Rituximab
A drug Information Sheet
What is rituximab?
Rituximab (brand name MabThera) is a new type of drug which removes antibody-producing white blood cells called B-cells. Antibodies are proteins which are produced by the body in response to germs, viruses or any other substances which the body sees as foreign or dangerous. However, in people with rheumatoid arthritis some B-cells produce harmful 'autoantibodies', such as rheumatoid factors. The purpose of rituximab is to remove these B-cells. Rituximab also removes B-cells which make useful antibodies, but these return after some months.
Why am I being prescribed rituximab?
Rituximab is available for people with rheumatoid arthritis. It will only be prescribed if the arthritis is causing symptoms such as pain and stiffness and you have already tried standard drugs (including sulfasalazine, gold injections, methotrexate and the 'anti-TNF' drugs – adalimumab, etanercept and infliximab), or cannot use these. Rituximab is available only on prescription from a consultant rheumatologist.
Rituximab will not be prescribed if:
- your rheumatoid arthritis is not causing trouble
- you have not tried standard treatments first (if suitable for you)
- you are pregnant or breastfeeding.
Your doctor may decide not to prescribe rituximab if:
- you get short of breath very easily
- your B-cell or antibody levels are low.
Rituximab is also used for other diseases associated with autoantibodies, such as lupus. You are less likely to be given rituximab if you have seronegative rheumatoid arthritis (with no rheumatoid factor), because it may be less effective for this condition. At present there is no reason to think rituximab would be useful for psoriatic arthritis or ankylosing spondylitis.
When and how do I take rituximab?
Rituximab is given by intravenous infusion ('drip') in a hospital clinic. A steroid injection is usually given first. Usually two infusions are given 1–2 weeks apart. This 'course' of treatment is repeated only when there are signs that improvement is wearing off, which can be anything from 6 months to 3 years later. Many people receive rituximab about once a year. Your rheumatologist will depend on you, to some extent, to say when you are having trouble again. This is something which the two of you should discuss in advance.
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 specialist. This is because if you become unwell, anyone treating you will know that you have received rituximab and that your B-cell count may be low.
How long will rituximab take to work?
If you respond to rituximab improvement may take several weeks. It is usually clear by 3 months whether or not rituximab will help you.
What are the possible risks or side-effects?
Experience with using rituximab in people with rheumatoid arthritis is still relatively limited, although many people have received it for other conditions. A small proportion of people have reactions to the infusion, with a temperature, wheeziness, rash or fall in blood pressure. Very rarely this is severe enough to need to stop the treatment. Chest problems, with cough or fever, may be more common after the treatment. If this happens to you, you should seek advice from your rheumatologist, GP or rheumatology nurse about taking antibiotics.
If you develop any other new symptoms after starting rituximab you should see your doctor or rheumatology nurse as soon as possible.
After 3 or 4 courses of rituximab, the levels of useful antibodies in the blood may go down. So far there is no indication that this is a major problem, but it may mean that repeated courses increase the risk of infections.
What other treatments could be used instead of rituximab?
A number of other drugs are used in the treatment of rheumatoid arthritis and related conditions (see arc leaflet 'Drugs and Arthritis'). Your rheumatologist will discuss these other options with you.
Do I need any special checks while on rituximab?
Before your course of treatment and every few months after you should have blood tests to check your antibody and B-cell levels.
May I take other medicines after a course of rituximab?
Most people prescribed rituximab are also taking methotrexate (see arc leaflet 'Methotrexate'). If you are on methotrexate, special care is needed with non-steroidal anti-inflammatory drugs (NSAIDs). You may only take anti-inflammatory drugs if they are prescribed by your doctor.
You should discuss any new medications with your doctor before starting them, and you should always tell any other doctor treating you that you are having, or have recently had, treatment with rituximab.
Rituximab is not a painkiller. So if you are on painkillers you may continue to take these as well as rituximab, unless your doctor advises otherwise.
Do not take over-the-counter preparations without discussing this first with your doctor, rheumatology nurse or pharmacist.
Can I have immunisations after a course of rituximab?
Because rituximab removes antibody-forming B-cells there is probably no point in having immunisations for about 7 months after a course of treatment. If you think you might benefit from immunisations, it may be best to have them before a course of rituximab, or in between courses when the B-cells have come back. You should discuss this with your rheumatologist, GP or rheumatology nurse.
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.
May I drink alcohol after a course of rituximab?
You may drink alcohol while taking rituximab. However, if you are also taking methotrexate, you should only drink alcohol in small amounts because methotrexate and alcohol can interact and damage your liver.
Does rituximab affect pregnancy?
We do not yet know if it is harmful to a baby if conceived shortly after the mother has received rituximab. The manufacturer suggests that avoiding pregnancy for up to 12 months might be advisable, but we have no way of knowing if such a long interval is necessary. You should take care to avoid becoming pregnant after treatment with rituximab unless you have discussed this in detail with your doctor. You should not receive rituximab during pregnancy.
What about breastfeeding?
Rituximab is an artificially produced antibody of a sort known to be secreted in breast milk. You should not receive rituximab if you are breastfeeding, and should not breastfeed for 12 months following a course of rituximab, because the baby's B-cells might be affected.
Where can I obtain further information?
If you would like any further information about rituximab, or if you have any concerns about your treatment, you should discuss this with your doctor, rheumatology nurse or pharmacist. You will also find a lot of information on the internet. This may include information about treatment for cancer. Please do not be concerned about this – although rituximab is used for certain types of cancer, this is not the reason for prescribing rituximab for you.
Remember to keep all medicines out of reach of children.
PLEASE NOTE: We have made every effort to ensure that the content of this information sheet is correct at time of going to press, but remember that information about drugs may change. This sheet does not list all the uses and side-effects associated with this drug. For full details please see the drug information leaflet which comes with your medicine. Your doctor will assess your medical circumstances and draw your attention to any information or side-effects which may be relevant in your particular case.
