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Rituximab Hypogammaglobulinaemia AAV Switch — ESENeph MCQ

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HardRenal VasculitisRituximab Hypogammaglobulinaemia AAV SwitchESENeph

A 43-year-old man with granulomatosis with polyangiitis (GPA) achieved remission with rituximab and reduced-dose prednisolone. He is 18 months into rituximab maintenance (500 mg every 6 months). His latest bloods show IgG 2.8 g/L (low), and he has had three lower respiratory tract infections in 6 months. ANCA is negative. What is the most appropriate management?

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Correct answer: B — Switch to azathioprine maintenance and consider IgG replacement

Rituximab-induced hypogammaglobulinaemia (IgG <4 g/L) with recurrent infections is a recognised and increasingly important complication requiring management. With IgG 2.8 g/L and recurrent infections, rituximab should be paused/stopped and switched to an alternative maintenance agent (azathioprine is first-line alternative per KDIGO 2024 AAV). IgG replacement therapy should be considered if infections persist despite rituximab cessation. Simply continuing rituximab with IVIg concurrently fails to address the underlying B-cell depletion driving the hypogammaglobulinaemia. ANCA negativity alone does not justify stopping all maintenance as relapse risk remains.

Reference: KDIGO 2024 – AAV Guideline; Barmettler et al 2018 – Rituximab-Associated Hypogammaglobulinaemia