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Rituximab Administration

  • 1.  Rituximab Administration

    Posted 03-18-2019 17:52
    ​​Dear colleagues-

    Rituximab was dropped by NIOSH as a hazardous agent, since this happened our system pharmacists insist that these medications do not need to be administered by Oncology RNs.  Recently we had a request to allow the critical care RNs administer Rituximab.  Can you please respond and let us know what the practice is at your hospital?

    Thank you.

    [Rosangel [Klein] [MS,RN,CNS,OCN]
    [Oncology Clinical Nurse Specialist][Sutter Health- Roseville]

  • 2.  RE: Rituximab Administration

    Posted 03-18-2019 18:45
    In my mind, these are two separate issues.
    For a thorough explanation as to why rituxan is not currently on the NIOSH HD list, go HERE and read the section on monoclonal antibodies.

    As for "who" can give the drug, it depends on what type of education is being provided for the staff on other units. If nurses do not know about potential side effects, how to manage them, post-infusion patient education, etc.then they should not be giving the drug. Hopefully this is clarified in the hospital policy.


    Seth Eisenberg RN ASN OCN BMTCN
    Seattle Cancer Care Alliance
    Federal Way WA

  • 3.  RE: Rituximab Administration

    Posted 03-24-2019 18:17
    Dear Rosangel

    I agree with Seth.

    In addition, I am concerned as to why a pharmacist is directing what a nurse can or cannot do. Nursing Practice is directed by nurses, not by pharmacists, physicians, etc. I am sure everyone means well and I know pharmacists can be fantastic resources for RNs - just concerned about everyone staying within their own professional scope of practice. I hope your institutional policies are clear re: the type of education a nurse needs in order to administer anti-cancer drugs and that your Nurse Leader can assist you.

    Rae Norrod, MS, RN, AOCN, CNS
    Manager, Cancer Support Services
    Kettering Health Network
    Kettering, OH

  • 4.  RE: Rituximab Administration

    Posted 03-19-2019 12:12
    We are having the same problem. To further complicate this, within my hospital​ only oncology nurses can administer IV chemo for oncology indications and non oncology indications.  With this change can any nurse give IV rituximab since it is no longer "chemo"? Does it need the required double check if it is no longer labeled as "chemo"? What are other organizations doing with these medications that changed on the NIOSH list with regards to nursing practice? What education/communication did you give to your staff regarding these changes?

    Kristin Norton RN
    Nursing Professional Practice Leader
    Stillwater MN

  • 5.  RE: Rituximab Administration

    Posted 03-20-2019 09:36
    In our facility I did train ICU nurses on administration of Rituxan.  It makes sense since it is not chemotherapy, they have a better patient ratio and are equipped to deal with a hypersensitivity reaction if one occurs.  For patients whose condition does not warrant ICU care they are treated on the unit where chemotherapy is given since those nurses are more familiar with its administration and making sure the patient is premedicated, it is appropriately titrated, and who to deal with a reaction.

    Catherine Jansen PhD RN
    Oncology Clinical Nurse Specialist
    Kaiser Permanente
    San Francisco CA

  • 6.  RE: Rituximab Administration

    Posted 03-20-2019 18:05
    ​Hi Rosangel,

    My first thought is yup, you're right, they shouldn't give it if they don't know what they're doing. But why not suggest that they all have to be Chemotherapy and Biotherapy Safety Handling certified.  They don't have to be ONS certified to administer chemo but they should be Safety certified. Problem solved, they are then responsible for the administration and intervention if any infusion related reactions occur.

    Mary Lynn Johnson, RN BSN
    Nurse Manager
    Utah Cancer Specialists
    Tooele & Bountiful

  • 7.  RE: Rituximab Administration

    Posted 03-21-2019 08:51
    ​I understand the thinking behind non-chemo nurses giving Rituxan, but if that is the standard, many of the new targeted therapies would fall under that same standard.  Many of the newer targeted therapies we give do not come up from pharmacy in chemotherapy caution bags because they are not considered hazardous. Even Herceptin does not come up in a chemo caution bag.

    If non-chemo nurses can start giving these drugs without being certified, they would not be aware of all the different potential side effects.

    In a way, it seems it would be like opening a can of worms, because where would it stop with all the new targeted therapy drugs coming up.

    Tammy Nelson RN BSN
    Chemotherapy Nurse
    Longwood FL

  • 8.  RE: Rituximab Administration

    Posted 03-22-2019 13:43

    Rituximab was dropped as an HD so ANY nurse can administer it - same practice at my facility too. We remind (usually calling our oncology floor for assistance with the drug admin) that they can now administer the drug. We use Lexicomp for our drug library and inform the nurse to refer to it for guidance/ guidelines for the drug administration. Lexicomp has very detailed information regarding titration, first time vs repeat doses, reactions, etc
    Alemtuzumab is also no longer an HD. Again, our nurses review and follow the drug administration guidelines per Lexicomp before administering to patients.

    Florence Okafor MPH, MSN, RN-BC, CPHON
    Dallas TX

  • 9.  RE: Rituximab Administration

    Posted 03-24-2019 17:50
    I disagree with some of the comments re: any RN can administer these drugs. It is important to remember that RNs who administer anti-cancer drugs need specialized education re: assessment and intervention that goes beyond whether or not the drug is classified as an HD under the NIOSH definition. There is much more to know than following OSHA safe-handling recommendations.

    Please refer to the ONS Position Statement - Education of the nurse who administers and cares for the individual receiving chemotherapy, targeted therapy, and immunotherapy.

    Rae Norrod, MS, RN, AOCN, CNS
    Manager, Cancer Support Services
    Kettering Health Network
    Kettering, OH

  • 10.  RE: Rituximab Administration

    Posted 03-25-2019 10:36

    We are also looking at expanding who can administer Rituxan to ICU areas.
    Our pharmacists are wondering why we want to continue independent double checks of Rituxan. Does anyone have information for or against a double check? We currently have the RNs complete a double check of the drug against the order, and also the pump settings- including with each rate change.

    Good discussion!

    Katherine Anderson RN BSN OCN
    Education Coordinator
    St. Joseph Mercy Hospital – Ann Arbor
    Ypsilanti MI

  • 11.  RE: Rituximab Administration

    Posted 03-25-2019 20:59
    Hi Katherine!

    We have similar questions at our center, both inpatient and outpatient. While Rituxan has been removed as a hazardous drug, I would maintain that it is still a high-alert medication. I have written our policy to state that any chemotherapy or biotherapy for oncological indications should have 2 chemo competent nurses verify dose, indication, etc. - full chemo check. I believe the ONS standards support this, but haven't gotten my hands on a copy of the new chemo/biotherapy book.

    It would be great for pharmacy and nursing to get on the same page on this, especially for front-line staff and patient clarity!


    Jessica Miles RN
    San Jose CA

  • 12.  RE: Rituximab Administration

    Posted 08-19-2019 02:52
    Yes Cathrine, I would agree with Jessica,
    It is still can be considered as high alert medication that needs Double Independent Check by to RNs.​

    Qasem Alnasr RN BSN MSN
    Education Coordinator
    King Faisal Specialist Hospital & Research Centre

  • 13.  RE: Rituximab Administration

    Posted 08-19-2019 03:04
    Great post Rosangel, thanks for the post

    In my opinion we need to consider that Rituximab specifically is administered to oncology and non-oncology patients. Also, side effects and hypersensitivity reactions are the same for oncology and non-oncology patients, because it is driven by the treatment not the disease. ​

    We nurses are responsible to know every treatment we give. Thus, nurses who administer rituximab to non-oncology patients are expected to read and familiarize themselves with the drug before administering it. I believe that nurses should know what to do in case of hypersensitivity reaction because it might happen even with any other drug/blood transfusion etc..

    Saying the above I still believe that we oncology nurses can play a role in educating the non-oncology nurses in administering non hazardous drugs to non-oncology patients.

    Qasem Alnasr RN BSN MSN
    Education Coordinator
    King Faisal Specialist Hospital & Research Centre

  • 14.  RE: Rituximab Administration

    Posted 08-20-2019 08:50

    Rituximab always creates great discussion.  What our facility has chosen to do is that if the medication is to be given in an outpatient setting for non-oncology purposes it can be administered by non-oncology nurses.  If the patient is receiving it as part of the oncology treatment it must be given by an Chemotherapy/Biotherapy certified nurse, no matter what department the patient is in.  Sometimes if the patient is in ICU a chemo nurse will come and initialize the Rituximab then come back every 30 minutes for rate changes.  The patient will stay in the care of the ICU nurse.

    No matter what the treatment reason is it requires a double check.  While no longer a hazardous drug it is a high risk drug and programming can be tricky.  We also put on a CSTD, clearly not necessary.  We do this so it doesn't change nursing practice.  Our pharmacy supports us on it.

    Hope all these answers help you.  Keep fighting the good fight!​

    Meredith Maheu RN BSN ONC CMSRN OCN
    Professional Development Specialist Cancer Center
    Northwestern Medicine Kishwaukee Hospital Cancer Center
    DeKalb Illinois
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