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Clinical Features of Rituximab-associated Gastrointestinal Toxicities

Mallepally, Niharika, MD, MPH*; Abu-Sbeih, Hamzah, MD; Ahmed, Osman, MD; Chen, Ellie, MD*; Shafi, Mehnaz A., MD; Neelapu, Sattva S., MD; Wang, Yinghong, MD, PhD

American Journal of Clinical Oncology: June 2019 - Volume 42 - Issue 6 - p 539–545
doi: 10.1097/COC.0000000000000553
Original Articles: Treatment Effects

Background: Rituximab is effective in treating several cancers. Little is known about gastrointestinal adverse events associated with rituximab. We describe the clinical, endoscopic, and histologic features of rituximab-associated colitis (RC) at a tertiary care cancer center.

Methods: We conducted a retrospective study of cancer patients who had received rituximab and had undergone a colonoscopy between 2000 and 2018. Patients with competing etiologies for colitis were excluded.

Results: Of the 13,717 patients who had received rituximab during the study period, 1660 had undergone colonoscopy. Among them, 70 (4%) had RC. Median time from rituximab treatment to RC onset was 181 days. Fifty-three patients had clinical gastrointestinal symptoms: 39 had diarrhea, 19 had abdominal pain, 11 had blood per rectum, and 5 had a concurrent fever. The median duration of symptoms was 21 days. Fifty patients (71%) received treatment for RC: immunosuppressive therapy in 12, antimicrobial agents in 21, antimotility agents in 42, and supportive care in 42. Nine patients had mucosal ulceration on endoscopy, and 52 had features of active inflammation on histology. Thirty-nine patients needed hospital admission, and 2 needed intensive care unit admission. One patient had colonic perforation that required surgical intervention. Patients who had abnormal endoscopic findings needed more frequent hospitalization (P=0.024) and more treatment for RC (P=0.001).

Conclusions: RC is usually a mild disease requiring supportive care only. Nonetheless, on rare occasions, it can be severe enough to lead to colonic perforation and intensive care unit admission. Steroids used with the chemotherapeutic regimen can hamper RC severity.

*Department of Internal Medicine, Baylor College of Internal Medicine

Departments of Gastroenterology, Hepatology, and Nutrition

Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX

N.M. and H. A.-S.: co-first authors.

The ethics approval of this study was granted by the IRB committee at the University of Texas MD Anderson Cancer Center (PA18-0472).

Medical editing of this paper was provided by the Department of Scientific Publications at MD Anderson Cancer Center.

Y.W.: was the senior author of this study, developed the concept, designed the study, interpreted the results, ensured that the accuracy and integrity of the data was preserved at all stages, agreed to be accountable for all aspects of this study, was in charge of the overall direction and planning of the study, and contributed to the writing of the manuscript with input from all authors. N.M. and H.A.-S.: collected the data for the study, assessed to conduct and interpret the analysis, and wrote the manuscript. O.A., E.C., M.S., and S.S.N.: revised critically the final version of the manuscript. All authors read and approved the final manuscript.

The authors declare no conflicts of interest.

Reprints: Yinghong Wang, MD, Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030. E-mail:

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