Home Administration of Subcutaneous Rituximab Is Safe and Associated with Significant Cost Saving: A Single Center Experience

Introduction

Rituximab is as a cornerstone of treatment of B-cell malignancies, given as monotherapy (including maintenance after induction) or in combination with chemotherapy. While developed as IV infusion, subcutaneous formulation is now available. It has been demonstrated that, compared to IV infusion, subcutaneous injection is quicker (5 minutes injection), easier to manage and non-inferior with respect to efficacy, in follicular lymphoma, chronic lymphocytic leukemia, and diffuse large B-cell lymphoma. Home administration of chemotherapies for patients treated for hematological malignancies is widely used, as it has demonstrated safety, cost saving and improvement of quality of life. However, few datas have been reported for monoclonal antibodies.

Objectives

The aim of our study was to describe our experience of home administration of SC rituximab to evaluate feasibility, safety and back to in-hospital administration. We also compared costs to in-hospital administration.

Methods

We included consecutive patients treated with at least one SC rituximab injection at home, from January 2016 to July 2017. All patients received approved dosage, ie.1400 mg. Patients received before injection paracetamol, prednisone and dexchlorpheniramine. Patients were eligible if 1°) they have previously received at least one IV infusion and one SC injection in ambulatory unit of our institution; 2°) they did not experienced adverse reaction to both administrations; 3°) they did not present comorbidity that require medical evaluation before each injection; 4°) their home was considered adequate for safe administration; 5°) they consented to home administration.

Results

We included 39 patients; median age was 71y (range: 40 to 88), 25 females and 14 males. Median CIRS was 3 (range: 0 to 10). Majority of patients had hematological malignancies (follicular lymphoma: n=25, mantle cell lymphomas: n=7, marginal zone lymphoma: n=3, hairy cell leukemia: n=1) and 3 had autoimmune hemolytic anemias. Rituximab was administered as a part of the first line therapy for 26 patients and as maintenance therapy for 37. The median and mean number of previous in-hospital SC injections was 1 (range 1 to 10) and 3.1, respectively. A total of 174 injections were performed at home (median per patient: 4, range: 1 to 10). Few side effects were notified; late-onset neutropenia (n=3), upper and lower respiratory tract infections (n=4), P. jirovecii pneumonia (n=1), grade 3 diarrhea of unknown etiology (n=1), incidental cancers (n=2) and one non-related death. Finally, 4 patients required hospitalization due to complication. One patient went back to in-hospital administration because of bone pain and local skin reaction related to injection. In France, the cost of care is a flat fee determined by the Health authorities which is 1049 euros for standard one-day hospitalization in ambulatory unit of public hospital, 233 euros for private and 201 euros for public one-day home hospitalization. In our cohort, home administration is associated with a cost saving of 146 592 euros (842 euros per injection, 3758 euros per patient), to which we must add patients' transport cost.

Conclusion

Our study showed that home administration of subcutaneous rituximab is feasible, safe, and well tolerated, leading to an alternative to standard hospitalization. Moreover, amount of cost saving should justify promotion of home administration by Health authorities. If quality of life is improved by home administration it must be confirmed by prospective studies. Currently, home administration of SC rituximab but also brentuximab vedotin, eculizumab and more recently daratumumab is part of our standard of care.