Rituximab

Rituximab is used to treat inflammatory types of arthritis, such as rheumatoid arthritis (RA) and granulomatosis with polyangiitis (GPA, also known as Wegener’s Granulomatosis).

For RA, rituximab is used in combination with methotrexate (MTX). Rituximab is generally reserved for treatment of RA that has not responded to other biologic medications (e.g., tumour necrosis factor (TNF) blocking agents). Rituximab is used in combination with steroids to treat GPA.

Rituximab is given by infusion.

Rituximab requires only two infusions, scheduled two weeks apart. The dose given is 1,000 mg with each infusion. Infusions are given with an intravenous steroid, such as methylprednisolone (Solumedrol®). Your healthcare provider may also recommend taking acetaminophen and an antihistamine (e.g., diphenhydramine) before the infusion. These medications will help prevent infusion reactions.

Repeat infusions of rituximab can be given every six months based on treatment response and the activity of your arthritis.

Each infusion can take from four to six hours in length.

Arthritis is caused by the immune system attacking tissues in the body. Rituximab works by suppressing the body’s immune system, specifically it binds to B-cells, a type of immune cell, and prevents it from becoming activated and attacking the body’s own tissues. By doing this, rituximab can help to reduce pain and swelling in the joints, improve day-to-day function, and prevent long term damage to the joints.

As with all of the biologics, you may not feel the effects of the rituximab right away. Some people begin to feel the effects of the medication fairly quickly; however, it may take three to six months to feel its full effect. It is important to be patient and keep taking your medication.

To provide symptom relief while you are waiting for rituximab to take effect, your healthcare provider may recommend taking a steroid, such as prednisone, or a non-steroidal anti-inflammatory drug (NSAID).

Rituximab can make it more difficult for your body to fight infections. Therefore, people with active infections should not take rituximab. If you have a fever, think you have an infection or have been prescribed an antibiotic, contact your healthcare provider. People who have had frequent infections in the past or a history of tuberculosis should discuss the use of rituximab with their healthcare provider.

Also contact your healthcare provider if you are having surgery as you may need to stop rituximab until you are healed and there is no sign of infection.

Rituximab has not been studied in pregnant people or lactating parents so its effect(s) on pregnant people or nursing babies are unknown. You should tell your doctor if you are pregnant or are planning to become pregnant. People that can become pregnant should use effective birth control methods during and for up to 12 months after treatment with rituximab. Because of the potential for adverse reactions in nursing infants, a decision should be made on whether or not to discontinue nursing or the medication, taking into account the importance of the drug to the lactating parent.

If you have ever had a rare infection of the brain called progressive multifocal leukoencephalopathy (PML) or if you have had a previous allergic reaction to rituximab, you should not take the medication.

In rare cases, severe skin reactions have been reported in patients receiving rituximab. Get medical help right away if you have signs of redness, swelling, blistering or peeling skin (with or without fever); red or irritated eyes; or sores in your mouth, throat, nose, or eyes.

Hepatitis B virus (HBV) reactivation has occurred in patients treated with rituximab, in some cases resulting in hepatic failure and death. All patients should be screened for HBV infection before treatment initiation and should be monitored for hepatitis during and after treatment with rituximab.    

Rituximab has been associated with abnormal heart rhythms. Tell your doctor if you have any such cardiac issues.

Make sure that your vaccinations are up to date before starting rituximab. Your healthcare provider will likely recommend a number of vaccines (e.g., influenzae, pneumonia, RSV, shingles) to get beforehand. Because rituximab can stop your ability to react to vaccines, you should wait at least two to three weeks after your vaccine before starting rituximab. If you are already on rituximab and need a vaccination, try to space it as long as you can after your last dose.  Live vaccines are not recommended due to risk of causing infection. Before receiving any vaccinations while taking rituximab, you should speak with your healthcare provider.

Like all medications, taking rituximab carries some risk of side effects, which must be balanced with the potential benefits. In general, the risk of joint damage and permanent disability (resulting from arthritis) is much greater than the risks of side effects from rituximab. When monitored properly the vast majority of side effects are rare, most improve over time and are reversible.

Rituximab can increase your risk of infections. You should take precautions to minimize your risk of being infected by common contagious infections such as COVID-19, influenzae, pneumonia, and the common cold.

Rituximab commonly causes an allergic reaction during the infusion (flushing, itching, changes in heart rate and blood pressure, etc.). A healthcare professional will monitor for this reaction during the infusion.

In rare cases, some people experience headaches, nausea, abdominal pain and diarrhea with rituximab. If any of these symptoms become severe, please consult your healthcare provider.

Also in rare occurrences, rituximab can cause a drop in blood counts and/or cause problems with the kidneys, bowels, heart and lungs. Your healthcare provider will monitor for these effects.

Take rituximab as prescribed and contact your healthcare provider if you have any concerns while taking the medication.

Intravenous steroid, such as methylprednisolone (Solumedrol®) is given prior to rituximab. Your healthcare provider may also recommend taking acetaminophen and an antihistamine (e.g., diphenhydramine) before the infusion. These medications will help prevent infusion reactions.

Keeping yourself well hydrated before getting your infusion and drinking while you get your infusion may also help reduce side effects.

Your healthcare provider may order periodic blood tests to check your blood counts and to follow the activity of your arthritis.

Rituximab must be refrigerated at 2 to 8 degrees Celsius and protected from light. Keep the product in the original package and out of the light.

Rituximab must be kept cool while travelling. Ask your pharmacist for a cool carrier if you are not able to put the drug in your refrigerator right away.

Each version of rituximab has its own patient support program. These can be found in the list below.

• Rituxan
  PSP: Joint Effort (1-888-532-1198)
• Riximyo
  PSP: XPose (1-888-449-7673)
• Ruxience
  PSP: Pfizer Flex (1-855-935-3539)
• Truxima
  PSP: Teva Support Solutions (1-833-981-2254)