(017) Assessment of Infusion Reaction Rates with Rituximab on Day One Versus Day Five or Later for Patients with Newly Diagnosed Aggressive Lymphoma Receiving DA-R-EPOCH (Top Ten Poster)

Poster Abstract:

Background:
Rituximab is an anti-CD20 monoclonal antibody approved for treating lymphoid malignancies expressing CD20, including aggressive lymphomas. Standard treatment includes combination chemotherapy regimens such as dose-adjusted doxorubicin, etoposide, vincristine, cyclophosphamide, and prednisone (DA-EPOCH). The addition of rituximab to cytotoxic chemotherapy has significantly reduced the risk of treatment failure and death; however, rituximab has one of the highest rates of hypersensitivity reactions amongst biologic agents. Traditionally, rituximab is given on day one of DA-EPOCH. To mitigate the risk of infusion reactions at Atrium Health Wake Forest Baptist, providers have begun administering rituximab on day five or later due to the theoretical benefit of decreased infusion reactions because of disease debulking. This was previously tested in a study comparing rituximab administered before or after cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) which found rituximab given after CHOP resulted in a significantly lower incidence of rigors and fewer rituximab rate reductions. Similar data is not available with DA-R-EPOCH.

Objectives:
The primary objective of this study is to evaluate whether infusion reaction rates differ when rituximab is given before or after chemotherapy during cycle one. Secondary objectives include evaluating differences in maximum infusion rate and emergency medication use during the first dose of rituximab, infusion reaction severity, and rituximab infusion duration for cycles one and two.

Methods:
This study is an IRB-approved, single-center, retrospective chart review. Patients 18 years and older who received at minimum cycles one and two of DA-R-EPOCH at our institution from November 2013 through November 2023 were screened for inclusion. Patients who previously received rituximab were excluded. Patients were identified via a report generated from Beacon treatment plans.

Results:
Screening identified 316 patients, and 190 were included for final analysis. Rituximab was administered on day one for 128 patients and on day five or later for 62 patients. Data collection is ongoing. Thus far, 29% (20/69) of patients who received rituximab on day one had an infusion reaction versus 17.5% (7/40) on day five or later. Emergency medications were administered in 85% of those who had a reaction in both groups. Of those who reacted, 45% (9/20) and 85% (6/7) of patients who received rituximab on day one versus day five or later were still eligible for rapid administration for cycle two, respectively.

Conclusion:
Preliminary data suggests a clinical benefit of administering rituximab on day five or later. Finalized data is required to determine if this translates to statistically significant outcomes.

References (must also be included in final poster):

1. Fouda GE, Bavbek S. Rituximab Hypersensitivity: From Clinical Presentation to Management. Front Pharmacol. 2020;11:572863. Published 2020 Sep 8. doi:10.3389/fphar.2020.572863

2. National Comprehensive Cancer Network. B-Cell Lymphomas. (Version 5.2023).

3. Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002 Jan 24;346(4):235-42. doi: 10.1056/NEJMoa011795. PMID: 11807147.

4. Wilson WH, Grossbard ML, Pittaluga S, et al. Dose-adjusted EPOCH chemotherapy for untreated large B-cell lymphomas: a pharmacodynamic approach with high efficacy. Blood. 2002 Apr 15;99(8):2685-93. doi: 10.1182/blood.v99.8.2685.

5. Hannawa IS, Bestul DJ. Rituximab tolerability when given before or after CHOP. J Oncol Pharm Pract. 2011;17(4):381-386. doi:10.1177/1078155210386989