Infectious Disease Considerations Before Starting Rituximab for PTLD

Mandatory Pre-Treatment Screening

• The European Hematology Association recommends screening all patients for HBV infection before the first rituximab dose by measuring both hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) 1, 2
• For patients who are HBsAg positive or anti-HBc positive, the American College of Rheumatology strongly recommends prophylactic antiviral therapy over monitoring alone when initiating rituximab 2

Infection Prophylaxis Considerations

• The American Thoracic Society recommends considering prophylaxis for Pneumocystis pneumonia in all patients receiving rituximab, especially those on concurrent immunosuppression 3
• The Centers for Disease Control and Prevention advises that patients should NOT receive live vaccines before or during rituximab treatment, and that non-live vaccines should be administered before starting rituximab whenever possible 4

Immunosuppression Management

• The European Society for Medical Oncology recommends planning for reduction of immunosuppressive therapy combined with rituximab when clinically feasible, as reduction of immunosuppression alone is rarely successful for PTLD and may increase graft-versus-host disease risk in HSCT recipients 1, 5, 6

Critical Pitfalls to Avoid

• The American Society of Hematology advises never using antiviral drugs for EBV-PTLD treatment or prophylaxis, as they are completely ineffective against EBV 1
• The American College of Rheumatology emphasizes the importance of not overlooking HBV screening, as reactivation can be fatal 2

Ongoing Monitoring During Treatment

• The American Thoracic Society recommends monitoring for signs of infection continuously, including fever, new respiratory symptoms, and unusual fatigue 3