Rapid development of infusion-related severe hypotension during rituximab therapy

Ann Pharmacother. 2011 May;45(5):e29. doi: 10.1345/aph.1P733. Epub 2011 Apr 19.


Objective: To report an incident of rapid development of profound hypotension, differing from the time described in previous reports, during the infusion of rituximab chemotherapy in a patient without prior exposure to the drug.

Case summary: An 84-year-old white male with Rai stage IV chronic lymphocytic leukemia was prescribed rituximab 375 mg/m(2) by intravenous infusion. Rituximab 50 mg/h was initiated after premedication with acetaminophen, diphenhydramine, dexamethasone, and ondansetron 3 days into his hospital course. Five minutes after the infusion had begun, he experienced a significant decrease in blood pressure to 76/45 mm Hg, and the infusion was stopped. After 30 minutes, the blood pressure returned to normal. Rechallenge with rituximab 25 mg/h was attempted, but the blood pressure again declined and the patient experienced chills and rigors. The infusion was discontinued, and the symptoms resolved 1 hour later.

Discussion: Infusion-related adverse reactions associated with rituximab are reported at a higher rate than with other monoclonal antibodies. Hypotension with rituximab has been reported to occur 30 minutes to 2 hours after initiation of the infusion. In contrast, severe hypotension in our patient occurred within 5 minutes after the infusion was started in a patient with no previous exposure to the drug. While many studies hypothesize that cytokine release from lymphocytes and tumor cell agglutination might contribute to severe infusion-related reactions with rituximab, the mechanism of action is not yet known. Use of the Naranjo probability scale indicated that the hypotension was probably associated with rituximab administration.

Conclusions: Awareness of the rapidity of this adverse effect in patients who have not received prior treatment with monoclonal antibodies is important during chemotherapy treatment.

Publication types

  • Case Reports

MeSH terms

  • Aged, 80 and over
  • Antibodies, Monoclonal, Murine-Derived / administration & dosage*
  • Antibodies, Monoclonal, Murine-Derived / adverse effects*
  • Antineoplastic Agents / administration & dosage*
  • Antineoplastic Agents / adverse effects*
  • Humans
  • Hypotension / chemically induced*
  • Infusions, Intravenous
  • Leukemia, Lymphocytic, Chronic, B-Cell / drug therapy
  • Male
  • Rituximab


  • Antibodies, Monoclonal, Murine-Derived
  • Antineoplastic Agents
  • Rituximab