Treatment of mixed cryoglobulinemia: a rheumatology perspective

The treatment of the cryoglobulinemic syndrome or vasculitis (CV) must be targeted to the individual patient, and requires clinical expertise and knowledge of the disease biology. In general, the treatment is suggested by the clinical picture, but biologic issues should also be considered. Both immunosuppressive and antiviral approaches deserve equal attention based on the wide clinical spectrum and on disease biology, where the viral trigger and the downstream autoimmune response may play a different role in different disease stages. The severity of the disease, previous history and therapies administered, comorbidities and other individual factors should be analysed in the single case. Acute and life-threatening conditions usually require high dose steroids, plasmapheresis and/or cyclophosphamide. Rituximab often represents the best option for severe CV. Antiviral therapy is a cornerstone for the management of CV in hepatitis-related cases, and has the strongest biologic rationale, in general, in this disease and should be always considered in stabilised patients. A multispecialistic approach is needed to better define treatment strategies in different subsets of patients.