Rituximab (Mabthera, Rixathon, Truxima)

Rituximab is a targeted cancer drug and is also known by its brand names MabThera, Rixathon and Truxima.

It is a treatment for:

• chronic lymphocytic leukaemia (CLL)
• some types of non-Hodgkin lymphoma (NHL)
• some non cancer related illnesses

You might have the original rituximab drug called Mabthera, or a biosimilar such as Truxima or Rixathon. A biosimilar is a very similar copy of the original drug, but it is not exactly the same. Biosimilars undergo strict testing to check they work just as well as the original drug.

How rituximab works

Rituximab is a monoclonal antibody. It targets a protein called CD20 on the surface of the leukaemia and lymphoma cells. Rituximab sticks to all the CD20 proteins it finds. Then the cells of the immune system pick out the marked cells and kill them.

How you have rituximab

You might have rituximab on its own or with other cancer drugs (as part of a treatment regimen). You usually have it as a drip into your bloodstream (intravenously). 

Depending on your cancer type, you may be able to have rituximab as an injection under your skin (subcutaneous). You can only have rituximab under your skin if you have had at least one dose of rituximab into your vein and you didn't have any serious side effects during the infusion.

Into your bloodstream

You have the treatment through a drip into your arm or hand. A nurse puts a small tube (a cannula) into one of your veins and connects the drip to it.

You might need a central line. This is a long plastic tube that gives the drugs into a large vein, either in your chest or through a vein in your arm. It stays in while you’re having treatment, which may be for a few months.

As an injection under your skin

You usually have injections under the skin (subcutaneous injection) into the stomach, thigh or top of your arm.

You might have stinging or a dull ache for a short time after this type of injection but they don't usually hurt much. The skin in the area may go red and itchy for a while.

When you have rituximab

For non-Hodgkin lymphoma (NHL)

For NHL, you may have rituximab in combination with other cancer drugs or on its own (maintenance therapy). 

You usually start by having rituximab in combination with other cancer drugs. You might have it every 2 to 3 weeks, for up to 24 weeks. A common way of having rituximab with other cancer drugs is a treatment regimen called R-CHOP. 

If the initial treatment works well, you may then go on to have further rituximab treatment as maintenance therapy. You have this treatment every 2 or 3 months for 2 years.

For CLL 

You usually have rituximab treatment alongside chemotherapy once a month for 6 months.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

Side effects

How often and how severe the side effects are can vary from person to person. They also depend on what other treatments you're having. For example, your side effects could be worse if you're also having other drugs or radiotherapy.

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you closely during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects 
• your side effects aren’t getting any better
• your side effects are getting worse

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Remember it is very unlikely that you will have all of these side effects, but you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Increased risk of getting an infection 

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Bruising and bleeding 

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

An allergic reaction 

Some people have an allergic reaction to rituximab. This reaction is most likely to happen during treatment and when you first have the treatment. Symptoms of an allergic reaction include high temperature (fever), chills, feeling or being sick and difficulty breathing. 

Your nurse will give you medicines beforehand to try to prevent a reaction. Tell your nurse straight away if you have any symptoms of an allergic reaction. They will slow down or stop your drip for a while.

Feeling or being sick 

Feeling or being sick is usually well controlled with anti sickness medicines. Avoiding fatty or fried foods, eating small meals and snacks, drinking plenty of water, and relaxation techniques can all help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treating it once it has started.

Hair loss 

You could lose all your hair. This includes your eyelashes, eyebrows, underarm, leg and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. 

Skin changes  

Skin problems include a skin rash, dry skin and itching. This usually goes back to normal when your treatment finishes. Your nurse will tell you what products you can use on your skin to help.

High temperature (fever), weakness and chills 

You might get a high temperature (fever), weakness and chills. Contact your doctor or nurse if you have this.

Headaches

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Low levels of an antibody called immunoglobulin G in your body 

Immunoglobulin G is an antibody made by the immune system to fight bacteria and viruses. You have regular blood tests during and after treatment to check for this. 

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• a severe whole body infection called sepsis which can be life threatening
• breathlessness and looking pale due to a drop in red blood cells (anaemia)
• weight loss
• high blood sugar levels
• swelling (oedema) in your arms, legs and face
• low levels of calcium in your body
• difficulty sleeping
• dizziness
• restlessness and anxiety
• a reduced sense of touch or tingling or pricking in your hands and feet
• heart problems such as an abnormal heart rhythm and a heart attack
• changes to your blood pressure
• eye problems such as inflammation of the eyes (conjunctivitis)
• hearing changes such as ringing or buzzing in the ear (tinnitus) and ear pain
• pain in your chest, tummy (abdomen), muscles, joints, back and neck
• difficulty breathing and cough
• constipation
• difficulty swallowing
• mouth sores and ulcers
• indigestion or heartburn
• loss of appetite
• night sweats
• flu like symptoms such as redness (flushing) of the skin and weakness
• an infection of the liver called hepatitis B

Rare side effects

These side effects happen in fewer than 1 in 100 people (fewer than 1%). You might have one or more of them. They include:

• changes to the way your blood clots
• a severe allergic reaction called anaphylaxis
• changes to the levels of chemicals in your body caused by a breakdown of tumour cells (tumour lysis syndrome)
• low mood (depression)
• taste changes
• a hole in your stomach or bowel (perforation)
• damage to the kidneys
• inflammation of the lungs (asthma)
• swollen tummy (abdomen)
• a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening
• pain at the site of injection

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do I need to know?

Other medicines, foods and drinks 

Cancer drugs can interact with some other medicines and herbal products. Tell your doctor or pharmacist about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies.

Loss of fertility 

It is not known whether this treatment affects fertility in people. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Pregnancy and contraception 

This treatment may harm a baby developing in the womb. It is important not to become pregnant or father a child while you are having treatment with this drug and for at least a year afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Breastfeeding 

Don’t breastfeed during this treatment and for 12 months afterwards. The drug may come through in the breast milk.

Treatment for other conditions

Always tell other doctors, nurses, pharmacists or dentists that you’re having this treatment if you need treatment for anything else, including teeth problems.

Immunisations 

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and the shingles vaccine (Zostavax).

You can:

• have other vaccines, but they might not give you as much protection as usual
• have the flu vaccine (as an injection)

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

More information about this treatment

For further information about this treatment go to the electronic Medicines Compendium (eMC) website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.