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Balsa A, Díaz Del Campo Fontecha P, Silva Fernández L, Valencia Martín J, Nistal Martínez V, León Vázquez F, Hernández Hernández MV, Corominas H, Cáliz Cáliz R, Aguado García JM, Candelas Rodríguez G, Ibargoyen Roteta N, Martí Carvajal A, Plana Farras MN, Puñal Riobóo J, Park HS, Triñanes Pego Y, Villaverde García V. Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2023; 19:533-548. [PMID: 38008602 DOI: 10.1016/j.reumae.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/06/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. METHODS Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. RESULTS 6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. CONCLUSIONS The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.
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Affiliation(s)
- Alejandro Balsa
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
| | | | - Lucía Silva Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - José Valencia Martín
- Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Fernando León Vázquez
- Medicina de Familia, Centro de Salud San Juan de la Cruz, Pozuelo de Alarcón, Madrid, Spain
| | - M Vanesa Hernández Hernández
- Servicio de Reumatología, Complejo Hospitalario Universitario de Canarias, San Cristóbal de la Laguna, Santa Cruz de Tenerife, Spain
| | - Héctor Corominas
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau & Hospital Dos de Maig, Barcelona, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. CIBERINFEC, ISCIII. Departamento de Medicina, UCM, Madrid, Spain
| | | | - Nora Ibargoyen Roteta
- Servicio de Evaluación de Tecnologías Sanitarias del País Vasco (Osteba). BIOEF, Barakaldo, Vizcaya, Spain
| | - Arturo Martí Carvajal
- Cátedra Rectoral de Medicina basada en la Evidencia, Universidad de Carabobo, Venezuela; Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - M Nieves Plana Farras
- Unidad de Evaluación de Tecnologías Sanitarias, Hospital Ramón y Cajal, IRYCIS. CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Janet Puñal Riobóo
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
| | - Hye Sang Park
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Yolanda Triñanes Pego
- Unidad de Asesoramiento Científico-técnico, Avalia-t, Agencia Gallega para la Gestión del Conocimiento en Salud, ACIS, Santiago de Compostela, A Coruña, Spain
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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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Saad MA, Yacoub RF, El Gendy HI. Infective endocarditis complicating rituximab in a lupus patient with lupus nephritis and dilated cardiomyopathy: case report and review of literature. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023. [DOI: 10.1186/s43162-023-00198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Abstract
Background
Systemic lupus erythematosus is a chronic multisystem disease that has a considerable morbidity and mortality. Rituximab is used in treating some severe manifestations of systemic lupus erythematosus; however, it may expose patients to serious infections. We report a case of post rituximab infective endocarditis as the second case in literature described in patients with SLE.
Case presentation
A 17-year-old male diagnosed as systemic lupus erythematosus with lupus nephritis and dilated cardiomyopathy received rituximab and underwent upper endoscopy and colonoscopy investigating iron deficiency anemia. Later on the patient developed septic shock secondary to infective endocarditis and passed away.
Conclusions
Infective endocarditis is a possible complication after rituximab therapy in lupus patients with lupus nephritis and dilated cardiomyopathy. Prophylactic antibiotics may be considered in those patients in the settings of gastrointestinal endoscopies.
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Wetzman A, Lukas C, Gaujoux-Viala C, Mamtani R, Barnetche T, Combe B, Morel J, Szafors P. Risk of Cancer After Initiation of Targeted Therapies in Patients With Rheumatoid Arthritis and a Prior Cancer: Systematic Review With Meta-Analysis. Arthritis Care Res (Hoboken) 2023; 75:260-271. [PMID: 34549898 DOI: 10.1002/acr.24784] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/29/2021] [Accepted: 09/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the risk of recurrent or new malignancy with exposure to targeted disease-modifying antirheumatic drugs (DMARDs) in adults with rheumatoid arthritis (RA), axial spondyloarthritis (SpA), or psoriatic arthritis (PsA) and a history of cancer. METHODS We performed a systematic search of the literature for articles published up to June 2019 that investigated adults with RA, axial SpA, or PsA who had a history of cancer and received biologic or targeted synthetic DMARDs (bDMARDs or tsDMARDs). We compared the risk of relapse or occurrence of new cancer between patients with and without bDMARDs. Rate ratios (RRs) with 95% confidence intervals (95% CIs) were estimated. The heterogeneity of the studies was evaluated by the Cochran Q test and the I2 statistic. RESULTS We included 24 observational studies of chronic inflammatory arthritis; of those, 12 were included in the meta-analysis of RA patients receiving bDMARDs. As compared with RA patients with a history of cancer and not receiving bDMARDs, for those receiving any bDMARD, the overall RR for risk of neoplasia was 1.09 (95% CI 0.92-1.32; P = 0.31, I2 = 8%); with tumor necrosis factor inhibitors, it was 1.11 (95% CI 0.85-1.46; P = 0.45, I2 = 48%); and with rituximab, it was 0.79 (95% CI 0.41-1.53; P = 0.49, I2 = 0%). The RR for risk of recurrence for skin cancer was 1.32 (95% CI 1.02-1.72; P = 0.04, I2 = 0%) and for breast neoplasia 1.21 (95% CI 0.84-1.72; P = 0.31, I2 = 0%). CONCLUSION Apart from skin cancers including melanoma, the risk of recurrent or new cancer is not increased with the initiation of bDMARDs for RA as compared with no bDMARDs.
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Affiliation(s)
| | | | - Cécile Gaujoux-Viala
- University of Montpellier, Montpellier, and Nîmes University Hospital, Nîmes, France
| | | | - Thomas Barnetche
- Fédération Hospitalo-Universitaire and Centre Hospitalier Universitaire, Pellegrin, Bordeaux, France
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Koehm M, Foldenauer AC, Rossmanith T, Alten R, Aringer M, Backhaus M, Burmester GR, Feist E, Kellner H, Krueger K, Müller-Ladner U, Rubbert-Roth A, Tony HP, Wassenberg S, Burkhardt H, Behrens F. Effectiveness of Different Rituximab Doses Combined with Leflunomide in the Treatment or Retreatment of Rheumatoid Arthritis: Part 2 of a Randomized, Placebo-Controlled, Investigator-Initiated Clinical Trial (AMARA). J Clin Med 2022; 11:7316. [PMID: 36555933 PMCID: PMC9784147 DOI: 10.3390/jcm11247316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The optimal dose of rituximab in combination with leflunomide in patients with rheumatoid arthritis (RA) is not known. METHODS In Part 1 (previously reported) of the investigator-initiated AMARA study (EudraCT 2009-015950-39; ClinicalTrials.gov NCT01244958), improvements at week (W)24 were observed in patients randomized to rituximab + leflunomide compared with placebo + leflunomide. In the study reported here (Part 2), Part 1 responders received rituximab 500 or 1000 mg at W24/26 plus ongoing leflunomide. Patients were randomized at baseline to their eventual W24 treatment group. The Part 2 primary outcome was the mean Disease Activity Score-28 joints (DAS28) at W52, based on the last observation carried forward (LOCF) analyses and a two-sided analysis of variance. Patient-reported outcomes (PROs) and adverse events were evaluated. RESULTS Eighty-three patients received rituximab at W24/26 (31 rituximab→rituximab 1000 mg; 29 rituximab→rituximab 500 mg; 10 placebo→rituximab 1000 mg; 13 placebo→rituximab 500 mg). At W52, there were no significant differences in DAS28 between rituximab doses in patients originally treated with rituximab or those originally treated with placebo. In the Part 1 placebo group, the higher rituximab dose was associated with greater improvements in ACR response rates and some PROs. Adverse events were similar regardless of rituximab dose. CONCLUSIONS Retreatment with rituximab 500 mg and 1000 mg showed comparable efficacy, whereas an initial dose of rituximab 500 mg was associated with lower response rates versus 1000 mg. Reduced treatment response with the lower dose in patients initially treated with placebo may have been influenced by small numbers and baseline disease activity.
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Affiliation(s)
- Michaela Koehm
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, 60596 Frankfurt am Main, Germany
- Division of Rheumatology, University Hospital Frankfurt, Goethe University, 60596 Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), 60596 Frankfurt am Main, Germany
| | - Ann C. Foldenauer
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, 60596 Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), 60596 Frankfurt am Main, Germany
| | - Tanja Rossmanith
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, 60596 Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), 60596 Frankfurt am Main, Germany
| | | | - Martin Aringer
- Department of Medicine III, University Medical Centre, Faculty of Medicine, Dresden University of Technology, 01307 Dresden, Germany
| | | | - Gerd R. Burmester
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | | | | | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University, Campus Kerckhoff, 61231 Bad Nauheim, Germany
| | - Andrea Rubbert-Roth
- Division of Rheumatology and Clinical Immunology, Cantonal Hospital St. Gallen, 9007 St. Gallen, Switzerland
| | - Hans-Peter Tony
- Department of Rheumatology/Immunology, University of Würzburg, 97080 Würzburg, Germany
| | | | - Harald Burkhardt
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, 60596 Frankfurt am Main, Germany
- Division of Rheumatology, University Hospital Frankfurt, Goethe University, 60596 Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), 60596 Frankfurt am Main, Germany
| | - Frank Behrens
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, 60596 Frankfurt am Main, Germany
- Division of Rheumatology, University Hospital Frankfurt, Goethe University, 60596 Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), 60596 Frankfurt am Main, Germany
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Blincoe A, Labrosse R, Abraham RS. Acquired B-cell deficiency secondary to B-cell-depleting therapies. J Immunol Methods 2022; 511:113385. [PMID: 36372267 DOI: 10.1016/j.jim.2022.113385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
The advantage of the newer biological therapies is that the immunosuppressive effect is targeted, in contrast, to the standard, traditional immunomodulatory agents, which have a more global effect. However, there are unintended targets and consequences, even to these "precise" therapeutics, leading to acquired or secondary immunodeficiencies. Besides depleting specific cellular immune subsets, these biological agents, which include monoclonal antibodies against biologically relevant molecules, often have broader functional immune consequences, which become apparent over time. This review focuses on acquired B-cell immunodeficiency, secondary to the use of B-cell depleting therapeutic agents. Among the many adverse consequences of B-cell depletion is the risk of hypogammaglobulinemia, failure of B-cell recovery, impaired B-cell differentiation, and risk of infections. Factors, which modulate the outcomes of B-cell depleting therapies, include the intrinsic nature of the underlying disease, the concomitant use of other immunomodulatory agents, and the clinical status of the patient and other co-existing morbidities. This article seeks to explore the mechanism of action of B-cell depleting agents, the clinical utility and adverse effects of these therapies, and the relevance of systematic and serial laboratory immune monitoring in identifying patients at risk for developing immunological complications, and who may benefit from early intervention to mitigate the secondary consequences. Though these biological drugs are gaining widespread use, a harmonized approach to immune evaluation pre-and post-treatment has not yet gained traction across multiple clinical specialties, because of which, the true prevalence of these adverse events cannot be determined in the treated population, and a systematic and evidence-based dosing schedule cannot be developed. The aim of this review is to bring these issues into focus, and initiate a multi-specialty, data-driven approach to immune monitoring.
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Affiliation(s)
- Annaliesse Blincoe
- Department of Paediatric Immunology and Allergy, Starship Child Health, Auckland, NZ, New Zealand
| | - Roxane Labrosse
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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Chow TG, Oppenheimer J, Joshi SR. A Review of Adverse Reactions to Biologics Used in Allergy-Immunology Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3075-3086. [PMID: 36162800 DOI: 10.1016/j.jaip.2022.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023]
Abstract
Biologic agents have become an integral therapeutic option for practicing allergists-immunologists for the management of asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and various immunologic conditions. As these agents vary considerably from traditional small-molecule drugs, various adverse reactions have been noted. A different approach must be used to classify these reactions beyond the classic Gell-Coombs classification system as it does not capture many of the adverse events seen with biologic therapy. This article addresses the available literature on proposed classification systems and diagnostic modalities for adverse events associated with biologics and reviews each approved agent used frequently in allergy-immunology practice.
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Affiliation(s)
- Timothy G Chow
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - John Oppenheimer
- Department of Internal Medicine, UMDMJ Rutgers University School of Medicine, Newark, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Shyam R Joshi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, Ore.
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Lovelace SE, Helmold Hait S, Yang ES, Fox ML, Liu C, Choe M, Chen X, McCarthy E, Todd JP, Woodward RA, Koup RA, Mascola JR, Pegu A. Anti-viral efficacy of a next-generation CD4-binding site bNAb in SHIV-infected animals in the absence of anti-drug antibody responses. iScience 2022; 25:105067. [PMID: 36157588 PMCID: PMC9490026 DOI: 10.1016/j.isci.2022.105067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/21/2022] [Accepted: 08/30/2022] [Indexed: 11/24/2022] Open
Abstract
Broadly neutralizing antibodies (bNAbs) against HIV-1 are promising immunotherapeutic agents for treatment of HIV-1 infection. bNAbs can be administered to SHIV-infected rhesus macaques to assess their anti-viral efficacy; however, their delivery into macaques often leads to rapid formation of anti-drug antibody (ADA) responses limiting such assessment. Here, we depleted B cells in five SHIV-infected rhesus macaques by pretreatment with a depleting anti-CD20 antibody prior to bNAb infusions to reduce ADA. Peripheral B cells were depleted following anti-CD20 infusions and remained depleted for at least 9 weeks after the 1st anti-CD20 infusion. Plasma viremia dropped by more than 100-fold in viremic animals after the initial bNAb treatment. No significant humoral ADA responses were detected for as long as B cells remained depleted. Our results indicate that transient B cell depletion successfully inhibited emergence of ADA and improved the assessment of anti-viral efficacy of a bNAb in a SHIV-infected rhesus macaque model. Highly potent CD4bs bNAb reduces viremia up to 4 log10 in SHIV-infected animals Sustained B cell depletion prevents development of ADA responses Lack of ADA enables multiple bNAb infusions over 12 weeks
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Affiliation(s)
- Sarah E Lovelace
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Sabrina Helmold Hait
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Eun Sung Yang
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Madison L Fox
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Cuiping Liu
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Misook Choe
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Xuejun Chen
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Elizabeth McCarthy
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - John-Paul Todd
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Ruth A Woodward
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Richard A Koup
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - John R Mascola
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Amarendra Pegu
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
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10
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Nikolic S, Panic N, Hintikka ES, Dani L, Rutkowski W, Hedström A, Steiner C, Löhr JM, Vujasinovic M. Efficacy and safety of rituximab in autoimmune pancreatitis type 1: our experiences and systematic review of the literature. Scand J Gastroenterol 2021; 56:1355-1362. [PMID: 34410885 DOI: 10.1080/00365521.2021.1963837] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Autoimmune pancreatitis (AIP) is a special form of pancreatitis that responds well to glucocorticoid (GC) treatment. Relapses of AIP are common. The anti-CD20 antibody rituximab (RTX) has shown promising results in GC refractory cases, but long-term data are scarce. The study aims to determine the clinical and imaging response to RTX and summarize the existing data on RTX therapy in patients with AIP type 1 in the literature. PATIENTS AND METHODS Retrospective analysis of electronic medical records was conducted. Additionally, we conducted a systematic review of the literature concerning RTX use in AIP type 1. RESULTS Twelve (11.7%) of 103 patients with AIP type 1 were treated with RTX during the study period: eight (66.7%) achieved complete and four (33.3%) partial remission. RTX was discontinued in one patient who developed fever and reactivation of latent tuberculosis. None of the remaining 11 patients relapsed during a median follow-up of 17 months. No significant differences were detected in baseline clinical characteristics or history of relapse between the patients who obtained complete and partial remission. Altogether, eight studies with 110 AIP type-1 patients treated with RTX were analyzed. Adverse effects ranged from 11-43% and the relapse-free period during follow-up (range 2-173 months) ranged from 38-94%. CONCLUSIONS Our results confirm that RTX is efficacious in the treatment of AIP type 1 by inducing remission and preventing relapse. In addition, there are few adverse effects of the treatment.
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Affiliation(s)
- Sara Nikolic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Nikola Panic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Lara Dani
- Rheumatology Division, Department of Medicine, Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Wiktor Rutkowski
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Aleksandra Hedström
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Corinna Steiner
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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11
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Nguyen H, Ahmed K, Luo W, Flint J, Giles I. A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy. Semin Arthritis Rheum 2021; 51:1205-1217. [PMID: 34689007 DOI: 10.1016/j.semarthrit.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period. METHOD Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs. RESULTS Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections. CONCLUSION Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.
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Affiliation(s)
- Hanh Nguyen
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK
| | | | - Weike Luo
- University College London (UCL), London, UK
| | | | - Ian Giles
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK; Department of Rheumatology, University College London Hospital, London, UK.
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12
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Merkel PA, Niles JL, Mertz LE, Lehane PB, Pordeli P, Erblang F. Long-Term Safety of Rituximab in Granulomatosis With Polyangiitis and in Microscopic Polyangiitis. Arthritis Care Res (Hoboken) 2021; 73:1372-1378. [PMID: 32475029 PMCID: PMC8457173 DOI: 10.1002/acr.24332] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/19/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The present study was undertaken to conduct a phase IV, open-label, prospective study to characterize the long-term safety of rituximab in a 4-year observational registry of adult patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) within the US. METHODS Patients initiating treatment with rituximab were evaluated every 6 months for up to 4 years. Outcomes included the incidence of serious adverse events (SAEs), infusion-related reactions (IRRs), and SAEs of specific interest, including serious infections, serious cardiac events, serious vascular events, and malignancies. RESULTS Overall, 97 patients (72 with GPA and 25 with MPA) received rituximab through a median of 8 (range 1-28) infusions and were followed up for a median of 3.94 years (range 0.05-4.32 years). The estimated incidence rates (95% confidence interval [95% CI]) of serious infections, serious cardiac events, and serious vascular events were 7.11 (4.55-10.58), 5.03 (2.93-8.06), and 2.37 (1.02-4.67) per 100 patient-years (PYs), respectively. No IRRs or SAEs occurred within 24 hours of an infusion of rituximab. None of the 9 deaths reported (crude mortality rate 2.67 [95% CI 1.22-5.06] per 100 PYs) were considered to be related to use of rituximab. CONCLUSION The safety profile of long-term treatment with rituximab in patients with GPA or MPA was consistent with that of rituximab administered for shorter durations and with rituximab's known safety profile in other autoimmune diseases for which it has received regulatory approval. These findings provide clinicians with long-term, practice-level safety data for rituximab in the treatment of GPA or MPA.
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13
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Abstract
Purpose of Review We reviewed the current data on infections associated with rituximab use published over the last 5 years. Recent Findings New literature was available on rates of serious infections, Hepatitis B reactivation and screening, and infection with Severe Acute Respiratory Syndrome Coronavirus 2. Summary Rates of infection varied by study and population, however, higher risk of infection in patients with underlying rheumatologic diseases was seen in those who required a therapy switch, had a smoking history, and those undergoing retreatment who had a serious infection with their first course of therapy. With regards to HBV, the proportion of patients screened continues to be inadequate. Despite the upfront cost, HBV screening and prophylaxis were found to be cost effective. There is still limited data regarding COVID-19 severity in the setting of rituximab, however, rituximab, especially in combination with steroids, may lead to more severe disease and higher mortality.
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14
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Fehmi J, Vale T, Keddie S, Rinaldi S. Nodal and paranodal antibody-associated neuropathies. Pract Neurol 2021; 21:practneurol-2021-002960. [PMID: 34039750 DOI: 10.1136/practneurol-2021-002960] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 12/23/2022]
Abstract
Within the last decade, antibodies targeting the node and paranode of myelinated peripheral nerves have been increasingly identified in patients with acquired immune-mediated neuropathies, commonly termed 'nodo-paranodopathies'. Crucially, these patients often present with additional clinical features not usually seen with the most common immune-mediated neuropathies, Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy, and respond poorly to conventionally used immunomodulatory therapies. Emerging evidence that these are pathologically distinct diseases has further prompted the use of more targeted treatment, such as the B cell depleting monoclonal antibody rituximab, which has been reported to significantly improve functional outcomes in this subset of patients. We provide an overview of the emerging clinical and serological phenotypes in patients with specific nodal/paranodal antibodies, the practicalities of antibody testing and current evidence supporting the use of non-standard therapies.
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Affiliation(s)
- Janev Fehmi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tom Vale
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Keddie
- Department of Molecular Neuroscience, National Hospital for Neurology and Neurosurgery, MRC Centre for Neuromuscular Diseases, London, UK
| | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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15
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Atzeni F, Rodríguez-Carrio J, Popa CD, Nurmohamed MT, Szűcs G, Szekanecz Z. Cardiovascular effects of approved drugs for rheumatoid arthritis. Nat Rev Rheumatol 2021; 17:270-290. [PMID: 33833437 DOI: 10.1038/s41584-021-00593-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
The risk of cardiovascular disease is increased in patients with rheumatoid arthritis compared with the general population owing to the influence of traditional and non-traditional risk factors. Inflammation has a pivotal contribution and can accelerate the atherosclerotic process. Although dampening inflammation with DMARDs should theoretically abrogate this process, evidence suggests that these drugs can also promote atherosclerosis directly and indirectly, hence adding to an increased cardiovascular burden. However, the extent and direction of the effects largely differ across drugs. Understanding how these drugs influence endothelial damage and vascular repair mechanisms is key to understanding these outcomes. NSAIDs and glucocorticoids can increase the cardiovascular risk. Conversely, conventional, biologic and targeted DMARDs control inflammation and reduce this risk, although some of these drugs can also aggravate traditional factors or thrombotic events. Given these data, the fundamental objective for clinicians should be disease control, in an individualized approach that considers the most appropriate drug for each patient, taking into account joint and cardiovascular outcomes. This Review provides a comprehensive analysis of the effects of DMARDs and other approved drugs on cardiovascular involvement in rheumatoid arthritis, from a clinical and mechanistic perspective, with a roadmap to inform the research agenda.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
| | - Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Călin D Popa
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, Nijmegen, The Netherlands
| | - Michael T Nurmohamed
- Deptartment of Rheumatology, Amsterdam University Medical Center & Reade, Amsterdam, The Netherlands
| | - Gabriella Szűcs
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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16
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Zahedi Niaki O, Anadkat MJ, Chen ST, Fox LP, Harp J, Micheletti RG, Nambudiri VE, Pasieka HB, Shinohara MM, Rosenbach M, Merola JF. Navigating immunosuppression in a pandemic: A guide for the dermatologist from the COVID Task Force of the Medical Dermatology Society and Society of Dermatology Hospitalists. J Am Acad Dermatol 2020; 83:1150-1159. [PMID: 32569797 PMCID: PMC7303642 DOI: 10.1016/j.jaad.2020.06.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023]
Abstract
Dermatologists treating immune-mediated skin disease must now contend with the uncertainties associated with immunosuppressive use in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Although the risk of infection with many commonly used immunosuppressive agents remains low, direct data evaluating the safety of such agents in coronavirus disease 2019 (COVID-19) are scarce. This article reviews and offers guidance based on currently available safety data and the most recent COVID-19 outcome data in patients with immune-mediated dermatologic disease. The interdisciplinary panel of experts emphasizes a stepwise, shared decision-making approach in the management of immunosuppressive therapy. The goal of this article is to help providers minimize the risk of disease flares while simultaneously minimizing the risk of iatrogenic harm during an evolving pandemic.
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Affiliation(s)
- Omid Zahedi Niaki
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Milan J Anadkat
- Division of Dermatology, Washington University in St. Louis School of Medicine, St Louis, Missouri
| | - Steven T Chen
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Joanna Harp
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Robert G Micheletti
- Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Helena B Pasieka
- Department of Dermatology, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Michi M Shinohara
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Misha Rosenbach
- Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Garcia-Montoya L, Villota-Eraso C, Yusof MYM, Vital EM, Emery P. Lessons for rituximab therapy in patients with rheumatoid arthritis. THE LANCET. RHEUMATOLOGY 2020; 2:e497-e509. [PMID: 38273611 DOI: 10.1016/s2665-9913(20)30033-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 02/07/2023]
Abstract
B-cell depletion therapy is an effective option for the treatment of rheumatoid arthritis but often does not result in complete B-cell depletion. Complete B-cell depletion after rituximab treatment is associated with clinical response, and this outcome leads to long-term maintenance of therapy. Low pretreatment plasmablast counts, concomitant treatment with disease-modifying antirheumatic drugs, no smoking exposure, the presence of anticitrullinated protein antibodies or rheumatoid factor, and a low interferon signature are all predictive of complete B-cell depletion and clinical response. Half of patients who initially show complete B-cell depletion and clinical response after rituximab treatment eventually lose responsiveness with further infusions. However three-quarters of these patients regain this outcome in their following treatment cycle, suggesting that loss of response is reversible and that patients can still benefit from rituximab retreatment. The efficacy of reduced doses of rituximab is being investigated, but preliminary results suggest that these strategies are best used for maintenance therapy, particularly in patients who suffer adverse events or who are at a high risk of infection. Infusion-related reactions are the most common adverse events associated with rituximab treatment, and monitoring of IgG concentrations is crucial, as low concentrations are correlated with an increased risk of infection.
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Affiliation(s)
- Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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18
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Karim MY. Increased Awareness of Hypogammaglobulinemia After B Cell-Targeted Therapy: Comment on the Article by Md Yusof et al. Arthritis Rheumatol 2020; 72:1230-1231. [PMID: 32134207 DOI: 10.1002/art.41242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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19
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Emery P, Furst DE, Kirchner P, Melega S, Lacey S, Lehane PB. Risk of Malignancies in Patients with Rheumatoid Arthritis Treated with Rituximab: Analyses of Global Postmarketing Safety Data and Long-Term Clinical Trial Data. Rheumatol Ther 2020; 7:121-131. [PMID: 31754941 PMCID: PMC7021875 DOI: 10.1007/s40744-019-00183-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Patients with rheumatoid arthritis (RA) are at an increased risk of developing malignancies, but it is unclear whether this increased risk is the result of disease pathobiology or immunosuppressant treatments for RA. This analysis evaluated the potential risk of malignancy in patients with RA treated with rituximab (MabThera®/Rituxan®) a CD20+ B-cell depleting agent manufactured by F. Hoffmann-La Roche Ltd. METHODS Malignancy rates were obtained from the rituximab global company safety database for adverse event reporting and from the rituximab global clinical trial program for RA consisting of eight randomized clinical trials, two long-term open-label extensions, and one open-label prospective study. Global company safety database searches were performed using the standard Medical Dictionary for Regulatory Activities (MedDRA) queries "Malignant tumors wide" and "Skin malignant tumors wide" up to April 30, 2017. Age- and sex-specific comparator values from the general population were obtained from the US National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database. RESULTS For the 409,706 patients with RA in the rituximab global company safety database since first market approval in 2006, 1739 cumulative malignant events were reported, with an overall malignancy reporting rate of approximately 4.2 events per 1000 patients. No evidence of increased risk of malignancy, of any organ-specific type, was found following rituximab treatment. The rate of malignancies from rituximab-treated patients in RA clinical trials was 7.4 per 1000 patient-years. This is within the expected range, with no evidence for increased risk over time or with additional rituximab courses. CONCLUSIONS Analyses of the global postmarketing safety database and long-term clinical trial data showed no evidence of an increased risk of malignancy of any type following rituximab treatment in patients with RA. FUNDING F. Hoffmann-La Roche Ltd.
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Affiliation(s)
- Paul Emery
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds University, Leeds, UK
| | - Daniel E Furst
- University of California, Los Angeles, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
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20
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de Camargo MC, Barros BCA, Fulone I, Silva MT, Silveira MSDN, de Camargo IA, Barberato-Filho S, Del Fiol FDS, Lopes LC. Adverse Events in Patients With Rheumatoid Arthritis and Psoriatic Arthritis Receiving Long-Term Biological Agents in a Real-Life Setting. Front Pharmacol 2019; 10:965. [PMID: 31572173 PMCID: PMC6749844 DOI: 10.3389/fphar.2019.00965] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Biological agents used for the treatment of psoriatic arthritis (PsA) and rheumatoid arthritis (RA) are associated with serious adverse effects (SAEs). Although several biologics have demonstrated good efficacy and tolerability in short-term trials, treatment guidelines recommend them as third line therapies due to a relative lack of long-term safety data. Objective: To determine the frequency and severity of adverse effects associated with the long-term use of biologics in the treatment of PsA and RA, and possible risk factors for such events in a real-life setting. Methods: We conducted a longitudinal study in PsA and RA patients only taking long-term biological agents from 2003 to 2011. Sources of information included dispensing pharmacy data and interviews with patients. Research staff conducted telephone interviews with patients inquiring about any apparent medication-related adverse drug reactions (ADRs) or SAEs. ADR/SAE’s data was based on pharmacy reports. We conducted a multivariate analysis to identify the factors associated with the risk of ADRs. Results: Of the 305 patients identified, we interviewed 268 patients. Most of these were taking adalimumab 127 (47.4%), 52 (19.4%) etanercept, 42 (15.7%) infliximab, 25 (9.3%) rituximab, 10 (3.7%) abatacept, 9 (3.4%) efalizumab, and 3 (1.1%) tocilizumab. Of the 268 patients, 116 (43.3%) experienced one or more adverse events related to biological agents with 1.6 events per patient, and of these 29 (25%) experienced one or more SAEs, with majority subjected to hospitalizations. The most frequently reported ADRs were administration site reactions as observed in 73 patients (27.2%), infections in 30 patients (11.2%), effects on nervous system in 22 patients (8.2%), and 15 (5.6%) patients withdrew due to ADRs. The use of rituximab was related with less risk of ADR [PR 0.42, 95% CI 0.18–0.96; p = 0.04] than other agents. No other predisposing factors were associated with risk of ADR. The monitoring of patients (medical consultation and laboratory test) was only completed by 48 patients (30.4%). Conclusion: These data showed the early biological experience in Brazil that were associated with ADRs, withdrawals due to ADRs and SAEs. The quantification of adverse effects (serious or nonserious) considering close monitoring and patients’ perceptions are increasingly important for future decision-making.
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Affiliation(s)
| | | | - Izabela Fulone
- Pharmaceutical Sciences Graduate Program, University of Sorocaba (UNISO), Sorocaba, Brazil
| | - Marcus Tolentino Silva
- Pharmaceutical Sciences Graduate Program, University of Sorocaba (UNISO), Sorocaba, Brazil
| | | | - Iara Alves de Camargo
- Pharmaceutical Sciences Graduate Program, University of Sorocaba (UNISO), Sorocaba, Brazil
| | - Silvio Barberato-Filho
- Pharmaceutical Sciences Graduate Program, University of Sorocaba (UNISO), Sorocaba, Brazil
| | | | - Luciane Cruz Lopes
- Pharmaceutical Sciences Graduate Program, University of Sorocaba (UNISO), Sorocaba, Brazil
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Tavakolpour S, Alesaeidi S, Darvishi M, GhasemiAdl M, Darabi-Monadi S, Akhlaghdoust M, Elikaei Behjati S, Jafarieh A. A comprehensive review of rituximab therapy in rheumatoid arthritis patients. Clin Rheumatol 2019; 38:2977-2994. [PMID: 31367943 DOI: 10.1007/s10067-019-04699-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
Rituximab (RTX) is an approved treatment for rheumatoid arthritis (RA) patients that do not respond adequately to disease-modifying antirheumatic drugs. However, different new concerns, such as efficacy, optimum dose, safety issues, prediction of response to RTX, and pregnancy outcomes have attracted a lot of attention. The PubMed database was systematically reviewed for the last published articles, new findings, and controversial issues regarding RTX therapy in RA using "Rheumatoid arthritis" AND "rituximab" keywords, last updated on June 18, 2019. From 1812 initial recorders, 162 studies met the criteria. Regarding the optimum dose, low-dose RTX therapy (2 × 500 mg) seems as effective as standard dose (2 × 1000 mg), safer, and more cost-effective. The most common reported safety challenges included de novo infections, false negative serologic tests of viral infections, reactivation of chronic infections, interfering with vaccination outcome, and development of de novo psoriasis. Other less reported side effects are infusion reactions, nervous system disorders, and gastrointestinal disorders. Lower exposure to other biologics, presence of some serological markers (e.g., anti-RF, anti-CCP, IL-33, ESR), specific variations in FCGR3A, FCGR2A, TGFβ1, IL6, IRF5, BAFF genes, and also EBV-positivity could be used to predict response to RTX. Although there is no evidence of the teratogenic effect of RTX, it is recommended that women do not expose themselves to RTX at least 6 months before the conception. Only a reversible reduction of B cell-count in the offspring may be the pregnancy-related outcome. Although RTX is an effective therapeutic option for RA, more studies on optimum doses, prevention of RTX-related side effects, prediction of RTX response, and safety during the pregnancy are required.
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Affiliation(s)
- Soheil Tavakolpour
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Samira Alesaeidi
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), department of aerospace and subaquatic medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mojtaba GhasemiAdl
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Meisam Akhlaghdoust
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Arash Jafarieh
- Amir'Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Myhr KM, Torkildsen Ø, Lossius A, Bø L, Holmøy T. B cell depletion in the treatment of multiple sclerosis. Expert Opin Biol Ther 2019; 19:261-271. [PMID: 30632834 DOI: 10.1080/14712598.2019.1568407] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The latest development of B-cell depletion by anti-CD20 monoclonal antibodies has been a large step forward in the treatment of this devastating disease. AREAS COVERED In this manuscript, we review mechanisms of action, efficacy, safety, and tolerance of anti-CD20 therapies for MS, including rituximab, ocrelizumab, and ofatumumab. EXPERT OPINION B-cell depletion efficiently suppresses acute inflammatory disease activity in relapsing-remitting MS (RRMS), and may slowdown progression in primary progressive MS (PPMS). The treatment is generally well tolerated, with manageable adverse events related to infusion reactions and infections. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is the first therapy to be approved for the treatment of both RRMS and PPMS.
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Affiliation(s)
- Kjell-Morten Myhr
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Øivind Torkildsen
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Andreas Lossius
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,d Department of Immunology and Transfusion Medicine, Faculty of Medicine , University of Oslo and Oslo University Hospital Rikshospitalet , Oslo , Norway
| | - Lars Bø
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Trygve Holmøy
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,e Department of Clinical Medicine , University of Oslo , Oslo , Norway
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