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
- Waldenstrom’s macroglobulinemia
- Autoimmune rheumatic diseases:
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.