Rituximab in Elderly Patients — and Those With Other Illnesses

Yes. Age alone is not a reason to withhold rituximab, and NCCN and ASCO guidance sets no upper age limit. What matters is your overall fitness, how well your heart and kidneys are functioning, and whether other conditions are controlled. Older patients routinely receive rituximab and benefit from it. The pre-treatment assessment is more detailed than it would be for a younger patient, and the infusion may be given more slowly, but the treatment itself is not withheld on the basis of age.

Very few cardiac conditions rule it out entirely. Rituximab infusions can temporarily affect blood pressure and, rarely, trigger arrhythmias, so your team will monitor your heart closely during each infusion. If you have unstable angina, a very recent heart attack, or severe heart failure, your cardiologist and oncologist will assess the situation together before starting. For most cardiac patients, rituximab proceeds with closer monitoring — often a slower infusion rate and more frequent checks during the first treatment.

Rituximab itself does not directly raise blood sugar. The issue is the steroid premedication — usually dexamethasone — given before each infusion to reduce infusion reactions. This can temporarily raise glucose levels, sometimes significantly in people who already have diabetes. Tell your diabetes team that you are having rituximab so they can advise on checking your glucose more closely on infusion days and the day after. If you use insulin, your dose may need adjustment on those days.

Reduced kidney function does not usually prevent rituximab. Your kidney function will be checked in blood tests before each cycle. The main concern your team will watch for is tumour lysis syndrome — the rapid breakdown of cancer cells can temporarily increase the load on the kidneys. Your team may give extra fluids around your infusions and ask you to drink well in the days beforehand. Report any swelling in the legs, a noticeable drop in how much urine you are passing, or unusual fatigue between cycles.

Inactivated vaccines — the flu jab, pneumococcal vaccine and COVID vaccines — are safe to receive and you should keep them up to date. Live vaccines, such as BCG, yellow fever or live typhoid, must be avoided while your B cells are suppressed, because they carry a genuine risk of causing infection. Inactivated vaccines work best when given before rituximab starts, because rituximab suppresses the antibody response that makes vaccines effective. Ask your team before any vaccine during or after treatment.

B cells — the cells rituximab depletes — can take six months to over a year to recover in some patients, and recovery may be slower in older patients. During this period, and for some time beyond it, your infection risk is higher than usual. Your team will monitor your immunoglobulin levels and may arrange immunoglobulin replacement if levels fall significantly. Report any signs of infection promptly, even mild ones, because what seems like an ordinary cold can escalate more quickly when your immune system is reduced.

Severe infusion reactions are uncommon but are managed at the chair. Premedication given before every infusion reduces the risk considerably, and the infusion is started slowly and increased only if you are tolerating it. If you develop significant breathlessness, chest tightness, a drop in blood pressure or a severe skin reaction, the infusion is stopped immediately and treatment is given on the spot. This is one reason rituximab is given in a day-care setting with trained staff present throughout.

Yes, and this matters more than it might seem. Your GP, cardiologist, diabetes team or any other specialist needs to know you are on rituximab, because it affects decisions about vaccines, how infections should be treated, and whether any planned procedure is safe. If you develop an infection between oncology visits, whoever sees you first needs to know to take it seriously. Carry a treatment letter or card from your oncology team if one is provided, and show it at every appointment with any doctor during and after treatment.