What are the steps to clerk an adult patient with non-Hodgkin's lymphoma or rheumatoid arthritis for rituximab (rituximab) treatment?

How to Clerk a Patient for Rituximab

Pre-Treatment Screening Requirements

Before initiating rituximab, obtain comprehensive baseline assessments including hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), hepatitis C antibody, latent tuberculosis screening, baseline immunoglobulin levels, complete blood count with differential, and comprehensive metabolic panel including hepatic and renal function. 1

Mandatory Infectious Disease Screening

• Screen all patients for hepatitis B virus (HBV) before treatment - test for both HBsAg and anti-HBc, as HBV reactivation can cause fulminant hepatic failure and death 1, 2
• For HBsAg-positive patients at high or medium risk, initiate prophylactic antiviral therapy with potent oral anti-HBV agents before starting rituximab 1
• For patients who are hepatitis B core antibody positive, provide prophylactic antiviral therapy when initiating rituximab, regardless of HBsAg status 3
• Screen for hepatitis C antibody status 1
• Perform latent tuberculosis screening 1

Baseline Laboratory Assessment

• Obtain complete blood count with differential to assess for cytopenias 1
• Check baseline serum immunoglobulin G levels, as hypogammaglobulinemia risk increases with multiple courses of rituximab 4
• Obtain comprehensive metabolic panel including hepatic and renal function tests 1
• Measure lactate dehydrogenase (LDH) and uric acid levels 5

Disease-Specific Staging and Risk Assessment

For non-Hodgkin's lymphoma patients:

• Perform CT scan with iodine contrast of neck, chest, abdomen and pelvis 5
• Obtain bone marrow aspirate and biopsy for patients amenable to curative therapy 5
• Consider diagnostic spinal tap with prophylactic intrathecal cytarabine or methotrexate in high-risk patients (>2 adverse parameters by International Prognostic Index) with bone marrow, testis, spine, or skull base involvement 5
• Assess tumor burden, as patients with high tumor burden or lymphocyte count >25 × 10⁹/L are at increased risk for cytokine release syndrome and require reduced infusion rates 4
• Establish International Prognostic Index score for prognostic purposes 5

For rheumatoid arthritis patients:

• Document inadequate response to one or more TNF antagonist therapies, as this is required for rituximab use 2
• Confirm patient will receive concomitant methotrexate therapy 2

History and Physical Examination

Critical Historical Elements

• Document vaccination history and any adverse events or disease flares following previous vaccinations 5
• Obtain detailed history of prior cardiovascular disease, as rituximab can cause arrhythmia, angina, myocardial infarction, and cardiogenic shock 5, 4, 6
• Assess for history of prior infusion reactions to biologics 5
• Document any history of severe mucocutaneous reactions 2
• Review prior chemotherapy exposure and response 5

Physical Examination Priorities

• Assess performance status using standardized scales 5
• Identify sites of bulky disease (>7.5 cm), as these may require radiotherapy consolidation 5
• Document all sites of lymphadenopathy and organomegaly 5
• Perform comprehensive cardiovascular examination given risk of cardiac complications 4, 6

Risk Stratification for Infusion Reactions

Rituximab carries a 77% incidence of infusion reactions during first administration, decreasing to 3-8% in subsequent infusions, with severe reactions (grade 3-4) occurring in approximately 10% of patients. 4

High-Risk Features Requiring Enhanced Monitoring

• High tumor burden or lymphocyte count >25 × 10⁹/L increases risk of cytokine release syndrome 4
• First infusion carries highest risk - approximately 80% of fatal reactions occur with first infusion 2
• Prior history of cardiovascular disease increases risk of cardiac complications 5, 4
• Patients with autoimmune diseases have higher rates of serum sickness-like reactions (78-85% of cases) 5

Mandatory Premedication Protocol

All patients must receive premedication with acetaminophen and an antihistamine 30 minutes before each rituximab infusion. 2

Standard Premedication Regimen

• Administer acetaminophen 650 mg orally 30 minutes before infusion 5
• Give diphenhydramine 25-50 mg orally or H1-antihistamine equivalent 30 minutes before infusion 5, 2
• For rheumatoid arthritis, GPA/MPA, and pemphigus vulgaris patients: administer methylprednisolone 100 mg intravenously or equivalent 30 minutes prior to each infusion 2
• For non-Hodgkin's lymphoma patients receiving CHOP: the glucocorticoid component of chemotherapy should be administered prior to rituximab infusion 2
• Corticosteroid premedication reduces severe reactions from 4.7% to 1% 4

Prophylactic Antimicrobial Therapy

Mandatory Prophylaxis Protocols

• Provide Pneumocystis jirovecii pneumonia (PCP) prophylaxis with sulfamethoxazole/trimethoprim throughout treatment and for 6-12 months after rituximab completion 3
• Administer herpes virus prophylaxis with acyclovir or equivalent 3
• Consider antibacterial/antiviral prophylaxis particularly when rituximab is combined with bendamustine due to risk of prolonged T-cell suppression and fatal infections 5

Monitoring During and After Infusion

Rituximab should only be administered by a healthcare professional with appropriate medical support to manage severe infusion-related reactions that can be fatal if they occur. 2

Infusion Monitoring Requirements

• Monitor patients continuously during infusion and for at least 1-2 hours after completion 4, 3
• Monitor vital signs continuously for at least 2 hours during infusion, particularly for high-risk patients 4
• Have emergency equipment and medications immediately available to manage severe reactions including bronchospasm, hypotension, and anaphylaxis 5, 2
• For severe reactions, discontinue infusion immediately 3, 2

Patient Education and Shared Decision-Making

Critical Information to Communicate

• Explain the 77% risk of infusion reactions during first administration, with most being mild to moderate flu-like symptoms that decrease with subsequent infusions 4
• Discuss risk of serious infections due to B-cell depletion, with median B-cell recovery time of 9 months (range 5.9-14.4 months) 4
• Warn about risk of progressive multifocal leukoencephalopathy (PML), a rare but fatal complication 2
• Inform patients about dramatically reduced antibody responses to recall antigens and need to avoid live vaccines 4
• Discuss potential for severe mucocutaneous reactions including DRESS, AGEP, Stevens-Johnson syndrome, and toxic epidermal necrolysis 5, 4

Vaccination Considerations

• Vaccines should be preferably administered prior to planned rituximab therapy, as rituximab has a suppressive effect on humoral response to influenza and pneumococcal vaccination 5
• In non-immunized patients already on rituximab, provide vaccination at least 6 months after administration and 4 weeks before the next course 5
• Avoid live vaccines during and after rituximab therapy until B-cell recovery 5

Documentation Requirements

• Record complete vaccination history and create individualized vaccination program 5
• Document all baseline screening results including HBV status, immunoglobulin levels, and tumor burden assessment 4, 1
• Obtain informed consent after discussing risks including fatal infusion reactions, HBV reactivation, PML, and severe mucocutaneous reactions 2
• Document performance status, comorbidities, and International Prognostic Index score for NHL patients 5