Is it safe to use Rituximab (rituximab) in a patient with active tuberculosis (TB) and scleroderma?

Rituximab Use in Active Tuberculosis for Scleroderma

Rituximab should NOT be used during active tuberculosis—complete TB treatment with full symptom resolution before initiating or reinitiating rituximab, and strongly consider non-anti-TNF biologics like rituximab over TNF inhibitors once TB is adequately treated. 1

Critical Management Algorithm for Active TB

Step 1: Immediate TB Treatment Priority

• Active tuberculosis is an absolute contraindication to starting any biologic therapy, including rituximab, until TB treatment is completed and symptoms have fully resolved 1
• Initiate standard antitubercular therapy immediately and defer all immunosuppressive biologics 1
• The recommended approach is completing the full TB treatment course (typically 6-9 months depending on regimen) before considering biologic initiation 1

Step 2: Post-TB Treatment Evaluation

• Document complete resolution of TB symptoms clinically 1
• Obtain chest radiography to confirm radiological improvement 1
• Ensure completion of the full antitubercular regimen as prescribed by infectious disease specialists 1

Step 3: Biologic Selection After TB Resolution

• Once TB is adequately treated and resolved, rituximab is actually a preferred choice over anti-TNF biologics for scleroderma management 1, 2
• Rituximab shows no increased risk of latent TB reactivation in multiple cohort studies, unlike anti-TNF agents which carry well-established reactivation risk 2, 3
• In patients with prior active TB who require biologics, non-anti-TNF biologic classes (including rituximab) should be preferentially considered 1, 2

Evidence Supporting Rituximab for Scleroderma

Efficacy Data

• The 2025 EULAR guidelines recommend rituximab for treatment of SSc skin fibrosis based on a double-blind RCT in Japan showing significant improvement in modified Rodnan skin score (−6.30 vs 2.14 in placebo; difference −8.44, p<0.0001) 1
• Rituximab should be considered alongside mycophenolate mofetil and methotrexate as treatment options for scleroderma skin fibrosis 1
• For SSc-ILD (interstitial lung disease), rituximab is recommended as one of three first-line options along with mycophenolate mofetil and cyclophosphamide 1

Safety Profile in TB Context

• A retrospective cohort study of 60 patients in Saudi Arabia (TB-endemic region) showed no TB reactivation in rituximab-treated patients during follow-up 4
• Review data from clinical trials showed no cases of active TB in patients with rheumatic conditions treated with rituximab, contrasting with anti-TNF agents 3
• One case report documented successful rituximab use in a patient with SLE and immune thrombocytopenia who had multisystem tuberculosis—the patient was already on antitubercular treatment and experienced no TB-related complications during or after rituximab therapy 5

Important Caveats and Pitfalls

Common Errors to Avoid

• Never initiate rituximab during active TB infection—this is fundamentally different from latent TB, where concomitant treatment is acceptable 1, 2
• Do not confuse active TB management (requires completion of treatment first) with latent TB management (can treat concomitantly with rituximab) 1, 2
• Avoid using anti-TNF biologics in patients with TB history when rituximab is a viable alternative for the underlying condition 1, 2

Concomitant Medication Risks

• Glucocorticoid use significantly increases TB risk in a dose-dependent manner, particularly when combined with immunosuppressants 1
• If the patient requires >15 mg prednisone equivalent daily for ≥4 weeks, annual latent TB screening is mandatory even after active TB treatment completion 1

Post-Treatment Monitoring

• After completing TB treatment and initiating rituximab, maintain heightened surveillance for TB recurrence, especially in the first year 1
• Perform baseline screening for hepatitis B and C, and obtain immunoglobulin levels (IgG, IgM, IgA) before rituximab initiation 2
• Screen for latent TB using IGRA and/or TST before any future biologic therapy, as reinfection risk persists in endemic areas 1

Practical Dosing for Scleroderma

Standard Rituximab Protocol

• The Japanese RCT used 375 mg/m² IV once weekly for 4 weeks (notably higher than typical rheumatologic dosing) 1
• Alternative dosing used in other rheumatic conditions is two 1000-mg doses given two weeks apart 6
• Premedicate with acetaminophen and antihistamines 30 minutes before each infusion to reduce infusion-related reactions 2, 6