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Although it has a good safety profile, a common side effect is infusional reactions. The majority occur in the first infusion, as the incidence rate of these reactions is reduced with successive infusions,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> so prior to administration of rituximab, guidelines recommend giving the patient paracetamol and an antihistamine (and glucocorticoids for the first infusion). Hypersensitivity reactions are the most common. Cardiological reactions, although less frequent, may manifest as: tachycardia/bradycardia, hypertension/hypotension, arrhythmias and, rarely (<0.1%), as an acute coronary syndrome (ACS). The occurrence of serious infusional reactions may compromise future administration in subsequent cycles and, thus, its effectiveness. We present the case of an infusional reaction to rituximab in the form of ACS and its subsequent management.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 67-year-old female being treated for dyslipidemia without heart disease or other cardiovascular risk factors. She was diagnosed following polyadenopathies and pleural effusion, of a grade 2 follicular lymphoma, stage IV (pleural and medullary infiltration). She initiated first-line treatment chemotherapy with R-CHOP (rituximab, cyclophosphamide, adriamycin, vincristine, prednisone). With the first infusion of rituximab, she presented oppressive chest pain with vegetations and desaturation requiring oxygen therapy; rituximab was withdrawn and a new administration was started with glucocorticoids and diphenhydramine.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The initial electrocardiogram showed an elevation of the ST segment in V1 to V3 with subsequent T-wave negativization. The troponin curve showed an elevation with ischemic kinetics (maximum at 6 h of 331.6 ng/ml [normal: <0.01 ng/ml]).</p><p id="par0025" class="elsevierStylePara elsevierViewall">It was diagnosed as a non-ST segment elevation acute coronary syndrome (NSTE ACS). Treatment with heparin and double antiplatelet therapy with acetylsalicylic acid and clopidogrel was initiated. Because of presenting a Hb of 7.2 g/dl, 2 red blood cell concentrates were transfused. A catheterisation was carried out, showing a non-significant stenosis in the right coronary artery and absence of lesions in the descending anterior (the responsible artery according to the ECG). An echocardiography was performed showing apical anteroseptal hypokinesia (previous ultrasound normal), suggestive of anterior ischemia. Since the patient presented an increase in B symptoms and in the pleural effusion, the first cycle of CHOP was administered without incident.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After consulting with the cardiology department, we decided to administer the following rituximab-CHOP cycles under cardiac monitoring and administered clopidogrel and diltiazem as prophylaxis two days before and after chemotherapy. The patient received a total of six cycles (the first without rituximab), without any other cardiac events. In the re-evaluation, there was a significant decrease in adenopathies (partial response). Subsequently, the patient received maintenance treatment with bimonthly rituximab as the aforementioned prophylaxis, without another adverse reaction.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cardiac infusional reaction described resembled other reactions to rituximab described in literature<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a>: they occur during the first cycle and a few minutes after initiation of administration.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The mechanism of ACS during rituximab infusion is still uncertain. The initial phenomenon is the release of cytokines (IL-6, IL-8, TNF-alpha), from which two hypothesis emerge: vasospasm and instability with atheroma plaque rupture. Vasospasm has already been described with other antineoplastic agents such as 5-fluorouracil and capecitabine,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and it is known that areas with atheroma plaques are the most prone to vasospasm. Thus, in practice, it is often difficult to discern the exact mechanism that causes the ACS. However, our case presented a transient elevation of the ST segment without lesions in the artery corresponding to the affected territory (observed in ECG and echocardiogram), very suggestive of coronary vasospasm. In our case, the administration of secondary prophylaxis with anti-aggregation and calcium antagonists allowed us to continue using rituximab in the following cycles, and in the subsequent maintenance therapy; one of the most effective first-line strategies in follicular lymphoma, as demonstrated by the PRIMA<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> study.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case reflects the importance of monitoring during infusion of rituximab, and opens the possibility of secondary prevention of these reactions with antiplatelet therapy (prevents atheroma plaques rupture) and a calcium antagonist (prevents vasospasm), offering a optimal treatment for patients who have presented infusional reactions of this type.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Triguero Moreno A, Gual Capllonch F, Sancho Cía JM. Profilaxis secundaria de un síndrome coronario agudo durante la infusión de rituximab. Med Clin (Barc). 2019;154:69–70.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A phase I-II study to determine the maximum tolerated infusion rate of rituximab with special emphasis on monitoring the effect of rituximab on cardiac function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Siano" 1 => "E. Lerch" 2 => "L. Negretti" 3 => "E. Zucca" 4 => "D. Rodriguez-Abreu" 5 => "M. 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Journal Information
Vol. 154. Issue 2.
Pages 69-70 (January 2020)
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Vol. 154. Issue 2.
Pages 69-70 (January 2020)
Letter to the Editor
Secondary prophylaxis of an acute coronary syndrome during rituximab infusion
Profilaxis secundaria de un síndrome coronario agudo durante la infusión de rituximab
a Departamento de Hematología, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain
b Departamento de Cardiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
c Departamento de Hematología, Institut Català d’Oncologia, Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
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