Comparison of entecavir and lamivudine in preventing HBV reactivation in lymphoma patients undergoing chemotherapy: a meta-analysis

Prevention and management of hepatitis B virus reactivation in patients with hematological malignancies in the targeted therapy era

Hepatitis due to hepatitis B virus (HBV) reactivation can be serious and potentially fatal, but is preventable. HBV reactivation is most commonly reported in patients receiving chemotherapy, especially rituximab-containing therapy for hematological malignancies and those receiving stem cell transplantation. Patients with inactive and even resolved HBV infection still have persistence of HBV genomes in the liver. The expression of these silent genomes is controlled by the immune system. Suppression or ablation of immune cells, most importantly B cells, may lead to reactivation of seemingly resolved HBV infection. Thus, all patients with hematological malignancies receiving anticancer therapy should be screened for active or resolved HBV infection by blood tests for hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen. Patients found to be positive for HBsAg should be given prophylactic antiviral therapy. For patients with resolved HBV infection, there are two approaches. The first is pre-emptive therapy guided by serial HBV DNA monitoring, and treatment with antiviral therapy as soon as HBV DNA becomes detectable. The second approach is prophylactic antiviral therapy, particularly for patients receiving high-risk therapy, especially anti-CD20 monoclonal antibody or hematopoietic stem cell transplantation. Entecavir and tenofovir are the preferred antiviral choices. Many new effective therapies for hematological malignancies have been introduced in the past decade, for example, chimeric antigen receptor (CAR)-T cell therapy, novel monoclonal antibodies, bispecific antibody drug conjugates, and small molecule inhibitors, which may be associated with HBV reactivation. Although there is limited evidence to guide the optimal preventive measures, we recommend antiviral prophylaxis in HBsAg-positive patients receiving novel treatments, including Bruton's tyrosine kinase inhibitors, B-cell lymphoma 2 inhibitors, and CAR-T cell therapy. Further studies are needed to determine the risk of HBV reactivation with these agents and the best prophylactic strategy.

Efficacy of nucleos(t)ide analogues(NAs) in preventing virus reactivation in oncology patients with HBV infection after chemotherapy or surgery: A network meta-analysis

Objective

In this study, we aimed to perform a network meta-analysis to compare the effectiveness of NAs in decreasing the reactivation of HBV, reducing chemotherapy disruption, and improving survival in oncology patients.

Methods

Relevant randomized controlled trials (RCT) evaluating the impact of NAs in HBV infected-related oncology patients were retrieved from electronic databases. The outcome indicators included reactivation rate, survival rate of 1 to 3 years after treatment, and chemotherapy disruption rate. The studies were evaluated for bias using the RCT risk of bias assessment tool recommended in the Cochrane Handbook. The risk ratio (RR) was used to compare the outcome indicators for the anti-viral treatment, and the surface under the cumulative ranking curves (SUCRA) was used to identify the optimal therapeutic regime.

Results

A total of 67 trials containing 5722 patients were included in this study. Regarding the reduction of reactivation rate, entecavir, lamivudine, adefovir alone were less effective than the combination of lamivudine and entecavir (94.9%), with RR values ranging from 3.16 to 3.73. However, based on SUCRA, the efficacy of telbivudine (80.3%) and the combination of lamivudine and adefovir dipivoxil (58.8%) were also acceptable. Entecavir (RR values ranging from 1.25 to 1.50) and lamivudine (RR values ranging from 1.27 to 1.35) can prolong the survival rate of patients at 1-3 years, and were better than adefovir dipivoxil in the comparison of 1-year survival rate. The RR values were 1.18 and 1.19, respectively. And entecavir 's ranking in SUCRA was more stable. Entecavir, lamivudine, and tenofovir all reduced chemotherapy interruption rates compared with no antiviral therapy, especially for tenofovir.

Conclusions

Current evidence shows that lamivudine combined with entecavir, telbivudine, and lamivudine combined with adefovir dipivoxil were the most effective in preventing virus reactivation in HBV infected-related cancer patients treated with chemotherapy. Entecavir had the most stable effect on survival, while tenofovir had the best impact on reducing the chemotherapy disruption rate. Due to limited quality and quantity of the included studies, more high-quality studies are required to verify the above conclusions.

Systematic review registration

PROSPEROI [https://www.crd.york.ac.uk/PROSPERO/index.php], identifier CRD4202250685.

Resolved hepatitis B infection in patients receiving immunosuppressive therapy: Monitor versus prophylaxis against viral reactivation

Risk of hepatitis B virus reactivation (HBVr) in patients with resolved HBV infection receiving immunosuppressive therapy has been a growing concern, particularly in the era of biological and targeted therapies. HBV monitoring versus antiviral prophylaxis against HBVr in those patients remains controversial. The aim of the study was to determine the incidence of HBVr and HBV-related hepatitis in resolved HBV patients who received immunosuppressive therapy with or without antiviral prophylaxis. This retrospective study included 64 patients with resolved HBV infection who received different regimens of immunosuppressive medications, with moderate risk of HBVr, for variable underlying diseases. Patients who had chronic HBV infection or other viral infections were excluded. Patients who received B-cell depleting therapies were ruled out. They were divided into 2 groups: group 1 included 31 patients who received immunosuppressive therapy without antiviral prophylaxis, and group 2 included 33 patients who received antiviral prophylaxis (entecavir) within 2 weeks of commencing the immunosuppressive therapy. HBVr, HBV-related hepatitis, and HBV-unrelated hepatitis were assessed along a 1-year duration. The overall HBVr incidence was 1.56% (1/64). This patient who had HBVr was seen in group 1. There were no significant differences between the 2 groups regarding the incidence of HBVr, HBV-related hepatitis, HBV-unrelated hepatitis, and immunosuppressive therapy interruption along a 1-year duration. Based on this retrospective study, close monitoring was equal to antiviral prophylaxis regarding the outcome of resolved HBV patients who received moderate risk immunosuppressive therapy. HBV treatment should commence once HBVr is confirmed.

Risk of Hepatitis B Virus (HBV) Reactivation in Patients with Immune-Mediated Inflammatory Diseases Receiving Biologics: Focus on the Timing of Biologics after Anti-HBV Treatment

Background/Aims

Anti-hepatitis B virus (HBV) therapy is required for patients with HBV infection receiving biologics because of the high risk of HBV reactivation. However, it is unclear when to start biologics after anti-HBV treatment. We investigated the risk of HBV reactivation according to the timing of biologics initiation after anti-HBV treatment in immune-mediated inflammatory disease (IMID) patients with HBV infection.

Methods

We retrospectively evaluated the incidence of HBV reactivation in IMID patients who received biologics between July 2005 and April 2020. The patients were divided into two groups (within 1-week and after 1-week) according to the timing of biologics initiation after anti-HBV treatment. The cumulative probabilities and factors associated with HBV reactivation were evaluated.

Results

A total of 60 hepatitis B surface antigen-positive patients with IMID received biologics (within 1-week group, n=23 [38%]; after 1-week group, n=37 [62%]). During a median follow-up of 34 months (interquartile range, 20 to 74 months), three patients (5%) developed HBV reactivation. In univariate analysis, the timing of biologics after anti-HBV treatment was not significantly associated with the risk of HBV reactivation (hazard ratio, 0.657; 95% confidence interval, 0.059 to 7.327; p=0.733). The cumulative probabilities of HBV reactivation did not significantly differ according to the timing of biologics (p=0.731).

Conclusions

The risk of HBV reactivation was not significantly associated with the timing of biologics administration after anti-HBV treatment. Thus, biologics may be initiated early in patients with IMID undergoing treatment for HBV.

Comparison of Tenofovir Disoproxil Fumarate and Entecavir in the Prophylaxis of HBV Reactivation

INTRODUCTION

Current guidelines recommend starting antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in patients receiving immunosuppressive treatments (IST). The aim of this study was to compare the efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) for prophylaxis.

METHODS

Patients, who were HBsAg and/or anti-HBc IgG positive and scheduled to receive IST for oncologic and hematologic diseases, were enrolled into the study. Those who were already receiving an antiviral treatment for HBV or had an associated HIV, hepatitis C, D were excluded. The remaining patients with a prophylaxis indication according to the AGA guideline were randomized to receive either ETV (0.5 mg/day) or TDF (245 mg/day). Prophylaxis was continued for 6-12 months after completion of IST. Patients were followed up for 1 year after completion of prophylaxis. The HBV reactivation rates and side effects of the drugs were compared.

RESULTS

The study group included 120 patients. There was no significant difference between the demographic data, viral serologic parameters and reactivation risk profiles of the ETV (n = 60) and TDF (n = 60) groups. Forty-one patients in the ETV and 36 in the TDF group completed the antiviral prophylaxis, and no HBV reactivation was observed. HBV reactivation was observed in 4 of 37 patients (10.8%) in the ETV group and 5 of 35 (14.3%) patients in the TDF group (including one with flare) during the follow-up after completion of prophylaxis. Ten patients in the ETV group (16.7%) and 14 patients (23.3%) in the TDF group experienced side effects (p = 0.77). One patient in the TDF group had to switch to ETV due to severe itchy, maculopapular rash-like lesions.

CONCLUSIONS

ETV and TDF had a similar efficacy in the prophylaxis of HBV reactivation in patients undergoing IST, with none of the patients experiencing reactivation.

HBV Reactivation During the Treatment of Non-Hodgkin Lymphoma and Management Strategies

Hepatitis B virus reactivation (HBV-R), which can lead to HBV-related morbidity and mortality, is a common and well-known complication that occurs during the treatment of non-Hodgkin lymphoma (NHL) patients with current or past exposure to HBV infection. HBV-R is thought to be closely associated with chemotherapeutic or immunosuppressive therapies. However, immunosuppressive agents such as anti-CD20 antibodies (e.g., rituximab and ofatumumab), glucocorticoids, and hematopoietic stem cell transplantation (HSCT) administered to NHL patients during treatment can cause deep immunodepression and place them at high risk of HBV-R. In this review, we explore the current evidence, the guidelines of several national and international organizations, and the recommendations of expert panels relating to the definition, risk factors, screening and monitoring strategies, whether to use prophylaxis or pre-emptive therapy, and the optimal antiviral agent and duration of antiviral therapy for HBV-R.

Management of Hepatitis B Virus Reactivation in Malignant Lymphoma Prior to Immunosuppressive Treatment

Hepatitis B reactivation is a common complication in lymphoma patients under immunosuppressive treatment with potentially serious and life-threating consequences. In this review, we discuss the basis of chronic Hepatitis B virus (HBV) infection, the definition and risk factors for HBV reactivation. We overview the management of HBV reactivation based on virological status and immunosuppressive regimen risk stratification. We also highlight and update information about the HBV reactivation in lymphoma patients under novel agent treatment, including newer monoclonal antibodies, small molecule inhibitors, and even chimeric antigen receptor T-cell immunotherapy.

Management of Hepatitis-B Virus Infection in Immunocompromised Children: A Single Center Experience

OBJECTIVES

The aims of the study was to expand the pediatric experience on hepatitis-B virus (HBV) reactivation, a known complication in patients with hematologic malignancies or on immunosuppression.

METHODS

Retrospective appraisal of HBV therapy/prophylaxis in immunocompromised children, studied from April 2006 to March 2020.

RESULTS

Eighteen HBV-positive patients, 5 girls, median age 11.1 (4.1--17.9) years were included. Seventeen of 18 were immunosuppressed at HBV-infection diagnosis. Seventeen were at high risk of reactivation, 1 at moderate risk. Five of 18 had acute hepatitis B as first infection or reactivation, 6 had HBeAg-positive infection, 1 an HBeAg-negative infection and 6 HBsAg-negative infection. Median follow-up was 2.7 (0.7--12.5) years. No HBV-related mortality was observed. Prophylaxis had to be repeated in 1. Lamivudine was used in 6/12 viremic patients and HBV-DNA negativization obtained in 2/6 (33%). Tenofovir-DF was used in 2/12 and entecavir in 4/12: 100% attained HBV-DNA negativization. Therapy had to be switched from tenofovir-DF to entecavir in 1 patient because of renal impairment. Virological breakthroughs were observed in 1 lamivudine-treated patient, leading to a hepatitis flare; 1 patient on entecavir had a hepatitis flare at immunoreconstitution. Mortality was 33% in the HBsAg-positive group. Seven prophylactic treatments were administered to 6 patients with HBsAg-negative infection: tenofovir-DF in 2 HBV-DNA-positive, lamivudine in 5 HBV-DNA-negative, without reverse HBsAg seroconversion, morbidity or mortality.

CONCLUSIONS

There is a residual risk of acute hepatitis B in immunocompromised children, mortality rate was substantial, potentially related to the delays in commencing chemotherapy caused by liver dysfunction. Tenofovir-DF or entecavir are the drugs of choice for HBV treatment in immunocompromised children.

[Prophylactic Antiviral Treatment in Immunosuppressed Chronic Hepatitis B Patients]

Improved management of chronic hepatitis B patients with oral nucleos(t)ide analogues has increased the number of these patients who are getting older and have other accompanying comorbidities. These comorbidities frequently require various immunosuppression treatments and/or cytotoxic chemotherapy. Not only the patients who are positive for HBsAg, but also the patients who are positive for isolated anti-HBc are at risk for hepatitis B reactivation during immunosuppression. Prophylactic antiviral treatment with oral nucleos(t)ide analogues with high genetic barriers can decrease the risks of HBV reactivation, HBV reactivation- associated hepatitis, and mortality in these patients. It is crucial to screen HBV markers in all of the patients who have to undergo immunosuppression, be administered prophylactic antiviral treatment in the high risk groups, and be monitored for HBV reactivation during and after immunosuppression and/or cytotoxic chemotherapy. This study summarizes the recommendations from the recently updated guidelines from Korea, United States, and Europe.

Prevention and management of viral hepatitis in inflammatory bowel disease: a clinical practice guideline by the Korean Association for the Study of Intestinal Diseases

The treatment of inflammatory bowel disease (IBD) has been revolutionized for the last 10 years by the increasing use of immunomodulators and biologics. With immunosuppression of this kind, opportunistic infection is an important safety concern for patients with IBD. In particular, viral hepatitis is determined by the interaction between the virus and the host's immunity, and the risk of reactivation increases if immunity is compromised by immunosuppression therapy. Parts of Asia, including Korea, still show intermediate endemicity for the hepatitis A virus and hepatitis B virus compared with the United States and Western Europe. Thus, members of IBD research group of the Korean Association for the Study of Intestinal Diseases have produced a guideline on the prevention and management of viral hepatitis in IBD.

Hematological Malignancies and HBV Reactivation Risk: Suggestions for Clinical Management

It is well known that hepatitis B virus reactivation (HBVr) can occur among patients undergoing treatment for hematological malignancies (HM). The evaluation of HBVr risk in patients undergoing immunosuppressive treatments is a multidimensional process, which includes conducting an accurate clinical history and physical examination, consideration of the virological categories, of the medication chosen to treat these hematological malignancies and the degree of immunosuppression induced. Once the risk of reactivation has been defined, it is crucial to adopt adequate management strategies (should reactivation occur). The purpose of treatment is to prevent dire clinical consequences of HBVr such as acute/fulminant hepatitis, and liver failure. Treatment will be instituted according to the indications and evidence provided by current international recommendations and to prevent interruption of lifesaving anti-neoplastic treatments. In this paper, we will present the available data regarding the risk of HBVr in this special population of immunosuppressed patients and explore the relevance of effective prevention and management of this potentially life-threatening event. A computerized literature search was performed using appropriate terms to discover relevant articles. Current evidence supports the policy of universal HBV testing of patients scheduled to undergo treatment for hematological malignancies, and clinicians should be aware of the inherent risk of viral reactivation among the different virological categories and classes of immunosuppressive drugs.

[Efficacy and prognostic analysis of relapsed/refractory diffuse large B-cell lymphoma patients with hepatitis B virus infection]

Objective: To evaluate the clinical and prognostic significance of hepatitis B virus infection on patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). Methods: A retrospective analysis was performed in 81 relapsed/refractory DLBCL cases who were treated with salvage regimens from January 2004 to November 2016. The patients were divided into two group, HBsAg positive and HBsAg negative group, and assessed the clinical features and survival time of two groups. Results: Twenty-four (29.6%) patients were HBsAg positive and 57(70.4%) were negative. HBsAg-positive DLBCL patients showed unique clinical features, including more younger patients (P=0.005), more advanced Ann Arbor stage (P<0.001), high-risk IPI (P=0.010), more hypohemoglobin (P=0.015), especially extra-nodal involvement (P=0.038) and recurrence (P=0.002). Overall response rate (29.2% vs 68.4%, χ(2)=10.720, P=0.001) and median overall survival time [(11.3±2.9) months vs (30.0±7.6) months, χ(2)=28.175, P<0.001] were inferior in HBsAg-positive patients, respectively. Conclusion: To strictly control HBV infection plays an important role on the survival and prognosis of relapsed/refractory lymphoma patients.

Antiviral prophylaxis for preventing reactivation of hepatitis B virus in rheumatic patients: a systematic review and meta-analysis

To estimate the risk of reactivation of hepatitis B virus (HBV) and evaluate the effectiveness of antiviral prophylaxis (AVP) in patients with different status of HBV infection undergoing antirheumatic therapies. We searched Cochrane Library, Medline, and EMBASE for randomized controlled trials (RCTs), quasi-RCTs, non-RCTs, cohort studies, or case series studies examining reactivation of HBV in patients undergoing antirheumatic therapy with or without AVP. We estimated the HBV reactivation rate (HRR) and its 95% confidence interval (CI) among different patient groups (indirect comparison). We also calculated rate ratio (RR), rate difference (RD) with their 95% CIs, and the number needed to treat (NNT) of AVP (direct comparison). Fifty-three case series studies with 2162 patients were included. The RD of AVP was - 0.13 (95% CI - 0.21 to - 0.05) for all patients, - 0.16 (95% CI - 0.26 to - 0.06) for rheumatic patients with chronic HBV infection, but not statistically significant for patients with other status of HBV infection. Lamivudine (RD - 0.10, 95% CI - 0.25 to 0.05) was less effective than other prophylactic antiviral drugs (RD - 0.31, 95% CI - 0.52 to - 0.11). The HHR varied from 55 to 5% by HBV status and treatment. There is limited evidence that AVP was effective for preventing reactivation of HBV in patients undergoing antirheumatic therapy. The effectiveness varies by patient HBV status and antiviral regimens. Rheumatic HBV carriers may be more beneficial from AVP, and lamivudine may be inferior to other AVP regimens. Findings in this study warrant further investigation in rigorous RCTs.

Entecavir-based combination therapies for chronic hepatitis B: A meta-analysis

BACKGROUND

Currently, there is no consensus on the efficacy and safety of the entecavir (ETV) monotherapy versus the ETV-based combination therapy for chronic hepatitis B.

METHODS

A comprehensive literature search was performed on the comparison of ETV-based combination therapy and monotherapy for chronical hepatitis B (CHB) patients in the PubMed, Embase, Web of Science, the Cochrane Libraries, and the Chinese BioMedical Literature Database. Both dichotomous and continuous variables were extracted, and pooled outcomes were expressed as odds ratio (OR) or mean difference (MD).

RESULTS

We included randomized clinical trials (RCTs) and cohorts involving Group A: nucleos(t)ide-naive patients (four RCTs, n = 719 patients), Group B: nucleos(t)ide-resistant patients (four cohorts, n = 196 patients), and Group C: entecavir-treated patients with undetectable hepatitis B virus DNA (two RCTs and two cohorts, n = 297). Group A. ETV monotherapy was better for rates of undetectable HBV DNA, while the rates of the HBV DNA levels at the end of treatment, HBeAg Loss, ALT normalization were similar between the two groups [MD, -0.85 (95% CI, -0.173-0.03); OR, 0.92 (95% CI, 0.24-3.56); OR, 1.31 (95% CI, 0.17-9.82)]; Group B. ETV monotherapy was better for rates of undetectable HBV DNA, while the rates of the HBV DNA levels at the end of treatment, HBeAg Loss, ALT normalization were similar; Group C. The ETV-based combination therapy was better for the rate of HBV DNA relapse.

CONCLUSION

Based on the current data, ETV-based combination therapy seemed to be no better than ETV monotherapy. Further studies are needed to verify this conclusion.

Tenofovir alafenamide associated fatal lactic acidosis in an autologous hematopoietic stem cell transplant recipient

Fatal lactic acidosis has been reported while on the treatment with Nucleoside/nucleotide analogues (NA) for the treatment of hepatitis B, C and HIV. No cases of such a complication have been reported in hematopoietic stem cell transplant (HSCT) recipients. We present a 65-year male who underwent autologous HSCT for the treatment of multiple myeloma. Prior to transplant he was started on single agent tenofovir alafenamide (TAF) for treatment of resolved hepatitis B infection. He presented few weeks later with severe lactic acidosis. Other causes of lactic acidosis were excluded. The patient died of multi-organ failure despite stopping TAF and aggressive supportive care. The case demonstrates the need for increased awareness of this potential complication of NA treatment in the course of transplantation.

Scoring system for risk stratification of viral reactivation during prophylactic antiviral treatment in Korean patients with hepatitis B undergoing anticancer chemotherapy: A multicenter study

Prophylactic antiviral therapy is recommended for hepatitis B virus (HBV)-infected patients with malignancies who are undergoing systemic chemotherapy. In the current study, we aimed to develop a risk scoring system to guide the selection of prophylactic antiviral agents. In this retrospective analysis, we included consecutive chronic hepatitis B patients who received antiviral prophylaxis for chemotherapy of solid or hematologic malignancies at three large-volume hospitals in Korea. The primary endpoint was HBV reactivation. The inverse probability treatment weighting method was used to minimize selection bias in terms of antiviral assignments. A total of 419 patients were enrolled: 129 patients received lamivudine (LAM), 216 received telbivudine (LdT), and 74 received entecavir (ETV), respectively. Of these, 36 patients developed on-treatment HBV reactivation (LAM, 17; LdT, 18; ETV, 1). Multivariate analysis identified three independent predictors for reactivation: hepatitis B e-antigen positivity, HBV DNA level, and type of malignancy. Accordingly, a risk scoring system was developed wherein one point was assigned for each of the risk factors. HBV reactivation occurred more frequently in the high-risk group (score ≥ 2) than in the low-risk group (hazards ratio, 14.17; P < 0.001). ETV exhibited superior prophylactic efficacy over LdT or LAM in the high-risk group, whereas no significant difference was noted in the low-risk group. The prognostic scoring system was useful for risk stratification of chemotherapy-related HBV reactivation. High genetic barrier agents appear to be vital for high-risk patients, whereas cost-effectiveness may be more relevant for low-risk patients.

Hepatitis B virus (HBV) reactivation-The potential role of direct-acting agents for hepatitis C virus (HCV)

Hepatitis C virus (HCV) is known to inhibit hepatitis B virus (HBV) replication in patients with HBV/HCV coinfection. Reactivation of HBV in patients treated for HCV with direct-acting agents (DAAs) has emerged recently as an important clinical consideration. A growing number of case reports and case series support the association between new HCV treatments and HBV reactivation. Yet, very little is known about the specific viral characteristics that facilitate reactivation as functional characterization of the reactivated HBV has been conducted only rarely. This review provides the most recent data on HBV reactivation in the context of DAA initiation and highlights the existing viral genomic data from reactivating viruses. Current functional studies of HBV reactivation are largely limited by the retrospective identification of cases, no standardization of genomic regions that are studied with respect to HBV reactivation, and the lack of inclusion of nonreactivating controls to establish specific viral mutations that are associated with HBV reactivation. Importantly, none of these sequencing studies included cases of HBV reactivation after initiation of DAAs. While new HCV treatments have revolutionized care for HCV infected patients, HBV reactivation will likely increase in frequency, as DAAs are more commonly prescribed. Pretreatment determination of HBV status and thoughtful management of HBV coinfections will be necessary and lead to improved patient safety and yield optimal treatment results.

Antiviral therapies for managing viral hepatitis in lymphoma patients

INTRODUCTION

In patients with lymphoma the detection of positive hepatitis B or C viruses (HBV and HCV) serology involves crucial therapeutic consequences. In HBV-infected patients the serological profile of active (HBsAg-positive) or resolved (HBsAg-negative/anti-HBcAb-positive) infection is associated to differential risk of viral reactivation during rituximab-based therapy and require appropriate strategies of monitoring and of antiviral prophylaxis. In HCV-associated NHL patients consolidated data demonstrated that interferon (IFN)-based antiviral therapy (AT) is able to induce lymphoma regression strictly related to viral eradication, while preliminary data of the new direct-acting antivirals (DAAs) are very promising. Areas covered: This review summarizes current evidences about HBV reactivation risk in patients undergoing rituximab-based treatments and appropriate options of antiviral prophylaxis with lamivudine, entecavir or tenofovir, as well as pre-emptive strategy in HBsAg-negative/HBcAb-positive patients. Moreover previous experiences with IFN-based AT as well as recent studies with DAAs in HCV-associated indolent lymphomas or diffuse large B-cell lymphoma (DLBCL) are reviewed. Expert opinion: Entecavir or tenofovir prophylaxis is recommended for HBsAg-positive patients, while universal prophilaxis with lamivudine may be preferred in HBsAg-negative/anti-HBc-positive patients. In asymptomatic patients with HCV-associated indolent lymphoma DAA-based AT should be used as first-line option, while in DLBCL its deliver after immunochemotherapy-induced complete remission is suggested.