Current Treatment Options in Cold Agglutinin Disease: B-Cell Directed or Complement Directed Therapy?

•Understanding the pathophysiology of cold agglutinin disease helps define targets for therapy.•Bendamustine plus rituximab results in high response rates and durable responses.•Therapy with sutimlimab, a complement C1 inhibitor, is also highly efficacious.•Each of these approaches has advantages and drawbacks.•In patients requiring treatment, the choice of therapy should be individualized. Two major steps are identified in the pathogenesis of cold agglutinin disease; clonal B-cell lymphoproliferation and complement-mediated hemolysis. Each of these steps constitutes a target for treatment. In this focused review, we address 2 successful therapeutic approaches; the bendamustine plus rituximab combination as a highly efficacious B-cell directed therapy and the anti-C1s monoclonal antibody sutimlimab as the most extensively studied complement-targeting therapy. We describe and discuss the prospective study of bendamustine plus rituximab and 2 recent, prospective studies of sutimlimab. Bendamustine-rituximab results in a high response rate, frequent complete responses and long median response duration, and the treatment is temporary. However, this therapy is relatively slow-acting and associated with some toxicity. Sutimlimab is also highly efficacious, is far more rapidly acting, and is low-toxic. Disadvantages of sutimlimab are the lack of effect on circulatory symptoms, the probable need for indefinite treatment, and the very high costs. In cold agglutinin disease patients who require treatment, the choice should be based on an individual assessment.