Rituximab for HIV-associated lymphoma: weighing the benefits and risks

This review discusses the potential benefits and risks of using the anti-CD20 monoclonal antibody rituximab for the treatment of HIV-associated B-cell non-Hodgkin's lymphoma.

Studies have consistently demonstrated that rituximab improves response and survival when combined with standard chemotherapy compared with chemotherapy alone in immunocompetent patients with intermediate-grade non-Hodgkin's lymphoma. Several recently reported phase II and III trials have evaluated the use of rituximab plus chemotherapy for HIV-associated B-cell non-Hodgkin's lymphoma. Phase II trials combining rituximab with either standard cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy or infusional chemotherapy have reported encouraging results, suggesting a similar benefit in HIV-positive individuals. A phase III trial comparing CHOP with CHOP-plus rituximab (R-CHOP) demonstrated a lower risk from progression of the lymphoma, but a higher risk of early and late infectious-related death in patients with a low CD4 count (< 50/microL).

Rituximab should be used cautiously in patients with advanced HIV infection who have a CD4 count of less than 50/microL, as it seems to increase the risk of developing fatal infectious complications. In patients with higher CD4 counts, the benefit of rituximab may outweigh its risk, although this has yet to be confirmed in prospective, randomized trials specifically performed in this population.