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van Beek N, Eming R, Reuss A, Zillikens D, Sárdy M, Günther C, Kiritsi D, Benoit S, Beissert S, Gläser R, Gollnick H, Horváth ON, Pfeiffer C, Röcken M, Schauer F, Schreml S, Steinbrink K, Zink A, Schade-Brittinger C, Hertl M, Schmidt E. Efficacy and safety of adjuvant immunoadsorption in pemphigus vulgaris and pemphigus foliaceus (IA-Pem Study): a multicentre randomized controlled trial. Br J Dermatol 2024; 190:657-667. [PMID: 38133541 DOI: 10.1093/bjd/ljad489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are potentially life-threatening autoimmune blistering diseases. Treatment is based on long-term immunosuppression with high doses of glucocorticosteroids in combination with potentially corticosteroid-sparing agents and/or rituximab. Immunoadsorption (IA) has emerged as a fast-acting adjuvant treatment option. OBJECTIVES To assess the clinical efficacy of IA in addition to best medical treatment (BMT). METHODS We conducted a multicentre (26 centres from Germany and Austria) randomized controlled trial in 72 patients with newly diagnosed, relapsed or chronic active PV or PF (34 female patients and 38 male patients, aged 42-72 years) comparing BMT (prednisolone 1.0 mg kg-1 per day plus azathioprine or mycophenolate) with adjuvant IA (BMT + IA). Central 1 : 1 randomization was done at the coordinating centre for clinical trials (KKS Marburg). The primary endpoint was analysed using Kaplan-Meier and Cox regression methods. RESULTS The study was ended prematurely owing to safety concerns after random allocation of 72 patients to BMT + IA (n = 34) or BMT (n = 38). The primary endpoint, time to complete remission on therapy, was not significantly different for the two groups [hazard ratio (HR) 1.35, 95% confidence interval (CI) 0.68-2.69; P = 0.39]. The cumulative dose of prednisolone was significantly lower in the BMT + IA group compared with BMT alone (difference -1214, 95% CI -2225 to -70; P = 0.03). In a post hoc analysis, patients with more extensive PV/PF showed a tendency towards a shorter time to remission in the BMT + IA group compared with the BMT group (HR 1.87, P = 0.17 in patients with baseline Pemphigus Disease Area Index ≥ 15). While more adverse events were observed in patients in the BMT group (29 vs. 25), severe adverse events were more frequent in patients in the BMT + IA group (17 events in 10 patients vs. 11 events in 8 patients). CONCLUSIONS In this study, adjuvant IA did not demonstrate a shorter time to clinical remission, but a corticosteroid-sparing effect was observed. In patients with extensive PV/PF, post hoc analysis suggests that adjuvant IA may lead to earlier remission, but potential adverse events must be carefully weighed against the expected benefits.
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Affiliation(s)
- Nina van Beek
- Department of Dermatology, Allergology and Venereology
| | | | - Alexander Reuss
- Coordinating Center for Clinical Trials, Phillips University, Marburg, Germany
| | | | - Miklós Sárdy
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Dimitra Kiritsi
- Department of Dermatology and Venereology, University Hospital Freiburg, Freiburg, Germany
| | - Sandrine Benoit
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Beissert
- Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Regine Gläser
- Department of Dermatology, Venereology and Allergology, Christian-Albrechts University, Kiel, Germany
| | - Harald Gollnick
- Department of Dermatology and Venereology, Otto-von-Guericke University, Magdeburg, Germany
| | - Orsolya N Horváth
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Christiane Pfeiffer
- Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany
| | - Martin Röcken
- Department of Dermatology, Eberhard Karls University, Tübingen, Germany
| | - Franziska Schauer
- Department of Dermatology and Venereology, University Hospital Freiburg, Freiburg, Germany
| | - Stephan Schreml
- Department of Dermatology, University Medical Centre Regensburg, Regensburg, Germany
| | - Kerstin Steinbrink
- Department of Dermatology, Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Alexander Zink
- Department of Dermatology and Allergology, Technical University Munich, Munich, Germany
| | | | | | - Enno Schmidt
- Department of Dermatology, Allergology and Venereology
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Abstract
BACKGROUND Pemphigus diseases are a heterogeneous group of potentially life-threatening autoimmune bullous disorders. Therefore, rapidly acting and effective therapeutic approaches are essential. OBJECTIVES In this review, current therapeutic options in line with available guidelines are presented and new therapeutic approaches are discussed. METHODS A literature search was performed using PubMed. RESULTS Treatment of pemphigus is based on systemic glucocorticosteroids, frequently combined with potentially corticosteroid-sparing immunosuppressants such as azathioprine and mycophenolate mofetil/mycophenolic acid. Recently, the impressive efficacy of the anti-CD20 antibody rituximab has been shown in a prospective randomized trial. In severe or treatment-refractory cases, immunoadsorption or high-dose intravenous immunoglobulins (IVIG) are recommended. Adjuvant immunoadsorption also seems to be useful within the first 8-12 weeks of therapy in patients with very high autoantibody levels. A variety of new therapeutic approaches is currently evaluated in phase IIa studies. CONCLUSION Therapy of pemphigus has been greatly improved by the employment of rituximab. The use of glucocorticosteroids, associated with a high number of adverse events and elevated mortality, could be reduced by the additional use of rituximab. After approval of rituximab for the treatment of pemphigus by the US Food and Drug Administration in 2018, licensing in Europe is expected in 2019.
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Affiliation(s)
- N van Beek
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - D Zillikens
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - E Schmidt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.,Lübecker Institut für Experimentelle Dermatologie (LIED), Universität zu Lübeck, Lübeck, Deutschland
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