Rituximab Administration in Patients on Low-Dose Tacrolimus

General Considerations for Rituximab Administration

The American College of Rheumatology recommends planning non-live vaccinations and other interventions requiring immune response just before the next scheduled dose of rituximab, and then delaying rituximab by at least 2 weeks for patients with rheumatic diseases receiving rituximab 2, 1
The same principle applies to patients already on low-dose tacrolimus who need rituximab treatment, according to the American College of Rheumatology 1
Concurrent use of multiple biologic agents is generally not recommended due to increased risk of serious infections without additional clinical benefit, as stated by the American College of Rheumatology 3

For patients with rheumatoid arthritis who have lymphoproliferative disorders, the American College of Rheumatology conditionally recommends rituximab over other DMARDs 4, 5, 6
In patients with hepatitis B infection, the American College of Rheumatology strongly recommends prophylactic antiviral therapy before initiating rituximab in patients who are hepatitis B core antibody positive 4, 5, 6
In patients with persistent hypogammaglobulinemia without infection, the American College of Rheumatology conditionally recommends continuation of rituximab therapy over switching to a different biologic DMARD 4, 5, 6

For patients with rheumatoid arthritis undergoing total hip or knee arthroplasty, the American College of Rheumatology conditionally recommends withholding rituximab prior to surgery and planning the surgery after the next dose is due 7
This principle can be applied when planning other interventions requiring immune response in patients on both rituximab and tacrolimus, according to the American College of Rheumatology 7

The American College of Rheumatology recommends assessing disease activity and specific indications for rituximab before administration 4, 5, 6
Consider the timing of rituximab administration in relation to tacrolimus dosing - ideally administering rituximab just before the next scheduled dose of tacrolimus, as suggested by the American College of Rheumatology 1
After rituximab administration, delay the next tacrolimus dose by at least 2 weeks, according to the American College of Rheumatology 1