Rituximab (Rheumatology)

How it works

It binds CD20 on B lymphocytes and depletes them through complement-dependent and antibody-dependent cytotoxicity and apoptosis, reducing autoantibody-producing and antigen-presenting B-cell activity.

Prescribing in practice

• Screen for hepatitis B before treatment, as B-cell depletion can reactivate hepatitis B with potentially fatal hepatitis — check serology and arrange prophylaxis/monitoring for those with past exposure.
• Infusion-related reactions are common, especially with the first infusion, so give premedication and monitor with resuscitation facilities available.
• It increases infection risk and rare progressive multifocal leukoencephalopathy has been reported, so investigate new neurological symptoms urgently.

Monitoring

Monitor full blood count and immunoglobulins, watch for infection and infusion reactions, and remain alert to hepatitis B reactivation and neurological changes between and after courses.

Counselling the patient

• Report fever or signs of infection without delay.
• Tell us about any new confusion, weakness or vision problems.
• Live vaccines should be avoided while your B cells are depleted.

Evidence & guidelines

Its rheumatology use is well established through randomised trials in rheumatoid arthritis and in ANCA-associated vasculitis, where it is a first-line option for remission induction.