Use of Rituximab in Patients with Latent Tuberculosis

Key Recommendations

The American Academy of Dermatology recommends treating latent TB concomitantly with rituximab rather than requiring completion of TB treatment before initiating the biologic, for patients with latent TB who require biologics 1, 2
The American Academy of Dermatology suggests that rituximab can be used in patients with latent tuberculosis and appears to be safer than anti-TNF biologics, though concomitant treatment of latent TB is recommended 1

Rituximab shows no increased risk of latent TB reactivation in multiple cohort studies, unlike anti-TNF agents which carry well-established reactivation risk 2
The 2025 North American guidelines for special populations explicitly state that latent TB can be treated concomitantly when using anti-IL-17s or anti-IL-12/23s, and this same approach applies to rituximab based on its safety profile 1, 2
TB screening prior to biologic initiation is still mandatory using interferon-γ release assays (IGRA) and/or tuberculin skin test (TST), with IGRA preferred in BCG-vaccinated or immunocompromised patients 1

Screen all patients for TB before rituximab initiation using IGRA and/or TST (5mm cutoff for immunosuppressed patients) 1, 3
Obtain chest radiography if screening is positive to rule out active TB 4
Check hepatitis B and C antibody levels and obtain baseline immunoglobulin levels (IgG, IgM, IgA) as part of standard rituximab pre-treatment workup 3
Initiate rifampin 10 mg/kg/day (max 600 mg) for 4 months as the preferred regimen for latent TB treatment, which is as effective as 9 months of isoniazid with superior completion rates 1, 2
Start rituximab concomitantly with TB prophylaxis rather than waiting for completion 1, 2

Concomitant corticosteroid use significantly increases TB risk in a dose-dependent manner, particularly when combined with immunosuppressants 2
Annual latent TB screening is advised for patients on long-term glucocorticoids (>15 mg prednisone equivalent daily for ≥4 weeks) 1
For high-risk patients with latent TB, non-TNF therapies (including rituximab) should be preferentially considered 1
If anti-TNFs are required in high-risk individuals, completion of TB treatment prior to biologic initiation is prudent, whereas rituximab can be started concomitantly 1, 2