Rituximab is a standard option for moderate-to-severe pemphigus, and B-cell depletion can reactivate hepatitis B with severe or fatal hepatitis. Check hepatitis B surface antigen and core antibody before the first infusion, and arrange antiviral prophylaxis with a hepatologist for anyone positive for either.
At the same time, check hepatitis C and HIV status and consider latent tuberculosis screening, which is particularly relevant in India. Bring vaccinations up to date beforehand where possible, because responses are blunted for months after rituximab, and avoid live vaccines once treatment starts. Patients on high-dose prednisone alongside also need bone protection and glucose monitoring.
- Check hepatitis B surface antigen and core antibody before the first rituximab dose.
- Arrange antiviral prophylaxis for anyone with positive hepatitis B serology.
- Screen for hepatitis C, HIV and latent tuberculosis before starting.
- Give non-live vaccines before rituximab where time allows; avoid live vaccines after.
- Add bone protection and glucose checks when prednisone is used alongside.
Why it matters
Hepatitis B reactivation after rituximab is preventable, and missing the screen can be fatal.
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