Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 25.09.2023

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Genetically engineered tumor therapeutic directed against a CD surface antigen. Rituximab is a monoclonal, chimeric mouse-human antibody that binds to the human transmembrane antigen CD20 in B cells. Since hematopoietic stem cells do not express CD20 antigen, they are not attacked by the antibody.

Pharmacodynamics (Effect)
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Binding of the Fc moiety of the CD20 antibody to the CD20 surface marker on B cells activates the complement cascade and causes cytolysis of these cells. In addition, the antibody with the Fc moiety binds to macrophages, NK cells, and other effector cells, which subsequently induce a cell-mediated cytotoxic response with apoptosis of CD20-positive cells.

Notice. Physiological B cells are also affected by cytolysis (regeneration of the population approx. 6 months after the last application).

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Rituximab is approved in Germany for the treatment of patients with stage III-IV follicular lymphoma that is resistant to chemotherapy or who have a second or recurrent relapse after chemotherapy, and for the treatment of CD20-positive large B-cell diffuse non-Hodgkin's lymphoma in combination with CHOP chemotherapy. Since 2018, rituximab has also been approved for therapy in pemphigus disease and, with an 89% remission rate after 2 years of therapy, has been a significant breakthrough in PV therapy since the introduction of systemic corticosteroids in the 1950s.

Rituximab is also approved for the treatment of severe active rheumatoid arthritis in adults in combination with methotrexate. Approval is limited to patients who have responded inadequately to or have been intolerant of other disease-modifying antirheumatic drugs, including one or more therapies with tumor necrosis factor inhibitors.

Experimental and Casuistic Contributions:

Pregnancy/nursing period
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There is insufficient data on therapy during pregnancy or lactation, so do not use in pregnant women or nursing mothers.

Dosage and method of use
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Monotherapy: 375 mg/m2 KO i.v. 4 times weekly. The infusion rate should be cautiously adjusted to 50 ml/hr for 30 minutes on initial administration and may be subsequently increased to 100 ml/hr, 200 ml/hr and 300 ml/hr. Concomitant medication: Uricostatic drugs, e.g. 150 mg allopurinol p.o. 1 time/day to control the uric acid increase in tumour decay during the entire therapy period. Analgesics (e.g. Indometacin) and antihistamines as well as volume administration (1000 ml NaCl 0.9% i.v.) approx. 30-60 minutes before infusion start, 4 hours and 8 hours after application to avoid side effects.

Whether intravenous is superior to intralesional application is still under discussion.

Combination with CHOP regimen: 375 mg/m2 KO i.v. on day 1 of each chemotherapy cycle after application of the corticosteroid component of the chemotherapy cycle. Concomitant medication as above.

Undesirable effects
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Up to 50 % of patients experience side effects, some of which are severe, with fever, chills, breathing difficulties and skin rashes. The symptoms are presumably triggered by a large number of cytokines that are released during therapy due to cell decay (cytokine release syndromes, see also under biologics). The clinical symptoms correspond to a Jarisch-Herxheimer reaction. Acute infusion-dependent reactions occur more frequently in oncological indications than in rheumatological indications (Jung JW et al. 2014).

Some UAWs (5-10% of cases?) are reminiscent of IgE-mediated allergic reaction (positive skin test reactions (Sachs B et al. 2018).

Other serious adverse reactions include the occurrence of progressive multifocal leukoencephalopathy (PML) in isolated cases.

Some reports exist on the triggering of various autoimmune diseases such as psoriasis, autoimmune lymphoproliferative syndrome, systemic lupus erythematosus and immune complex vasculitis (see below leukocytoclastic vasculitis)

Kaposi's sarcoma: There are isolated reports of the occurrence of iatrogenic Kaposi's sarcoma during therapy with rituximab.

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Hypersensitivity to mouse proteins. Immune deficiency diseases e.g. with CD20 immunodeficiencies(see below CVID5 with mutation in the CD20 gene).

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Reminder. Women of childbearing age should use effective contraceptive measures during and 12 months after treatment with MabThera!

Caution! In individual cases, therapy with rituximab has led to progressive multifocal leukoencephalopathy (PML) with a fatal outcome. This is shown in a Health Professional Letter from the manufacturers, which was published on the pages of the US regulatory authority FDA. In addition, there is a warning in this regard in the manufacturers' product information.

Test concentrations for suspected allergic reactions (recommended test concentrations cited from Sachs B et al. 2018)

  • Prick: 10mg/ml
  • i.c.: 0.1;1.0; 10mg/ml

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Last updated on: 25.09.2023