Characteristics and management of rash following lenalidomide and rituximab in patients with untreated indolent non-Hodgkin lymphoma.

Low-grade rash may occur with lenalidomide, rituximab, or their combination (R) in non-Hodgkin lymphoma (NHL). From our phase II study of R in previously untreated indolent lymphoma (n=110), 52 (47%) patients had rash, which was associated with pruritus in 22 (42%). Worst grade 1, 2, and 3 rash was found in 19%, 21%, and 7%, respectively. Grade 1/2 rash was effectively managed with observation, antihistamines and/or topical steroids, and resolved within a median of 7-9 days. Grade 3 rash was manageable through lenalidomide interruption and prednisone treatment, with successful R rechallenges. Practical recommendations described here for rash management enable optimal R treatment in patients with previously untreated indolent lymphoma. Indolent lymphomas constitute one-third of all types of NHL, with the most common form being follicular lymphoma (FL), followed by small lymphocytic lymphoma and marginal zone B-cell lymphoma. Optimal treatment for newly diagnosed indolent lymphomas remains to be determined. For patients with advanced stage disease requiring treatment, first-line rituximab alone or in combination with chemotherapy is recommended. Lenalidomide is an oral immunomodulator with singleagent activity in relapsed/refractory indolent lymphoma. Preclinical studies indicate that lenalidomide has multiple antitumor and antiproliferative mechanisms of action and suggest possible synergy between lenalidomide and rituximab, thereby providing the basis for clinical evaluation of the combination. Multiple phase II studies in relapsed/refractory and newly diagnosed indolent lymphoma show that R is active and well tolerated. Although not considered a prominent adverse event for either agent, rash has the potential to affect quality of life negatively and to hinder optimal treatment. Rash has generally been observed as a grade 1/2 adverse event with few