Updated 20 June 2007
Patients found to have a positive test for either hepatitis B surface antigen (HBsAg) or antibody to hepatitis B core antigen (HBcoreAb) are at risk for fulminant hepatitis if treated with immunosuppressive chemotherapy, especially agents such as corticosteroids or purine analogues, and including monoclonal antibodies such as rituximab. All patients with lymphoid cancer should be tested for both HBsAg and HBcoreAb. If either test is positive when such patients require systemic treatment they should also be treated with lamivudine 100 mg/day orally, for the entire duration of the systemic treatment and for six months afterwards. Systemic treatments include chemotherapy, rituximab (including maintenance rituximab) and radio-immunotherapy. Such patients should also be monitored with frequent liver function tests and hepatitis B virus DNA at least every two months during the systemic treatment. If the hepatitis B virus DNA level rises during this monitoring, management should be reviewed with an appropriate specialist with experience managing hepatitis and consideration given to halting chemotherapy. Special note for patients with coincident human immunodeficiency virus (HIV) infection and prior hepatitis B: To prevent rapid emergence of lamivudine-resistant HIV, patients with prior hepatitis B infection should not initiate lamivudine prophylaxis until HAART has also been started.