Oral glucocorticoid premedication for preventing infusion-related reactions to rituximab in rheumatoid arthritis

In current practice, intravenous prednisolone is administered as pretreatment to rituximab (RTX) to prevent infusion-related reactions (IRRs). This retrospective observational cohort study investigated whether 50 mg oral prednisolone is as effective as 50 mg intravenous methylprednisolone in preventing IRRs in rheumatoid arthritis (RA) patients, as this could potentially be a more practical, patient-friendly, and cost-effective alternative.

Since January 2022, the local RTX pretreatment protocol changed from 50 mg methylprednisolone intravenously to 50 mg prednisolone orally. All RTX infusions in RA patients, administered between 31 January 2020 and 30 January 2024, were examined for the occurrence of IRRs. The adjusted odds ratio (OR) for IRRs was calculated for oral versus intravenous prednisolone administration. All IRRs were evaluated for symptoms, severity, type, and outcome of reaction.

In total, 2253 RTX infusions in 515 patients were included, 976 with oral and 1277 with intravenous premedication. IRRs were reported after 84 infusions (3.7%). The adjusted OR was non-significantly in favour of oral treatment (OR 0.61, 95% confidence interval 0.30-1.20). IRRs were mostly mild and required little or no intervention, and a trend towards lower IRR risk for lower RTX dosing and when using concomitant disease-modifying anti-rheumatic drugs was observed.

Oral prednisolone pretreatment to RTX does not result in more infusion-related reactions in patients with RA, and may therefore, based on other advantages, be preferable to intravenous glucocorticoids.