Prophylaxis against hepatitis B reactivation among patients with lymphoma receiving rituximab

Figures & data

Table 1. Summary of recommendations on hepatitis B virus screening and prevention of reactivation in patients receiving cancer chemotherapy or immunosuppressive therapy: three organizations.

	AASLD	EASL	ASCO
Who to screen	All needing immunosuppressive therapy and high risk for HBV infection	All candidates for chemotherapy and immunosuppressive therapy (rituximab is particularly mentioned as with high risk for reactivation)	Not all (use clinical judgment);High risk for HBV and who will receive therapy, including HSCT and rituximab
Screening tests ^†	HBsAg, anti-HBc	HBsAg, anti-HBc;HBV DNA in HBsAg^+	HBsAg;Anti-HBc in some (use clinical judgment);No evidence for testing anti-HBs
For HBsAg^+ status	Antiviral prophylaxis	Test for HBV DNA;Preemptive therapy in HBV DNA^+	May be given antiviral prophylaxis
For HBsAg−/anti-HBc^+ status	Not enough information to support antivral prophylaxis; monitor and start prophylaxis if HBV DNA^+	Test for HBV DNA;HBV DNA^+ should be treated as HBsAg^+;HBV DNA− should be monitored every 1–3 months (LFTs and HBV DNA);HSCT patients should get prophylaxis;(Some say prophylaxis for all who get rituximab &/or combined chemotherapy in hematologic cancers)	Unclear clinical significance;Generally indicates resolved infection;Reactivation may occur with immunosuppressive therapy;May be false positivie
When to initiate antiviral prophylaxis	At the onset of chemotherapy	During chemotherapy and/or immunosuppressive therapy	May be given before starting and while on chemotherapy
Antiviral prophylaxis/pre-emptive therapy	Lamivudine or telbivudine for <12 months of chemotherapy;Tenofovir or entecavir if >12 months of therapy;Until 6 months after completing chemotherapy	Lamivudine if HBV DNA <2000 IU/ml and short-term chemotherapy;Entecavir or tenofovir if HBV DNA >2,000 IU/ml and multiple cycles of therapy	Hepatology or infectious diseases consultation

^†Cost–effectiveness is demonstrated for screening all lymphoma patients for HBsAg⁺ status.

AASLD: American Association for the Study of Liver Diseases; Anti-HBc: Antibody to hepatitis B core antigen; Anti-HBs: Antibody to hepatitis B surface antigen; ASCO: American Society of Clinical Oncology; EASL: European Association for the Study of the Liver; HBsAg: Hepatitis B surface antigen; HSCT: Hematopoietic stem cell transplant; LFTs: Liver function tests.