because virological reactivation may precede hepatitis, so waiting for an ALT rise delays intervention. D is a reasonable pre-emptive strategy for resolved HBV during many lower-risk antirheumatic treatments, making it the principal near-miss, but anti-CD20 therapy places this patient in a higher-risk category in which prophylaxis is preferred.

Reference: 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases (2023) — https://ard.bmj.com/content/82/6/742 Truxima 100 mg concentrate for solution for infusion — Summary of Product Characteristics (19 March 2025) — https://www.medicines.org.uk/emc/product/8878/smpc Advances in the management of hepatitis B (3 June 2025) — https://www.bmj.com/content/389/bmj-2024-079579