PEG Placement in Patients on Subcutaneous Rituximab
Yes, PEG placement can be safely performed in patients receiving subcutaneous rituximab, as rituximab is not listed among the contraindications for PEG placement and does not significantly impair coagulation or wound healing in the manner that would preclude the procedure.
Key Considerations for Safety
Absolute Contraindications to Assess
The only absolute contraindications to PEG placement that you must exclude are 1:
- Mechanical obstruction of the small bowel (unless for decompression)
- Serious coagulation disorders (INR >1.5, platelets <50,000/mm³)
- Hemodynamic or respiratory instability
- Active gastrointestinal bleeding from peptic ulcer
Rituximab does not cause these contraindications, making PEG placement feasible from a procedural standpoint 1.
Pre-Procedure Laboratory Assessment
Before proceeding, verify the following thresholds 1:
- Platelet count >50,000/mL
- International normalized ratio (INR) <1.5
- Patient fasting for at least 8 hours 1, 2
Infection Risk Management
Administer prophylactic antibiotics (2 g cefazolin IV or clindamycin/vancomycin if cephalosporin allergy) before the procedure 1. This is particularly important as rituximab can affect B-cell function and potentially increase infection susceptibility, though this is not a contraindication to PEG placement 1.
Procedural Approach
Standard Technique Applies
Use the standard "pull" technique with proper site identification 1:
- Ensure "one-to-one" finger indentation without overlying bowel or liver
- Perform "safe track technique" with small-bore needle and anesthetic solution while pulling back on plunger to confirm no interposed bowel 1
- Place trocar only after confirming safe tract 1, 3
Post-Procedure Care
Initiate feeding 4 hours after placement for tube feedings (medications can be given after 1 hour) 1, 4. Daily wound care with sterile dressing changes is essential until granulation occurs (days 1-7) 4.
Critical Pitfalls to Avoid
Do not delay PEG placement if nutritionally indicated—patients typically lose approximately 12 kg in the 3 months before PEG is considered, and this weight is rarely fully regained even in benign diseases 1, 2.
Monitor closely for wound infection (occurs in approximately 15% of cases), as this is the most common complication regardless of underlying medication use 4, 5, 6.
Bottom Line
Subcutaneous rituximab therapy does not represent a contraindication to PEG placement. Proceed with standard pre-procedure assessment, prophylactic antibiotics, proper technique, and meticulous post-procedure wound care 1, 4.