Repeated rituximab can lower serum immunoglobulins, particularly IgG, and hypogammaglobulinaemia is linked to serious infections. Measuring IgG before the first course and periodically during maintenance identifies patients at risk before an infection does.
Falling IgG, especially with recurrent infections, should prompt review of the need to continue, vaccination status, and, where infections are serious and recurrent, discussion of immunoglobulin replacement with immunology.
- Measure baseline IgG, IgA and IgM before starting rituximab.
- Repeat IgG before each maintenance dose or at least every six months.
- Ask about infections at every review and record them.
- Review the case for continuing rituximab when IgG falls or infections recur.
Why it matters
Low immunoglobulins are a measurable warning of the infections that limit maintenance therapy.
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