Description
Rituximab (Rituxan_®, Genentech, Inc., South San Francisco, CA) is a genetically engineered monoclonal antibody that targets a specific protein, known as CD20 found on the surface of normal and malignant B-lymphocytes.

 Policy:

Riabni (rituximab-arrx)
 Rituxan (rituximab)
 Ruxience (rituximab-pvvr) 
Truxima (rituximab-abbs)
 Rituxan Hycela (rituximab and hyaluronidase human) 

Coverage of these drugs is provided when the criteria below is met and there has been a trial and failure of preferred therapy.

1. Chronic lymphocytic leukemia (CLL)
   • Rituximab is considered MEDICALLY NECESSARY for either of the following indications:
     • Chronic lymphocytic leukemia
     • Hairy Cell Leukemia
2. Hodgkin and non-Hodgkin lymphoma (NHL)
   • Rituximab is considered MEDICALLY NECESSARY for any of the following indications:
     • Treatment of CD20+ lymphoma (Hodgkin or non-Hodgkin)
     • Treatment of Waldenström's Macroglobulinemia
     • Maintenance therapy of CD20+ follicular B-cell NHL for up to two (2) years
     • Maintenance therapy of symptomatic relapsed or refractory lymphocyte predominant Hodgkin lymphoma following second-line therapy with rituximab
     • Zevalin^® (Ibritumomab tiuxetan, Biogen Idec Inc., Cambridge, MA) regimen- as part of the Zevalin therapeutic regimen for NHL
3. Rheumatoid Arthritis
   • Rituximab is considered MEDICALLY NECESSARY when all of the following are met:
     • Individual is 18 years of age or older with moderately- to severely-active rheumatoid arthritis.
     • Rituximab is given in combination with methotrexate (MTX) unless intolerant or contraindicated.
     • Individual had an inadequate response to TWO or more tumor necrosis factor (TNF) antagonist therapies, or oral Janus Kinase Inhibitor or has a medical contraindication to TNF therapy.
4. Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA) Rituximab, in combination with glucocorticoids unless intolerant or contraindicated, is considered MEDICALLY NECESSARY for the treatment of individuals with Wegener's granulomatosis and microscopic polyangiitis.
5. Other Indications
   • Rituximab is considered MEDICALLY NECESSARY for individuals with any of the following conditions:
     • Acute lymphoblastic leukemia (ALL), de novo, when all of the following are met:
       • Individual has CD20+ Philadelphia chromosome-negative ALL.
       • The individual is greater than or equal to 40 years of age.
       • Rituximab is a component of an induction and consolidation regimen consisting of HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine with rituximab.
     • Autoimmune hemolytic anemia, refractory
     • Graft Versus Host Disease (GVHD) as third line of therapy or greater
     • Multicentric Castleman's disease (MCD), CD20+
     • Neuromyelitis Optica (NMO)
     • Pemphigus vulgaris and other autoimmune blistering skin diseases (for example, pemphigus foliaceus, bullous pemphigoid, cicatricial pemphigoid, epidermolysis bullosa acquisita and paraneoplastic pemphigus) when refractory
     • Posttransplant lymphoproliferative disease, CD20+
     • Renal transplant setting for either of the following indications:
       • Pre-transplant to suppress panel reactive anti-HLA antibodies in individuals with high panel reactive antibody (PRA) levels to human leukocyte antigens (HLA)
       • Post-transplant in individuals with acute rejection who had received rituximab treatment pretransplant
     • Systemic Autoimmune Disorders (specifically, Cryoglobulinemia, Primary Sjögren Syndrome [SS], Systemic Lupus Erythematosus [SLE]) refractory to standard therapy (lack of response to corticosteroids and at least two immunosuppressive agents)
     • Thrombocytopenic purpura, immune or idiopathic with the following are met:
       • Trial and failure, contraindication, or intolerance to at least ONE of the following: Corticosteroids Immunoglobulins, Splenectomy
       • Documented platelet count of less than 50 x 10^9 / L
     • Acquired inhibitors in individuals with hemophilia who fail cyclophosphamide and prednisone.
   • Central Nervous System (CNS) cancers- leptomeningeal metastases from lyphomas or primary CNS lymphoma

Use of rituximab is investigational and/or unproven and therefore NOT MEDICALLY NECESSARY when the above criteria are not met.

Use of rituximab is investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY limited to:

• • Graft Versus Host Disease (GVHD) as first- or second-line therapy.
  • Membranous glomerulonephropathy.
  • Multiple sclerosis.
  • Renal transplant rejection, except as specified above.
  • Myasthenia.
  • Immune checkpoint inhibitor-related toxicities.

Dosage and Administration
Administer only as an intravenous infusion.

Do not administer as an intravenous push or bolus.

Rituxan should only be administered by a health care professional with appropriate medical support to manage severe infusion reactions that can be fatal if they occur.

• The dose for NHL is 375 mg/m².
• The dose for CLL is 375 mg/m² in the first cycle and 500 mg/m² in cycles 2 – 6, in combination with FC, administered every 28 days.
• The dose as a component of Zevalin (Ibritumomab tiuxetan) Therapeutic Regimen is 250 mg/m².
• The dose for RA in combination with methotrexate is two-1000 mg intravenous infusions separated by 2 weeks (one course) every 24 weeks or based on clinical evaluation, but not sooner than every 16 weeks. Methylprednisolone 100 mg intravenous or equivalent glucocorticoid is recommended 30 minutes prior to each infusion.
• The dose for GPA and MPA in combination with glucocorticoids is 375 mg/m²once weekly for 4 weeks.

BlueCross BlueShield of South Carolina recognizes uses and indications of injectable oncology medications (including chemotherapy / systemic therapy, therapeutic radiopharmaceuticals, and selected supportive therapies) to be medically necessary if they are listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence + Consensus of 1, 2A and 2B. Treatments listed with a Category of Evidence and Consensus of 3 are considered unproven and not medically necessary.

Rationale
Rituximab is a chimeric monoclonal antibody that targets the CD20 antigen located on the cell surface of malignant and normal B-lymphocytes. Rituximab rapidly depletes circulating and tissue based B-cells, and demonstrates a prolonged effect on cell depletion. Rituximab was originally approved in 1997, by the U.S. Food and Drug Administration (FDA) for the treatment of relapsed, refractory, low-grade or follicular, B-cell non-Hodgkin lymphoma. Subsequently, the FDA approved additional specific indications for non-Hodgkin lymphoma and for moderately- to severely-active rheumatoid arthritis when there has been an inadequate response to other treatments. Rituximab is not recommended for use in individuals with severe, active infections (Product Information Label, 2012).

Rheumatoid arthritis and other systemic autoimmune diseases involve complex, ongoing interactions between various types of cells and cell mediators in a cascade of inflammatory processes (Mease, 2008). B-cells are stimulated by activated T-cells to differentiate into plasma cells, which produce autoantibodies such as rheumatoid factor (RF). Bcells can also function as antigen-presenting cells (APCs), and may produce pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α) and activate T-cells in a self-perpetuating cycle (Mease, 2008; Sibilia, 2008). Mease and colleagues (2008) described the role of B-cell depletion and cell death by various mechanisms which include, but are not limited to:

The exact role of B-cells in the immunopathogenesis of rheumatoid arthritis and other autoimmune diseases is unclear. Rituximab rapidly depletes the circulating B-cells in the peripheral blood and the effect may be sustained for months after treatment is completed. However, the correlation between the measured amount of circulating B-cells compared to the volume of B-cells present in the bone marrow, spleen, lymph nodes or inflammatory tissue is unclear. Globin and colleagues (2007) noted "The absence of CD20 on bone marrow stem cells and the earliest B-lymphocyte precursors allows for the regeneration of naïve B lymphocytes following rituximab therapy, with the potential of profound amelioration of autoimmunity." Based on this concept, rituximab is being studied for various indications including rheumatic, inflammatory and autoimmune diseases.

Chronic Lymphocytic Leukemia
In February 2010, the FDA approved the combined use of rituximab with fludarabine and cyclophosphamide (FC) for the treatment of previously untreated, and previously treated CD20+ chronic lymphocytic leukemia (CLL).

Chronic lymphocytic leukemia (CLL) is an indolent form of non-Hodgkin lymphoma marked by immunologically lessmature lymphocytes and manifested by progressive accumulation of these cells in the blood, bone marrow, and lymphatic tissues. The lymphocytes are characterized by immunophenotype (CD5- and CD23-positive B cells).Additionally, B-cell antigens CD19 and CD20 are also co-expressed on CLL lymphocytes. CLL may progress to a generally enlarged lymphatic system as well as complications resulting from pancytopenia (National Cancer Institute[NCI], 2013). According to the NCI (2013), treatment with "conventional doses of chemotherapy are not curative" for individuals with progressing CLL. Therefore, treatments to prolong disease-free survival for indolent and active diseasecontinue to be studied.

Hairy Cell Leukemia
Hairy cell leukemia is a mature B-cell, chronic lymphoproliferative disorder for which 10% of the individuals will not require any type of therapy (NCI, 2013). Characteristics include the presence of a leukemic cell with "hairy" cytoplasmic projections, pancytopenia and bone marrow involvement, including fibrosis. Treatment includes nucleoside analogs (for example, cladribine, pentostatin), interferon-alpha, or splenectomy, with reported 5-year survival rates of more than85%. The NCI (2013) notes rituximab can induce durable complete remissions in individuals with multiple relapsing or refractory disease after purine analog therapy or after interferon. The use of rituximab in relapsed or refractory hairy cell leukemia is limited to case reports and uncontrolled, retrospective case series. However, the American Hospital Formulary Service® (AHFS®, 2013) notes that rituximab is used off-label in the treatment of hairy cell leukemia. In addition, specialty consensus opinion suggests rituximab is indicated for treatment of hairy cell leukemia.

Rheumatoid Arthritis
The FDA approved the use of rituximab in combination with methotrexate as a treatment of adults with moderately- to severely- active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies (2006). The product information label (2012) states there is limited available safety data on the use of biologic agents or disease modifying antirheumatic drugs (DMARDs) other than methotrexate following rituximab treatment in individuals with rheumatoid arthritis. A favorable risk-benefit relationship has not been established to utilize rituximab in individuals with inadequate responses to non-biologic DMARDs and those who are methotrexate-naïve. Therefore, the use ofrituximab is not recommended if the individuals with rheumatoid arthritis have not had prior inadequate response to one.

In 2008, the American College of Rheumatology (ACR) Task Force Panel (TFP) had developed treatment recommendations concerning the therapeutic indications for rituximab in the treatment of rheumatoid arthritis (RA)(Saag). There was no agreement within the TFP and no statement made regarding the use of rituximab in the setting of early RA without features of a poor prognosis. The ACR (2008) reported the following:

The TFP recommended the use of rituximab in patients for whom methotrexate in combination with disease-modifying antirheumatic drugs (DMARDs) or sequential administration of other nonbiologic DMARDs led to an inadequate response, with high disease activity and features of a poor prognosis. The TFP did not recommend combinations of biologic agents, based in part on data suggesting a higher rate of adverse events with combinations and/or lack of additive efficacy.

The ACR 2012 (Singh, 2012) update of biologics in high-risk individuals with rheumatoid arthritis includes the following recommendations:

The panel only recommends starting or resuming rituximab in RA patients with: 1) a previously treated solid malignancy within the last 5 years, 2) a previously treated nonmelanoma skin cancer within the last 5 years, 3) a previously treated melanoma skin cancer, or 4) a previously treated lymphoproliferative malignancy. Little is known about the effects of biologic therapy in patients with a history of a solid cancer within the past 5 years owing to the exclusion of such patients from participation in clinical trials and the lack of studies examining the risk of recurrent cancer in this subgroup of patients.

In an updated consensus statement from the 10th Annual Workshop on Advances in Targeted Therapies, Furst and colleagues (2008) noted evidence (category A) from randomized controlled trials supporting the combination of rituximab with MTX "Yields better clinical efficacy for RA than monotherapy." Edwards and colleagues (2004) reported results from a double blind, randomized controlled trial with 161 individuals with active rheumatoid arthritis. Individuals were randomly assigned to one of four cohorts — methotrexate; rituximab; rituximab plus cyclophosphamide; or rituximab plus methotrexate. The primary endpoint was the proportion of individuals with an ACR 50, (improvement of at least 50% from baseline) response at 24 weeks. The group treated with rituximab monotherapy did not reach statistical difference when compared to the control group of methotrexate. However, the groups using rituximab in combination with cyclophosphamide or methotrexate showed statistically significant improvement in the ACR 50 scores compared to the control group at week 24.

Lymphoma (Hodgkin and non-Hodgkin)
Hodgkin Disease (Lymphoma)
Schulz and colleagues (2007) reported long-term outcomes from a phase II trial with 21 individuals with relapsed or refractory, nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) with CD20-positive expression. Four individuals were reclassified as CD10+ classic Hodgkin lymphoma (cHL) and two individuals were reclassified as Hodgkin lymphoma transformed to T-cell rich B-cell lymphoma (TCRBCL). Fifteen individuals had NLPHL confirmed by a reference laboratory and were evaluated for overall response. Standard doses of rituximab were infused weekly for a total of four weeks. An overall response was achieved in 94% of fifteen individuals, which included 8 complete remissions (CR) and 6 partial remissions (PR). Median time to progression (TTP) was 33 months with the median overall survival (OS) not reached. One NLPHL and three cHL individuals have died since enrollment.

The NCCN Clinical Practice Guideline (CPG) (2013) lists the off-label use of rituximab with or without radiation therapy or used in combination with other chemotherapy agents for treatment of Hodgkin lymphoma. Rituximab may also be used as maintenance therapy of symptomatic, relapsed or refractory lymphocyte predominant Hodgkin lymphoma after second-line of therapy that included rituximab. These recommendations were based on 2A category of evidence and uniform consensus. The peer-reviewed literature consists of case series and nonrandomized, uncontrolled trials.

Non-Hodgkin Lymphoma
A Cochrane report (Schulz, 2007) described results from a meta-analysis of seven randomized controlled trials involving 1,943 individuals with follicular lymphoma, mantle cell lymphoma, or other indolent lymphomas. Better OS rates were served in individuals treated with combination rituximab and other chemotherapy agents (R-chemo) (hazard ratio [HR] for mortality 0.65; 95% confidence interval [CI] 0.54 to 0.78). An overall response (relative risk of tumor response 1.21; 95% CI 1.16 to 1.27), and disease control (HR of disease event 0.62; 95% CI 0.55 to 0.71) was noted in individuals treated with R-chemo versus those treated with chemotherapy alone. R-chemo improved overall survival in individuals with follicular lymphoma (HR for mortality 0.63; 95% CI 0.51 to 0.79) and in individuals with mantle cell lymphoma (HR for mortality 0.60; 95% CI 0.37 to 0.98). The authors concluded "Concomitant treatment with rituximab and standard chemotherapy regimens should be considered the standard of care for individuals with indolent and mantle cell lymphomas who require therapy and for individuals with follicular lymphoma."

Vidal and colleagues (2009) performed a systematic review and meta-analysis of randomized controlled trials that studied the use of rituximab as maintenance therapy in individuals with follicular lymphoma. Induction therapy consisted of chemotherapy alone, chemotherapy with or without rituximab, and rituximab alone. The meta-analysis included 1143 individuals in five trials that compared observation or treatment upon relapse, versus rituximab as maintenance therapy. Meta-analysis of OS data was available for 985 individuals. OS was statistically significant and better in individuals treated with maintenance rituximab, versus those in the observation cohort or treated at the time of relapse (HR of death = 0.60, 95% CI = 0.45 to 0.79). With further analysis, the authors noted individuals with refractory or relapsed follicular lymphoma treated with maintenance rituximab therapy had a survival benefit (HR for death = 0.58, 95% CI = 0.42 to 0.79) compared to that (HR for death = 0.68, 95% CI = 0.37 to 1.25) of previously untreated individuals. However, infection-related adverse events were higher (HR = 1.99, 95% CI = 1.21 to 3.27) in the maintenance treatment group. Despite the higher rates of adverse events, the data from one trial did not show a negative impact on OS. The authors concluded maintenance rituximab therapy should be included as treatment for individuals with relapsed or refractory follicular lymphoma who responded to induction therapy. The risk and management of infections should be included in treatment decisions when utilizing rituximab.

A randomized controlled, phase III, PRIMA trial of two years of rituximab maintenance after first-line treatment of individuals with follicular lymphoma demonstrated significant progression-free survival (PFS) (Salles, 2010). This multicenter trial included an induction and a maintenance phase. After induction, 513 individuals were randomized to the observation group and 505 participants were assigned to the rituximab treatment group. The rituximab maintenance regimen included a total of 12 infusions of 375mg/m2 infused every 8 weeks. At a median follow-up of 36 months in both groups, 3-year PFS was significantly prolonged at 74.9% (95% CI 70.9 – 78.9) in the treatment group compared to 57.6% (53.2 – 62.0) in the observation cohort (p < 0.0001).

Nonimmunosuppressed Primary Central Nervous System Lymphoma
Lymphoma that is limited to the cranial-spinal region without systemic disease is defined as primary central nervous system (CNS) lymphoma. According to the NCI (2013), diffuse large B-cell neoplasms comprise almost all primary CNS lymphomas. Treatment includes radiation therapy alone or with chemotherapeutic agents. Retrospective, uncontrolled case series have investigated the off-label use of rituximab for the treatment of primary CNS lymphoma. Wong (2004) reported five individuals with complete radiographic responses and two partial responses in a retrospective review of seven individuals who received rituximab induction prior to temozolomide treatments. Median duration of response was six months and the median survival was eight months. The authors noted the sequential dosing of rituximab prior to temozolomide appears to sensitize the CD20+ B-cells. Larger trials are needed to confirm the findings. The off-label use of rituximab for refractory or relapsed primary CNS lymphoma is reported by the NCI (2013) and is a NCCN level 2A category of evidence and uniform consensus recommendation (2013).

Waldenström's Macroglobulinemia
Lymphoplasmacytic lymphoma is an indolent lymphoproliferative disease also known as Waldenström's macroglobulinemia. Waldenström's macroglobulinemia usually includes involvement of the bone marrow, lymph nodes, spleen, and may develop into hyperviscosity syndrome. The monoclonal serum paraprotein immunoglobulin M (IgM) gammopathy is typically associated with Waldenström's (NCI, 2013). Treatment of acute symptoms usually includes plasmapheresis and long-term management of individuals with serum viscosity of four or less is typically managed with chemotherapeutic agents.

Dimopoulos and colleagues (2007) reported on a series of 72 symptomatic individuals with Waldenström's macroglobulinemia (WM) in a phase II study. The enrolled individuals were treated with dexamethasone, rituximab andcyclophosphamide (DRC) over a period of five days. The regimen was repeated every 21 days for a period of six months. Responses were evaluated on an intention-to-treat analysis. The overall response rate was 84% (95% CI, 73% – 91%) which included 7% complete responses (CRs), 67% partial responses (PRs), and 9% minimal responses (MR). The 2-year PFS rate for all participants was 67% and for individuals who responded to DRC, 80%. Grade 3 or 4 neutropenia occurred in seven individuals. Twenty infectious episodes with one death were recorded.

The Fourth International Workshop on Waldenström's macroglobulinemia (Dimopoulos, 2009) updated treatment recommendations include rituximab-based therapies, which may be the preferred first line of therapy as a single agent or in combination regimens for most individuals with Waldenström's macroglobulinemia. The authors noted "reuse of a first-line single agent or combination is reasonable if an individual achieved an unmaintained response that lasted for at least 12 months." Additional considerations when determining the choice of salvage therapy include first-line therapy used, quality and duration of response and specific variables such as age, performance status, and side effects. The NCI Adult non-Hodgkin Lymphoma Treatment PDQ^® (2013) includes the use of rituximab either as a single agentor in combination regimens as first-line therapy for Waldenström's macroglobulinemia. The peer-reviewed literature consists of case series.

The NCCN Clinical Practice Guideline (2013) recommends the off-label use of rituximab as a single agent along with plasmapheresis for treatment of symptomatic hyperviscosity for Waldenström's macroglobulinemia. Additional indications include follow-up treatment as a single agent for progressive or relapsed disease and palliative treatment. Single agent use in individuals with an M-protein greater than 5g/dL is discouraged. These recommendations are based on 2A category of evidence and uniform consensus. The peer-reviewed literature consists of case series and nonrandomized trials.

The American Hospital Formulary Service^® (AHFS^®, 2013) notes that rituximab is used as an off-label treatment of Waldenström's macroglobulinemia.

Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA)
WG disorder and MPA are subgroups of primary systemic small vessel vasculitis associated with ANCA (antineutrophil cytoplasmic antibodies), also known as ANCA-associated vasculitis (AAV). AAV causes blood vessels to become inflamed or swollen and as a result, blood flow is restricted. The respiratory tract and kidneys are frequently the primary targets (Keogh, 2006). In early 2011, the recommendation was made by several specialty societies to change the name of WG to granulomatosis with polyangiitis, abbreviated as GPA (Falk, 2011). WG is a rare, and rapidly progressive, immune mediated disorder that is typically treated with glucocorticosteroids and cytotoxic agents. However, relapsing disease and long-term toxicities as a result of standard therapies continue to pose challenges. Activated B-lymphocytes have been correlated with disease activity and response to therapies (Stone, 2010).

The FDA approved the combination of rituximab and glucocorticoids as a treatment for adults with WG and MPA in April, 2011. Use of concomitant immunosuppressants other than corticosteroids has not been studied in individuals with GPA or MPA exhibiting peripheral B-cell depletion following treatment with rituximab (Product Information Label, 2013).

The pivotal randomized trial was Rituximab in ANCA-Associated Vasculitis (RAVE), which was a double-blind, double-dummy, noninferiority trial that enrolled 197 ANCA-positive individuals with WG or MPA (Stone, 2010). For remission induction, participants received rituximab 375mg/m2 per week for 4 weeks and placebo-cyclophosphamide in the treatment group. The control group received standard therapy with cyclophosphamide 2mg/kg per day plus placeborituximab infusions. Individuals in the treatment group who achieved remission between 3 and 6 months were switched from placebo-cyclophosphamide to placebo-azathioprine. Participants in the control group who had a remission between 3 and 6 months were switched from cyclophosphamide to azathioprine. Both groups received glucocorticoid treatment of one to three pulses of 1000mg methylprednisolone followed by prednisone 1mg/kg/day. The dose was tapered by 5 months to have glucocorticoids discontinued for individuals who were in remission. Primary endpoints were Birmingham Vasculitis Activity Score for Wegener's Granulomatosis (BVAS/WG) of 0 and successful prednisone taper at 6 months. There were 99 individuals randomized to the rituximab group, and 98 assigned to the control group. In each group, approximately 49% of the participants were newly diagnosed. Mean BVAS/WG entry scores were 8.5 ± 3.2 in the treatment group and 8.2 ± 3.2 in the control group. Completion of 6 months of treatment without early treatment failure was achieved in 84 individuals in the rituximab group (85%) and 81 participants in the control group (83%). The primary end point was reached in 64% of the treatment group and 53% of the control group, which met the criterion for noninferiority (P < 0.001). In a subset analysis, 34 of 51 individuals with relapsing disease at baseline and treated with rituximab had reached the primary end point (67%) compared to 21 of 50 participants (42%, P = 0.01) in the control group. Adverse events occurred in 33 participants in the control group (33%) compared to 22 individuals in the rituximab group (22%). Stone and colleagues (2010) concluded treatment with rituximab and glucocorticoids was not inferior to the standard regimen of cyclophosphamide and glucocorticoids for remission induction in severe relapsing ANCA associated vasculitis.

Specks and colleagues (2013) provided updated data for the RAVE trial. The primary outcome was complete remission of disease by 6 months with remission maintained at 18 months. A total of 64% of individuals treated with rituximab had achieved CR at 6 months, with CR maintained at 12 months and 18 months at 48% and 39%, respectively. The control group had corresponding rates of CR at 6, 12 and 18 months of 53%, 39%, and 33%. There was no significant difference in mean duration of CR between the treatment groups (P = 0.76). The authors noted the criterion for noninferiority was met (P < 0.001), but the criterion for superiority was not. At 18 months, there were no significant differences between the treatment groups in the number or rates of total adverse events, serious adverse events or nondisease related adverse events. There were two deaths in each group. The authors noted, additional study is needed to determine "whether conventional remission-maintenance therapy or repeated B-cell depletion with rituximab is more effective in preventing relapses after initial induction of remission with rituximab."

Other Indications
Based on the results from published data, rituximab treatment for other indications that are not currently approved by the FDA continue to be investigated.

Acquired Inhibitors in Hemophilia
A rare condition of acquired inhibitors in individuals with hemophilia may occur and could cause life-threatening bleeding. Replacement factors are used as prophylaxis and treatment of bleeding episodes in hemophiliacs. The development of high titers of inhibitors resulting from antibodies to the replacement factor is a serious complication and decreases the efficacy of hemophilia therapy. Due to the low incidence rate of acquired inhibitors, published data consists of case reports, case series and reviews (Collins, 2009; Kruse-Jarres, 2011; Sperr, 2007; Wiestner, 2002). Treatment typically involves immune tolerance and/or depletion of inhibitors with immune suppression with prednisone and cyclophosphamide (Kruse-Jarres, 2011; Sperr, 2007). For those individuals without a sufficient reduction in inhibitors with standard immunosuppression with cyclophosphamide and prednisone, rituximab therapy has resulted in a CR rate of inhibitor reduction of 77% (Sperr, 2007). Published data demonstrate the use of rituximab after failure of cyclophosphamide and prednisone immunosuppression can reduce acquired inhibitors and allow therapeutic results from factor replacement in hemophiliacs (Collins, 2009; Kruse-Jarres, 2011; Sperr, 2007; Wiestner, 2002). Additionally, specialty consensus opinion suggests the use of rituximab to treat individuals with acquired inhibitors and who have failed cyclophosphamide and prednisone treatment.

Acute Lymphoblastic Leukemia (ALL)
ALL is an aggressive type of leukemia that involves an overabundance of lymphoblasts or lymphocytes in the bone marrow and the peripheral blood. This condition is also called acute lymphocytic leukemia. Treatment of ALL includes combination chemotherapy and may include radiation (NCI, 2013). The National Comprehensive Cancer Network^® (NCCN) Clinical Practice Guideline in Oncology (NCCN Guidelines^®, 2013) includes rituximab as a treatment option with the Hyper-CVAD (hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with high-dose methotrexate and cytarabine) regimen for individuals with CD20+, Philadelphia chromosome-negative ALL. This 2A off-label recommendation was based on improved CR duration rate and OS rates from phase II trials.

Autoimmune Hemolytic Anemia (AIHA)
AIHA is typically idiopathic or secondary to another diagnosis, and involves the production of autoantibodies and the hemolysis of red blood cells (RBCs). AIHA is an uncommon condition with cases classified as warm AIHA or cold agglutinin disease. Treatment of AIHA depends on this classification and typically includes corticosteroids, immunosuppressants, immunoglobulin and splenectomy. Rituximab, as an alternative treatment for refractory AIHA, is limited to small retrospective case series, case reports and uncontrolled trials. Further investigation is ongoing to determine whether rituximab achieves durable, effective, long-term results to improve overall health outcomes. Specialty consensus opinion recommends the use of rituximab for treatment of this condition.

Graft Versus Host Disease (GVHD)
GVHD may occur in transplant recipients as a result of a T-cell mediated reaction to antigens from a donated hematopoietic stem cell graft. Symptoms include anorexia, gastrointestinal symptoms, jaundice, skin rash or blisters, a dry mouth, or dry eyes. Treatment of GVHD includes steroids, calcineurin inhibitors, immunosuppressants, T-cell depleting agents and extracorporeal photopheresis. There has been published literature regarding various treatment and prophylaxis regimens for GVHD as well as varying response rates. However, individuals that are unresponsive or are refractory to corticosteroids and standard therapies have a poor prognosis and there is no standard treatment in this setting (Teshima, 2009). The published literature consists of retrospective, case series and uncontrolled trials studying the role of rituximab as a treatment for refractory GVHD.

Investigators hypothesize B-cells and other factors may have a role in GVHD (Cutler, 2006). Low-dose (50 mg/m²)rituximab was used to treat 13 individuals with steroid-refractory GVHD. An overall response rate of 69%, with 23% (3 individuals) achieving CR,15% PR and 30% mixed response (MR), was reported by von Bonin (2008). Two individuals developed complications due to infection, with one death. Teshima and colleagues (2009) reported results from a phase II trial of 7 individuals with refractory chronic GVHD (cGVHD) who were treated with weekly rituximab doses of 375 mg/m² over four weeks. At 1-year follow-up, the overall response rate was 43% with PR in 3 participants, stable disease (SD) in 3 individuals and 1 participant had progressive disease (PD). The median reduction of steroids was 67%. At a median follow-up of 30 months, 5 participants were alive and 2 deaths from infection were noted. In a retrospective study by GITMO (Gruppo Italiano Trapianto Midollo Osseo; Zaja, 2007), 38 participants with refractory GVHD were treated with rituximab. The 2-year actuarial survival was 76% and the overall response rate was 65%. Steroid therapy was reduced by 82%. There were 8 deaths during the study period with 3 cases of progressive cGVHD, 1 relapsed disease, 3 cases of sepsis and 1 sudden death.

Kharfan-Dabaja and colleagues (2009) performed a review and meta-analysis of rituximab as a treatment for steroidrefractory chronic GVHD. From the published literature, 6 studies met inclusion criteria for review, of which 3 studies were prospective and 3 were retrospective studies. There were no randomized controlled trials. There were a total of 108 individuals in the 6 trials. The authors were unable to analyze the heterogeneity of the responses. The data suggest rituximab is effective in treating cutaneous cGVHD; however the response was not noted in other organs. The authors concluded the "evidence generated through this systematic review demonstrates the gaps in the existing evidence base related to the efficacy of rituximab in treating patients with steroid-refractory cGVHD. This underscores the need for well-designed and adequately powered prospective studies to conclusively address this issue."

The off-label use of rituximab as third-line treatment or greater, for refractory GVHD is based on the data from uncontrolled trials and case series which demonstrated improvement in GVHD and reduction of steroid use. Based on the data for refractory GVHD, the safety and efficacy of rituximab as a prophylaxis and as first-line therapy for GVHD are being studied.

Multicentric Castleman's Disease, CD20+
Multicentric Castleman's disease (MCD) is an uncommon lymphoproliferative disorder, which has been associated with human herpesvirus 8 (HHV-8) and Kaposi's sarcoma (KS), and may evolve towards HHV-8-associated non-Hodgkin lymphoma (Gerard, 2007; Mylona, 2008). An increased prevalence of MCD is noted in human immunodeficiency virus (HIV) infection. A systematic review of the published literature on MCD conducted by Mylona and colleagues (2008) identified 84 individuals in 25 studies which met criteria for analysis. Chemotherapy treatment data was available for 75 out of the 84 individuals. Rituximab was utilized as first- or second-line therapy in seven of the 75 individuals. Five cases have led to complete responses. The authors highlighted there were three cases of responders with worsening of existing KS.

 In a prospective, open-label phase II trial, four weekly rituximab infusions were given to 24 individuals with HIV-associated MCD (Gerard, 2007). One individual died as a result of progressive MCD before completing the infusions and one individual died at day 112 from infection related respiratory failure. The primary endpoint was a sustained remission (SR) at day 60 while remaining off of other chemotherapeutic agents. Seventeen of 22 individuals achieved SR at day 60 and remained off of chemotherapy at day 365. The authors concluded the estimated OS rate was 92% (95% CI, 71% – 98%), event free survival (EFS) was 71% (95% CI, 48% – 85%) and disease free survival (DFS) was 77% (95% CI, 54% – 90%). Adverse events included exacerbation of KS lesions in eight of the twelve individuals who had pre-existing KS.

In a single-group, open-label, phase II trial, 21 individuals with HIV-associated MCD were treated with rituximab as first-line treatment. The median follow-up was 12 months (range 1 – 49 months). One individual died before completion of the therapy regimen. Fourteen participants (67%) achieved radiologic response, and 20 individuals achieved remission of symptoms. At 2 years, the overall survival rate was 95% (95% CI, 86% – 100%) and the DFS rate was 79% (CI, 52% – 100%) (Bowers, 2007).

NCCN CPG (2013) recommends the off-label use of rituximab in combination regimens to treat CD20+ AIDS related diffuse large B-cell lymphoma and lymphoma associated with Castleman's disease. These recommendations were based on level 2A category of evidence and uniform consensus.

Neuromyelitis Optica (NMO)
Neuromyelitis optica is a rare, inflammatory, demyelinating central nervous system (CNS) disease that selectively targets the optic nerve and spinal cord (Jacob, 2007). Magnetic resonance spine imaging often reveals longitudinally extensive transverse myelitis (LETM) defined as large, contiguous lesions over three or more vertebral segments. A specific serum antibody (NMO-Ig-G/aquaporin-4) has been identified in individuals with NMO along with perivascular immunoglobulin deposition and B-cell participation in the activated complement lytic pathway (Jacob, 2007). Glucocorticoids, plasmapheresis and immunosuppressants have been used to treat NMO. Cree and colleagues (2005) reported results from an open-label series of eight consecutive individuals with NMO who were treated with rituximab. At an average follow-up of 12 months, six individuals have remained free from attacks. Five individuals received retreatment with rituximab when CD19+ cells were detectable. The authors noted the possibility that previous immunosuppression may have confounded results, or the timing of the rituximab was attributable to the natural onset of remission.

Jacob and colleagues (2008) reported retrospective, multicenter data on a series of 25 individuals with NMO treated with rituximab. The rituximab regimens utilized were 375 mg/m 2 weekly for 4 weeks and 1000 mg infused twice, with a 2-week interval between infusions. Median follow-up of 19 months (range 6 – 40 months) occurred with five participants discontinuing treatment. In addition, two deaths were attributed to disease progression and sepsis. The authors reported the median annualized pretreatment relapse rate was 1.7 relapses (range 0.5 – 5 relapses) and the median annualized posttreatment relapse rate was 0 (range 0 – 3.2 relapses, P < .001). Because NMO is a rare, relapsing and debilitating disease, the off-label use of rituximab as a treatment of NMO is based on the data from case series which demonstrated improvements in relapse rates. S-pecialty consensus opinion suggests the use of rituximab as treatment for NMO.

Pemphigus Vulgaris and Other Autoimmune Blistering Skin Diseases
Autoimmune blistering skin diseases are rare, and treatment with corticosteroids and immunosuppressive drugs may not control disease, leading to increased morbidity and mortality. Rituximab treatment for individuals with refractory pemphigus vulgaris has been studied in open label, nonrandomized, uncontrolled case series. Joly and colleagues (2007) reported on 18 (86%) out of 21 individuals who achieved complete remission of severe, refractory pemphigus with rituximab therapy. With a median follow-up of 34 months, 18 individuals were free of disease and eight of these individuals had stopped corticosteroid therapy. In another similar study (Allen, 2007) the investigators note rituximab "Appears to be effective in the treatment of refractory disease." Additionally, the American Hospital Formulary Service^® (AHFS^®, 2013) notes rituximab is used off-label for the treatment of pemphigus vulgaris.

Posttransplant Lymphoproliferative Disorder
Posttransplant lymphoproliferative disorder (PTLD) is a rare and life-threatening complication after organ transplantation. PTLD presents as a heterogeneous group of lymphoproliferative disorders resulting from immune suppression, and the prognosis is dependent on additional risk factors such as the presence of Epstein-Barr virus (EBV). The primary treatment of PTLD has been a reduction in immunosuppression. However, many individuals fail to respond to reduction and modifications of the immunosuppression therapy.

Lee and colleagues (2007) performed a systematic review of six studies of PTLD treatment with rituximab as a single agent or in combination with chemotherapy. A majority of the individuals involved in the studies were CD20+. There have been case reports and phase II trials reported, but there is a lack of randomized, prospective, head-to-head comparisons of treatment regimens. The authors noted results from the limited trials, in combination with some long-term retrospective follow-up data, demonstrated rituximab therapy as a single agent or in combination, produced an ORR of 50 – 100% and a 5-year OS of 60%. Prospective, randomized controlled trials are needed to identify the optimal timing and treatment regimens for individuals with PTLD that have failed immunosuppressive therapy.

In a retrospective, multi-center analysis of 80 solid organ transplant (SOT) recipients, Evens (2010) noted individuals treated with first-line rituximab, with or without chemotherapy, had significantly improved PFS and OS. Of the 80 SOT recipients with PTLD, 59 individuals had early treatment with rituximab. With a median 40-month follow-up, significant differences in the rituximab treated cohort were noted with PFS 70% versus 21% (P < .0001) and OS 73% versus 33% (P = .0001).

Renal Transplant
Renal transplantation is used for individuals with end-stage renal disease (ESRD). The demand for kidney transplantation has outpaced the supply of organs, thus increasing the wait-time until transplantation. Additionally, wait times are increased when there is difficulty in matching organs to recipients resulting from sensitization with reactive human leukocyte antigen (HLA)-specific antibodies. Vo (2010) reported "the rate of transplantation with any level of sensitization is difficult to transplant". Individuals with panel reactive antibodies (PRA) 10% to 80% were transplanted 16% per year whereas PRA greater than 80% were transplanted less than 8% per year.

A phase I-II trial examined if a treatment protocol, consisting of intravenous immune globulin (IVIG) and rituximab, administered prior to kidney transplantation would improve transplantation rates by reducing anti-HLA antibody levels in highly sensitized individuals. Twenty individuals, who were highly sensitized, were treated with the combination regimen between 2005 and 2007. Vo and colleagues (2008) reported PRAs were "Significantly reduced after treatment with IVIG and rituximab (77 ± 19% before the first infusion of IVIG, vs. 44 ± 30% after the second infusion (P < 0.001)." CD19+ cells were significantly reduced after rituximab treatment (mean percentage of total B cell lymphocytes, 6.12 ± 0.18% prior to treatment, vs. 0.90 ± 0.02% after treatment, P < 0.001). Sixteen of the 20 participants received successful transplantation (6 received a deceased donor kidney; 10 received a living donor kidney). The remaining 4 participants had PRA levels greater than 50% and were awaiting a deceased donor kidney transplant. Mean follow-up was 22.1 ± 6 months with recipient and allograft survivals of 100% and 94%, respectively. One graft was lost due to severe rejection after a reduction of immunosuppressive therapy. Acute rejection occurred in 50% of the transplanted individuals. Acute antibody-mediated rejections (AMR) occurred in 31% of the episodes and 2 individuals had late (greater than 6 months) AMR episodes. Individuals with AMR were treated with methylprednisolone, rabbit antithymocyte globulin and rituximab. Recipients of deceased donor kidneys had a mean waiting list time of 12 years (range, 5 – 27) prior to desensitization, but received transplants within 5 to 6 months after receiving combination treatment with IVIG and rituximab.

In 2010, Vo and colleagues reported on 76 HLA-sensitized individuals who were treated with IVIG and rituximab prior to kidney transplantation during 2006 and 2009. The study examined the efficacy of IVIG and rituximab on the reduction of anti-HLA antibodies that led to kidney transplantation with incurring the risk of AMR and immediate graft loss. All participants were deemed high immunologic risks with PRA 30% – 79% in 25% of individuals and 75% of the participants had PRA ≥ 80%. Thirty-one individuals received living donor (LD) and 45 individuals received deceased donor (DD) kidney transplants. Data from 39 individuals show mean pretreatment class I PRA was 79.7 % ± 35.6% versus post-treatment 67.1% ± 28.6% (P = 0.0001). Recipients of deceased donor kidneys had a mean waiting list time of 95 ± 46 months prior to desensitization, but received transplants within 4 months after receiving combination treatment with IVIG and rituximab. Acute rejection (AR) occurred in 37% of participants (8% cell mediated rejection [CMR] and 29% AMR). Nine individuals had graft losses, with AMR involved in 6 cases. Recipient and allograft survivals were 95% and 84%, respectively. The authors concluded, "IVIG and rituximab seems to offer significant benefits in reduction of anti-HLA antibodies, allowing improved rates of transplantation for highly sensitized patients, especially those awaiting DD, with acceptable antibody-mediated rejection and survival rates at 24 months" (Vo, 2010). Additional analysis in a randomized trial was encouraged.

Tyden (2009) reported results from 140 individuals transplanted on a prospective, double-blind, randomized, placebo-controlled study. Participants meeting criteria, including PRA less than 50%, were randomized to induction therapy (tacrolimus, mycophenolate mofetil and steroids) plus rituximab versus induction therapy plus placebo. One hundred thirty-six participants fulfilled the criteria for analysis. Treatment failure was the primary endpoint, with 10 occurrences in the rituximab group and 14 in the placebo group (P = 0.348). Rejection episodes occurred 8 times in the treatment cohort versus 12 episodes in the placebo group (P = 0.317). Although rejection episodes in the treatment group "tended to be less severe," survival in both groups at 6-months was 98.5% and death censored graft survival of 98%. Biopsy-proven acute rejections were not statistically significant with 11.6% in the rituximab group and 17.6% in the placebo cohort. The 3-year follow-up of this study population is ongoing.

Systemic Autoimmune Disorders (Cryoglobulinemia, Primary Sjögren Syndrome [SS], Systemic Lupus Erythematosus [SLE])
Rituximab has been increasingly used for a variety of systemic autoimmune diseases (SAD). In a systematic review of the published literature, Ramos-Casals and colleagues (2008) noted, due to the lack of randomized controlled trials and the heterogeneity in clinical features in the SAD population, definitive off-label recommendations for biologic agents were difficult to make. However, based on the therapeutic response of > 80% in individuals, the authors noted rituximab should be considered a first choice biologic agent for treatment for individuals with cryoglobulinemia, primary SS and SLE who are refractory to standard therapy (lack of response to corticosteroids and at least two immunosuppressive agents). Immunosuppressive agents utilized for the treatment of SS include cyclosporine, methotrexate, azathioprine, corticosteroids, hydroxychloroquine, d-penicillamine, thalidomide, and nucleoside analogues (Mavragani, 2007). In addition, specialty consensus opinion suggests the use of rituximab for treatment of SAD.

Thrombocytic Purpura, Idiopathic or Immune
Idiopathic thrombocytopenic purpura (ITP), also known as primary immune thrombocytopenic purpura, is an immune mediated hematologic disorder characterized by impaired production of platelets in the bone marrow, and destruction of the peripherally circulating platelets. These individuals typically present with low platelet counts, bleeding episodes, and platelet autoantibodies. Treatment may include maintaining hemostatic levels, administering prednisone and immune globulin and in severe cases, splenectomy.

Arnold and colleagues (2007) performed a systematic review of rituximab as a treatment of ITP in adults. Nineteen studies including a total of 313 individuals were identified for evaluation of efficacy and 29 articles including a total of 306 individuals were identified for assessment of safety. The authors noted an absence of controlled studies. In 16 out of 19 studies, rituximab was given at standard weekly dosing for up to 4 weeks. Complete response, noted by a platelet count greater than 150 x 10 9 cells/L, was observed in 43.6% of individuals. An overall response, defined as platelet count greater than 50 x 10 9 cells/L, was noted in 62.5% individuals treated with rituximab. Median duration of response was 10.5 months and a median follow-up was 9.5 months. Evaluation of all deaths in rituximab-treated individuals identified 9 deaths out of 306 individuals, with 2 deaths attributed to rituximab administration. The authors concluded from the uncontrolled studies, that rituximab treatment improved platelet counts. However, prospective, randomized controlled trials are encouraged to identify the optimal timing and dose of rituximab for the treatment of ITP.

 The first report from a phase III, open-label trial of rituximab as first-line of therapy for ITP was reported by Gudbrandsdottir (2013). Individuals with newly diagnosed adults with ITP and platelet counts ≤ 25 X 10 9 /L or ≤ 50 X 109 /L with concomitant bleeding symptoms were randomized to treatment with dexamethasone alone (DXM) or in combination with rituximab (RTX + DXM). Between 2006 and 2011, a total of 137 individuals were randomized. Four participants did not have complete data available for analysis. The DXM group included 71 individuals who received DXM 40 mg/day for 4 days. The treatment group of 62 individuals received DXM and rituximab 375 mg/m 2 weekly for 4 weeks. In addition, up to 6 cycles of supplemental DXM every 1 to 4 weeks was allowed. The median follow-up was 922 days. Fifty-eight percent of participants in the RTX + DXM group met the primary endpoint of sustained response (i.e., platelets platelets ≥ 50 X 109/L) at 6 months follow-up compared to 37% treated with DXM alone in the control group (P = .02). The time to relapse was defined as a decrease in platelet counts to < 50 X 109/L following initial response to therapy. The RTX + DXM group had a significantly longer time to relapse compared to the DXM group (P = .03). An increased incidence of grade 3 to 4 adverse events was observed in the RTX + DXM group (P = .04).

 The American Hospital Formulary Service^® (AHFS^®, 2013) notes that rituximab is used as an off-label treatment of ITP.

Other Proposed Uses:
The published literature includes investigation of rituximab treatment for various other off-label uses. However, the published literature consists of case reports, small case series, non-randomized and uncontrolled trials which preclude reliable conclusions on safety and long-term net health outcomes.

Membranous Nephropathy (MN)
Membranous nephropathy involves the abnormal thickening of the glomerular basement membrane and is a leading cause of nephrotic syndrome. Majority of MN cases occur from unknown causes and secondary MN may be a result of other predisposing diseases, infection or medical therapy. In most cases, conservative treatment with renin-angiotensin system (RAS) blockade is provided. Immunomodulatory therapies (e.g., alkylating agents, calcineurin inhibitors and corticosteroids) are used to treat individuals who are unresponsive to conservative therapy. Rituximab has been used to treat MN and reported in numerous case reports and series. Bomback and colleagues (2009) performed a systematic review of 21 articles involving 85 individuals with biopsy-proven MN treated with rituximab as primary or secondary immunosuppression. Majority of the individuals in the analysis were reported from two centers. However, there were significant variations in selection criteria, previous treatments and rituximab treatment protocols which precluded pooled data analysis. Complete remission in 15 to 20% and partial remission in 35 to 40% of individuals with refractory disease were similar to response rates for alkylating agents and calcineurin inhibitors. The authors cautioned the response rates from case series were "Not valid for direct comparisons to the randomized clinical trial-based data on alkylating agents and calcineurin inhibitors." Although positive case series have been published, Bomback (2009) concluded rituximab as a treatment for MN should not be provided outside of a research setting. Large, randomized controlled trials are needed to determine the optimal schedule, dose and long-term safety and efficacy.

Multiple Sclerosis (MS)
In a Cochrane review (He, 2011) of a randomized, double-blind trial investigating rituximab to treat relapsing and remitting MS (RR-MS), the authors concluded the available evidence was inconclusive and did not support any treatment recommendations at this time. Larger trials with longer follow-up are needed to evaluate the treatment. Treatment of MS with rituximab has been published in phase I studies (Bar-Or, 2008), case reports, case series and nonrandomized, uncontrolled trials (Naismith, 2010). A manufacturer sponsored Phase II/III randomized, double-blind, placebo-controlled multicenter trial to evaluate the safety and efficacy of rituximab as a treatment for primary-progressive multiple sclerosis (PPMS) failed to meet the primary endpoints (Genentech Press Release, 2008). A randomized, double-blind, placebo-controlled trial included 439 participants who were evaluated over a period of 96 weeks. There were no significant differences in the primary endpoint which was time to confirmed disease progression between the rituximab treatment group and the placebo cohort (Hawker, 2009).

Hauser and colleagues (2008) reported results from a phase II, double-blind trial with 104 participants with relapsing-remitting MS. The 48-week trial included 69 participants randomized to 1000 rituximab given intravenously on days 1 and 15, and 35 participants randomized to placebo infusion. The primary endpoint of the study was the total count of gadolinium-enhancing lesions detected on magnetic resonance imaging (MRI) brain scans at weeks 12, 16, 20 and 24. Twenty-four percent of the 104 participants discontinued from the trial before week 48 (14 participants [40%] from the control group and 11 participants [15.9%] in the treatment group). In the intention to treat analysis, there was a reduction of total gadolinium-enhancing lesion counts with rituximab treatment (mean 0.5 lesions) versus placebo (5.5 lesions). The authors concluded the trial data suggests rituximab "May be an option for treating relapsing-remitting multiple sclerosis, provided the observed efficacy and safety profile are sustained in larger and longer-term controlled trials" (Hauser, 2008).

The published peer reviewed literature regarding the off-label use of rituximab to treat multiple sclerosis is not sufficient to draw reasonable conclusions regarding the long-term clinical effectiveness and improvement on net health outcomes and safety.

Transplant Rejection
Published case reports, case series and reviews have reported the use of rituximab for treatment of transplant rejection. A prospective, randomized trial of 20 individuals with acute renal transplant rejection compared rituximab versus standard of care immunosuppression. One-year outcomes with some benefit for recovery of graft function were reported Zarkhin (2008). The study had short term follow-up and further investigation for B-cell mediated graft rejection was recommended. In a review of antibody-mediated rejection (AMR) by Singh (2009), the suppression or depletion of B-cells by rituximab was noted as one treatment option to treat AMR. Other treatments of AMR include suppression of T-cell dependent antibody responses; removal of donor reactive antibody and blockade of the residual alloantibody. However, Singh and colleagues (2009) concluded, "Rituximab deletes the naïve B-cell pool, but has no effect on plasma cells" and the efficacy of rituximab in the treatment of AMR "remains poorly understood. Although all published (AMR) protocols report a variable rate of success, a major weakness of all current protocols is the lack of effective antiplasma cell agents."

The published peer reviewed literature regarding off-label use of rituximab as a treatment for transplant rejection includes case series, phase I and pilot studies. This is not sufficient to draw reasonable conclusions regarding the long-term clinical effectiveness, optimal anti-rejection regimen and safety of rituximab as a treatment for solid organ transplant rejection. Prospective, randomized control trials are needed to determine the clinical effectiveness and net health outcomes of rituximab therapy on transplant grafts and overall survival.

Background/Overview:
Hodgkin Diease (also know as Hodkin Lymphoma)
In Hodgkin disease, cells in the lymphatic system grow abnormally and may spread beyond the lymphatic system. As the disease progresses, it compromises the body's ability to fight infection. Many initial signs and symptoms may be similar to those of influenza, such as fever, fatigue and night sweats. Hodgkin disease is distinguished by the presence of an abnormal Reed-Sternberg cell in the lymphoma tissue. Eventually, tumors develop. Hodgkin disease most commonly affects people between the ages of 15 and 34 and people older than age 55.

In 2013, the NCI reported chemotherapy and radiation therapy may cure more than 75% of all newly diagnosed Hodgkin disease. Advances in diagnosis, staging and treatment of Hodgkin disease have helped to make this once uniformly fatal disease highly treatable with the potential for full recovery. The national mortality rate for adult Hodgkin lymphoma has fallen more rapidly than for any other malignancy.

non-Hodgkin Lymphoma 
NHL is a collection of more than a dozen different cancers of the lymphatic system, which generates the body's immune defenses. This system includes a network of channels akin to blood vessels through which lymphocytes--important white blood cells of the immune system--patrol the body for invading microbes. Along these lymphatic routes in the neck, armpits, abdomen, and groin are clusters of bean-shaped lymph nodes that house platoons of the infection-fighting lymphocytes. These cells also cluster in areas that serve as gateways to the body, including the mucous membranes lining the respiratory and digestive tracts, and the skin. Lymphocytes travel in the bloodstream, as well. The lymphatic system also includes such organs as the spleen, thymus and tonsils.

According to the NCI (2013), NHL can be divided into two prognostic groups: the indolent lymphomas and the aggressive lymphomas. Indolent NHL types have a relatively good prognosis with a median survival as long as 10 years, but they usually are not curable in advanced clinical stages. Early stage (stage I and stage II) indolent NHL can be effectively treated with radiation therapy alone. Most of the indolent types are nodular (or follicular) in morphology. The aggressive type of NHL has a shorter natural history, but a significant number of these individuals can be cured with intensive combination chemotherapy regimens. In general, with modern treatment of individuals with NHL, overall survival at 5 years is approximately 50% to 60%, and 30% to 60% of individuals with aggressive disease can be cured. The vast majority of relapses occur in the first 2 years after therapy. The risk of late relapse is higher in individuals with a divergent histology of both indolent and aggressive disease.

Indolent NHL is usually responsive to radiation therapy and chemotherapy. However, a continuous rate of relapse is usually seen in advanced stages. Individuals can be re-treated with considerable success as long as the disease histology remains low grade. Individuals who present with or convert to aggressive forms of NHL may have sustained complete remissions with combination chemotherapy regimens or aggressive consolidation with marrow or stem cell support (NCI, 2013).

Rheumatoid Arthritis
Rheumatoid arthritis is a chronic inflammatory and progressive disease characterized by symmetrical joint involvement, which causes pain, swelling, stiffness, and loss of function in the joints. If left untreated it may lead to joint destruction and progressive disability. Rheumatoid arthritis affects 2.1 million Americans usually striking people between the ages of 20 and 60, and people in their mid to late fifties are especially vulnerable. Rheumatoid arthritis is three times more common in women than in men. Arthritis and related musculoskeletal conditions such as rheumatoid arthritis cost the U.S. economy nearly $125 billion per year in medical care and indirect expenses such as lost wages and production. The traditional pharmacologic approach consists of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain, swelling, and inflammation, plus a DMARD such as MTX to slow the course of the disease and prevent joint and cartilage destruction.

Adverse Events and Warnings
Black box warnings from the FDA Product Information Label (2013) include the following:

• • Rituximab administration can result in serious, including fatal infusion reactions. Deaths within 24 hours of rituximab infusion have occurred. Approximately 80% of fatal reactions occurred in association with the first infusion. Carefully monitor individuals closely during infusions. Discontinue rituximab infusion for severe reactions and provide medical treatment for Grade 3 or 4 infusion reactions.
  • Severe, including fatal, mucocutaneous reactions can occur in individuals receiving rituximab. Hepatitis B Virus (HBV) reactivation. HBV reactivation can occur in individuals treated with rituximab, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all individuals for HBV infection before treatment initiation, and monitor individuals during and after treatment with rituximab. Discontinue rituximab and concomitant medications in the event of HBV reactivation.
  • Progressive multifocal leukoencephalopathy (PML), including fatal PML, can occur in individuals receiving rituximab.

Additional Warnings from the FDA Product Information Label (2013) include:

• • Hepatitis B virus (HBV) reactivation with fulminant hepatitis, hepatic failure, and death can occur in individuals treated with rituximab. The median time to the diagnosis of hepatitis among individuals with hematologic malignancies was approximately 4 months after the initiation of rituximab and approximately one month after the last dose.
  • Serious, including fatal, bacterial, fungal, and new or reactivated viral infections can occur during and following the completion of rituximab-based therapy. Infections have been reported in some individuals with prolonged hypogammaglobulinemia (defined as hypogammaglobulinemia > 11 months after rituximab exposure). New or reactivated viral infections included cytomegalovirus, herpes simplex virus, parvovirus B19, varicella zoster virus, West Nile virus, and hepatitis B and C.
  • Discontinue infusions for serious or life-threatening cardiac arrhythmias. Perform cardiac monitoring during and after all infusions of rituximab for individuals who develop clinically significant arrhythmias, or who have a history of arrhythmia or angina.
  • Severe, including fatal, renal toxicity can occur after rituximab administration in individuals with NHL. Renal toxicity has occurred in individuals who experience tumor lysis syndrome and in individuals with NHL administered concomitant cisplatin therapy during clinical trials. The combination of cisplatin and rituximab is not an approved treatment regimen. Monitor closely for signs of renal failure and discontinue rituximab in individuals with a rising serum creatinine or oliguria.
  • Abdominal pain, bowel obstruction and perforation, in some cases leading to death, can occur in individuals receiving rituximab in combination with chemotherapy.
  • The safety of immunization with live viral vaccines following rituximab therapy has not been studied and vaccination with live virus vaccines is not recommended.

Definitions: 
Complete response (CR): The disappearance of all signs of cancer as a result of treatment; also called complete remission; does not indicate the cancer has been cured.

Disease free survival (DFS): In cancer, the length of time after primary treatment for a cancer ends that the individual survives without any signs or symptoms of that cancer. In a clinical trial, measuring the disease-free survival is one way to see how well a new treatment works.

Disease modifying anti-rheumatic drugs (DMARDs): A variety of medications (i.e., methotrexate, sulfasalazine, hydroxychloroquine) which work by altering the immune system function to halt the underlying processes that cause certain forms of inflammatory arthritis including rheumatoid arthritis.

Event-free survival (EFS): In cancer, the length of time after primary treatment for a cancer ends that the individual remains free of certain complications or events that the treatment was intended to prevent or delay. These events may include the return of the cancer or the onset of certain symptoms, such as bone pain from cancer that has spread to the bone. In a clinical trial, measuring the event-free survival is one way to see how well a new treatment works.

Line of therapy:

• • First-line therapy: The first or primary treatment for the diagnosis, which may include surgery, chemotherapy, radiation therapy or a combination of these therapies.
  • Second-line therapy: Treatment given when initial treatment (first-line therapy) is not effective or there is disease progression.
  • Third-line therapy: Treatment given when both initial (first-line therapy) and subsequent treatment (second-line therapy) are not effective or there is disease progression.

Maintenance therapy: Treatment given to help keep cancer from coming back after it has disappeared following the initial therapy.

Monoclonal Antibody: A protein developed in the laboratory that can locate and bind to specific substances in the body and on the surface of cancer cells.

Nonbiologic disease modifying antirheumatic drugs (DMARDs): A class of drugs, also referred to as synthetic DMARDs, thought to work by altering the immune system function to halt the underlying processes that cause certain forms of inflammatory conditions, although their exact mechanisms of action are unknown; includes azathioprine, hydroxychloroquine, leflunomide, methotrexate, minocycline, organic gold compounds, penicillamine, and sulfasalazine.

Partial response (PR): A decrease in the size of a tumor, or in the amount of cancer in the body, resulting from treatment. Also called partial remission.

Progressive disease (PD): Cancer that is growing, spreading, or getting worse.

Refractory disease: Illness or disease that does not respond to treatment.

Relapse: After a period of improvement, the return of signs and symptoms of illness or disease.

Stable disease (SD): Cancer that is neither decreasing nor increasing in extent or severity.

Tumor Necrosis Factor (TNF) antagonists: A class of drugs (including, but not limited to adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab) designed to neutralize inflammatory cytokines.

References:

05/09/2023	Annual review, added Janus Kinase Inhibitor to medically necessary criteria in paragraph number 3, bullet 3 of the policy section.
04/18/2022	Annual review, no change to policy intent.
05/12/2021	Interim review adding Coverage of these drugs is provided when the criteria is met and there has been a trial and failure of preferred therapy and expanding drug list. Also updating verbiage for Wegener's Granulmatosis to include "unless intolerant or contraindicated".
04/19/2021	Annual review, no change to policy intent.
10/29/2020	Interim review to add the statement : BlueCross BlueShield of South Carolina recognizes uses and indications of injectable oncology medications (including chemotherapy / systemic therapy, therapeutic radiopharmaceuticals, and selected supportive therapies) to be medically necessary if they are listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence + Consensus of 1, 2A and 2B. Treatments listed with a Category of Evidence and Consensus of 3 are considered unproven and not medically necessary.
08/13/2020	Interim review to add Truxima , Q5115 to the coding section. No other changes made.
06/17/2020	Updated coding. Added Code Q5119 to be effective 7/1/2020. No other changes.
04/21/2020	Annual review adding policy statement for clarity and specificity related to treatment of thrombocytopenic purpura. No other changes made.
04/11/2019	Adding myasthenia and immune checkpoint inhibitor related toxicities as investigational.
01/07/2019	Updating with 2019 codes
04/02/2018	Annual review, adding medical necessity criteria for central nervous system cancers (leptomeningeal metastases from lymphoma and primary CNS lymphoma. No other changes made.
04/19/2017	Annual review, no change to policy intent.
04/27/2016	Annual review, no change to policy intent.
04/28/2015	Annual review, no change to policy intent. Added coding.
4/1/2014	NEW POLICY