To see all protocols that comply with the WHO Essential Medicine List 

This document is a quick and concise evidence-based summary to provide additional information, instruction, or guidance to complement a treatment protocol or clinical resource document. 

Infusion related reactions (IRRs) are a common adverse event that can occur anytime during rituximab administration, with majority of IRRs occurring during the first infusion. While most IRRs are mild to moderate, IRRs can be life-threatening or even fatal. Premedications administered prior to rituximab administration and graded administration rates reduces the likelihood and severity of IRRs.r Patients who tolerate the first infusion of rituximab at the standard administration rate without experiencing any IRRs may be eligible to receive subsequent infusions at a faster rate.

Note: The rapid infusion regimen is ONLY to be used in patients who meet the following criteria: 

  • receiving their second or subsequent infusion of rituximab 
  • previous infusion/s received without grade 3 or 4 infusion-related toxicities
  • circulating lymphocyte count < 5.0 x 109/L

Studies have shown that for patients who have received the initial infusion of rituximab at the standard rate without any grade 3 or 4 infusion related reactions (IRR), subsequent infusions of rituximab can be administered safely via a rapid infusion 90 minute protocol and are well tolerated.rrrrr Rapid infusion rituximab can be administered either as monotherapy or in combination with chemotherapy.rr

Patients with clinically significant cardiovascular disease, congestive heart failure (New York Heart Association [NYHA] grade II or higher), ventricular arrhythmia requiring medication within 1 year, or peripheral vascular disease (NYHA grade II or higher) were excluded from the phase III safety study by Dakhil et al. and therefore use of the rituximab rapid infusion for this patient population is at the discretion of the treating clinician.r

Administration:

  • it is recommended that patients omit their antihypertensive medication on the day of rituximab treatment and take their premedication orally before they arrive at the clinic
  • give premedications 30 to 60 minutes prior to administration of rituximab:
    • paracetamol 1000 mg PO AND
    • loratadine 10 mg PO (or similar antihistamine)
    • patients who are receiving prednisolone or dexamethasone as part of their chemotherapy regimen may receive this as part of their rituximab premedication (the rituximab product information recommends a glucocorticoid premedication should be considered if not part of the chemotherapy regimen)
  • measure and document baseline observations and repeat every 30 minutes

Use a controlled rate infusion pump set when administering rituximab as per table:

Infusion time First 30 mins 30 min - 1 hr 1 - 1.5 hrs 1.5 - 2 hrs 2 - 2.5 hrs 2.5 - 3 hrs 3 - 3.5 hrs 3.5 hrs onwards 
First infusion

50 mg/hr

100 mg/hr 150 mg/hr 200 mg/hr 250 mg/hr 300 mg/hr 350 mg/hr 400 mg/hr (MAX rate)
Subsequent infusions – if nil adverse events during first infusion 100 mg/hr 200 mg/hr 300 mg/hr 400 mg/hr (MAX rate)

     

Rapid infusion protocol# -  second or subsequent infusions (see Note)  

Administer over 90 minutes (approx.)

20% of dose

(i.e. 200 mL/hr for dose loaded in 500 mL bag)

Remaining 80% of dose to be given over approx. 60 mins

(i.e. 400 mL/hr (MAX rate) for dose loaded in 500 mL bag)

         

# For first dose with rapid infusion regimen, patients are to be under constant visual observation during all rate increases and for 30 minutes after infusion is completed.

  • if cytokine-release syndrome or acute infusion reaction occurs, temporarily discontinue infusion and notify medical officer
  • when symptoms have resolved, recommence infusion at half the rate prior to the reaction
  • for severe reactions stop infusion and manage as per emergency
  • if applicable, administer accompanying cytotoxic regimen either prior to, or after the rituximab according to institutional policy

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https://www.eviq.org.au/p/3044

19 Mar 2024