Vaccines Before Rituximab

Essential Vaccines to Administer Pre-Rituximab

The American College of Rheumatology recommends administering all indicated vaccines at least 2-4 weeks before initiating rituximab therapy, with optimal timing being 4-6 weeks prior to the first infusion to maximize immune response 1, 2
Administer PCV13 (13-valent pneumococcal conjugate vaccine) first, followed by PPV23 (23-valent pneumococcal polysaccharide vaccine) 8 weeks later, as recommended by the Centers for Disease Control and Prevention 1
If time is limited, give PCV13 at minimum 2-4 weeks before rituximab and plan PPV23 for the next rituximab cycle, according to the Infectious Diseases Society of America 1
Both vaccines should ideally be completed before rituximab whenever possible, as stated by the American College of Rheumatology 2, 1
The dosing for PCV13 and PPV23 is 0.5 mL intramuscular or subcutaneous injection for both vaccines, as recommended by the Centers for Disease Control and Prevention 1

The Centers for Disease Control and Prevention recommends administering seasonal inactivated influenza vaccine (quadrivalent) annually, at least 2-4 weeks before rituximab initiation 1
Use only inactivated (non-live) influenza vaccine, never live attenuated influenza vaccine (LAIV), as stated by the American Academy of Pediatrics 3
Ensure Tdap (tetanus, diphtheria, acellular pertussis) is up to date, and administer if not received within past 10 years, as recommended by the Centers for Disease Control and Prevention 1
Rituximab severely impairs tetanus toxoid responses for at least 6 months; patients with contaminated wounds during this period require tetanus immunoglobulin in addition to vaccine, according to the Infectious Diseases Society of America 3
Complete hepatitis B series if patient lacks documented immunity, with optimal timing being 8-12 weeks before rituximab to allow for multi-dose series, as recommended by the Centers for Disease Control and Prevention 1

Administer PCV13, influenza, Tdap, hepatitis B dose 1, and any indicated live vaccines at week 0, as recommended by the American College of Rheumatology 1
Administer MMR or varicella if needed (must be at least 4 weeks before rituximab) at week 4, according to the Centers for Disease Control and Prevention 1, 3
Administer PPV23 and hepatitis B dose 2 at week 8, as recommended by the Infectious Diseases Society of America 1
Initiate rituximab at week 8-12, as stated by the American College of Rheumatology 1

Measure antibody titers 4 weeks after vaccination to confirm adequate response, including pneumococcal serotype-specific antibodies, hepatitis B surface antibodies, and other vaccine-specific antibodies as indicated, as recommended by the Centers for Disease Control and Prevention 1, 6
Rituximab profoundly impairs vaccine responses for up to 6 months after treatment, according to the American College of Rheumatology 2

Rituximab causes B-cell depletion that typically lasts 6-9 months, with full B-cell recovery usually occurring 9-12 months after therapy, as stated by the Infectious Diseases Society of America 2
Humoral (antibody) responses to vaccines are severely impaired during this period, according to the American College of Rheumatology 2
Patients vaccinated before rituximab initiation achieve significantly higher seroconversion rates (87-91%) compared to those vaccinated after rituximab (61-65%), as reported by the Centers for Disease Control and Prevention 2

Never administer live vaccines after rituximab has been started, as stated by the American Academy of Pediatrics 3
Do not assume vaccine responses are adequate without checking titers, according to the Infectious Diseases Society of America 1
Do not delay rituximab indefinitely for vaccination if disease is active, as recommended by the American College of Rheumatology 5, 6
Remember that vaccine impairment is reversible, and adequate vaccination 9 months or more after rituximab cessation can restore responses comparable to healthy controls, as reported by the Centers for Disease Control and Prevention 5, 6, 2