Rituximab Care Pathway for Rheumatoid Arthritis

RITUXIMAB CARE PATHWAY FOR RHEUMATOID ARTHRITIS

DiagnosisRh.factor pos Consultant

Date:

Treatment Course 1 / 2 / 3 / 4 /

NICE Technology Guidance 126

Rituximab in combination with methotrexate is recommended as an option for the treatment of adults with severe active rheumatoid arthritis who have had an inadequate response to or intolerance of other disease-modifying anti-rheumatic drugs (DMARDs), including treatment with at least one tumour necrosis factor α (TNF-α) inhibitor therapy

PRE-SCREENING

Previous DMARDS / Duration / Why Stopped / Previous Biologics / Why Stopped
Etanercept
Infliximab
Adalimumab
Rituximab
Blood Tests Screening Tests / Date / Checked by / Comments
Prioris / Ist course / Subsequent courses
FBC +ESR
U&E/LFT/CRP
Immunoglobulins
B cell count
CD 19 (FACS)
Rheumatoid Factor
Hepatitis.B /C / n/a
HIV (consented) / n/a
CXR result within last year
VaccinationsList any to have at least 4 weeks before start of treatment / 6 months after treatment / Date / Initial

PLAN

1. Patient to receive Rituximab 1000mg on Day 0 and Day 14

2. Other______Signature & Date: ______

TREATMENT

To be completed on Day 0 by patient

Have you had in the last 2 weeks?

YES / NO
Fever
Hot & Cold spells
Shivering
Cough / Cold
Sputum
Wheeze
Chest pain
Shortness of breath
Palpitations
Vomiting
Diarrhoea
Abdominal pain
Stinging on passing urine
Passing urine more frequently than usual
Rashes
Swelling of joints
Ulcers
Changes in vision / hearing or speech
Headaches
Dental problems

Signature & Date:

Date SHO Day Unit Nurse

Baseline Observations

Temperature
Blood Pressure
Pulse
O2 Sats
Urinalysis
Patient review:

Milestone - Is patient able to receive rituximab? YES NO

If NO state reasons and actions below

Pre-medication to be given 30-60 mins prior to starting Rituximab

Date / Drug / Dose / Route / Signature / Given By / Time
Paracetamol / 1 G / P.O
Chlorphenamine / 4mg / P.O. *
Chlorphenamine / 10mg / I.V. *
Methylprednisolone / 100mg / I.V
In 100ml N/Saline
Date / Drug / Dose / Route / Signature / Given By / Time
start / stop
Rituximab / 1000mg / I.V
in 500ml of N/Saline

1st infusion 1000mg ( 100mls) in 500ml = 600mls total volume

Infusion Rate

0 – 30mins / 30ml/hr
30 – 60 mins / 60ml/hr
60 – 90 mins / 90ml/hr
90 – 120 mins / 120mls/hr
2hr - 2½ hr / 150ml/hr
2 ½- 3 hr / 180ml/hr
3hr - 3½ hr / 210ml/hr
3½- 4hr / 240ml/hr – maximum rate

Increase every 30 mins if tolerated to a maximum of 400mg /hr - minimum time 4 ½ hours

If there are any side effects stop the infusion and seek medical advice. When symptoms have resolved recommence infusion at half the previous rate.

Observations– T. P. B/P. O2 sats

¼ hrly for first hour, then hourly until 1 hour after completion of infusion,

Discharge home if there are no problems

ALERT CARD GIVENDate Initial

OBSERVATION CHART

TIME / TIME
220 / 220
210 / 210
200 / 200
190 / 190
180 / 180
170 / 170
160 / 160
B / P / 150 / 150
140 / 140
130 / 130
120 / 120
110 / 110
100 / 100
90 / 90
80 / 80
Pulse / 70 / 70
60 / 60
50 / 50
40 / 40
30 / 30
20 / 20
15 / 15
10 / 10
5 / 5
0 / 0
38.5 / 38.5
Temp / 38.0 / 38.0
37.5 / 37.5
37.0 / 37.0
36.5 / 36.5
36.0 / 36.0
35.5 / 35.5
35.0 / 35.0
34.5 / 34.5
34.0 / 34.0
02 Sats
Infusion Rate
MLS/HR

2nd infusion on Day 14

To be completed on Day 14 by patient

Have you had in the last 2 weeks?

Have you attended any hospital appointments Yes

since your last clinic appointment here?

If yes, where and who with?

Signature Date

Date SHO Day Unit Nurse

Baseline Observations

Temperature
Blood Pressure
Pulse
O2 Sats
Urinalysis
Patient review

Milestone - Is patient able to receive rituximab? YES NO

If NO state reasons and actions below

Date / Drug / Dose / Route / Signature / Given By / Time
Paracetamol / 1 G / P.O.
Chlorphenamine / 4mg / P.O. *
Chlorphenamine / 10mg / I.V.*
Methylprednisolone / 100mg / I.V.
In 100ml N/Saline
Date / Drug / Dose / Route / Signature / Given By / Time
start / stop
Rituximab / 1000mg / I.V
in 500ml of N/Saline

2nd infusion

If first cycle tolerated then start at 100mg an hour and increase every 30 mins, to a maximum of 400mg/hr. Minimum time 3 ¼ hours.

If there were side effects at first infusion give at first infusion rate.

2nd infusion rate

0-30mins / 60ml/hr
30-60mins / 120ml/hr
60-90mins / 180ml/hr
90mins – completion / 240ml/hr

Observations - T.P.B/P. O2 Sats

½ hourly for first hour, then hourly until 1 hour after completion if infusion.

Discharge home if no problems.

ON DISCHARGE

Give patient blood cards and bottles for CD19 & instructions

(1 month post treatment and 1 week prior to out patient appt. please send card & specimen toJohnRadcliffeHospital)

Post G.P. rituximab letter with discharge letter.

OBSERVATION CHART

3 month post treatment out patient appointment in Consultant Biologics Clinic

Date of appointmentSigned

CD 19 taken by G.P

In 1 monthDate:Result:

CD 19 taken by G.P

1 Week prior to OPA Date:Result:

C.Jess/J.Carter/Rheumatology Dept/Version 4/January 2009