NHSL Guidelines
Administration: Intravenous infusion
Dose: Two 1000mg IV rituximab infusions separated by 2 weeks. These infusions may be repeated at intervals of 24 weeks depending on response. Weekly methotrexate therapy is usually given to increase efficacy.
Time to response: Up to 16 weeks
Indications:
- Rheumatoid Arthritis.
- Granulomatosis with Polyangiitis.
- Microscopic Polyangiitis.
- Refractory Systemic Lupus Erythematosis.
Contraindications:
- Pregnancy & breast feeding.
- Recurrent or active infection including HBV, HCV & HIV.
- NYHA class IV heart failure.
- Severe uncontrolled cardiac disease.
- Hypogammaglobulinaemia.
Pre-Treatment Screening:
- FBC, U&Es, LFTs, CRP
- Immunoglobulins
- Hepatitis B & C, VZV serology
- Check pneumoccocal serology after pneumovax.
Monitoring:
- FBC, CRP, U&Es and LFTs 4 weeks post infusion
- Rheumatology nurse assessment with DAS, HAQ, FBC, ESR, U&Es, LFTs, CRP 16 weeks post infusion
- Immunoglobulins levels prior to each infusion
Vaccinations:
- Avoid live attenuated vaccines.
- Offer annual influenza vaccination.
- In those who are biologic naïve pneumococcal vaccination and Sars-Cov-2 vaccination should ideally be performed at least 2 weeks before commencing RITUXIMAB treatment.
- Assuming no contraindications before starting treatment:
- Patients >50 should undergo vaccination against HZV.
- Those who are varicella zoster negative should be offered varicella vaccination.
- Consider hepatitis B vaccination prior to RITUXIMAB in those at high risk.
In the event of:
- Infusion reactions – will be managed on MDBU.
- Flu-like symptoms – advise patients to drink plenty of fluids and rest.
- Fever or chills – screen for infection.
- Nausea & vomiting – try anti-emetics.
- Increasing dyspnoea – arrange CXR.