To provide an updated guideline on the use of rituximab in lymphoma and chronic lymphocytic leukemia (CLL).# 
For information about this document, please contact Dr. Tom Kouroukis or Dr. Matthew Cheung through the PEBC via: Phone: 905-527-4322 ext. 42822 Fax: 905-526-6775 E-mail: ccopgi@mcmaster.ca:
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# INTENDED USERS
Intended users of this updated guideline include hematologists and oncologists treating patients with lymphoma or CLL.

# RECOMMENDATIONS Recommendation 1 Aggressive histology B-cell lymphomas, including Burkitt lymphoma: first-line, secondline and maintenance treatment and patients with human immunodeficiency virus (HIV)-associated lymphomas.
Previously Untreated Patients a. Previously untreated patients with aggressive histology CD20-positive B-cell lymphomas who are candidates for treatment with curative intent and will receive combination chemotherapy with curative intent (including cyclophosphamide, doxorubicin, vincristine, and prednisone CHOP-like, or similar dose-intense regimens) should receive this therapy in combination with rituximab.
Patients with Relapsed/Refractory Disease b. For previously treated patients with aggressive histology CD20-positive B-cell lymphomas:
There is insufficient evidence at this time to support treatment with a rituximabcontaining chemotherapy regimen in patients who have been previously treated with a rituximab-containing chemotherapy regimen. ii.
If patients have not previously received rituximab as part of their treatment regimen, the addition of rituximab to chemotherapy is reasonable.
Rituxmab Maintenance Treatment c. There is insufficient evidence at this time to support the use of maintenance rituximab in aggressive histology B-cell lymphomas.
Patients with HIV-Associated Lymphomas d. Previously untreated patients with HIV-related lymphoma with a CD4 count 50/mm 3 who are candidates for treatment with curative intent and will receive combination chemotherapy with curative intent (including CHOP, CHOP-like, or similar dose-intense regimens), should receive this therapy in combination with rituximab. The addition of rituximab to chemotherapy in patients with CD4 <50/mm 3 is not recommended.

# Recommendation 2 Indolent histology B-cell lymphomas: first-line, second-line, and maintenance treatment and patients with asymptomatic CD20-positive B-cell lymphomas
Previously Untreated Patients a. Previously untreated patients with indolent histology CD20-positive B-cell lymphomas, excluding small lymphocytic lymphoma (SLL), who are appropriate candidates for chemotherapy, should receive their chemotherapy in combination with rituximab. b. For patients with indolent histology CD20-positive B-cell-histology lymphomas, excluding SLL, who are candidates for therapy, but not combination chemotherapy, rituximab monotherapy is a reasonable option.
Patients with Relapsed/Refractory Disease c. For previously treated patients with indolent histology CD20-positive B-cell lymphomas, excluding SLL: i. Patients who have not previously received rituximab and who are appropriate candidates for chemotherapy should receive this chemotherapy in combination with rituximab or as rituximab monotherapy. ii. Patients who have previously received rituximab (including combination rituximab chemotherapy, rituximab monotherapy, or maintenance rituximab) and who have achieved a response of at least one year's duration from the last rituximab administration and who are appropriate candidates for therapy should receive this therapy in combination with rituximab or as rituximab monotherapy.
Rituxmab Maintenance Treatment d. For patients with indolent histology CD20-positive B-cell lymphomas, excluding SLL, who respond to treatment with combination chemotherapy and/or rituximab, this treatment should be followed by the use of maintenance rituximab.

# Patients with Asymptomatic CD20-Positive B-Cell Lymphomas
e. There is insufficient evidence at this time to support or refute upfront treatment with rituximab monotherapy for asymptomatic indolent histology CD20-positive B-cell lymphomas.

# Recommendation 4 Hepatitis B virus reactivation in all patients treated with rituximab
The Hematology Disease Site Group recommends that all patients be screened for surface antigen for hepatitis B (HBsAg) and for hepatitis B core antibody (HBcAb) prior to treatment with rituximab. Consultation with an expert in hepatitis B virus (HBV) should be considered for all patients who test positively for HBV. Patients who are HBsAg positive should receive prophylactic antiviral therapy during and after rituximab. Patients who are HbsAg negative/HBcAb positive should be considered for either prophylactic antiviral therapy, close monitoring for viral reactivation, and/or should be followed by an expert in HBV. In the absence of active hepatitis (elevated transaminases), it is not usually necessary to delay rituximab. In most cases, HBV screening and management can occur in parallel with non-Hodgkin lymphoma/CLL treatment.