Timing of Rituximab Administration After Vaccinations
For non-live attenuated vaccines (except influenza), rituximab should be delayed for at least 2 weeks after vaccination to allow time for the patient to develop an immune response, assuming disease activity allows. 1
Specific Recommendations by Vaccine Type
For Influenza Vaccination:
- Give influenza vaccination on schedule regardless of rituximab timing
- Delay any subsequent rituximab dosing for at least 2 weeks after influenza vaccination if disease activity allows 1
For Other Non-Live Attenuated Vaccines:
- Ideally time vaccination for when the next rituximab dose is due
- Then hold rituximab for at least 2 weeks after vaccination 1
- This timing improves vaccine immunogenicity as rituximab significantly blunts vaccine responses
For Live Attenuated Vaccines:
- Live vaccines should be avoided in patients receiving rituximab
- If absolutely necessary, rituximab should be held for 6 months after live attenuated virus vaccine administration 1, 2
Rationale and Evidence
Rituximab significantly impairs immune responses to vaccinations through B-cell depletion. The timing recommendations aim to maximize vaccine efficacy while maintaining disease control:
- Vaccine responses are greater when vaccines are administered later rather than earlier after rituximab treatment 1
- Studies show rituximab blunts responses to pneumococcal and other vaccines 1
- For COVID-19 vaccines specifically, research shows only 17.3% of patients developed detectable antibody responses when vaccinated within 6 months of rituximab treatment, compared to 66.7% when vaccinated 9-12 months after treatment 3
Practical Algorithm for Timing Vaccinations with Rituximab
Before starting rituximab therapy:
- Complete all vaccinations at least 4 weeks before initiating rituximab when possible 2
If already on rituximab therapy:
- For influenza: Give on schedule regardless of rituximab timing, then delay next rituximab dose by 2+ weeks
- For other non-live vaccines: Time vaccination just before next scheduled rituximab dose, then delay rituximab by 2+ weeks
- For COVID-19 vaccines: Consider delaying vaccination until >6 months after last rituximab dose when possible, as studies show significantly improved antibody response with longer intervals 4, 3
Important Caveats
- Disease activity must always be considered when deciding to delay rituximab
- Patients may still receive some protective immunity even with suboptimal timing
- Consider measuring B-cell counts before vaccination, though hypogammaglobulinemia appears to be a stronger predictor of poor vaccine response than timing alone 5
- For patients at high risk of infection, vaccination with suboptimal timing may be preferable to no vaccination at all
Remember that these recommendations aim to balance the need for effective vaccination with maintaining disease control through rituximab therapy.