Rituximab in cryoglobulinemic vasculitis: First- or second-line therapy?

Rituximab is a monoclonal chimeric anti-CD20 antibody selectively targeting B cells. It has been shown to induce remission in HCV-associated cryoglobulinemic vasculitis as a first- or second-line treatment option. While rituximab induces a complete clinical response in 60-70% of patients with HCV-associated cryoglobulinemic vasculitis, viremia persists or even increases. Moreover, 30% of the patients are subject to relapses during peripheral blood B-cell recovery. The combination of rituximab and PEG-IFN-α plus ribavirin is aimed at providing the anti-proliferative impact and anti-viral potencies of both treatment approaches, with subsequent improvement of outcome. Rituximab and PEG-IFN-α plus ribavirin induce remission in severe and refractory HCV-associated cryoglobulinemic vasculitis. Based on the currently available evidence, combined treatment with rituximab and PEG-IFN-α plus ribavirin should be considered as the first-line treatment in patients with active disease resistant to anti-viral therapy and in those with severe manifestations and activity of cryoglobulinemic vasculitis. The inclusion of such patients in trials for further assessment and evaluation is highly desirable.