For clinicians
Rituximab
anti-CD20, RTX
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Bottom lineBottom line: prefer to dose before pregnancy; its effect can persist into a pregnancy. Deliberate use in the second/third trimester is generally avoided because of neonatal B-cell depletion, which affects infant live-vaccine timing. Inadvertent early exposure is generally low risk. Compatible with breastfeeding (minimal transfer of a large antibody).
By reproductive phase
| Phase | Position | Detail | Evidence |
|---|---|---|---|
| Pre-conception | Use if needed | May be used pre-pregnancy; plan conception after dosing given prolonged B-cell effect.[1, 2] | ●●○○low evidenceconditional |
| 1st trimester | Use if needed | Inadvertent first-trimester exposure generally low risk (limited placental transfer early); avoid deliberate use unless needed.[2, 3] | ●●○○low evidenceconditional |
| 2nd/3rd trimester | Avoid | Avoid later-pregnancy use except for serious maternal indications; expect neonatal B-cell depletion if given.[2] | ●●○○low evidenceconditional |
| Breastfeeding | Continue | Compatible with lactation; minimal milk transfer.[2] | ●●○○low evidenceconditional |
| Paternal | Continue | Compatible with paternal exposure; limited data.[2] | ●○○○very low evidenceconditional |
Guideline comparison
| Guideline | Position | Strength |
|---|---|---|
| ACR 2020 | Conditionally recommend discontinuing at conception; during pregnancy conditionally reserved for life- or organ-threatening maternal disease. Breastfeeding: strongly recommend compatible. Paternal: conditionally recommend continuing.[1] | Conditional (discontinue at conception; reserve for severe disease); strong compatible (breastfeeding) |
| EULAR 2024 | May be used in pregnancy if needed to control maternal disease (4/C); compatible with lactation (2a/B); continuable in men (4/C).[2] | Oxford LoE/GoR as shown |
| BSR 2022/23 | Consider stopping at conception; in the first and second/third trimesters use only for severe maternal disease if no other pregnancy-compatible drugs are suitable. Breastfeeding and paternal exposure compatible (limited evidence). If used in the third trimester, avoid infant live vaccinations until 6 months of age.[3] | Verified against BSR Table 1 |
=Guideline divergence. VERIFIED DIVERGENCE. EULAR 2024 (5b) states rituximab may be used in pregnancy if needed to effectively control maternal disease (4/C). BSR 2023 is more restrictive: consider stopping at conception, and use in either trimester only for severe maternal disease when no other pregnancy-compatible drug is suitable. Both agree it is compatible with breastfeeding, and both advise delaying infant live vaccines to 6 months after third-trimester exposure.
Key points
| Point | Evidence |
|---|---|
| Timing dosing pre-conception avoids most fetal exposure while retaining disease control.[2] | ●●○○low evidenceconditional |
Special populations
- After later-pregnancy exposure, anticipate neonatal B-cell depletion; check infant counts and defer live vaccines per local guidance. ●●○○low evidenceconditional[2]
Monitoring
- EULAR 2024 (footnote b): after non-TNFi bDMARD exposure in the 2nd/3rd trimester, delay infant live-attenuated vaccines for 6 months (4/C-5/D).
References
- Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in RMD. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
- Ruegg L, et al. EULAR recommendations for antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
- Russell MD, et al. BSR guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory drugs and corticosteroids. Rheumatology (Oxford). 2023;62(4):e48-e88. https://academic.oup.com/rheumatology/article/62/4/e48/6783012