Rituximab (Mabthera ®)
Rituximab, which is also known as Mabthera ®, is used to treat non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukaemia (CLL).
You'll see your doctor regularly while you have this treatment so they can monitor its effects. This information should help you discuss any queries about your treatment and its side effects with your doctor or specialist nurse.
Rituximab belongs to a group of cancer drugs known as monoclonal antibodies. Monoclonal antibodies are sometimes called targeted therapies because they work by ‘targeting’ specific proteins (receptors) on the surface of cells.
Rituximab ‘locks on’ to a protein called CD20, which is found on the surface of white blood cells called B-lymphocytes (B-cells). CD20 is found on normal B-cells and on most of the abnormal (malignant) B-cells that occur in many types of NHL. CD20 is also found on some of the abnormal B-cells that occur in CLL.
Rituximab destroys both abnormal and normal B-cells by triggering the body’s immune system to attack the cells and destroy them. However, the body can replace normal B-cells that are damaged, so their numbers recover once treatment is over.
When rituximab is used
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Rituximab is used to treat several types of CD20-positive NHL (NHL where CD20 is found on the surface of the cancer cells). It may also be used to treat CLL. It's often given in combination with chemotherapy, but it may be given on its own. Your doctor or specialist nurse can tell you whether rituximab is suitable for your situation.
Rituximab may also be used to treat other, non-cancerous conditions.
What rituximab looks like
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Rituximab is a colourless fluid.
How rituximab is given
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Rituximab is given as a drip into a vein (intravenous infusion). It may be given on its own or with chemotherapy.
Some people have an allergic reaction to rituximab. Reactions are most common with the first dose so, to reduce the risk of a reaction, the first infusion is given slowly over a number of hours. You‘ll be given medicines before the treatment that help to prevent or reduce any reaction.
If you have a reaction, the infusion can be stopped and started again when the symptoms are over. You may need to stay in hospital overnight for the first treatment so you can be monitored. After the first treatment, rituximab can usually be given in the outpatient department and over shorter periods of time.
When used by itself, rituximab is usually given weekly over a period of four weeks. The treatment may be repeated later if necessary.
If used as a maintenance treatment following successful chemotherapy, rituximab is often given every two months for a maximum of two years.
If rituximab is used with chemotherapy, it's usually given on the first day of each cycle of chemotherapy treatment.
Each person’s reaction to cancer treatment is different. Some people have very few side effects while others may experience more. The side effects described here won't affect everyone having this treatment.
We've outlined the most common side effects, but haven't included those that are rare and therefore unlikely to affect you.
If you notice any effects that aren't listed here, discuss them with your doctor or specialist nurse. The side effects of rituximab are generally mild and some of these can be reduced with medicines.
Side effects of rituximab fall into two groups:
infusion-related side effects, which occur while you’re receiving the treatment (during the infusion) or within a few hours of it being given - these are usually most noticeable with the first dose
later side effects, which occur after a few days or weeks of treatment.
Infusion-related side effects
These are most common with the first few infusions. Reactions are usually mild or moderate but sometimes they can be more severe.
If you have a reaction it can usually be treated by slowing or stopping the drip until you feel better. You may also be given treatment such as an antihistamine or paracetamol. When you feel better, the infusion can be continued. These reactions are less likely to happen after the second infusion.
You’ll be monitored closely during the infusion, but it's very important to tell your nurse or doctor if you feel unwell or have any of the following symptoms:
flu-like symptoms, such as headache, feeling flushed, having a fever, chills or dizziness
feeling sick (nausea)
red, warm and itchy bumps on the skin (like nettle rash)
a feeling of swelling in the lips, tongue or throat
breathlessness, wheezing, a cough or sudden difficulty in breathing
pain in your back or stomach
a tight chest or chest pain.
Sometimes an infusion-related reaction can happen a few hours after treatment. If you develop these symptoms or feel unwell after you get home, contact the hospital straight away for advice.
Low blood pressure
Some people's blood pressure drops during the infusion. Your blood pressure will be checked regularly. If you normally take medicines to lower your blood pressure, tell the doctor. You may be given instructions about when it's best to take these before rituximab is given.
During the infusion, some people experience mild pain in the parts of the body where they have cancer. Painkillers can be given to relieve this.
Later side effects
Risk of infection
Rituximab can reduce the number of white blood cells in your blood, which help to fight infection. White cells are produced by the bone marrow. If your number of white blood cells is low, you’ll be more prone to infections. A low white blood cell count is called neutropenia.
Contact your doctor or the hospital straight away if:
your temperature goes above 38˚C (100.4˚F)
you suddenly feel unwell, even if your temperature is normal.
Your blood cell numbers (blood count) will be monitored throughout your treatment. Occasionally, it may be necessary to delay your treatment if the number of blood cells is too low.
Bruising and bleeding
Rituximab can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. You can have a platelet transfusion if your platelet count is low.
Anaemia (low number of red blood cells)
Rituximab can reduce the number of red blood cells, which carry oxygen around the body. A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Feeling sick (nausea)
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or greatly reduce nausea or vomiting. If the sickness isn't controlled, or if it continues, tell your doctor as they can prescribe other anti-sickness drugs that may be more effective.
Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.
Rituximab may worsen heart problems for people who already have them. For this reason, it's used with caution in anyone who has heart disease. Tests to see how well your heart is working may sometimes be carried out.
It’s important to let your doctor know straight away if you feel unwell or have any severe side effects, even if they’re not mentioned above.
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You should avoid having live vaccines during treatment and for at least six months afterwards. Live vaccines include BCG (tuberculosis), yellow fever, measles, mumps, rubella, liquid typhoid, poliomyelitis and MMR (combined measles, mumps and rubella).
Some medicines, including those that you can buy in a shop or chemist, can be harmful to take when you are having cancer treatment. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
It is not known what effect rituximab may have on an unborn baby. So it's recommended that women who are able to become pregnant and men who are sexually active use effective contraception while having rituximab. It's also important to use effective contraception for at least 12 months after the treatment has ended.
There is a potential risk that rituximab may be present in breast milk, so women are advised not to breastfeed during this treatment and for a few months afterwards.
It's not known what effects rituximab may have on your ability to have children in the future. If you have concerns about fertility, it's important to discuss them with your doctor before beginning treatment.
Non-cancer hospital admission
If you’re admitted to hospital for a reason not related to the cancer, it’s important to tell the doctors and nurses looking after you that you are having treatment with rituximab. You should tell them the name of your cancer specialist so they can ask them for advice.
It’s a good idea to find out who you should contact if you have any problems or troublesome side effects when you’re at home. During office hours, you can contact the clinic or ward where you had your treatment. Your specialist nurse or doctor will tell you who to contact during the evening or at weekends.
This information has been compiled using a number of reliable sources, including:
electronic Medicines Compendium (eMC). Summary of product characteristics. www.emc.medicines.org.uk (accessed 4 September 2012).
National Institute for Health and Clinical Excellence (NICE). Rituximab for the first-line treatment of stage III-IV follicular lymphoma (TA243). January 2012. National Institute for Health and Clinical Excellence (NICE).
National Institute for Health and Clinical Excellence (NICE). Rituximab for Aggressive Non‑Hodgkin’s Lymphoma TA65). September 2003.National Institute for Health and Clinical Excellence (NICE).
National Institute for Health and Clinical Excellence (NICE). Rituximab for the treatment of relapsed or refractory stage III or IV follicular non-Hodgkins lymphoma (TA137). February 2008. National Institute for Health and Clinical Excellence (NICE)
National Institute for Health and Clinical Excellence (NICE). Rituximab for the first-line treatment of chronic lymphocytic leukaemia. July 2009. National Institute for Health and Clinical Excellence (NICE).
National Institute for Health and Clinical Excellence (NICE). Rituximab for the treatment of relapsed or refractory chronic lymphocytic leukaemia (TA193). July 2010. National Institute for Health and Clinical Excellence (NICE)
Scottish Medicines Consortium (SMC). Advice on 675/11 - Rituximab (Mabthera). February 2011. Scottish Medicines Consortium (SMC).
Scottish Medicines Consortium (SMC). Advice on 591/09 - Rituximab (Mabthera). January 2010. Scottish Medicines Consortium (SMC).
Scottish Medicines Consortium (SMC). Advice on 540/09 - Rituximab (Mabthera). June 2009. Scottish Medicines Consortium (SMC).
Scottish Medicines Consortium (SMC). Advice on 493/08 - Rituximab (Mabthera). September 2008. Scottish Medicines Consortium (SMC).
With thanks to Professor Rajnish Gupta, Consultant Medical Oncologist, and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network.