Introduction Rituximab is a potent immunosuppressant used to treat haematological malignancies, rheumatological diseases and autoimmune disorders. Patients with current or past infection with the hepatitis B virus (HBV) are at high risk of reactivation following treatment with rituximab and other immunosuppressants.1HBV reactivation can cause liver failure and is associated with a 5–12% mortality. Guidelines advise screening for HBV surface antigen (HBsAg) and core antibody (anti-HBcAb) prior to initiating immunosuppression, and recommend antiviral prophylaxis for all found to be positive.2
Method A baseline audit was conducted on all patients receiving rituximab in our Trust between Sept-Dec 2012 to determine the proportion of patients tested for HBsAg and anti-HBcAb. Data was also collected on prophylactic antiviral prescriptions. Following the baseline audit, a hospital guideline was developed and targeted education was conducted for rituximab prescribers. Two follow-up audits were conducted in Feb–April 2014 and Sept–Dec 2014.
Results A summary of the baseline results and follow-up audits is shown in Table 1. The baseline audit showed very low rates of HBV testing; only 23% tested for HBsAg and 19% for anti-HBcAb. None were HBsAg positive, but 2 were anti-HBcAb positive and neither received antiviral prophylaxis. One of these patients experienced HBV reactivation and despite tenofovir treatment developed liver failure requiring a 3-week hospital admission. The rituximab prescriptions were mainly from our rheumatology (56%) and haematology (32%) departments. This audit highlighted the need for education of clinicians prescribing rituximab. A Trust protocol was introduced and targeted education sessions were delivered to the specialties using rituximab. A significant stepwise increase in HBV testing was seen in follow-up audits (Table 1). By Sept-Dec 2014, 79% of patients were tested for HBsAg.
Conclusion In our Trust, introduction of a protocol and targeted education of clinicians has led to a dramatic increase in HBV screening prior to receiving rituximab (19% to 79%). However, reinforcement of the guidelines is needed to further increase testing rates and appropriate hepatology referrals. Importantly, prophylactic antiviral treatment was indicated for 5% of patients tested.
Disclosure of interest None Declared.
EASL Guidelines: Management of chronic HBV infection. J Hepatol. 2012;57:167–185
NICE Hepatitis B guidelines, 2013