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Rituximab and Hyaluronidase

Medically reviewed by Drugs.com. Last updated on Aug 29, 2020.

Pronunciation

(ri TUK si mab & hye al yoor ON i dase)

Index Terms

  • Anti-CD20 Monoclonal Antibody
  • Hyaluronidase and Rituximab
  • Rituximab Subcutaneous

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Subcutaneous [preservative free]:

Rituxan Hycela: Rituximab 1400 mg and hyaluronidase human 23,400 units per 11.7 mL (11.7 mL); Rituximab 1600 mg and hyaluronidase human 26,800 units per 13.4 mL (13.4 mL) [contains polysorbate 80]

Brand Names: U.S.

  • Rituxan Hycela

Pharmacologic Category

  • Antineoplastic Agent, Anti-CD20
  • Antineoplastic Agent, Monoclonal Antibody

Pharmacology

Rituximab is a monoclonal antibody directed against the CD20 antigen on the surface of pre-B and mature B-lymphocytes. CD20 regulates cell cycle initiation; and, possibly, functions as a calcium channel. Rituximab binds to the antigen on the cell surface, activating complement-dependent B-cell cytotoxicity; and to human Fc receptors, mediating cell killing through an antibody-dependent cellular toxicity.

Hyaluronidase increases the absorption rate of rituximab-containing products by increasing permeability of subcutaneous tissue through temporary depolymerization of hyaluronan; at the recommended doses, hyaluronidase acts locally and the effects are reversible. Permeability of the subcutaneous tissue is restored within 24 to 48 hours.

Distribution

Vdss: SubQ: 8.52 L (CLL); 8.09 L (FL)

Onset of Action

CLL: B-cells begin to deplete following the first cycle of rituximab, with 28% of patients B-cell depleted prior to the dose in cycle 2; by cycle 6, 96% of patients were B-cell depleted.

FL: Peripheral B-cell counts decrease to levels below normal following the first cycle of rituximab and are maintained during treatment with rituximab/hyaluronidase.

Duration of Action

CLL: Patients remained B-cell depleted until month 9, where signs of repletion were seen.

FL: After discontinuing rituximab/hyaluronidase, B-cell repletion begins after 6 months (may be longer in some patients)

Half-Life Elimination

Terminal: 32 days (CLL); 34.1 days (FL)

Use: Labeled Indications

Chronic lymphocytic leukemia: Treatment of adult patients with previously untreated and previously treated chronic lymphocytic leukemia (CLL) (in combination with fludarabine and cyclophosphamide)

Diffuse large B-cell lymphoma: Treatment of adult patients with previously untreated diffuse large B-cell lymphoma (DLBCL) in combination with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or other anthracycline-based chemotherapy regimens

Follicular lymphoma: Treatment of adult patients with:

Relapsed or refractory follicular lymphoma (FL) as a single agent;

Previously untreated FL (in combination with first-line chemotherapy) and, in patients achieving a complete or partial response to rituximab in combination with chemotherapy (as single-agent maintenance therapy);

Non-progressing (including stable disease) FL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy

Limitations of use: Initiate treatment with rituximab/hyaluronidase only after patients have received at least 1 full dose of a rituximab product by intravenous infusion; rituximab/hyaluronidase is not indicated for the treatment of non-malignant conditions.

Contraindications

There are no contraindications listed in the manufacturer's US labeling.

Canadian labeling: Known type 1 hypersensitivity or anaphylactic reaction to murine proteins, Chinese Hamster Ovary (CHO) cell proteins, or any component of the formulation; patients who have or have had progressive multifocal leukoencephalopathy (PML); patients with severe, active infections

Dosing: Adult

Note: All patients must receive at least one full dose of intravenous rituximab (without experiencing severe adverse reactions) prior to initiating treatment with subcutaneous rituximab/hyaluronidase; patients who do not tolerate a full IV dose should continue to receive IV rituximab in subsequent cycles. May switch to SubQ rituximab/hyaluronidase when a full IV dose is successfully administered.

Premedicate with acetaminophen and an antihistamine prior to each dose (consider glucocorticoid premedication if necessary). Antihyperuricemic therapy and aggressive hydration are recommended for patients at risk for tumor lysis syndrome (high tumor burden or lymphocytes >25,000/mm3). In patients with chronic lymphocytic leukemia (CLL), Pneumocystis jirovecii pneumonia (PCP) and antiherpetic viral prophylaxis is recommended during treatment (and for up to 12 months following treatment).

Chronic lymphocytic leukemia: SubQ: Rituximab 1,600 mg/hyaluronidase 26,800 units (fixed dose) on day 1 of a 28-day cycle in cycles 2 through 6 (in combination with fludarabine and cyclophosphamide) (Assouline 2016) (IV rituximab should be administered in cycle 1).

Diffuse large B-cell lymphoma: SubQ: Rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) on day 1 of cycles 2 through 8 in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (IV rituximab should be administered in cycle 1).

Follicular lymphoma:

Previously untreated: SubQ: Induction: Rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) on day 1 of a 21-day cycle in cycles 2 through 8 (in combination with chemotherapy) (Davies 2017); IV rituximab should be administered in cycle 1. In patients with complete or partial response following combination chemotherapy, initiate maintenance treatment (see below).

Maintenance: SubQ: In patients with complete or partial response, initiate rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) once every 8 weeks for 12 doses (Davies 2017). Maintenance treatment should be initiated 8 weeks following completion of initial combination chemotherapy treatment.

Non-progressing disease following 6 to 8 cycles of first-line CVP chemotherapy: SubQ: Rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) once weekly for 3 weeks (IV rituximab should be administered in week 1 for a total of 4 weeks of therapy) at 6-month intervals to a maximum of 16 doses.

Relapsed or refractory: SubQ: Rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) once weekly for 3 or 7 weeks (IV rituximab should be administered in week 1) for a total of 4 or 8 weeks of therapy

Relapsed or refractory (retreatment): SubQ: Rituximab 1,400 mg/hyaluronidase 23,400 units (fixed dose) once weekly for 3 weeks (IV rituximab should be administered in week 1) for a total of 4 weeks of therapy

Relapsed or refractory (maintenance treatment after response to induction treatment) [Canadian labeling]: SubQ: 1,400 mg (fixed dose) once every 3 months until disease progression or maximum duration of 2 years (Rituxan SC Canadian product labeling)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Adjustment for Toxicity

Dosage adjustments for rituximab/hyaluronidase are not recommended; however, adjustments for concomitant chemotherapy may be necessary.

Reconstitution

Rituximab/hyaluronidase (for subcutaneous administration) and rituximab (for IV administration) are not interchangeable; verify vial label prior to use to prevent medication errors. Withdraw dose volume into a syringe using any length, narrow gauge needle (eg, 25 to 30 gauge); label with the peel-off sticker. To avoid clogging the needle, change the needle to a 1/2-inch to 5/8-inch long, narrow gauge needle (eg, 25 to 30 gauge) immediately prior to administration. Rituximab/hyaluronidase is compatible with polypropylene and polycarbonate syringes and stainless steel transfer and injection needles.

Administration

SubQ: For SubQ administration only. Inject subcutaneously into the abdomen over ~5 minutes (rituximab 1.4 g/hyaluronidase 23,400 units) to 7 minutes (rituximab 1.6 g/hyaluronidase 26,800 units). To avoid clogging the needle, change needle to a new 1/2-inch to 5/8-inch long, narrow gauge needle (eg, 25 to 30 gauge) immediately prior to administration. Do not inject into areas where the skin is red, bruised, tender, or hard, or where there are moles or scars. If administration is interrupted, continue administration at the same or at a different site (restricted to the abdomen). Rituximab/hyaluronidase is compatible with polypropylene and polycarbonate syringes and stainless-steel transfer and injection needles. Do not administer other subcutaneous medications at the same sites as rituximab/hyaluronidase. Monitor patients for 15 minutes following administration.

Storage

Store intact vials at 2°C to 8°C (36°F to 46°F); do not freeze. Store in original packaging to protect from light. Following transfer from vial to syringe, the manufacturer recommends immediate use. If not used immediately, syringes may be stored for 48 hours at 2°C to 8°C (36°F to 46°F) and subsequently for 8 hours at 30°C (86°F) in diffuse light.

Drug Interactions

Alpha-/Beta-Agonists: Hyaluronidase may enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Exceptions: EPINEPHrine (Nasal); EPINEPHrine (Oral Inhalation); Isometheptene; Pseudoephedrine. Consider therapy modification

Antihistamines: May diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving antihistamines (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

Belimumab: May enhance the immunosuppressive effect of Biologic Disease-Modifying Antirheumatic Drugs (DMARDs). Avoid combination

Biologic Disease-Modifying Antirheumatic Drugs (DMARDs): May enhance the immunosuppressive effect of other Biologic Disease-Modifying Antirheumatic Drugs (DMARDs). Avoid combination

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Monitor therapy

Cladribine: May enhance the immunosuppressive effect of Immunosuppressants. Avoid combination

Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy

Corticosteroids (Systemic): May diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Consider therapy modification

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

DOPamine: Hyaluronidase may enhance the adverse/toxic effect of DOPamine. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of dopamine. Use of hyaluronidase for other purposes in patients receiving dopamine may be considered as clinically indicated. Consider therapy modification

Echinacea: May diminish the therapeutic effect of Immunosuppressants. Management: Consider avoiding Echinacea in patients receiving therapeutic immunosuppressants. If coadministered, monitor for reduced efficacy of the immunosuppressant during concomitant use. Consider therapy modification

Estrogen Derivatives: May diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving estrogens (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification

Inebilizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification

Local Anesthetics: Hyaluronidase may enhance the adverse/toxic effect of Local Anesthetics. Exceptions: Benzocaine; Benzydamine; Cocaine (Topical); Dibucaine; Dyclonine; Ethyl Chloride; Hexylresorcinol; Lidocaine (Ophthalmic); Lidocaine (Topical); Pramoxine; Proparacaine; Tetracaine (Ophthalmic); Tetracaine (Topical). Monitor therapy

Mesalamine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Management: Avoid use of immunosuppressants (including systemic corticosteroids) prior to initiation of nivolumab. Use of immunosuppressants after administration of nivolumab (eg, for immune-related toxicity) is unlikely to affect nivolumab efficacy. Consider therapy modification

Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy

Ozanimod: Immunosuppressants may enhance the immunosuppressive effect of Ozanimod. Monitor therapy

Phenylephrine (Systemic): Hyaluronidase may enhance the vasoconstricting effect of Phenylephrine (Systemic). Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of phenylephrine. Use of hyaluronidase for other purposes in patients receiving phenylephrine may be considered as clinically indicated. Avoid combination

Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy

Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Management: Consider avoiding concomitant use of roflumilast and immunosuppressants as recommended by the Canadian product monograph. Inhaled or short-term corticosteroids are unlikely to be problematic. Consider therapy modification

Salicylates: May diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving salicylates (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

Siponimod: Immunosuppressants may enhance the immunosuppressive effect of Siponimod. Monitor therapy

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy. Consider therapy modification

Smallpox and Monkeypox Vaccine (Live): Immunosuppressants may diminish the therapeutic effect of Smallpox and Monkeypox Vaccine (Live). Monitor therapy

Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Exceptions: Smallpox and Monkeypox Vaccine (Live). Avoid combination

Adverse Reactions

Also see individual agents. All incidences are from combination therapy regimens unless otherwise specified.

>10%:

Dermatologic: Alopecia (14% to 24%), dermatological reaction (16%), erythema of skin (9% to 15%), skin rash (10% to 12%; including severe mucocutaneous reactions)

Gastrointestinal: Abdominal pain (7% to 14%), constipation (8% to 25%), diarrhea (14% to 18%), nausea (22% to 38%), vomiting (11% to 21%)

Hematologic & oncologic: Anemia (13% to 23%; grades 3/4: 5%), febrile neutropenia (8% to 14%; grades 3/4: 7% to 14%), leukopenia (6% to 19%; grades 3/4: 3% to 14%), neutropenia (31% to 65%; grades 3/4: 25% to 56%), thrombocytopenia (24%; grades 3/4: 6%)

Immunologic: Antibody development (anti-hyaluronidase antibodies: 11% to 15%; anti-rituximab antibodies: 2% to 12%)

Infection: Serious infection (46% to 56%)

Local: Erythema at injection site (13% to 26%), pain at injection site (8% to 16%)

Nervous system: Chills (8% to 13%), fatigue (11% to 20%), headache (6% to 13%), paresthesia (9% to 16%), peripheral neuropathy (12%; grades 3/4: ≤2%)

Neuromuscular & skeletal: Arthralgia (9% to 13%), asthenia (8% to 17%)

Respiratory: Cough (11% to 23%), dyspnea (4% to 11%), pneumonia (2% to 11%), upper respiratory tract infection (13% to 15%)

Miscellaneous: Fever (13% to 32%)

1% to 10%:

Cardiovascular: Chest pain (6%), hypertension (6%), hypotension (1%), peripheral edema (5% to 8%)

Dermatologic: Pruritus (8% to 10%)

Endocrine & metabolic: Weight loss (8%)

Gastrointestinal: Decreased appetite (8%), dyspepsia (5% to 8%), stomatitis (5% to 8%; grades 3/4: ≤1%), upper abdominal pain (5%)

Genitourinary: Urinary tract infection (2% to 8%)

Hematologic & oncologic: Lymphocytopenia (5%; grades 3/4: 1%)

Infection: Influenza (4%)

Local: Infusion site reaction (≤7%; monotherapy in maintenance setting; higher with combination therapy and initial infusions)

Nervous system: Dizziness (7%), insomnia (1% to 9%)

Neuromuscular & skeletal: Back pain (9%), limb pain (7% to 10%), muscle spasm (8%), myalgia (8%), ostealgia (6% to 10%)

Ophthalmic: Conjunctivitis (5%)

Respiratory: Bronchitis (7% to 8%), flu-like symptoms (3%), nasopharyngitis (10%), oropharyngeal pain (6% to 9%), respiratory tract infection (8%), sinusitis (7%)

Frequency not defined:

Hepatic: Fulminant hepatitis, hepatic failure

Hypersensitivity: Hypersensitivity reaction

Infection: JC virus infection, reactivation of HBV

<1%, postmarketing, and/or case reports: Bone marrow depression, bronchiolitis obliterans, hypogammaglobulinemia (prolonged), inflammatory polyarthropathy, interstitial pulmonary disease, intestinal obstruction, intestinal perforation, Kaposi sarcoma (disease progression), lichenoid dermatitis, lupus-like syndrome, optic neuritis, pancytopenia (prolonged), pemphigoid reaction, pleurisy, progressive multifocal leukoencephalopathy, pyoderma gangrenosum (including genital presentation), serum sickness, severe dermatological reaction, Stevens-Johnson syndrome, toxic epidermal necrolysis, uveitis, vasculitis (systemic; with rash), vesiculobullous dermatitis, viral infection

ALERT: U.S. Boxed Warning

Mucocutaneous reactions:

Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab-containing products, including rituximab/hyaluronidase.

Hepatitis B virus reactivation:

Hepatitis B virus (HBV) reactivation can occur in patients treated with rituximab-containing products, including rituximab/hyaluronidase, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with rituximab/hyaluronidase. Discontinue rituximab/hyaluronidase and concomitant medications in the event of HBV reactivation.

Progressive multifocal leukoencephalopathy:

Progressive multifocal leukoencephalopathy (PML), including fatal PML, can occur in patients receiving rituximab-containing products, including rituximab/hyaluronidase.

Warnings/Precautions

Concerns related to adverse effects:

• Bowel obstruction/perforation: Abdominal pain, bowel obstruction, and perforation have been reported (rarely fatal) in patients receiving rituximab-containing products, with an average onset of symptoms of ~6 days (range: 1 to 77 days); evaluate abdominal pain or repeated vomiting.

• Cardiovascular effects: Cardiac events (eg, ventricular fibrillation, myocardial infarction, and cardiogenic shock) may occur with rituximab-containing products. Discontinue rituximab/hyaluronidase for serious or life-threatening cardiac arrhythmias. Perform cardiac monitoring during and after administration in patients who develop clinically significant arrhythmias or who have a history of arrhythmia or angina.

• Cytopenias: Rituximab is associated with lymphopenia, leukopenia, neutropenia, thrombocytopenia, and anemia; the duration of cytopenias may be prolonged and may extend months beyond treatment. Monitor blood counts.

• Hepatitis B virus reactivation: [US Boxed Warning]: Hepatitis B virus (HBV) reactivation may occur with rituximab-containing products, including rituximab/hyaluronidase, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with rituximab/hyaluronidase. Discontinue rituximab/hyaluronidase and concomitant medications in the event of HBV reactivation. Screening should include hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc); monitor patients for clinical and laboratory signs of hepatitis or HBV reactivation during and for several months after treatment. If viral hepatitis develops, initiate appropriate antiviral therapy. Reactivation has occurred in patients who are HBsAg positive as well as in those who are HBsAg negative but are anti-HBc positive; HBV reactivation has also been observed in patients who had previously resolved HBV infection. HBV reactivation has been reported up to 24 months after rituximab discontinuation. Use cautiously in patients who show evidence of prior HBV infection (eg, HBsAg positive [regardless of antibody status] or HBsAG negative but anti-HBc positive); consult with appropriate clinicians regarding monitoring and consideration of antiviral therapy before and/or during rituximab treatment. The safety of resuming rituximab-containing treatment following HBV reactivation is not known; discuss reinitiation of therapy in patients with resolved HBV reactivation with physicians experienced in HBV management.

- American Society of Clinical Oncology (ASCO) provisional clinical opinion update on hepatitis B virus screening recommendations (Hwang 2015): Patients receiving anti-CD20 antibodies are at high risk for hepatitis B virus (HBV) reactivation. Screen for HBV infection with HBsAG and anti-HBc tests prior to treatment initiation; either a total anti-HBc (with both IgG and IgM) or anti-HBc IgG test should be used to screen for chronic or resolved HBV infection (do not use anti-HBc IgM as it may only confirm acute HBV infection). In addition, patients who have risk factors for HBV infection (eg, birthplace in a country with ≥2% HBV prevalence, household or sexual contact with HBV infected patients, high-risk behaviors [eg, intravenous drug use], and HIV infection) should also be screened prior to beginning therapy. Initiate prophylactic antiviral therapy (utilizing antivirals with low rates of viral resistance) for HBsAg positive/anti-HBc positive patients (without delaying cancer therapy) and continue the antivirals during and for ~6 to 12 months after completing treatment. HBsAg negative/anti-HBc positive patients should be monitored for HBV reactivation with HBV DNA and ALT testing approximately every 3 months during treatment; antiviral therapy may be initiated prophylactically or begun promptly at the first sign of HBV reactivation.

• Hypersensitivity: Rituximab-containing products are associated with hypersensitivity reactions (may be related to cytokine release and/or other chemical mediators). Due to the higher risk of hypersensitivity and other acute reactions, patients must receive at least one full dose of intravenous rituximab prior to receiving subcutaneous rituximab/hyaluronidase. Infusion-related reactions (with the use of intravenous rituximab formulations) usually occur within 30 to 120 minutes and may include hypotension, angioedema, bronchospasm, hypoxia, urticaria, and in more severe cases pulmonary infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, cardiogenic shock, and/or anaphylactoid events. Anaphylactic and other hypersensitivity reactions may occur (typically occur within minutes of infusion initiation); severe cytokine release syndrome may occur within 1 to 2 hours of starting infusion. Patients with a history of pulmonary insufficiency or with pulmonary tumor infiltration may have a poorer outcome. Closely monitor patients with a history of prior cardiopulmonary reactions or with preexisting cardiac or pulmonary conditions and patients with high numbers of circulating malignant cells (>25,000/mm3). Prior to administration, premedicate patients with acetaminophen and an antihistamine (and consider glucocorticoids). Observe patients for at least 15 minutes following subcutaneous administration; increase observation time in patients at higher risk of hypersensitivity reactions. Interrupt rituximab/hyaluronidase administration immediately for signs of a severe reaction; initiate aggressive symptomatic treatment. Medications for the treatment of hypersensitivity reactions (eg, bronchodilators, epinephrine, antihistamines, corticosteroids) should be available for immediate use.

• Infections: Serious and potentially fatal bacterial, fungal, and either new or reactivated viral infections may occur during treatment and after completing therapy with rituximab-containing products. Infections have been observed in patients with prolonged hypogammaglobulinemia, defined as hypogammaglobulinemia >11 months after rituximab exposure. Associated new or reactivated viral infections have included cytomegalovirus, herpes simplex virus, parvovirus B19, varicella zoster virus, West Nile virus, and hepatitis B and C. Discontinue rituximab/hyaluronidase in patients who develop serious infections and initiate appropriate anti-infective treatment.

• Mucocutaneous and cutaneous reactions: [US Boxed Warning]: Severe, including fatal, mucocutaneous reactions may occur in patients receiving rituximab-containing products, including rituximab/hyaluronidase. Paraneoplastic pemphigus, Stevens-Johnson syndrome, lichenoid dermatitis, vesiculobullous dermatitis, and toxic epidermal necrolysis have been reported. Discontinue in patients experiencing severe mucocutaneous skin reactions; the safety of reexposure following mucocutaneous reactions has not been evaluated. Subcutaneous rituximab has been associated with localized cutaneous (and injection site) reactions (eg, pain, erythema, swelling, induration, rash, pruritus, hemorrhage); may occur >24 hours after administration. Reactions have been mostly mild to moderate and have resolved without intervention. Local reactions were most common during the first rituximab/hyaluronidase cycle (incidence decreases with subsequent injections).

• Progressive multifocal leukoencephalopathy: [US Boxed Warning]: Progressive multifocal leukoencephalopathy (PML) (including fatalities) may occur in patients receiving rituximab-containing products, including rituximab/hyaluronidase. Promptly evaluate any patient presenting with neurological changes; consider neurology consultation, brain MRI and lumbar puncture for suspected PML. Discontinue rituximab/hyaluronidase in patients who develop PML; consider reduction/discontinuation of concurrent chemotherapy or immunosuppressants.

• Renal toxicity: Rituximab-containing products may cause severe or fatal renal toxicity. Patients who received combination therapy with cisplatin and rituximab for NHL experienced renal toxicity (associated with tumor lysis syndrome) during clinical trials; this combination is not an approved treatment regimen. Renal toxicity also occurred due to tumor lysis syndrome. Monitor for signs of renal failure; discontinue rituximab-containing products with increasing serum creatinine or oliguria.

• Tumor lysis syndrome: Tumor lysis syndrome may occur within 12 to 24 hours after administration of a rituximab-containing product. Hyperkalemia, hypocalcemia, hyperuricemia, and/or hyperphosphatemia may occur. Administer prophylaxis (antihyperuricemic therapy, hydration) in patients at high risk (high numbers of circulating malignant cells ≥25,000/mm3 or high tumor burden). Correct electrolyte abnormalities; monitor renal function and hydration status, and administer supportive care as indicated.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

• Immunizations: Live vaccines should not be given concurrently with rituximab; there is no data available concerning secondary transmission of live vaccines with or following rituximab-containing treatment.

Dosage form specific issues:

• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer’s labeling.

Monitoring Parameters

Electrolytes (in patients at risk for tumor lysis syndrome [TLS]), CBC with differential; renal function (in patients at risk for TLS), fluid/hydration status balance; BP, vital signs; verify pregnancy status prior to treatment in females of reproductive potential.

Screen all patients for hepatitis B virus (HBV) infection prior to therapy initiation (eg, hepatitis B surface antigen [HBsAG] and anti-HBc measurements). In addition, carriers and patients with evidence of current infection or recovery from prior hepatitis B infection should be monitored closely for clinical and laboratory signs of HBV reactivation and/or infection during therapy and for up to 2 years following completion of treatment. HBV screening recommendations (ASCO provisional clinical opinion update [Hwang 2015]): Screen for HBV infection with HBsAG and hepatitis B core antibody (anti-HBc) tests prior to treatment initiation; either a total anti-HBc (with both IgG and IgM) or anti-HBc IgG test should be used to screen for chronic or resolved HBV infection (do not use anti-HBc IgM as it may only confirm acute HBV infection). HBsAg negative/anti-HBc positive patients should be monitored for HBV reactivation with HBV DNA and ALT testing approximately every 3 months during treatment.

Monitor for hypersensitivity reactions (observe for 15 minutes following administration); signs of active hepatitis B infection (during and for up to 12 months after therapy completion); cardiac monitoring during and after infusion (in patients with preexisting cardiac disease or if arrhythmias develop during or after subsequent infusions); monitor for signs/symptoms of bowel obstruction/perforation (abdominal pain, vomiting); signs or symptoms of progressive multifocal leukoencephalopathy (focal neurologic deficits, which may present as hemiparesis, visual field deficits, cognitive impairment, aphasia, ataxia, and/or cranial nerve deficits); signs/symptoms of TLS and/or mucocutaneous or cutaneous skin reactions.

Reproductive Considerations

Verify pregnancy status prior to treatment initiation in females of reproductive potential.

Effective contraception should be used in females of reproductive potential during therapy and for 12 months following the last rituximab/hyaluronidase dose.

Rituximab/hyaluronidase may be used as monotherapy or in combination with other chemotherapy agents (eg, cyclophosphamide, doxorubicin, fludarabine, vincristine); refer to the rituximab, hyaluronidase, and other individual monographs for additional information.

Pregnancy Considerations

Rituximab crosses the placenta. Based on human data, rituximab-containing products may cause adverse outcomes in infants following in utero exposure.

Rituximab/hyaluronidase may be used as monotherapy or in combination with other chemotherapy agents (eg, cyclophosphamide, doxorubicin, fludarabine, vincristine); refer to the rituximab, hyaluronidase, and other individual monographs for additional information.

Patient Education

What is this drug used for?

• It is used to treat types of leukemia and lymphoma.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Injection site irritation

• Loss of strength and energy

• Nausea

• Vomiting

• Abdominal pain

• Lack of appetite

• Constipation

• Diarrhea

• Hair loss

• Common cold symptoms

• Nose irritation

• Throat irritation

• Muscle spasm

• Muscle pain

• Joint pain

• Bone pain

• Back pain

• Trouble sleeping

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Stevens-Johnson syndrome/toxic epidermal necrolysis like red, swollen, blistered, or peeling skin (with or without fever); red or irritated eyes; or sores in mouth, throat, nose, or eyes

• Progressive multifocal leukoencephalopathy like confusion, depression, trouble with memory, behavioral changes, change in strength on one side is greater than the other, trouble speaking, change in balance, or vision changes

• Infection

• Tumor lysis syndrome like fast heartbeat or abnormal heartbeat; any passing out; unable to pass urine; muscle weakness or cramps; nausea, vomiting, diarrhea or lack of appetite; or feeling sluggish

• Bowel problems like black, tarry, or bloody stools; fever; mucus in stools; vomiting; vomiting blood; severe abdominal pain; constipation; or diarrhea

• Heart problems like cough or shortness of breath that is new or worse, swelling of the ankles or legs, abnormal heartbeat, weight gain of more than five pounds in 24 hours, dizziness, or passing out

• Liver problems like dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin

• Cytokine release syndrome like chills, dizziness, loss of strength and energy, fever, headache, passing out, rash, swelling of the face, trouble breathing, nausea, vomiting, or wheezing

• Kidney problems like unable to pass urine, blood in the urine, change in amount of urine passed, or weight gain

• Lung problems like shortness of breath or other trouble breathing, cough that is new or worse

• Severe headache

• Dizziness

• Passing out

• Vision change

• Bruising

• Bleeding

• Burning or numbness feeling

• Chest pain

• Fast heartbeat

• Abnormal heartbeat

• Severe injection site pain, swelling, hardness, redness, bleeding, itching, or rash

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.