Rituximab

RITUXIMAB (Truxima, MabThera)

What is Rituximab?

Rituximab is a drug known as a monoclonal antibody.  It binds to the surface of a type of white blood cell, the B lymphocyte, which is involved in the making of antibodies by the immune system. The immune system produces antibodies and immune cells to attack viruses and bacteria. In autoimmune conditions such as Neuromyelitis Optica (NMO), there is abnormal activity of the immune system. After taking Rituximab, B cells become undetectable in the blood for several months and then slowly return to normal levels.

Rituximab can be used where relapses have occurred despite being on other drugs.  It can also be used when intolerable side effects have occurred with other drugs like azathioprine, mycophenolate or methotrexate”

How long does it take to work?
Rituximab takes 2-6 weeks to take effect.
Rituximab does not cure the condition and you may need to take it for several years to keep your relapses under control.

What dose do I take? Rituximab is given by intravenous infusion, initially, two infusions are given two weeks apart. Subsequently, you may be given six monthly or a variable dosing regime depending on B cell production. The drug is infused in hospital over four to six hours on each visit. The cells that Rituximab affects help to fight infection. If you think you may have an infection, even a mild one such as cold, you should wait until the infection has passed before you have an infusion. If you are prescribed Rituximab it is recommended that you carry a therapy alert card, then if you become unwell, anyone treating you will know that you have had Rituximab and that your B-cell count may be low.

Can I take other medicines along with Rituximab?
Rituximab may be prescribed along with other drugs in treating your condition. Discuss any new medications with your doctor before starting them, and tell any other doctor treating you that you are taking Rituximab.
Do not take over-the-counter preparations or herbal
remedies without discussing this first with your doctor, nurse or pharmacist.

What are the possible side effects?
 Rituximab can cause side effects. During or within the first 2 hours of the first infusion you may develop fever, chills and shivering. Other side effects uncommonly seen during infusion are itching of your skin, sickness, tiredness, headache, breathing difficulties, sensation of the tongue or throat swelling, itchy, runny nose, flushing, back pain and irregular heart rate. Pre-existing conditions such as heart disease may be affected and worsened. Paracetamol, anti-histamine and corticosteroid will be given prior to the infusion to reduce these effects. Tell the person giving you the infusion immediately if you develop any of these symptoms as the infusion may need to be slowed down or stopped for a while. When these symptoms go away, or improve, the infusion can be continued. The frequency of these reactions decreases during subsequent infusions.
– There is a theoretical risk of increased infections after Rituximab but this is very unusual in practice.
– Rituximab may rarely also cause abnormalities of your blood and affect liver function.
– If you have had hepatitis B there is a risk of reactivation which may cause serious liver damage.
– Very rarely, patients have developed a serious brain infection, Progressive Multifocal Leukoencephalopathy (PML), caused by a virus called JC virus, which has been fatal. Tell your doctor immediately if you have memory or visual loss, trouble thinking or difficulty walking.
Despite this list of side-effects, over a million patients worldwide have received Rituximab and serious side-effects have been rare. For the great majority of patients, Rituximab is safe and well-tolerated.
If you have not had chickenpox but come into contact with someone who has chickenpox or shingles, or if you
develop chickenpox or shingles, you should contact your doctor as soon as possible. This is because chickenpox and shingles can be severe in people on treatment such as Rituximab which has effects on the immune system.
Therefore you may require antiviral treatment.

Vaccinations
Immunisations should be given at least two weeks before Rituximab, as Rituximab removes antibody forming cell.
It is recommended that you should not be immunised with ‘live’ vaccines such as yellow fever. However, in certain situations a live vaccine may be necessary (for example rubella immunisation in women of childbearing age), in which case your doctor will discuss the possible risks and benefits of the immunisation with you. Pneumovax and yearly flu vaccines are safe and recommended.

Do I need any special checks while on Rituximab?
You will have a physical examination and blood tests in the 7 days prior to treatment *Full blood count *urea and electrolytes *liver function test *screen for hepatitis B and C *Pregnancy test *ECG *Chest x-ray.
Hepatitis screen, ECG or CXR do not need repeating before the second dose of each course unless there is new pertinent history or findings (eg cough with fever, jaundice). You will need to have monthly bloods taken whilst on Rituximab to check your full blood counts, immunoglobulins and CD markers to help us to plan when your next infusion should be given.

Alcohol
Yes, in moderate amounts.
What happens if I need an operation?
Let the doctor or nurse know so they can advise you. If the operation is planned Rituximab will be given at least 1 month before.

What if I am thinking of getting pregnant?
No one knows the risk of Rituximab to an unborn baby.
Rituximab is an antibody and can cross the placenta and may affect the baby. For female patients, we would generally recommend a gap of 6 weeks between having Rituximab and trying for a baby.
Do not breastfeed while on Rituximab. It is not yet known whether Rituximab could pass into the breast milk or the risks to the baby.