An argument for the universal prophylaxis of hepatitis B infection in patients receiving rituximab: a 7-year institutional experience of hepatitis screening.

Reactivation of hepatitis B virus (HBV) replication in patients receiving rituximab is well described. Current international guidelines recommend HBV screening prior to the commencement of immunosuppressive therapy. However, adherence to such protocols has not previously been studied. We therefore audited screening practices and clinical outcomes in patients prescribed rituximab since its introduction in a large metropolitan health service. All patients receiving rituximab over an 88-month period were identified via pharmacy records. Medical records and laboratory results were reviewed to determine the timing and type of hepatitis screening. HBV flares were identified and correlated with clinical outcomes and any screening or prophylaxis given. Rituximab was given to 355 patients over 88 months (average age, 61 years; 51% male, 48% born overseas); 83% received rituximab for treatment of a hematological malignancy. HBV screening occurred in 31% of patients and, of these, 66% had pre-emptive screening. Five patients given cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab experienced HBV flares. Four died from viral reactivation. None received antiviral prophylaxis. Hepatitis screening rates in patients receiving rituximab in this study were lower than recommended in clinical guidelines. The identification of five patients with clinically important flares and four deaths in this group highlight the critical need to identify at-risk patients and provide timely prophylactic antiviral therapy to prevent serious morbidity and mortality. Even those with evidence of HBV seroconversion are at risk for fatal flares without active prophylactic antiviral therapy.