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Rituximab Infusion Protocol

1. Patient is admitted for treatment by staff.
2. On admission
   • Vital signs: Obtain on initial evaluation and Hourly during infusion
   • Height and weight: Measure for Rituximab dose calculation.
3. Patient is evaluated: Obtain
   • Interval history
   • Pertinent physical exam
   • Adverse events
4. Outcome assessments
   • Quantitative dynamometry (Muscle strength, distal & proximal): Every 3 months
   • Quantitative sensory testing: RS tuning fork at toes, ankles, knees & fingers
   • Gait testing: Tandem gait up to 8 steps
5. Laboratory
   • Blood: CBC and electrolytes, glucose, and creatinine (BMP)
   • First and last admissions: Blood is also drawn for
     • Antibody titers to GM1 and GalNAc-GD1a ganglioside, or MAG, or TS-HDS
       • 2 red top tubes to Room 404 IWJ, Washington University
       • Pretreatment sample: On requisition, Ask our lab to save for future comparison with post-treatment samples
     • Immunocompetency panel: Send at least for CD3, CD19
     • Quantitative immunoglobulins (IgM; IgG; IgA)
       • More likely response to treatment of IgM antibody-related neuropathy: If IgM levels fall
       • More likely infectious complications: If IgG levels are low before treatment

1. Start IV heparin lock
2. Start normal saline at 100 cc/hr
3. Run saline at keep vein open (kvo) rate during infusion

• Frequency of IV treatments
  • Weekly x 2 doses
  • Then 1 dose every 10 to 12 weeks for 2 years
• Premedication: Thirty minutes prior to infusion of Rituximab with
  • Benadryl 25 mg p.o.
  • Tylenol 650 mg p.o.
• Rituximab dose: 375 mg/M² for each treatment. Calculate absolute dose to be administered.
• Rituximab Infusion
  • Begin at 25 mg/hr
  • Follow-up rates: Increase if systolic blood pressure remains between 170 and 100.
    • First infusion: Double every hour to a maximum of 100 mg/hr
    • Subsequent infusions: Double every hour to a maximum of 200 mg/hr
• Patients may take all regular medicines.
• Continue saline infusion for 1 to 2 hours after Rituximab is completed.

1. Problems: Contact the Neuromuscular fellow immediately.
   • A fellow is available 24 hours a day
   • Phone #: 747-3000
2. Notify MD for
   • Temp > 38.0
   • Cardiac complaints
   • Respiratory symptoms: Shortness of breath must be reported immediately.
   • Rash
3. Activity while in treatment center: Patient may be up ad lib
4. After infusion is finished
   • Treatment 1 : Patient should be observed overnight.
   • Follow-up treatments: Patient may be discharged 1 to 2 hours after the infusion is completed.

1. Patient should be sent home on their regular medicines
2. Follow-up in the Neuromuscular clinic: Exam & Lab testing every 3 months; 2 months after final infusion.
3. Questions or problems: Patient should call Neuromuscular office at 314-362-6981.

• CBC and electrolytes, glucose, and creatinine (BMP)
• Antibody titers: IgM vs GM1 & GalNAc-GD1a ganglioside, MAG, GD1b or TS-HDS
  • 2 red top tubes to
      Neuromuscular Clinical Laboratory
      Box 8111 - Neurology; Room 404 IWJ
      660 South Euclid Avenue
      St. Louis, MO 63110
      Phone: 314-362-6981
      Fax: 314-362-3752
    
  • Save serum specimen for comparison with post treatment samples
• Immunocompetency panel: Send for CD3, CD19
• Quantitative immunoglobulins: IgM, IgG, IgA