From the Guidelines
Patients receiving rituximab should receive several vaccines before starting treatment, ideally at least 4 weeks prior to the first dose, including pneumococcal vaccines (both PCV13 and PPSV23), influenza vaccine (annual inactivated version), hepatitis B vaccine series, and COVID-19 vaccination. During rituximab treatment, patients should avoid all live vaccines including measles-mumps-rubella, varicella, oral typhoid, yellow fever, and the live attenuated influenza vaccine 1. This recommendation exists because rituximab causes B-cell depletion that significantly impairs immune response to vaccines for approximately 6-12 months after treatment. If vaccination is needed during this period, inactivated vaccines may be given but will likely produce suboptimal protection.
Key Recommendations
- Administering influenza vaccination on schedule is conditionally recommended rather than deferring vaccination until the next rituximab administration is due 1.
- Deferring non–live attenuated vaccinations, other than influenza vaccination, until the next rituximab administration is due, and delaying rituximab for 2 weeks after vaccination, is conditionally recommended 1.
- For patients on maintenance rituximab, timing vaccines toward the end of a treatment cycle (just before the next scheduled dose) may improve vaccine response.
- Household members of rituximab patients should receive all age-appropriate vaccines, including annual influenza vaccination, to provide indirect protection through community immunity.
Considerations
- Rituximab has been shown to blunt responses to pneumococcal polysaccharide PPSV23 vaccination 1.
- Influenza vaccine responses are greater when the vaccine is administered later rather than earlier after rituximab 1.
- Patients could also be vaccinated in the interest of acquiring some immunity and then revaccinated later (influenza vaccination could also be repeated using this same rationale) 1.
- Whenever possible, vaccinations should be administered prior to rituximab initiation, and rituximab should be delayed for at least 2 weeks after any vaccination to allow time for the patient to develop an immune response, assuming that disease activity allows 1.
From the FDA Drug Label
The safety of immunization with live viral vaccines following RITUXAN therapy has not been studied and vaccination with live virus vaccines is not recommended before or during treatment For patients treated with RITUXAN, physicians should review the patient's vaccination status and patients should, if possible, be brought up-to-date with all immunizations in agreement with current immunization guidelines prior to initiating RITUXAN and administer non live vaccines at least 4 weeks prior to a course of RITUXAN
The recommended vaccines for patients taking rituximab are:
- Non-live vaccines, which should be administered at least 4 weeks prior to a course of rituximab. It is also recommended that patients be brought up-to-date with all immunizations prior to initiating rituximab, in agreement with current immunization guidelines. Live viral vaccines are not recommended before or during treatment with rituximab, as the safety of immunization with these vaccines following rituximab therapy has not been studied 2.
From the Research
Recommended Vaccines for Rituximab
- The efficacy of influenza vaccination in patients treated with rituximab is a significant concern, as studies have shown poor response to the vaccine 3.
- Research has indicated that the ability to respond to the influenza vaccine appears to be related to the degree of B cell recovery at the time of vaccination 3.
- In a study of 17 evaluable subjects treated with rituximab for rheumatologic conditions, only 16% of subjects had a four-fold increase in titer after receiving the standard inactivated influenza vaccine 3.
- The study suggests that pre-existing titers were retained throughout the study, but the overall responsiveness to the influenza vaccine was poor 3.
- There is no clear recommendation for alternative vaccines, as the study primarily focused on the efficacy of the influenza vaccine in rituximab-treated patients 3.