Barriers to Rituximab therapy in Pakistan

Rituximab is available in Pakistan by the brand names of Ristova and MabThera (Roche Pakistan Ltd).

It is indicated for a variety of conditions worldwide. Some of the common indications of Rituximab are:

• Blood cancers:
  • Chronic Lymphocytic Leukemia
  • Lymphoma
  • Waldenstrom’s macroglobulinemia
• Autoimmune rheumatic diseases:
  • Rheumatoid Arthritis
  • Wegener’s Granulomatosis
  • Microscopic polyangiitis
  • Immune thrombocytopenia
  • Autoimmune hemolytic anemia
  • Refractory Lupus Nephritis
  • Myasthenia gravis
  • Pemphigus vulgaris
  • Graft versus host disease

A complete list of Rituximab indications can be viewed @ emedz.net

There is a long list of indications, however, rituximab is rarely used to treat these disorders in Pakistan.

I have compiled just a few of the barriers to its use. To add more to the list, leave a comment below.

List of barriers to the use of Rituximab in Pakistan:

• Rituximab is too costly:

  • Probably, this is the among the top barriers to its use. I have seen most patients with the above mentioned chronic diseases in Pakistan are getting treatment through the Baitulmaal (Social Welfare funds) and zakat funds.
  • Patients can not even afford the conventional therapies. Most of them even cannot afford to get the tests done. Flowcytometry and the immune markers are also very costly.
  • Patients who need intensive and high dependency care start taking loans.

I have seen the attendants of the patients skipping meals to save money, get the tests done, and buy the medications.

• • Our doctors raise funds (among the doctors’ community) almost on a daily basis but that is way too less.

• Most doctors are reluctant to start immunotherapy because of lack of experience:

  • Since very few centers in Pakistan treat their patients with the biologics, most physicians lack the experience.
  • Therapy with the Biologics requires pretreatment evaluation, dose calculations, monitoring during treatment, and post-treatment regular assessments for complications.

• The use of Biologics is associated with serious infections:

  • Rituximab use is associated with the incidence of serious infections. These include fatal bacterial and fungal infections and serious viral infections like CMV infections, Herpes, Varicella, and ParvoVirus infections.
  • Reactivation of Tuberculosis and Hepatitis B infection is very common and all patients need to be screened for these infections prior to the therapy.
  • Since Tuberculosis is very common in Pakistan, latent TB is not uncommon. This results in reactivation of Tuberculosis that may lead to the progression of the primary disease.

• Backup support is not available to deal with the complications:

  • Rituximab therapy may sometimes result in severe anaphylactic reactions that may require intensive care support.
  • Cardiovascular complications include fatal arrhythmias, myocardial infarction, and cardiogenic shock.
  • Serious anaphylactic reactions include anaphylaxis, angioedema, and acute respiratory distress syndrome.
  • Other adverse reactions include liver and renal toxicity that may at times require dialysis support.
  • Backup support including dialysis support and intensive care support is lacking, limiting the use of rituximab therapy.

Click here for Detailed Indications, Contraindications, Dosages, and Side effects.