Viral reactivation and clinical hepatitis in patients with hepatitis C who receive rituximab as part of chemotherapy for treatment of lymphoma: A case series.

Abstract

e18559 Background: Rituximab has been implicated in the reactivation of quiescent viruses, although its impact on Hepatitis C (HCV) remains poorly understood. We report outcomes from a case series of 9 HCV+ patients who received rituximab-based chemotherapy. Methods: We obtained IRB approval to perform a retrospective chart review on HCV+ patients who received rituximab-based chemotherapy for lymphoma from 2001-08. Clinical hepatitis (CH) was defined as either an AST or ALT 2x ULN. Viral reactivation (VR) was defined at a viral load (VL) increase of 10x the pretreatment value. Results: Eight of 9 patients developed a CH within 12 months of exposure to r- chemo, average months to CH was 3.86. Five of 7 patients developed CH before VR, 2 of 7 patients develop CH after VR. Of the 5 patients whose CH occured before their VR, only 1 has a VL that increases at time of CH. Two of 5 patients do not have viral loads reported around the time of CH. Two of 5 do not have increasing VL at time of CH. Four of 6 VR occurred within 12 months, on average 7.25 months post exposure. Six of 8 patients with >2 VL had a VR. Of those 6, 4 had a VR within 12 months of being exposed to r-chemo. Average AST at VR was 89.6, average ALT at VR was 72.5 Two of the 3 HIV+ patients developed VR within 12 months of receiving r-chemo. The average time to VR was similar in the HIV+ (7.5 months) vs. in the HIV- (7 months) patients. One patient's chemo regimen was changed due to HCV reactivation. None of the patients received dose reduction in other chemo agents for hepatitic insufficiency and none developed hepatitic failure. Conclusions: In this study we noted a trend toward increasing LFTs and VLs in HCV+ patients who received rituximab-based chemotherapy. Patients were more likely to have a CH after exposure to rituximab, but were not more likely to have a CH following VR. This pattern makes it difficult to say whether CH was a marker of liver toxicity due to VR vs. ongoing chemo or other co-morbidities. Despite impaired cellular immunity, the 3 HIV+ patients had the same rate of VR as the HIV- patients. Our study illustrates the possible relationship between rituximab exposure and increasing VL, but no clear relationship could be determined between VR and CH. No significant financial relationships to disclose.