Evaluation of the safety and feasibility of rapid rituximab infusion

Rituximab-based combination therapy in patients with Waldenström macroglobulinemia: a systematic review and meta-analysis

Background

To evaluate the efficacy and safety of rituximab-based combination therapy for Waldenström macroglobulinemia (WM), we conducted this meta-analysis by pooling the rates of overall response, major response, complete response, and grade ≥3 hematological adverse events.

Methods and materials

We searched for relevant studies in the databases of PubMed, Web of Science, Embase, and the Cochrane Library. The qualitative assessment of all the included articles was conducted with reference to the Newcastle–Ottawa Scale. A random-effects model was selected to perform all pooled analyses.

Results

We identified altogether 22 studies with a total of 806 symptomatic WM patients enrolled. The pooled analysis indicated that the rituximab-based combination therapy achieved an overall response rate (ORR) of 84% (95% CI: 81%–87%), a major response rate (MRR) of 71% (95% CI: 66%–75%), and a complete response rate (CRR) of 7% (95% CI: 5%–10%). Rituximab plus conventional alkylating agents–containing chemotherapy (subgroup A) yielded an ORR of 86% (95% CI: 81%–89%), an MRR of 74% (95% CI: 69%–79%), and a CRR of 8% (95% CI: 4%–14%). Rituximab plus purine analog (subgroup B) resulted in an ORR of 85% (95% CI: 79%–89%), an MRR of 74% (95% CI: 66%–81%), and a CRR of 9% (95% CI: 4%–15%). Rituximab plus proteasome inhibitor (subgroup C) resulted in an ORR of 86% (95% CI: 81%–90%), an MRR of 68% (95% CI: 58%–77%), and a CRR of 7% (95% CI: 3%–11%). Rituximab plus immunomodulatory drug (subgroup D) attained relatively lower response rates, with an ORR of 67% (95% CI: 51%–81%), an MRR of 56% (95% CI: 27%–83%), and a CRR of 5% (95% CI: 1%–12%). Common grade ≥3 hematological adverse events consisted of neutropenia (33%, 95% CI: 17%–52%), thrombocytopenia (7%, 95% CI: 3%–11%), and anemia (5%, 95% CI: 3%–9%).

Conclusion

Rituximab in combination with an alkylating agent, purine analog, or proteasome inhibitor is highly effective with tolerable hematological toxicities for WM.

Rapid infusion rituximab is well tolerated in patients with primary CNS lymphoma

Aim:

To establish the safety and feasibility of rapidly infusing rituximab over 90 min in patients with primary CNS lymphoma (PCNSL).

Patients & methods:

We retrospectively reviewed all patients with PCNSL who received rapid rituximab infusions (RRI) from January 2016 to January 2017. Primary end point was incidence of infusion reactions.

Results & conclusion:

11 patients received a total of 44 RRIs. Rituximab was dosed at 500 or 750 mg/m². Premedication included acetaminophen and diphenhydramine. No infusion reactions occurred during any RRI. Two infusions were administered with steroids for neurologic symptoms at baseline (4.5%). Rapid administration of rituximab was safe and feasible for patients with PCNSL and at the higher doses received.

A Phase II Trial Evaluating the Safety of Rapid Infusion of Ofatumumab in Patients with Previously Treated Chronic Lymphocytic Leukemia

LESSONS LEARNED

Ofatumumab infusion reactions can be diminished by escalating the dose rate in individual patients in sequential infusions.

BACKGROUND

Ofatumumab (OFA) is a fully humanized, anti-CD20 antibody approved for use in chronic lymphocytic leukemia (CLL). The recommended administration requires long infusion times. We evaluated an accelerated infusion regimen of 2 hours.

METHODS

The first dose of OFA (300 mg) was given on week 1 day 1 starting at 3.6 mg/hour and doubling every 30 minutes until a rate of 240 mg/hour was reached. If tolerated, the second dose (1,000 mg) was given on week 1 day 3 starting at 50 mg/hour and doubling every 30 minutes until a rate of 800 mg/hour was reached. If tolerated, the third dose (2,000 mg) was given on week 2 day 1 at 800 mg/hour over the first 30 minutes and, if tolerated, at 1,068 mg/hour over the next 90 minutes (goal infusion time: 120 minutes). Subsequent OFA infusions were administered weekly in the same manner for 8 weeks, and then monthly for 4 months.

RESULTS

Thirty-four patients were treated. Most infusion-related reactions occurred during the first and second infusion. Eighty-seven percent (87%) of patients finished the third infusion within 15 minutes of the planned 2 hours and only one had an infusion reaction.

CONCLUSION

Using this stepped-up dosing regimen, a rapid infusion of OFA is safe and well tolerated.

Microcosting Study of Rituximab Subcutaneous Injection Versus Intravenous Infusion

PURPOSE

The goal of this study is to identify and compare all direct costs of intravenous and subcutaneous rituximab given to patients with diffuse large B-cell lymphoma in the Netherlands.

METHODS

Using a prospective, observational, bottom-up microcosting study, we collected primary data on the direct medical costs of the preparation, administration, and acquisition of rituximab. Drug costs and costs of drug wastage, labor costs, material costs, and outpatient costs were identified using standardized forms, structured using prices from official pricelists, and compared for the intravenous and subcutaneous forms of rituximab.

FINDINGS

Measurements were taken on 53 rituximab administrations (33 intravenous and 20 subcutaneous) and on 13 rituximab preparation (7 intravenous and 6 subcutaneous). The mean total costs were €2176.77 for the intravenous infusion and €1911.09 for the subcutaneous injection. The estimated difference of €265.17 (95% CI, €231.99-`€298.35) per administration was mainly attributable to differences in time spent in the chemotherapy unit, related outpatient costs, drug wastage, and drug costs.

IMPLICATIONS

Rituximab administered in the form of subcutaneous injection is less costly than its intravenous form. With their equal effectiveness taken into account, subcutaneous rituximab administration can result in significant savings when transferred to the total diffuse large B-cell lymphoma population in the Netherlands.

Use of a pharmacy protocol to convert standard rituximab infusions to rapid infusion shortens outpatient infusion clinic visits

STUDY OBJECTIVE

To evaluate the impact of a pharmacy protocol that converts standard rituximab infusions to a rapid 90-minute infusion on the duration of outpatient infusion center clinic visits.

DESIGN

Prospective interventional study.

SETTING

Outpatient infusion clinic at an academic medical center.

PATIENTS

Sixty-four adults who received at least one rituximab infusion that was eligible for conversion to rapid infusion between August 2010 and July 2011 and who did not receive concurrent chemotherapy or colony-stimulating agents during the same clinic visit. Of the 64 patients, 37 received the rapid infusion (intervention cohort); 27 received the nonrapid infusion (control cohort).

INTERVENTION

Using a hospital-approved protocol, pharmacists converted rituximab infusions that met eligibility criteria (noninitial rituximab infusion, rituximab given in the previous 90 days, age 18 yrs or older, dose 375 mg/m(2) or less per infusion, dose 1000 mg or less per infusion, and no history of a grade 3 or higher reaction) to a rapid 90-minute infusion.

MEASUREMENTS AND MAIN RESULTS

The durations of rituximab infusion time and clinic visit time were evaluated and compared between the intervention cohort and the control cohort. Use of the pharmacy protocol to convert standard rituximab infusion to rapid rituximab infusion reduced infusion time by 110.5 minutes/infusion (median 94.5 min [interquartile range (IQR) 90-105 min] for rapid infusion vs 205 min [IQR 138-263 min] for nonrapid infusion; p<0.001) and reduced clinic visit time by 92 minutes/outpatient encounter (median 233 min [IQR 208-277] min for rapid infusion vs 325 min [IQR 275-415 min] for nonrapid infusion; p<0.001). This resulted in a reduction of the duration of outpatient clinic visits by an estimated 255-299 hours in 1 year.

CONCLUSION

Use of a pharmacist protocol that converted standard rituximab infusions to a rapid 90-minute infusion decreased the duration of outpatient infusion clinic visits for rituximab infusion.