Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
