Contraindicated Vaccines in Patients on Rituximab (Rituxan)

Live-attenuated vaccines are contraindicated in patients on rituximab (Rituxan) due to the risk of inducing infection by vaccination. 1, 2

Live-Attenuated Vaccines to Avoid

Rituximab is a chimeric anti-CD20 monoclonal antibody that depletes B cells and impairs both cellular and humoral immunity 3
Rituximab impairs immune responses for up to 6 months after treatment 1
B-cell depletion reduces the ability to mount an adequate immune response to vaccines, particularly live vaccines 4
This immunosuppression increases the theoretical risk of developing infection from live vaccine strains 1

Live-attenuated vaccines should be withheld for at least 6 months after the last dose of rituximab 1
If live vaccines are required, they should ideally be administered before initiating rituximab therapy 1
For non-live vaccines, it is recommended to vaccinate before rituximab use whenever possible 1
If vaccination must occur during rituximab therapy, optimal timing is just before the next scheduled dose, followed by delaying rituximab by at least 2 weeks 5, 6

While not contraindicated, non-live vaccines may have reduced effectiveness in patients on rituximab:

Reduced response to influenza vaccines 1
Reduced response to pneumococcal polysaccharide vaccine (PPV23) 1
Reduced response to tetanus toxoid (TT) vaccination in the first month after rituximab treatment 1
Reduced response to COVID-19 vaccines when administered within 6 months of rituximab 7

For patients with contaminated wounds, tetanus immunoglobulin should be administered if the patient has been treated with rituximab in the past 6 months 1
Patients should receive pneumococcal and influenza vaccinations before starting rituximab whenever possible 1
Consider checking antibody titers after vaccination to confirm adequate response 1
Patients on rituximab should receive mRNA vaccines when available (for vaccines like COVID-19) and boosters more than 6 months after their last infusion when possible 7

Some clinicians may not realize that the immunosuppressive effect of rituximab lasts for up to 6 months after the last dose 1
Failure to check vaccination status before initiating rituximab can lead to missed opportunities for immunization 3
Administering tetanus toxoid alone after exposure in rituximab-treated patients may not provide adequate protection; tetanus immunoglobulin should be considered 1
The FDA label for rituximab specifically warns against live virus vaccinations during treatment 2

In certain cases where the risk of infection outweighs the theoretical risk of vaccination, live-attenuated vaccines may be considered on a case-by-case basis 1
Yellow fever booster vaccine has been reported safe in a very small number of patients (3) on rituximab, but this is insufficient evidence to recommend routine use 1