From the FDA Drug Label
RITUXAN is a CD20-directed cytolytic antibody indicated for the treatment of: Adult patients with Non-Hodgkin's Lymphoma (NHL) (1. 1). Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent.
The next preferred chemotherapy regimen for follicular lymphoma relapse post CHOP and ICE is not explicitly stated in the provided drug label.
- Rituximab can be used as a single agent for relapsed or refractory follicular lymphoma. However, the label does not provide information on the specific sequence or combination of chemotherapy regimens after CHOP and ICE. Therefore, a conservative clinical decision would be to consider rituximab as an option, but the optimal next step should be determined based on individual patient factors and clinical judgment, considering other available treatment options and guidelines 1.
From the Research
For follicular lymphoma that has relapsed after both CHOP and ICE regimens, the preferred next chemotherapy approach would be bendamustine-rituximab (BR). This recommendation is based on the most recent and highest quality study available, which demonstrated the efficacy and safety of BR in patients with relapsed follicular lymphoma 2. The study compared the outcomes of patients treated with BR versus RCHOP-like regimens and found that BR was associated with improved progression-free survival and reduced toxicity.
Key Considerations
- The choice of BR is based on its favorable efficacy and toxicity profile, as well as its different mechanism of action from prior therapies, making it effective in this setting of double-refractory disease.
- Alternative options, such as R-GEMOX or CAR T-cell therapy, may also be considered, particularly in eligible patients.
- Phosphoinositide 3-kinase (PI3K) inhibitors, such as idelalisib, duvelisib, or copanlisib, may also be considered, particularly in heavily pretreated patients.
- The decision between these regimens should be based on the patient's age, comorbidities, prior toxicities, duration of previous remissions, and availability of treatments.
Treatment Regimen
- Bendamustine-rituximab (BR) typically consists of bendamustine 90 mg/m² on days 1 and 2, combined with rituximab 375 mg/m² on day 1, repeated every 28 days for 4-6 cycles.
- This regimen has been shown to be effective in patients with relapsed follicular lymphoma, with a manageable side effect profile 2.
Supporting Evidence
- A study published in 2025 compared the outcomes of patients treated with BR versus RCHOP-like regimens and found that BR was associated with improved progression-free survival and reduced toxicity 2.
- Another study published in 2018 demonstrated the efficacy and safety of BR in patients with relapsed follicular lymphoma, with a favorable efficacy and toxicity profile compared to RCHOP 3.