Parenteral Manual

RiTUXimab

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
RITUXAN®
Classification: 
Chimeric Monoclonal Antibody
Original Date: 
September 2014
Indications: 
  • Non-Hodgkin's lymphoma (CD-20 positive, B-cell)
  • Transplant-related lymphoma
Reconstitution and Stability: 
  • Available as a 10 mg/mL solution.  Refrigerate.
  • Dilute dose in NS or D5W to a concentration of 1-4 mg/mL.  DO NOT SHAKE BAG.  Invert gently to mix.
  • Diluted solutions stable 24 hours refrigerated and at room temperature for additional  12 hours; if not refrigerated -stable 12 hours at room temperature
Compatibility: 

- Solutions Compatible: D5W, NS

NO COMPATIBILITY information with other drugs.  Run in dedicated line; do not mix with any other drug

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC NO
IM NO
IV Push

NO
IV Intermittent Infusion

YES
Usual dilution: 1-4 mg/mL

FIRST DOSE:

  • Start infusion at 0.5 mg/kg/hr, maximum of 50 mg/hr.  If no hypersensitivity or infusion-related events occur, increase rate in increments of 0.5 mg/kg/hr, maximum of 50 mg/hr, every 30 minutes to a maximum of 400 mg/hr.  If reaction occurs, stop infusion temporarily and notify physician.  Once patient improves and tumor lysis syndrome and pulmonary infiltrate have been ruled out, re-start at 50% of rate at which reaction occurred.
  • Subsequent infusions may be started at 1 mg/kg/hr, maximum 100 mg/hr, and increased by 1 mg/kg/hr, maximum 100 mg/hr, up to 400 mg/hr if tolerated well.
IV Continuous Infusion NO
Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

  • 375 mg/m2 every 1-3 weeks for 4-8 doses total

** Dosage may differ according to protocol

Potential hazards of parenteral administration: 
  • Premedication with diphenhydramine (Benadryl®) and acetaminophen is mandatory. Reactions generally occur 30 minutes to 2 hours after the start of the first infusion.  If reaction occurs, stop infusion temporarily and notify physician.
  • Infusion-related Syndrome: consists of allergic reactions (eg. rash, urticaria, fever, chills, bronchospasm, angioedema) and other symptoms (eg. flushing, hypotension, rhinitis, nausea, asthenia, headache)
  • Tumor Lysis Syndrome: consists of hyperuricemia, hyperkalemia, hypocalcemia, acute renal failure, elevated LDH and high fever.  Risk factors include: high numbers of circulating blasts or large tumor burden.  Tumor Lysis Syndrome usually will occur within 1-2 hours of first infusion, but can be delayed until 12-24 hours after.
  • Cytokine Release Syndrome (rare 4-7 patients/10,000) may occur within 24 hours of first infusion and can be fatal.  Large tumor burden is risk factor.
  • Severe pulmonary events (rare) such as bronchospasm, dyspnea, hypoxia, pulmonary infiltrates and acute respiratory failure may occur within 1-2 hours after starting the first infusion.  Patients with pre-existing pulmonary insufficiency or tumor infiltration of the lungs are at higher risk.

- Treatment for unusual side effects are available through the study chair identified on the front page of the protocol and/or pharmacy

Notes: 
  • See pre-printed orders for premedication doses and mandatory monitoring protocol (pulse, respiratory rate, blood pressure every 15 minutes while increasing rate)
  • Anaphylaxis precautions are necessary; have available at bedside: diphenhydramine, hydrocortisone, and epinephrine.  Ventolin nebules may be indicated for respiratory difficulty.

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