Rituximab administration can result in serious, including fatal, infusion reactions. Deaths within 24 hours of rituximab infusion have been reported. Approximately 80% of fatal infusion reactions occurred in association with the first infusion.
Monitor patients closely. Discontinue rituximab infusion for severe reactions and administer medical treatment for grade 3 or 4 infusion reactions.
Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab.
Hepatitis B virus (HBV) reactivation can occur in patients treated with rituximab, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with rituximab. Discontinue rituximab and concomitant medications in the event of HBV reactivation.
Progressive multifocal leukoencephalopathy (PML) and death can occur in patients receiving rituximab.
Note: Pretreatment with acetaminophen and an antihistamine is recommended for all indications. For oncology uses, antihyperuricemic therapy and aggressive hydration are recommended for patients at risk for tumor lysis syndrome (high tumor burden or lymphocytes >25,000/mm3). In patients with chronic lymphocytic leukemia (CLL), Pneumocystis jirovecii pneumonia (PCP) and antiherpetic viral prophylaxis is recommended during treatment (and for up to 12 months following treatment). In patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), PCP prophylaxis is recommended during and for 6 months after rituximab treatment. For patients with rheumatoid arthritis (RA), premedication with methylprednisolone 100 mg IV (or equivalent) is recommended 30 minutes prior to each dose.
Chronic lymphocytic leukemia: IV: 375 mg/m2 on the day prior to fludarabine/cyclophosphamide in cycle 1, then 500 mg/m2 on day 1 (every 28 days) of cycles 2 to 6 (in combination with fludarabine and cyclophosphamide)
Chronic lymphocytic leukemia (off-label combinations): IV: 375 mg/m2 on the day prior to bendamustine in cycle 1, then 500 mg/m2 on day 1 (every 28 days) of cycles 2 to 6 (in combination with bendamustine) (Eichorst 2016) or 375 mg/m2 on day 1, followed by 500 mg/m2 every 14 days for 4 doses and then 500 mg/m2 every 28 days for 3 doses (in combination with idelalisib) (Furman 2014)
Granulomatosis with polyangiitis (GPA; Wegener granulomatosis): IV: 375 mg/m2 once weekly for 4 doses (in combination with methylprednisolone IV for 1 to 3 days followed by daily prednisone)
Microscopic polyangiitis (MPA): IV: 375 mg/m2 once weekly for 4 doses (in combination with methylprednisolone IV for 1 to 3 days followed by daily prednisone)
Non-Hodgkin lymphoma (NHL; relapsed/refractory, low-grade or follicular CD20-positive, B-cell): IV: 375 mg/m2 once weekly for 4 or 8 doses (as a single agent)
Re-treatment following disease progression: 375 mg/m2 once weekly for 4 doses
For maintenance therapy (as a single agent, in patients with response to induction therapy), the following recommendations have been made: IV: 375 mg/m2 every 3 months until disease progression or maximum duration of 2 years (Rituxan IV Canadian product labeling 2016)
NHL (diffuse large B-cell): IV: 375 mg/m2 given on day 1 of each chemotherapy cycle for up to 8 doses (in combination with CHOP chemotherapy [or other anthracycline-based regimen])
NHL (follicular, CD20-positive, B-cell, previously untreated): IV: 375 mg/m2 given on day 1 of each chemotherapy cycle for up to 8 doses (in combination with first-line chemotherapy)
Maintenance therapy (as a single agent, in patients with partial or complete response to rituximab plus chemotherapy; begin 8 weeks after completion of rituximab in combination with chemotherapy): IV: 375 mg/m2 once every 8 weeks for 12 doses
NHL (nonprogressing, low-grade, CD20-positive, B-cell, after 6 to 8 cycles of first line CVP are completed): IV: 375 mg/m2 once weekly for 4 doses every 6 months for a maximum of 16 doses (as a single agent)
NHL: Combination therapy with ibritumomab: IV: 250 mg/m2 IV day 1; repeat in 7 to 9 days with ibritumomab (also see Ibritumomab monograph)
Rheumatoid arthritis: IV: 1,000 mg on days 1 and 15 (in combination with methotrexate); subsequent courses may be administered every 24 weeks (based on clinical evaluation), if necessary may be repeated no sooner than every 16 weeks
Antibody-mediated rejection in cardiac transplantation, treatment (off-label use): IV: 375 mg/m2 once weekly for 1 to 4 doses (AHA [Colvin 2015]; ISHLT [Costanzo 2010]) or 1,000 mg on days 7 and 21 or on days 7 and 22 (AHA [Colvin 2015])
Autoimmune hemolytic anemia, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses (may continue systemic corticosteroids); a second course may be administered for relapse (Gobert 2011; Reynaud 2015; Roumier 2014)
Burkitt lymphoma (off-label use): IV: 375 mg/m2 on day 1 and 11 of cycles 1 and 3 and days 2 and 8 of cycles 2 and 4 (Thomas 2006) or 375 mg/m2 at the start of each chemotherapy cycle, followed by 2 additional doses 3 and 6 weeks after the completion of chemotherapy (Hoelzer 2014) or 50 mg/m2 on day 8 and 375 mg/m2 on days 10 and 12 of cycle 2 followed by 375 mg/m2 on day 8 of cycles 3 to 7 (Rizzieri 2014).
CNS lymphoma (off-label use): IV:
Newly diagnosed: 375 mg/m2 on day 3 every 14 days (in combination with high-dose methotrexate) until disease progression or unacceptable toxicity, or for 2 doses beyond a complete response followed by monthly treatments for up to a total of 1 year (Holdhoff 2014) or 500 mg/m2 on day 1 of each cycle for 5 to 7 induction cycles (in combination with high-dose methotrexate, vincristine, and procarbazine, followed by whole-brain radiotherapy and cytarabine consolidation) (Shah 2007)
Refractory disease: 375 mg/m2 on day 1 every 28 days (in combination with temozolomide) for 4 cycles, then followed by temozolomide monotherapy (Wong 2004)
Graft-versus-host disease (GVHD), chronic, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses; a second course of 4 weekly doses may be administered 8 weeks after initial therapy for lack of or incomplete response (Cutler 2006) or 375 mg/m2 once weekly for 4 to 8 doses (Wolff 2011)
Hodgkin lymphoma, nodular lymphocyte-predominate, advanced (off-label use): IV: 375 mg/m2 once weekly for 4 weeks (Ekstrand 2003; Schulz 2008) or 375 mg/m2 once weekly for 4 weeks followed by maintenance dosing of 375 mg/m2 once weekly for 4 weeks every 6 months for 2 years (Advani 2014). May be administered as a single agent or in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone [R-CHOP], or for relapsed disease, in combination with ifosfamide, carboplatin and etoposide [RICE]) (Advani 2013).
Idiopathic membranous nephropathy, resistant (off-label use): IV: 375 mg/m2 once weekly for 4 doses; repeat cycle at 6 months (Fervenza 2010) or 1,000 mg (flat dose) on days 1 and 15; may repeat cycle at 6 months (Fervenza 2008) or 375 mg/m2 once weekly for 2 doses (Dahan 2016) or 375 mg/m2 once weekly for 4 doses (Ruggenenti 2012; Ruggenenti 2015) or 375 mg/m2 as a single dose and repeated at least 1 week later only if circulating B-cells >5/mm3 were detected (Ruggenenti 2012; Ruggenenti 2015)
Immune thrombocytopenia, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses (Arnold 2007; Godeau 2008; Provan 2010) or some patients may have a response with a dose of 100 mg (flat dose) once weekly for 4 weeks (Zaja 2010).
Lupus nephritis, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses (Diaz-Largares 2012; Melander 2009) or 1,000 mg (flat dose) on days 0 and 15 (Diaz-Largares 2012) or 500 to 1,000 mg (flat dose) on days 1 and 15 (Vigna-Perez 2006)
Mucosa-associated lymphoid tissue lymphoma (gastric), advanced (off-label use): IV: 375 mg/m2 once weekly for 4 doses (Martinelli 2005)
Myasthenia gravis, severe, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 weeks, then once a month for 2 months; repeat if symptomatic (Diaz-Manera 2012) or 375 mg/m2 once weekly for 4 weeks; may repeat if clinically indicated (Tandan 2017). Additional data may be necessary to further define the role of rituximab in the management of refractory myasthenia gravis.
Neuromyelitis optica, relapse prevention (off-label use): IV: 1,000 mg once every 2 weeks for 2 doses, repeat every 6 months or when monthly CD19 cells counts are >0.1% of total lymphocytes (Damato 2016; Mealy 2014; Trebst 2014) or 375 mg/m2 once weekly for 4 weeks, repeat every 6 months (Damato 2016; Trebst 2014). Additional data may be necessary to further define the role of rituximab in the prevention of neuromyelitis optica relapse.
Pemphigus vulgaris, newly diagnosed (off-label use): IV: 1,000 mg once every 2 weeks for 2 doses (in combination with prednisone), followed by 500 mg at months 12 and 18 (Joly 2017). Additional data may be necessary to further define the role of rituximab as initial therapy for newly diagnosed pemphigus vulgaris.
Pemphigus vulgaris, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses (some patients also continued immunosuppressant therapy); may repeat a second time (based on response) if needed (Cholera 2016; El Tal 2006; Kasperkiewicz 2008) or 375 mg/m2 once weekly of weeks 1, 2, and 3 of a 4-week cycle, repeat for 1 additional cycle, then 1 dose per month for 4 months (total of 10 doses in 6 months), in combination with IV immune globulin (Ahmed 2006) or 1,000 mg once every 2 weeks for 2 doses (some patients also continued immunosuppressant therapy) (Cholera 2016; Kasperkiewicz 2008)
Posttransplant lymphoproliferative disorder (off-label use): IV: 375 mg/m2 once weekly for 4 doses (Choquet 2006) or 375 mg/m2 once weekly for 4 doses, followed 4 weeks later with 4 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy (Trappe 2012)
Splenic marginal zone lymphoma (off-label use): IV: 375 mg/m2 once weekly for 6 weeks followed by 375 mg/m2 once every 2 months for 1 to 2 years (Kalpadakis 2013) or 375 mg/m2 once weekly for 4 weeks as monotherapy or 375 mg/m2 on day 1 of each chemotherapy cycle for up to 6 cycles; 1 to 2 additional cycles of rituximab monotherapy may be administered for consolidation or to improve response (Else 2012). Additional data may be necessary to further define the role of rituximab in this condition.
Thrombotic thrombocytopenic purpura (acquired) (off-label use): IV: 375 mg/m2 once weekly for 4 doses (in combination with plasma exchange); up to 4 additional doses may be administered for ADAMTS13 levels remaining below normal or for persistently detectable anti-ADAMTS13 IgG antibodies (Scully 2007; Scully 2011). Rituximab should be timed to be administered immediately following plasma exchange; allow 24 hours after rituximab before the next plasma exchange (McDonald 2010; Sayani 2015).
Waldenström macroglobulinemia (off-label use): IV:
Single-agent rituximab: 375 mg/m2 once weekly for 4 weeks as a single agent; may repeat cycle one time after 12 weeks (Dimopoulos 2002).
In combination with cyclophosphamide and dexamethasone: 375 mg/m2 on day 1 every 21 days for 6 cycles (Dimopoulos 2007).
In combination with bortezomib: 375 mg/m2 on days 1, 8, 15, and 22 every 28 days during cycles 1 and 4; treatment is continued for 6 cycles, with a total of 8 rituximab doses (Ghobrial 2010).
In combination with bortezomib and dexamethasone: 375 mg/m2 on days 1, 8, 15, and 22 every 35 days during cycles 2 and 5; treatment is administered for 6 cycles, with a total of 8 rituximab doses (Dimopoulos 2013) or 375 mg/m2 on day 11 every 21 days for 4 cycles (induction); after a 12-week break, 4 additional maintenance cycles (spaced 12 weeks apart) were administered (Treon 2009).
In combination with bendamustine: 375 mg/m2 on day 1 every 28 days for 4 cycles; single rituximab doses were also administered 1 week prior to the first cycle and 4 weeks after the last cycles (for a total of 6 rituximab doses) (Rummel 2005).
In combination with carfilzomib and dexamethasone: 375 mg/m2 on days 2 and 9 every 21 days for 6 induction cycles, followed by 375 mg/m2 on day 2 every 8 weeks for 8 maintenance cycles (Treon 2014).
(For additional information see "Rituximab (intravenous): Pediatric drug information")
Note: Pretreatment with acetaminophen and an antihistamine is recommended.
Autoimmune hemolytic anemia, refractory (off-label use): IV: 375 mg/m2 once weekly for 2 to 4 doses (may continue systemic corticosteroids); a second course may be administered for relapse (Rao 2008; Zecca 2003).
Immune thrombocytopenia, refractory (off-label use): IV: 375 mg/m2 once weekly for 4 doses (Parodi 2009; Provan 2010; Wang 2005)
Nephrotic syndrome, severe, refractory (off-label use): IV: 375 mg/m2 once weekly for 2 to 4 doses or 375 mg/m2 (maximum dose: 500 mg) as a single dose (Dello Strologo 2009; Fujinaga 2010; Guigonis 2008; Prytula 2010). Additional data may be necessary to further define the role of rituximab in this condition.
Refer to adult dosing.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Dosage adjustments for rituximab are not recommended; however, adjustments for concomitant chemotherapy may be necessary.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous [preservative free]:
Rituxan: 10 mg/mL (10 mL, 50 mL) [contains polysorbate 80]
An FDA-approved patient medication guide, which is available with the product information and at http://www.fda.gov/downloads/Drugs/DrugSafety/UCM169892.pdf, must be dispensed with this medication.
Note: Some pediatric protocols utilize an alternate rituximab administration rate. Refer to specific protocol for administration rate guidelines.
IV: For IV administration only. Do not administer IV push or bolus. Do not administer IV rituximab subcutaneously. If an infusion reaction occurs, slow or stop the infusion. If the reaction abates, restart infusion at 50% of the previous rate. Discontinue infusion in the event of serious or life-threatening cardiac arrhythmias.
Initial infusion: Start infusion at a rate of 50 mg/hour; if there is no infusion reaction, increase the rate by 50 mg/hour increments every 30 minutes, to a maximum rate of 400 mg/hour.
Standard infusion rate: If patient tolerated initial infusion, start at 100 mg/hour; if there is no infusion reaction, increase the rate by 100 mg/hour increments every 30 minutes, to a maximum rate of 400 mg/hour.
Accelerated infusion rate (90 minutes): For patients with previously untreated follicular NHL and diffuse large B-cell NHL who are receiving a corticosteroid as part of their combination chemotherapy regimen, have a circulating lymphocyte count <5,000/mm3, or have no significant cardiovascular disease. After tolerance has been established (no grade 3 or 4 infusion-related event) at the recommended infusion rate in cycle 1, a rapid infusion rate may be used beginning with cycle 2. The daily corticosteroid, acetaminophen, and diphenhydramine are administered prior to treatment, then the rituximab dose is administered over 90 minutes, with 20% of the dose administered over the first 30 minutes and the remaining 80% is given over 60 minutes (Sehn 2007). If the 90-minute infusion in cycle 2 is tolerated, the same rate may be used for the remainder of the treatment regimen (through cycles 6 or 8).
Chronic lymphocytic leukemia: Treatment of previously untreated or previously treated CD20-positive chronic lymphocytic leukemia (CLL) (in combination with fludarabine and cyclophosphamide).
Granulomatosis with polyangiitis: Treatment of granulomatosis with polyangiitis (GPA; Wegener granulomatosis) (in combination with glucocorticoids).
Microscopic polyangiitis: Treatment of microscopic polyangiitis (MPA) (in combination with glucocorticoids).
Non-Hodgkin lymphomas: Treatment of CD20-positive non-Hodgkin lymphomas (NHL):
Relapsed or refractory, low-grade or follicular B-cell NHL (as a single agent)
Follicular B-cell NHL, previously untreated (in combination with first-line chemotherapy, and as single-agent maintenance therapy if complete or partial response to first-line rituximab with chemotherapy)
Nonprogressing (including stable disease), low-grade B-cell NHL (as a single agent after first-line CVP treatment)
Diffuse large B-cell NHL, previously untreated (in combination with CHOP chemotherapy [or other anthracycline-based regimen])
Rheumatoid arthritis: Treatment of moderately to severely active rheumatoid arthritis (in combination with methotrexate) in adult patients with inadequate response to one or more TNF antagonist therapies.
Limitations of use: Rituximab is not recommended for use in patients with severe, active infections.
Antibody-mediated rejection in cardiac transplantation (treatment); Autoimmune hemolytic anemia (refractory) (adults); Autoimmune hemolytic anemia (refractory) (children/adolescents); Burkitt lymphoma; CNS lymphoma; Graft-versus-host disease (chronic, steroid-refractory); Hodgkin lymphoma (nodular lymphocyte-predominant), advanced; Idiopathic membranous nephropathy (resistant); Immune thrombocytopenia (refractory) (adults); Immune thrombocytopenia (refractory) (children/adolescents); Lupus nephritis (refractory) (adults); Mucosa-associated lymphoid tissue lymphoma (gastric) (advanced); Myasthenia gravis (refractory); Nephrotic syndrome, severe, refractory (pediatrics); Neuromyelitis optica (relapse prevention); Pemphigus vulgaris (newly diagnosed); Pemphigus vulgaris (refractory); Post-transplant lymphoproliferative disorder; Splenic marginal zone lymphoma; Thrombotic thrombocytopenic purpura (acquired); Waldenström macroglobulinemia
Rituxan may be confused with Remicade, Rituxan Hycela
RiTUXimab may be confused with brentuximab, bevacizumab, inFLIXimab, obinutuzumab, ofatumumab, ramucirumab, rituximab and hyaluronidase, ruxolitinib
This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes that have a heightened risk of causing significant patient harm when used in error.
Rituximab is for intravenous (IV) administration only. Do not substitute rituximab and hyaluronidase (SubQ) for rituximab (IV). Use caution during product selection, preparation, and administration.
The rituximab dose for rheumatoid arthritis is a flat dose (1000 mg) and is not based on body surface area (BSA).
Patients treated with rituximab for rheumatoid arthritis (RA) may experience fewer adverse reactions.
Cardiovascular: Peripheral edema (8% to 16%), hypertension (6% to 12%)
Central nervous system: Fatigue (13% to 39%), chills (3% to 33%), neuropathy (≤30%), headache (17% to 19%), insomnia (≤14%), pain (12%)
Dermatologic: Skin rash (10% to 17%), pruritus (5% to 17%), night sweats (15%)
Endocrine & metabolic: Weight gain (11%)
Gastrointestinal: Nausea (8% to 23%), diarrhea (10% to 17%), abdominal pain (2% to 14%)
Hematologic & oncologic: Lymphocytopenia (48%; grades 3/4: 40%; median duration: 14 days), anemia (8% to 35%; grades 3/4: 3%), leukopenia (NHL: 14%, grades 3/4: 4%; CLL: grades 3/4: 23%; GPA/MPA: 10%), neutropenia (NHL: 14%, grades 3/4: 4% to 6%, median duration: 13 days; CLL: grades 3/4: 30% to 49%; late-onset: <1%, occurs >40 days after last dose), thrombocytopenia (12%; grades 3/4: 2% to 11%), cytopenia (may be prolonged), febrile neutropenia (CLL)
Hepatic: Increased serum ALT (≤13%)
Hypersensitivity: Angioedema (11%)
Immunologic: Antibody development (human antichimeric antibody [HACA] positive: 1% to 23%)
Infection: Infection (19% to 62%), bacterial infection (19%)
Neuromuscular & skeletal: Weakness (2% to 26%), muscle spasm (≤17%), arthralgia (6% to 13%)
Respiratory: Cough (13%), rhinitis (3% to 12%), epistaxis (≤11%)
Miscellaneous: Infusion related reaction (lymphoma: first dose: 77%, decreases with subsequent infusions and may include rigors; CLL: 59%, grades 3/4: 7% to 9%; RA: first infusion: 32%; GPA/MPA: 12%), fever (5% to 53%)
1% to 10%:
Cardiovascular: Hypotension (10%), flushing (5%)
Central nervous system: Dizziness (10%), anxiety (2% to 5%), migraine (RA: 2%), paresthesia (2%)
Dermatologic: Urticaria (2% to 8%)
Endocrine & metabolic: Hyperglycemia (9%), increased lactate dehydrogenase (7%)
Gastrointestinal: Vomiting (10%), dyspepsia (RA: 3%)
Infection: Viral infection (10%), fungal infection (1%)
Neuromuscular & skeletal: Back pain (10%), myalgia (10%)
Respiratory: Dyspnea (≤10%), throat irritation (2% to 9%), bronchospasm (8%), upper respiratory tract infection (RA: 7%), sinusitis (6%)
<1%, postmarketing and/or case reports: Acute mucocutaneous toxicity, acute renal failure, acute respiratory distress, anaphylactoid reaction, anaphylaxis, angina pectoris, aplastic anemia, arthritis (polyarticular), bone marrow depression, bronchiolitis obliterans, cardiac arrhythmia, cardiac failure, cardiogenic shock, encephalitis, fulminant hepatitis, gastrointestinal perforation, hemolytic anemia, hepatic failure, hepatitis, hypogammaglobulinemia (prolonged), hypoxia, increased serum immunoglobulins (hyperviscosity syndrome in Waldenstrom’s macroglobulinemia), interstitial pneumonitis, intestinal obstruction, intestinal perforation, Kaposi’s sarcoma (progression), laryngeal edema, lichenoid dermatitis, lupus-like syndrome, mucositis, myelitis, myocardial infarction, nephrotoxicity, optic neuritis, pancytopenia (prolonged), pemphigus (paraneoplastic; uncommon), pleurisy, pneumonia, pneumonitis, polymyositis, progressive multifocal leukoencephalopathy, pure red cell aplasia, reactivated tuberculosis, reactivation of HBV, reversible posterior leukoencephalopathy syndrome, serum sickness, Stevens-Johnson syndrome, supraventricular cardiac arrhythmia, toxic epidermal necrolysis, tumor lysis syndrome, uveitis, vasculitic rash, vasculitis (systemic), ventricular fibrillation, ventricular tachycardia, vesiculobullous dermatitis, viral infection (reactivation; includes JC virus infection, cytomegalovirus, herpes simplex virus, parvovirus B19, varicella-zoster virus, West Nile disease, and hepatitis C), wheezing
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Known type 1 hypersensitivity or anaphylactic reaction to murine proteins, Chinese Hamster Ovary (CHO) cell proteins, or any component of the formulation; patients who have or have had progressive multifocal leukoencephalopathy (PML); patients with severe, active infections
Concerns related to adverse effects:
• Bowel obstruction/perforation: Abdominal pain, bowel obstruction, and perforation have been reported (rarely fatal), with an average onset of symptoms of ~6 days (range: 1 to 77 days); evaluate abdominal pain or repeated vomiting.
• Cardiovascular effects: Discontinue infusion for serious or life-threatening cardiac arrhythmias. Perform cardiac monitoring during and after the infusion in patients who develop clinically significant arrhythmias or who have a history of arrhythmia or angina.
• Cytopenias: Rituximab is associated with lymphopenia, leukopenia, neutropenia, thrombocytopenia, and anemia; the duration of cytopenias may be prolonged and may extend months beyond treatment. Monitor blood counts.
• Hepatitis B virus reactivation: [US Boxed Warning]: Hepatitis B virus (HBV) reactivation may occur with rituximab and in some cases may result in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection prior to treatment initiation, and monitor patients during and after treatment with rituximab. Discontinue rituximab and concomitant medications in the event of HBV reactivation. Screening should include hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc); monitor patients for clinical and laboratory signs of hepatitis or HBV reactivation during and for several months after treatment. If viral hepatitis develops, initiate appropriate antiviral therapy. Reactivation has occurred in patients who are HBsAg positive as well as in those who are HBsAg negative but are anti-HBc positive; HBV reactivation has also been observed in patients who had previously resolved HBV infection. HBV reactivation has been reported up to 24 months after discontinuation. Use cautiously in patients who show evidence of prior HBV infection (eg, HBsAg positive [regardless of antibody status] or HBsAg negative but anti-HBc positive); consult with appropriate clinicians regarding monitoring and consideration of antiviral therapy before and/or during rituximab treatment. The safety of resuming rituximab treatment following HBV reactivation is not known; discuss reinitiation of therapy in patients with resolved HBV reactivation with physicians experienced in HBV management.
- American Society of Clinical Oncology (ASCO) provisional clinical opinion update on hepatitis B virus screening recommendations (Hwang 2015): Patients receiving anti-CD20 antibodies are at high risk for hepatitis B virus (HBV) reactivation. Screen for HBV infection with HBsAg and anti-HBc tests prior to treatment initiation; either a total anti-HBc (with both IgG and IgM) or anti-HBc IgG test should be used to screen for chronic or resolved HBV infection (do not use anti-HBc IgM as it may only confirm acute HBV infection). In addition, patients who have risk factors for HBV infection (eg, birthplace in a country with ≥2% HBV prevalence, household or sexual contact with HBV infected patients, high-risk behaviors [eg, intravenous drug use], and HIV infection) should also be screened prior to beginning therapy. Initiate prophylactic antiviral therapy (utilizing antivirals with low rates of viral resistance) for HBsAg positive/anti-HBc positive patients (without delaying cancer therapy) and continue the antivirals during and for ~6 to 12 months after completing treatment. HBsAg negative/anti-HBc positive patients should be monitored for HBV reactivation with HBV DNA and ALT testing approximately every 3 months during treatment; antiviral therapy may be initiated prophylactically or begun promptly at the first sign of HBV reactivation.
• Infections: Use is not recommended in patients with severe active infection. Serious and potentially fatal bacterial, fungal, and either new or reactivated viral infections may occur during treatment and after completing rituximab. Infections have been observed in patients with prolonged hypogammaglobulinemia, defined as hypogammaglobulinemia >11 months after rituximab exposure. Associated new or reactivated viral infections have included cytomegalovirus, herpes simplex virus, parvovirus B19, varicella zoster virus, West Nile virus, and hepatitis B and C. Discontinue rituximab (and concomitant chemotherapy) in patients who develop viral hepatitis and initiate antiviral therapy. Discontinue rituximab in patients who develop other serious infections and initiate appropriate anti-infective treatment.
• Infusion reactions: [US Boxed Warning]: Serious (including fatal) infusion-related reactions have been reported, usually with the first infusion; fatalities have been reported within 24 hours of infusion; monitor closely during infusion; discontinue for severe reactions and provide medical intervention for grades 3 or 4 infusion reactions. Reactions usually occur within 30 to 120 minutes and may include hypotension, angioedema, bronchospasm, hypoxia, urticaria, and in more severe cases pulmonary infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, cardiogenic shock, and/or anaphylactoid events. Closely monitor patients with a history of prior cardiopulmonary reactions or with preexisting cardiac or pulmonary conditions and patients with high numbers of circulating malignant cells (>25,000/mm3). Prior to infusion, premedicate patients with acetaminophen and an antihistamine (and methylprednisolone for patients with RA). Medications for the treatment of hypersensitivity reactions (eg, bronchodilators, epinephrine, corticosteroids, oxygen) should be available for immediate use; treatment is symptomatic. If infusion reaction occurs, temporarily or permanently discontinue infusion (depending on the severity of the reaction and required interventions). After symptoms resolve, infusion may be resumed with at least a 50% infusion rate reduction.
• Mucocutaneous reactions: [US Boxed Warning]: Severe and sometimes fatal mucocutaneous reactions (lichenoid dermatitis, paraneoplastic pemphigus, Stevens-Johnson syndrome, toxic epidermal necrolysis and vesiculobullous dermatitis) have been reported; onset has been variable but has occurred as early as the first day of exposure. Discontinue in patients experiencing severe mucocutaneous skin reactions; the safety of reexposure following mucocutaneous reactions has not been evaluated.
• Progressive multifocal leukoencephalopathy: [US Boxed Warning]: Progressive multifocal leukoencephalopathy (PML) due to JC virus infection has been reported with rituximab; may be fatal. Cases were reported in patients with hematologic malignancies receiving rituximab either with combination chemotherapy, or with hematopoietic stem cell transplant. Cases were also reported in patients receiving rituximab for autoimmune diseases who had received concurrent or prior immunosuppressant therapy. Onset may be delayed, although most cases were diagnosed within 12 months of the last rituximab dose. A retrospective analysis of patients (n=57) diagnosed with PML following rituximab therapy, found a median of 16 months (following rituximab initiation), 5.5 months (following last rituximab dose), and 6 rituximab doses preceded PML diagnosis. Clinical findings included confusion/disorientation, motor weakness/hemiparesis, altered vision/speech, and poor motor coordination with symptoms progressing over weeks to months (Carson 2009). Promptly evaluate any patient presenting with neurological changes; consider neurology consultation, brain MRI and lumbar puncture for suspected PML. Discontinue rituximab in patients who develop PML; consider reduction/discontinuation of concurrent chemotherapy or immunosuppressants.
• Renal toxicity: May cause fatal renal toxicity in patients with NHL. Patients who received combination therapy with cisplatin and rituximab for NHL experienced renal toxicity during clinical trials; this combination is not an approved treatment regimen. Renal toxicity also occurred due to tumor lysis syndrome. Monitor for signs of renal failure; discontinue rituximab with increasing serum creatinine or oliguria.
• Tumor lysis syndrome: Tumor lysis syndrome leading to acute renal failure requiring dialysis (some fatal) may occur within 12 to 24 hours following the first dose when used as a single agent in the treatment of NHL. Hyperkalemia, hypocalcemia, hyperuricemia, and/or hyperphosphatemia may occur. Administer prophylaxis (antihyperuricemic therapy, aggressive hydration) in patients at high risk (high numbers of circulating malignant cells ≥25,000/mm3 or high tumor burden). Correct electrolyte abnormalities; monitor renal function and hydration status, and administer supportive care as indicated.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Immunizations: Live vaccines should not be given concurrently with rituximab; there is no data available concerning secondary transmission of live vaccines with or following rituximab treatment. Rheumatoid arthritis patients should be brought up to date with nonlive immunizations (following current guidelines) at least 4 weeks before initiating therapy; response to some immunizations may be lower in some patients receiving rituximab.
• Elderly: Use with caution in the elderly. There is a higher risk of cardiac (supraventricular arrhythmia) and pulmonary adverse events (pneumonia, pneumonitis) and the incidence of serious infections and/or grade 3 or 4 adverse reactions are higher in elderly patients.
• Granulomatosis with polyangiitis (GPA; Wegener granulomatosis)/microscopic polyangiitis (MPA): The safety of concomitant immunosuppressants other than corticosteroids has not been evaluated in patients with GPA or MPA after rituximab-induced B-cell depletion. There are only limited data on subsequent courses of rituximab for GPA or MPA; safety and efficacy of re-treatment have not been established.
• Rheumatoid arthritis: There are limited data on the safety of other biologics or disease-modifying antirheumatic drugs (DMARDs) other than methotrexate in patients with rheumatoid arthritis with B-cell depletion following rituximab treatment. Monitor patients closely for infection if biologic agents or DMARDS are used concomitantly. The use of rituximab is not recommended in RA patients who have not had prior inadequate response to one or more TNF antagonists.
Dosage form specific issues:
• Administration: Rituximab is for IV administration only. Do not substitute rituximab and hyaluronidase (SubQ) for rituximab (IV). Use caution during product selection, preparation, and administration.
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer's labeling.
Abatacept: RiTUXimab may enhance the adverse/toxic effect of Abatacept. Risk X: Avoid combination
BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
Belimumab: Monoclonal Antibodies may enhance the adverse/toxic effect of Belimumab. Risk X: Avoid combination
Certolizumab Pegol: RiTUXimab may enhance the immunosuppressive effect of Certolizumab Pegol. Risk X: Avoid combination
Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy
CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor therapy
Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Risk C: Monitor therapy
Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Risk X: Avoid combination
Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Risk C: Monitor therapy
Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy modification
Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Risk D: Consider therapy modification
Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Risk D: Consider therapy modification
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Risk X: Avoid combination
Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Risk D: Consider therapy modification
Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Risk C: Monitor therapy
Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy
Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Risk X: Avoid combination
Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy
Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Risk D: Consider therapy modification
Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Risk C: Monitor therapy
Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Risk X: Avoid combination
Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Risk C: Monitor therapy
Tofacitinib: RiTUXimab may enhance the adverse/toxic effect of Tofacitinib. Risk X: Avoid combination
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Risk D: Consider therapy modification
Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Risk X: Avoid combination
C (show table)
Animal reproduction studies have demonstrated adverse effects including decreased (reversible) B-cells and immunosuppression. Rituximab crosses the placenta and can be detected in the newborn. In one infant born at 41 weeks' gestation, in utero exposure occurred from week 16 to 37; rituximab concentrations were higher in the neonate at birth (32,095 ng/mL) than the mother (9,750 ng/mL) and still measurable at 18 weeks of age (700 ng/mL infant; 500 ng/mL mother) (Friedrichs 2006).
B-cell lymphocytopenia lasting <6 months may occur in exposed infants. Retrospective case reports of inadvertent pregnancy during rituximab treatment collected by the manufacturer (often combined with concomitant teratogenic therapies) describe premature births and infant hematologic abnormalities and infections; no specific pattern of birth defects has been observed (limited data) (Chakravarty 2010).
Effective contraception should be used in women of reproductive potential during and for 12 months following treatment with rituximab.
The European Society for Medical Oncology has published guidelines for diagnosis, treatment, and follow-up of cancer during pregnancy. The guidelines recommend referral to a facility with expertise in cancer during pregnancy and encourage a multidisciplinary team (obstetrician, neonatologist, oncology team). Based on limited data, if pregnancy occurs during rituximab treatment, the pregnancy may continue provided rituximab treatment is withheld. In general, although the risk of B-cell depletion in the newborn is increased, if postponing rituximab treatment would significantly compromise maternal outcome in patients diagnosed with B-cell lymphoma during pregnancy, rituximab use is not discouraged during the pregnancy (Peccatori 2013). An international consensus panel has published guidelines for hematologic malignancies during pregnancy. In patients with aggressive lymphomas, rituximab (as a component of the R-CHOP chemotherapy regimen) may be administered in the second and third trimesters, however, the cytotoxic portion of the regimen should not be administered within 3 weeks prior to anticipated delivery (Lishner 2016).
Other agents are preferred for treating lupus nephritis in pregnant women (Hahn 2012). When treating rheumatoid arthritis, it is recommended to discontinue use and switch to a safer medication prior to conception unless no other pregnancy compatible medication is able to control maternal disease (Götestam Skorpen 2016).
Data collection to monitor pregnancy and infant outcomes following exposure to rituximab is ongoing. A pregnancy registry is available for all cancers diagnosed during pregnancy at Cooper Health (877-635-4499).
It is not known if rituximab is present in human milk. However, human IgG is excreted in breast milk, and therefore, rituximab may also be excreted in milk. Although rituximab would not be expected to enter the circulation of a breastfed infant in significant amounts, the unknown risks to the breastfed infant from oral rituximab ingestion should be weighed against the known benefits of breastfeeding. When treating rheumatoid arthritis, it is recommended to avoid breastfeeding during therapy unless no other compatible medication is able to control maternal disease. Breastfeeding should not be discouraged if no other agent is available (Götestam Skorpen 2016).
CBC with differential and platelets (obtain prior to treatment and at weekly to monthly intervals and more frequently in patients with lymphoid malignancies, or at 2- to 4-month intervals in rheumatoid arthritis patients, GPA and MPA), electrolytes (in patients at risk for TLS), renal function (in patients at risk for TLS), fluid/hydration status balance; blood pressure, vital signs.
Screen all patients for HBV infection prior to therapy initiation (eg, HBsAG and anti-HBc measurements). In addition, carriers and patients with evidence of current infection or recovery from prior hepatitis B infection should be monitored closely for clinical and laboratory signs of HBV reactivation and/or infection during therapy and for up to 2 years following completion of treatment. Hepatitis B virus (HBV) screening recommendations (ASCO provisional clinical opinion update [Hwang 2015]): Screen for HBV infection with hepatitis B surface antigen (HBsAG) and hepatitis B core antibody (anti-HBc) tests prior to treatment initiation; either a total anti-HBc (with both IgG and IgM) or anti-HBc IgG test should be used to screen for chronic or resolved HBV infection (do not use anti-HBc IgM as it may only confirm acute HBV infection). HBsAg negative/anti-HBc positive patients should be monitored for HBV reactivation with HBV DNA and ALT testing approximately every 3 months during treatment.
Monitor for infusion reactions; signs of active hepatitis B infection (during and for up to 12 months after therapy completion); cardiac monitoring during and after infusion (in rheumatoid arthritis patients and in patients with pre-existing cardiac disease or if arrhythmias develop during or after subsequent infusions); monitor for signs/symptoms of bowel obstruction/perforation (abdominal pain, vomiting); signs or symptoms of progressive multifocal leukoencephalopathy (focal neurologic deficits, which may present as hemiparesis, visual field deficits, cognitive impairment, aphasia, ataxia, and/or cranial nerve deficits); if PML is suspected, obtain brain MRI scan and lumbar puncture; signs/symptoms of TLS and/or mucocutaneous skin reactions.
Rituximab is a monoclonal antibody directed against the CD20 antigen on the surface of B-lymphocytes. CD20 regulates cell cycle initiation; and, possibly, functions as a calcium channel. Rituximab binds to the antigen on the cell surface, activating complement-dependent B-cell cytotoxicity; and to human Fc receptors, mediating cell killing through an antibody-dependent cellular toxicity. B-cells are believed to play a role in the development and progression of rheumatoid arthritis. Signs and symptoms of RA are reduced by targeting B-cells and the progression of structural damage is delayed.
Immune thrombocytopenia: Initial response: 7 to 56 days; Peak response: 14 to 180 days (Neunert 2011).
NHL: B-cell depletion: Within 3 weeks.
Rheumatoid arthritis (RA): B-cell depletion: Within 2 weeks.
NHL: Detectable in serum 3 to 6 months after completion of treatment; B-cell depletion is sustained for up to 6 to 9 months and B-cell recovery begins ~6 months following completion of treatment; median B-cell levels return to normal by 12 months following completion of treatment
RA: B-cell depletion persists for at least 6 months.
Distribution: RA: 3.1 L; GPA/MPA: 4.5 L
CLL: Median terminal half-life: 32 days (range: 14 to 62 days)
NHL: Median terminal half-life: 22 days (range: 6 to 52 days)
RA: Mean terminal half-life: 18 days (range: 5 to 78 days)
GPA/MPA: 23 days (range: 9 to 49 days)
Solution (Rituxan Intravenous)
100 mg/10 mL (10 mL): $1,084.06
500 mg/50 mL (50 mL): $5,420.28
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