Can Rituximab (rituximab) cause vomiting with a blood tinge and other side effects?

Rituximab Can Cause Blood-Tinged Vomiting and Other Side Effects

Yes, rituximab can cause gastrointestinal side effects including nausea, vomiting (which may contain blood), and a range of other adverse reactions. 1 Rituximab-associated gastrointestinal toxicity is documented in clinical practice guidelines and research.

Gastrointestinal Side Effects of Rituximab

• Nausea and vomiting are recognized gastrointestinal adverse effects of rituximab, particularly during infusion reactions 1
• Blood-tinged vomiting can occur as part of rituximab-associated gastrointestinal toxicity, which may range from mild symptoms to severe colitis with mucosal ulceration 2
• Abdominal pain and diarrhea may accompany vomiting as part of the gastrointestinal symptom complex 2
• The median duration of gastrointestinal symptoms is approximately 21 days, though severity varies considerably 2

Mechanism of Rituximab-Related Adverse Effects

Rituximab can cause two distinct types of reactions that may present with gastrointestinal symptoms:

1. Mast cell-mediated reactions (hypersensitivity):

   • Include gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain 1
   • Often accompanied by skin manifestations like flushing, pruritus, angioedema, or urticaria 1

2. Cytokine release syndrome:

   • More common with high tumor burden 1
   • Typically presents with fever, rigors, chills, and other constitutional symptoms 1
   • Can include gastrointestinal symptoms as part of the syndrome 1

Other Common Side Effects of Rituximab

• Infusion-related reactions: Most common during first infusion, affecting up to 77% of patients with B-cell lymphoma 1, 3

  • Range from mild flu-like symptoms to severe reactions including bronchospasm and hypotension 1
  • Fatal infusion reactions characterized by hypoxia, pulmonary infiltrates, respiratory distress, and cardiovascular complications have been reported 1

• Hematological effects:

  • Neutropenia, particularly with long-term therapy 1
  • Acute thrombocytopenia (rare but documented) 4, 5
  • Risk increases when combined with chemotherapy 1

• Infectious complications:

  • Increased risk of various infections due to B-cell depletion 1
  • Reactivation of latent viral infections 1
  • Progressive multifocal leukoencephalopathy (rare but serious) 1

• Pulmonary complications:

  • Interstitial pneumonitis (can be fatal) 1
  • Cough, rhinitis, nasal congestion, wheezing, dyspnea 1

Risk Stratification and Management

The severity of reactions to rituximab can be graded to guide management:

• Grade 1: Primarily cutaneous symptoms (rash, itching, flushing) 1
• Grade 2: Includes urticaria, nausea, vomiting, dyspnea, or asymptomatic bronchospasm 1
• Grade 3: Symptomatic bronchospasm, dyspnea, hypoxia, and/or wheezing 1
• Grade 4: Anaphylaxis or hypotension 1

Management approaches based on reaction grade:

• For grade 1 reactions, same-day rechallenge at reduced infusion rate is often possible 1
• For grade 2 reactions, shared decision-making regarding rechallenge versus desensitization 1
• For grade 3-4 reactions, desensitization protocols are recommended if rituximab must be continued 1

Important Considerations and Monitoring

• Blood cell counts should be carefully monitored after rituximab infusion, especially in patients with autoimmune diseases 5
• Premedication with antipyretics, antihistamines, and sometimes corticosteroids can reduce infusion reactions 1
• The risk of reactions is highest during the first infusion and typically decreases with subsequent infusions 1, 3
• Patients with high tumor burden are at increased risk for cytokine release syndrome and should be monitored closely 1

Conclusion

Blood-tinged vomiting can occur with rituximab administration, particularly as part of infusion reactions or gastrointestinal toxicity. Clinicians should be vigilant about monitoring for this and other potential adverse effects, especially during the first infusion when reactions are most common.