What is rituximab?

Rituximab (MabThera™) is a type of drug called a biological therapy. In some conditions, B-cells in the body produce harmful autoantibodies which attack the body's own tissues. Rituximab works by depleting the B-cells to reduce inflammation and improve your symptoms.

If rituximab works for you, you should start to feel better within 2–16 weeks.

Uses

Rituximab can be prescribed by a rheumatologist for:

Are there any reasons I won't be prescribed rituximab?

Rituximab won't be started if:

  • the disease isn't active
  • you've not tried other treatments appropriate for your condition first
  • you have an infection.

Doctors sometimes use a score known as DAS28 to work out how active your arthritis is. This counts how many of 28 specific joints are tender and swollen, and looks at inflammation levels in a blood test. You'll also be asked to score how well you feel on a scale of 0 to 10.

Your doctor may decide not to prescribe rituximab if you're pregnant or breastfeeding, or 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).

You'll have blood tests to check your antibody and possibly your B-cell levels before treatment and every few months afterwards. Your doctor may also check for previous hepatitis infection as rituximab may increase the risk of hepatitis being reactivated.

How is it taken and how long does it take to work?

Rituximab is given through a drip into a vein (intravenous infusion) in hospital. The first infusion takes around six hours, although following infusions will take a bit less time.

Usually two infusions are given two weeks apart. This process is repeated when the improvement is wearing off (from around six months to three years later). Many people have rituximab about once a year.

You may have a steroid injection or infusion first, together with paracetamol and an antihistamine, to reduce the chance of a reaction.

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

Side-effects and risks

A few people experience a fever, wheeziness, a rash or fall in blood pressure during or shortly after the infusion, or you may feel unwell during infusions. If this happens, 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 pick up infections. Tell your doctor or rheumatology nurse straight away if you develop a sore throat, fever or other signs of infection, or any other new symptoms that concern you.

You should also see your doctor if you develop chickenpox or shingles or come into contact with someone who has chickenpox or shingles. These illnesses can be more severe if you're on rituximab, and you may need antiviral treatment.

After three or four courses of rituximab, the levels if useful antibodies in your blood (the ones that protect against infection) may go down. This may not be a problem, but rarely it might mean that repeated courses increase your risk of infection. Your clinical team will discuss this with you before considering further treatment.

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 rituximab can cause 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 or unsteadiness
  • loss of vision
  • speech problems
  • changes in behaviour or mood
  • difficulty moving your face, arms or legs.

Reducing the risk of infection

Effects on other treatments

Rituximab may be prescribed alongside other drugs, including methotrexate. However, some drugs may interact with rituximab so check with your doctor before starting any new medications, and remember to mention you're on rituximab if you're treated by anyone other than your usual rheumatology team.

Vaccinations

It's usually recommended that people on rituximab avoid live vaccines such as yellow fever. However, sometimes a live vaccine may be necessary (for example, rubella immunisation in women of childbearing age).

If you're offered shingles vaccination (Zostavax) it's best if you can have this before starting rituximab. Otherwise, you may be able to have the vaccine between courses of rituximab when your B-cells have returned. Check with your rheumatology team.

Pneumococcal vaccine (which protects 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 continue with rituximab if I'm going to have an operation?

Planned operations are usually scheduled at least a month after your last rituximab infusion. Make sure your surgeon knows you're on rituximab.

Alcohol

You can drink alcohol while on rituximab. However, you should keep within the recommended limits (14 units per week for adults) if you're also taking methotrexate as this can interact with alcohol and affect your liver.

In some circumstances, your doctor may advise lower limits.

Fertility, pregnancy and breastfeeding

We don't yet know how rituximab might affect an unborn baby. Current guidelines advise that you take care to avoid becoming pregnant for at least six months after treatment.

However, if you do have a rituximab infusion in early pregnancy (for example, before your pregnancy is confirmed) then it's unlikely to be harmful.

The guidelines now state there's no need for men to stop rituximab treatment when trying to father a baby.

Rituximab is an antibody that can be passed on in breast milk and the effects on the baby aren't yet known. Therefore you shouldn't have rituximab treatments if you're breastfeeding.