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Side effects and safety
Hepatitis B Reactivation and Rituximab: — The Test You Must Not Skip
Hepatitis B can lie dormant for years and come back aggressively when rituximab depletes the immune cells that keep it in check. Reactivation can cause liver failure and is potentially fatal — but it is also largely preventable when the right tests are done before treatment begins.
Medically reviewed by Dr. Bharati Devi Gorantla, Medical Oncologist, MBBS · MD · DM (Adyar, Chennai) · ECMO · MRCP SCE (UK) · Last reviewed August 2026
- Past infection carries its own risk — Even if you were told your hepatitis B resolved years ago, rituximab can wake it up.
- Symptoms come late — By the time you feel unwell, liver damage may already be serious. Blood tests catch it earlier.
- It can happen after treatment ends — Reactivation can appear months after your last dose, not only during the infusions.
- Largely preventable — Screening before rituximab and antiviral medicine for those at risk dramatically reduces the danger.
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Hepatitis B reactivation during or after rituximab can cause liver failure and is potentially fatal. NCCN and ASCO require testing for hepatitis B before rituximab begins, and antiviral medicine for those at risk. If you develop yellowing of skin or eyes, dark urine, or abdominal pain, go to hospital today — do not wait.
Normal tiredness after rituximab, or a liver warning sign?
| Feature | Expected after rituximab | Possible reactivation — call your team today |
|---|---|---|
| Fatigue | Common, improves gradually | Sudden new worsening, especially with abdominal symptoms |
| Urine colour | Normal yellow | Dark, orange or tea-coloured |
| Skin or eye colour | Unchanged | Yellow tinge in the whites of the eyes or on the skin |
| Nausea | Mild, most common in the first days after infusion | Persistent, worsening, with abdominal pain |
| Abdominal comfort | Mild and settles | Tenderness or pain, especially on the upper right side |
| Typically starts | Predictable pattern around each infusion | Weeks to months after starting treatment; can appear after the last dose |
What should I do at home while I am being monitored?
- Keep every scheduled blood test appointment — liver function tests can detect reactivation before you feel any symptoms.
- Tell your team the same day if your urine darkens, even if you feel otherwise well.
- Do not take any new medicine — including herbal, ayurvedic or over-the-counter — without checking with your oncology team first.
- Avoid alcohol completely throughout treatment and for the period your team advises afterwards.
- Write down any new symptom, however small, so you can describe it accurately when you call or attend.
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Why does rituximab cause hepatitis B to come back?
Rituximab works by depleting B-cells — the white blood cells your immune system uses to make antibodies. One of the things B-cells do is help keep the hepatitis B virus suppressed in people who have ever been exposed to it.
When B-cells are eliminated, that immune control is lifted. The virus can multiply rapidly in the liver. This can happen even if your hepatitis B was treated years ago and your liver tests were completely normal when you started rituximab.
The danger is that reactivation often begins silently. Blood tests rise before you feel unwell, which is why monitoring continues for an extended period after your last dose — not just while you are receiving infusions.
What should have happened before rituximab began?
NCCN, ASCO and ESMO guidance requires every patient to be tested for hepatitis B before rituximab begins. Two tests are needed: one that detects active infection, and one that detects past exposure. Both matter, because past exposure carries its own risk of reactivation.
If either test shows active or past hepatitis B, antiviral medication is started before rituximab begins and continued for a defined period after treatment ends. This prophylaxis dramatically reduces the risk.
If you were not asked about hepatitis B, or do not know whether these tests were done, raise it with your oncology team today. It is not too late to check.
Did you know?
Hepatitis B reactivation caused by rituximab has been reported in patients who had no symptoms and whose liver tests were completely normal at the start of treatment.
Routine screening before rituximab was introduced by global oncology bodies specifically because reactivation was being missed until it had already caused severe liver damage.
Source: ASCO Clinical Practice Guideline on Prevention of Hepatitis B Virus Reactivation in Patients With Hematologic Malignancies
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Common questions
Frequently asked questions
I had hepatitis B years ago and was told I recovered. Am I still at risk from rituximab?
Yes, and this is one of the most important points to understand. Past hepatitis B infection — even when it was successfully resolved and your blood tests have been normal for years — still leaves viral material in your liver cells. Rituximab's depletion of B-cells can allow that dormant virus to reactivate. NCCN and ASCO guidance treats past exposure as a reason for antiviral prophylaxis before rituximab begins, not just active infection. Tell your oncology team your history and ask whether both hepatitis B tests were done and what they showed.
What antiviral medicine is used, and will I need to take it long term?
Your oncologist will prescribe an antiviral based on your individual test results and your treatment plan. How long you take it depends on your hepatitis B status and the duration of your rituximab treatment — antiviral medicine is typically continued for a defined period after your last rituximab dose, not just during the infusions themselves. Do not stop the antiviral without being told to by your team, even if you feel completely well, because reactivation risk continues after treatment ends.
How long after my last rituximab dose can reactivation still happen?
Reactivation can occur for months after your final dose of rituximab, because the drug continues to suppress B-cells for an extended period after it is given. NCCN and ASCO monitoring recommendations reflect this extended window — monitoring and, where prescribed, antiviral prophylaxis continue well after your last infusion. Tell any new doctor you see for any reason that you have received rituximab recently, so they have the full picture if a liver symptom arises.
Can I still have rituximab if I have active hepatitis B?
In most cases, yes — but only after antiviral treatment has been established and your hepatitis B is being actively managed. The decision is made jointly between your oncologist and, in many cases, a hepatologist or infectious disease specialist. Delaying rituximab until hepatitis B is under control is usually safer than proceeding without it. The risk of leaving a lymphoma untreated has to be weighed carefully, and your team will make that judgement with you based on your individual situation.
What blood tests will I need, and how often?
Before rituximab begins, you need tests to detect both active infection and past exposure to hepatitis B — ask your team to confirm both were done and what the results showed. During treatment and afterwards, liver function tests are checked regularly. If you were prescribed antiviral medicine, additional tests may monitor whether the virus remains suppressed. The exact schedule depends on your hepatitis B status and treatment plan. Ask your team when your next liver test is scheduled so you are not waiting without a clear timeline.