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.