Initial therapy for patients with a new diagnosis of mixed cryoglobulinemia syndrome (MCS)

HCV: hepatitis C virus; HBV: hepatitis B virus.
* All patients with MCS with an associated underlying etiology of the MCS should receive therapy directed against the underlying disease. As examples, patients with HCV who have chronic hepatitis should receive antiviral therapy, while patients with an underlying lymphoproliferative disorder should receive appropriate disease-specific therapy. For patients with MCS due to HCV infection who have immediate, life-threatening manifestations, simultaneous introduction of direct-acting antiviral therapy and immunosuppression is reasonable. Refer to relevant UpToDate content on disease-specific management considerations in patients with MCS.
¶ Refer to relevant UpToDate content on the dosing of glucocorticoids and rituximab therapy. If rituximab therapy is unavailable, fails to produce a clinical response, or is not tolerated, cyclophosphamide is a reasonable alternative.
Δ Plasma exchange is typically performed daily for 10 to 14 sessions or 3 exchanges per week (eg, Monday, Wednesday, or Friday) for 2 to 3 weeks. Plasma exchange should not be performed before at least 2 to 3 days from rituximab administration.