Clinical Neurology · Neuro-Immunology

Rituximab Protocol

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Rituximab protocol: indications, screening, premedication, and infusion rate titration for first and subsequent infusions.

Indication

Relapsing remitting MS
Neuromyelitis optica
Myasthenia gravis
CIDP
Inflammatory myopathy
Paraneoplastic neurological disorders

Screening labs

HCG (for women)
Hepatitis B screen
CBC with differential
Creatinine, BUN
CD19 flow cytometry

Pre-medicate patient with

Acetaminophen 650 mg PO
Benadryl 50 mg IV
Solumedrol 100 mg IV

Administration

Dose: 1000 mg rituximab (Rituxan) in 250 ml of NS.

First infusion: start at 50 ml/h then increase by 50 ml/hr every 30 minutes to target of 400 mg/hr. Slow infusion if patient developed mild infusion reactions (nausea, flushing, mild hypotension); stop if patient developed severe infusion reactions (marked drop in BP, arrhythmia, chest pain).

Timing after starting infusion	Total dose given so far	Increase infusion rate to
0 minute (start time)	0 mg	Start at 50 mg/hr
30 minutes	25 mg	100 mg/hr
60 minutes	75 mg	150 mg/hr
1.5 hr	150 mg	200 mg/hr
2 hr	250 mg	250 mg/hr
2.5 hr	325 mg	300 mg/hr
3 hr	475 mg	350 mg/hr
3.5 hr	650 mg	400 mg/hr
4 hr	850 mg	400 mg/hr
4 hr 22 minutes	1000 mg	Stop

Next infusions: start at 100 mg/hr and increase by 100 mg/hr every one hour to target of 400 mg/hr. Slow infusion if patient developed mild infusion reactions (nausea, flushing, mild hypotension); stop if patient developed severe infusion reactions (marked drop in BP, arrhythmia, chest pain).

Timing after starting infusion	Total dose given so far	Increase infusion rate to
0 minute (start time)	0 mg	Start at 100 mg/hr
30 minutes	50 mg	200 mg/hr
60 minutes	150 mg	300 mg/hr
1.5 hr	300 mg	400 mg/hr
2 hr	500 mg	400 mg/hr
2.5 hr	700 mg	400 mg/hr
3 hr	900 mg	400 mg/hr
3 hr 15 minutes	1000 mg	Stop

Ahmed Koriesh, MD