Can solumedrol (methylprednisolone) be given due to rash from rituximab?

Management of Rituximab-Induced Skin Rash with Methylprednisolone

Yes, methylprednisolone (Solumedrol) can be given to treat skin rash from rituximab, especially for grade 2-3 reactions, as systemic glucocorticoids are recommended in treatment protocols for rituximab-related hypersensitivity reactions. 1

Classification of Rituximab-Related Skin Reactions

• Skin manifestations are common during rituximab treatment and can present as part of infusion-related reactions (IRs), serum sickness-like reactions (SSLRs), or other hypersensitivity reactions 1
• Cutaneous reactions may include urticaria, erythema, pruritus, and rash, which can vary in severity from mild to severe 2
• Reactions are graded from 1-4, with management strategies differing based on severity 1

Treatment Approach Based on Reaction Severity

For Grade 1-2 Reactions (Mild to Moderate):

• Methylprednisolone is indicated as part of the management strategy 1
• For grade 2 reactions, slowed infusion (typically 50% of usual rate), along with corticosteroid premedication is recommended 1
• H1-antihistamines and systemic glucocorticoids have been used successfully for managing skin reactions, though no large validated premedication regimens exist 1

For Grade 3-4 Reactions (Severe):

• Methylprednisolone (40 mg IV) or equivalent is specifically recommended 20 minutes before infusion for severe reactions 1
• Allergy specialist consultation is preferred for grade 3-4 reactions before attempting rechallenge 1
• Desensitization protocols under specialized care may be necessary 1, 3

Dosing Recommendations

• For moderate to severe reactions, methylprednisolone 40 mg IV is commonly used as premedication 1
• For treatment of active reactions, doses may range from 2-40 mg IV based on reaction severity 1
• Higher pulse doses (15 mg/kg) have been used in combination protocols for severe cases 4

Implementation Protocol

1. Assess reaction severity:

   • Grade 1 (mild): Localized cutaneous symptoms 1
   • Grade 2 (moderate): More widespread rash with other mild symptoms 1
   • Grade 3-4 (severe): Extensive rash with systemic symptoms 1

2. For active reactions:

   • Interrupt rituximab infusion 1
   • Administer methylprednisolone IV (dose based on severity) 1
   • Monitor vital signs and symptoms 1
   • Resume infusion at 50% rate once symptoms resolve 1

3. For subsequent infusions (prevention):

   • Premedicate with methylprednisolone 40 mg IV 20-30 minutes before infusion 1
   • Add diphenhydramine (25-50 mg) and acetaminophen (650 mg) 1, 2
   • Consider slower initial infusion rate 1

Important Considerations and Caveats

• Distinguish between different types of reactions, as management differs for cytokine release syndrome versus true allergic reactions 1, 5
• Serum sickness-like reactions (SSLRs) to rituximab are more common in patients with autoimmune diseases (78-85% of cases) and may respond well to systemic glucocorticoids 1
• Severe delayed reactions like DRESS, SJS, or TEN are not amenable to desensitization and require drug avoidance 1
• Oral prednisone (40 mg) given 30 minutes before infusion has been shown to be an effective alternative to IV methylprednisolone in preventing infusion reactions 6
• Tryptase levels may help differentiate mast cell-mediated reactions from cytokine release syndrome 3

Follow-up Monitoring

• Monitor for resolution of skin manifestations after methylprednisolone administration 1
• Assess for any signs of infection, as both rituximab and corticosteroids can increase infection risk 7
• Document reaction details to guide management of future rituximab administrations 1