Like all monoclonal antibodies given intravenously rituxan can have side effects. These are very seldom serious, but most people get something. Fever, shivering attacks, falls in blood pressure, feeling generally unwell are quite common. In my experience the best way of preventing them is to give the antibody slowly. When I first started treating people with antibody I used to infuse it over 12 hours.

The first time it is given is generally the worst. Patients often say that they had problems for the first course but after that there were no problems. There are special problems with CLL patients because of the high white count. CLL cells can be destroyed in the circulation and this releases a number of chemicals into the bloodstream that can have alarming effects. Chief of these are the anaphylactoids C3a and C5a which can cause breathing problems and low blood pressure, but there are others like bradykinin which slows the heart down. Again slowing the drip right down is usually the right thing to do.

Some doctors prefer to give pre-meds to prevent these side effects. Most usually the pre-meds are paracetamol (or acetaminophen which is the American name for it), an antihistamine and steroids (hydrocortisone, prednisolone, Solumed - there are many different names for essentially the same thing).

I guess there is no argument about paracetamol or antihistamines, but there is a lot of debate about steroids. Steroids are actually very effective drugs against CLL, and for the very resistant types with p53 mutations high-dose methylprednisolone works when fludarabine and rituxan fail. But they also have side effects, making patients more susceptible to virus and fungus infections. Michael Keating's trial of fludarabine plus prednisolone showed no advantage over fludarabine alone and too high a risk of infection. It used to be common to give piriton and hydrocortisone to everybody having a blood transfusion - the nurses gave it routinely. I heard of a Transplant Unit that was getting an unacceptably high level of fungus infections which was attributed to inadvertent steroid usage. Patients were being given hydrocortisone by the nurses to prevent transfusion reactions and the senior doctors were unaware of it.

Steroids have other problems too. After a high dose of steroids some patients get steroid let-down. They feel rotten when the steroids stop and have to be put back on steroids and the dose tailed off. In addition patients get idiosyncratic symptoms after intravenous steroids that are unique to themselves. I had one patient who complained of having an orgasm after intravenous dexamethasone.

The general rule for steroids is only use them when you mean to, and be aware of the possible risks and benefits.They should not be handed out like sweeties. They can be very useful, but they have their hazards.