Pneumotox » Drug » Rituximab

Rituximab

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When the drug is used in combination with chemotherapy drugs (R-X regimens) which can also cause respiratory problems, the respective role of each drug in causing the reaction can be difficult to evaluate (PMID 15857843), even though authors may specifically attribute causality of the AE to rituximab. When used as a solo agent for instance to treat connective tissue disease, rituximab can cause lung reactions on its own. Rituximab also exposes to the risk of pneumocystis pneumonia, which can be prevented (PMID 22157468, 23258406). Rituximab may induce hypogammaglobulinemia, which may result in infection, airway inflammation, bronchiolitis and bronchiectasis

Last update : 18/09/2022

I.a Pneumonitis (ILD), acute and/or severe (may cause ARDS)

2

I.b Pneumonitis (ILD)

2

I.d Organizing pneumonia pattern (an area or areas of consolidation on imaging)

2

I.g Pulmonary fibrosis

1

I.l Diffuse alveolar damage (DAD) (see alsoo under IIb and XVf)

2

I.v Abnormal lung function/pulmonary physiology (PFTs) without necessarily imaging or clinical evidence

1

II.a Pulmonary edema, noncardiogenic (NCPE)

2

II.b ARDS - Acute lung injury

2

II.i Flash (fulminate) pulmonary edema

1

III.a Alveolar hemorrhage (AH), diffuse AH (DAH)

1

III.c Hemoptysis

1

IV.a Bronchospasm - Wheezing - Asthma

1

IV.c Obliterative bronchiolitis (a pattern consistent with) (see also IVn, XVx)

1

IV.d Cough (lone)

-

IV.f Severe or catastrophic bronchospasm or asthma attack (can be fatal)

1

IV.j Bronchiolitis (a clinical-imaging pattern suggestive of)

2

IV.k Bronchiectasis

1

VII.g Hemomediastinum - Mediastinal hematoma

1

VIII.x Opportunistic large airway infection (bacterial, fungal, viral)

1

IX.t CNS involvement/dysfunction/damage

1

IX.ab Guillain-Barré (or GB-like) syndrome (w/wo ARF)

1

X.b Antiphospholipid antibodies w/wo the APL syndrome

1

X.f Anaphylaxis-Anaphylactoid reaction (can be fatal)

1

X.g Hypersensitivity reaction (may manifest with fever and/or skin, throat or airway involvement)

3

X.k Sarcoid-like granulomatosis (endo-/extrathoracic)

1

X.n Tumor lysis syndrome (TLS)

1

X.s Vasculitis, pulmonary (w/wo AH), extrapulmonary, systemic: ANCA-positive

1

X.ao Flare of preexisting vasculitis

1

XI.n Neutropenia, agranulocytosis (w/wo infection/sepsis)

2

XII.f Cardiomyopathy (acute, subacute, chronic)

1

XII.g Coronary artery disease (acute) - Myocardial ischemia/infarction

1

XV.c Path: Organizing pneumonia (OP/BOOP) pattern (see also Id)

1

XV.j Path: Pulmonary fibrosis (UIP-pattern)

1

XVII.a Respiratory tract infection incl. pneumonia

3

XVII.b Opportunistic pulmonary/systemic infections

1

XVII.e Pneumocystis jiroveci pneumonia

2

XVII.g Tuberculosis (pulmonary, pulmonary, extrapulmonary or disseminated). Reactivation or de novo

1

XVII.m Fungal airway infection

1

XVII.q Viral pneumonia

1

XVII.w Hypogammaglobulinemia - Antibody deficiency

1

XIX.a BAL: An excess proportion of lymphocytes

1

XXI.c Tolerance can be induced successfully starting with minute dosage of the drug

1

Diagnosing DIRD

1

Drug and radiation history

2

Drug singularity - Correct identification of the drug

3

Consistent timing of exposure v. onset of symptoms

4

Clinical, imaging, BAL, pathological pattern consistent with the specific drug

5

Careful exlusion of another cause

6

Remission of symptoms with removal of drug

7

Recurrence with rechallenge (rarely advisable)

8

Causality assessment

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