Rituximab | Indications, Contraindications & IV Infusion Protocols #nephrologists #rituximab #ccl

Here are the details : Section 1: Pre-Infusion Preparation I. Patient Evaluation: 1. Confirm diagnosis and dosage recommended 2. Take history to rule out contraindications: i. Contraindicated in: a. Active severe infection b. Severe heart failure or severe, uncontrolled cardiac disease c. History of hypersensitivity to Rituximab 3. -Immunizations: In patients who require immunizations (eg, for seasonal influenza, pneumococcal, and hepatitis B vaccines), we vaccinate patients at least four weeks before the administration of rituximab, when feasible. 4. Stop live vaccines 4 weeks prior to infusion 5. Assess current medications: Advise to stop antihypertensives on morning of infusion -risk of hypotension 6. For Female patients of child bearing potential : Contraindicated in Pregnancy as it causes fetotoxicity. Advise females of reproductive potential of the potential risk to a fetus and use of effective contraception Ref: https://www.uptodate.com/contents/rit... II. Check the Baseline Labs: 1. CBC with Differential Count 2. Renal Function test 3. Liver Function tests 4. Screen for the following: a. HBV b. HCV c. HIV 4: IgG levels (if recurrent infections suspected). 5: Chest X ray: if not done 6 months prior 6: ECG: If not done within past 4 weeks 7: ECHO: If not done within past 4 weeks III. Pre-Medications (30–60 mins prior): Methylprednisolone 100 mg IV (or oral prednisone) to reduce infusion reactions. Antihistamine (e.g., diphenhydramine 25–50 mg IV/PO) Acetaminophen 650 mg PO. IV. Consent & Counseling: Discuss benefits (proteinuria reduction, steroid-sparing effects) and risks (infections, hypersensitivity). Emphasize delayed B-cell depletion effects. Section 2: Infusion Protocol 1: PREPARATION OF INFUSION Use appropriate aseptic technique. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. ZYTUX should be a clear, colorless liquid. Do not use vial if particulates or discoloration is present. • The 10 mL vial contains 100 mg of rituximab (10 mg/mL). • The 50 mL vial contains 500 mg of rituximab (10 mg/mL). Use a sterile needle and syringe to prepare ZYTUX . Withdraw the necessary amount of ZYTUX and dilute to a final concentration of 1 mg/mL to 4 mg/mL in an infusion bag containing either 0.9% Sodium Chloride, USP, or 5% Dextrose Injection, USP. Gently invert the bag to mix the solution. Do not mix or dilute with other drugs. Discard any unused portion left in the vial. Storage Diluted ZYTUX solutions for infusion may be stored refrigerated at 2°C to 8°C (36°F to 46°F) for 24 hours.. Today we are giving a 1000 mg infusion Dose: 1,000 mg IV × 2 doses, 2 weeks apart (or 375 mg/m² weekly × 4 doses). Dilution: Mix in 500 mL normal saline (final concentration 1–4 mg/mL). Initial Rate: Start at 50 mg/hr (or 25% of total rate if higher concentration). Titration: Increase by 50 mg/hr every 30 minutes if no reactions (max 400 mg/hr). First infusion typically takes 4–6 hours; | Time (mins) | Rate (mg/hr) | |-------------|-------------| | 0–30 | 50 | | 30–60 | 100 | | 60–90 | 150 | | 90–120+ | 200–400 | (Max per tolerance; slower if high-risk patient.) For Second /Subsequent infusion If the initial infusion is well tolerated, we start the subsequent infusion(s) at a rate of 100 mg/hour, and the rate can be increased by 100 mg/hour every 30 minutes to a maximum of 400 mg/hour if there is no evidence of hypersensitivity. The subsequent infusions may be faster (3–4 hours) if tolerated. III: Section 3: Safety Monitoring During Infusion Vital Signs: Check BP, HR, temp, O2 saturation every 15–30 mins. Watch For: Fever, chills, rigors (most common). Hypotension, bronchospasm, angioedema (stop infusion if severe). Severe Reactions: STOP infusion for anaphylaxis (give epinephrine, fluids, corticosteroids). Restart at 50% slower rate once resolved. IV: Section 4: Post-Infusion Instructions (Visual: Discharge paperwork, patient education.) 1. Immediate Monitoring: Observe for 1-2 hours after completion. Educate on delayed reactions (fever, fatigue, anaphylaxis within 24–48 hrs). 2. Follow-Up: Schedule CBC, CD19/20 counts in 2–4 weeks to confirm B-cell depletion. Monitor for infections (e.g., URTI, UTI, reactivation of HBV). 3. Patient Counseling: Avoid crowds/sick contacts; report fever or dyspnea promptly. Live vaccines contraindicated until B-cells recover (≥6 months).