What is Rituximab?

Why is Rituximab prescribed?

What are the possible side-effects?

What are the risks?

What else should I know about Rituximab?

What is Rituximab?

Rituximab (trade name MabThera) is a type of drug called a biological therapy. It removes a type of cell called B-cells. Some B-cells produce harmful autoantibodies which attack the body’s own tissues. It also removes the B-cells which make useful antibodies that protect you against infection, but these return after a few months.

What type of drug is rituximab (trade name MabThera)?

Rituximab is a biological therapy.

What does it do?

It is used to treat a variety of conditions including rheumatoid arthritis, lupus, vasculitis and dermatomyositis.

How is it taken?

Usually two infusions are given two weeks apart.

Are there any side-effects?

Most people do not have any side-effects. However, a small number of people experience fever, wheeziness, a rash or fall in blood pressure during or shortly after the infusion. It can also make you more likely to develop infections.

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Why is Rituximab prescribed?

Rituximab can be used for rheumatoid arthritis, lupus, vasculitis and dermatomyositis. It is also used to treat certain types of cancer.

Rituximab will be prescribed if your arthritis is active and usually after you have tried methotrexate and another disease-modifying anti-inflammatory drug (DMARD) such as sulfasalazine or hydroxychloroquine and at least one anti-TNF drug, or if you cannot use these drugs for any reason.

Rituximab was originally only available as a drug called MabThera. More recently, two new versions of rituximab, known as Truxima and Rixathon, have become available. These drugs are known as biosimilars and work in a similar way to the original form of rituximab. New versions of biologic drugs are becoming available all the time, so you may be prescribed rituximab under a different name.

Is there any reason I will not be prescribed rituximab?

Rituximab will not be prescribed if:

  • your arthritis is not active
  • you are pregnant or breastfeeding
  • you have an infection.

Your doctor may decide not to prescribe rituximab if:

  • you have severe heart problems
  • you get short of breath very easily
  • your B-cell or antibody levels are low
  • you have seronegative rheumatoid arthritis (with no rheumatoid factor and no anti-CCP antibodies).

When and how do I take rituximab?

Rituximab is given by intravenous infusion (a drip into a vein) in hospital. You may have a steroid injection first together with paracetamol and an antihistamine to reduce the chance of a reaction. The first infusion takes around six hours, although following infusions will be a bit shorter. Usually two infusions are given two weeks apart, which is repeated when the improvement is wearing off (around six months to three years later). Many people have rituximab about once a year. You will need to let your rheumatologist know if your condition gets worse.

How long does rituximab take to work?

If you respond to rituximab, you will probably feel better within 2–16 weeks.

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What are the possible side-effects?

Most people do not have any side-effects. However, a few people experience a fever, wheeziness, a rash or fall in blood pressure during or shortly after the infusion. Occasionally you may feel unwell during infusions. If this happens you should tell the person giving you the infusion so they can slow it down. If your symptoms are severe you may need to stop treatment, but this is rare.

Rituximab affects your immune system, so you may be more likely to develop infections. You should tell your doctor or rheumatology nurse straight away if you develop any of the following after starting rituximab:

  • a sore throat
  • a raised temperature
  • a fever
  • any other symptoms of infection
  • any new symptoms or anything else that concerns you. 

What should I look out for?

You should see your doctor immediately if:

  • you develop new symptoms
  • you have not had chickenpox and you come into contact with someone who has chickenpox or shingles
  • you develop chickenpox or shingles. 

Chickenpox and shingles can be severe in people on rituximab. You may need antiviral treatment, which your doctor will be able to prescribe.

The long-term side-effects of rituximab are not yet fully understood because it is a relatively new drug.

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What are the risks?

After three or four courses of rituximab, the levels of useful antibodies in your blood (the ones that protect you against infection) may go down. This may not be a major problem, but it might mean that repeated courses increase your risk of infection.

Very rarely severe skin reactions have been reported with rituximab up to four months after the infusion. You should tell your doctor or rheumatology nurse straight away if you develop a rash after starting rituximab.

In very rare cases patients treated with rituximab have developed a serious condition called progressive multifocal leukoencephalopathy (PML), which can damage the brain and spinal cord. You must see your doctor immediately if you notice any of the following:

  • pins and needles
  • weakness
  • shaky movements
  • unsteadiness
  • loss of vision
  • speech problems
  • changes in behaviour or mood
  • difficulty with movements (face, arms or legs).

You should always read the patient information leaflet included with your medicines package to keep you informed about any possible side effects of your prescribed medications.

How can I reduce the risk of infection?

Because of its effects on the immune system, rituximab may make you more likely to pick up infections. You should avoid close contact with people with severe active infections, and visit the Food Safety Authority of Ireland website www.fsai.ie for information on reducing your risk of infection from foods.

Will it affect vaccinations?

Because rituximab affects your immune system, it is best to have any vaccinations before treatment, or in between courses when your B-cells have come back. You should discuss this with your rheumatologist, GP or rheumatology nurse.

If you are taking rituximab it is recommended that you avoid live vaccines, including the chickenpox vaccine. 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 vaccination with you.

If you are in your 70s and are offered shingles vaccination (Zostavax) your doctor may advise you to have this before starting rituximab. Shingles vaccination is not recommended for people who are already on rituximab.

Pneumovax (which gives protection against the most common cause of pneumonia) and yearly flu vaccines should be given at least one month before a course of rituximab.

Can I drink alcohol while on rituximab? 

You can drink alcohol while on rituximab but keep within the recommended limits (1–2 units per day for women and 2–3 units per day for men). If you are also taking methotrexate, you should keep within these limits because methotrexate and alcohol can interact and damage your liver.

Does rituximab affect fertility or pregnancy?

If you are thinking of having a baby or if you become pregnant, you should discuss this with your rheumatologist. We do not yet know how rituximab might affect an unborn baby. You should therefore take care to avoid becoming pregnant for at least 6 months after treatment. You should not have rituximab during pregnancy. Men who are on methotrexate as well as rituximab should avoid fathering a child for at least three months (and some doctors advise six months) after stopping treatment.

Does it affect breastfeeding?

Rituximab is an antibody that can be passed on in breast milk. You should not have rituximab if you are breastfeeding, as it may affect your baby’s immune system.

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What else should I know about Rituximab?

If you are prescribed rituximab it is recommended that you carry a biological therapy alert card, which you can obtain from your doctor or rheumatology nurse. Then if you become unwell, anyone treating you will know that you have had rituximab and that your antibody levels may be low.

Are there any alternatives?

A number of other drugs are used in the treatment of rheumatoid arthritis and related conditions. Your doctor and rheumatology nurse will discuss these with you.

Will I need any special checks while on rituximab?

You will have blood tests to check your antibody and possibly your B-cell levels before treatment and every few months afterwards.

Rituximab may increase the risk of the hepatitis B infection being reactivated in people who carry the virus. If your doctor decides that you may be at risk from a previous hepatitis B infection, they may test your blood for the presence of hepatitis B.

Can I take other medicines alongside rituximab?

Rituximab may be prescribed alongside other drugs, including methotrexate. You should discuss any new medications with your doctor before starting them, and always tell any other doctor treating you that you have been treated with rituximab. You should also be aware of the following points:

  • Rituximab is not a painkiller. If you are already on a non-steroidal anti-inflammatory drug (NSAID) or painkillers you can carry on taking these, unless your doctor advises otherwise. If rituximab works for you, you may be able to reduce your NSAIDs or painkillers after a time.
  • Do not take over-the-counter preparations or herbal remedies without discussing this first with your doctor, rheumatology nurse or pharmacist.

Can I continue with rituximab if I am going to have an operation?

Yes, but planned operations are usually scheduled at least a month after your last infusion.

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