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Scavone C, Liguori V, Adungba OJ, Cesare DDG, Sullo MG, Andreone V, Sportiello L, Maniscalco GT, Capuano A. Disease-modifying therapies and hematological disorders: a systematic review of case reports and case series. Front Neurol 2024; 15:1386527. [PMID: 38957352 PMCID: PMC11217193 DOI: 10.3389/fneur.2024.1386527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024] Open
Abstract
IntroductionDisease modifying therapies (DMTs) used to treat multiple sclerosis (MS) can be associated to the occurrence of hematological disorders. This systematic review aims to provide an overview of these events occurring in real-life conditions, by describing case reports and series published in the literature.MethodsA literature search of all publications up to January 5th 2024 on the Medline and Embase databases was carried out. The results were presented both in the text and in tables.ResultsSixty-seven case reports/series were included in this review, of which more than half related to alemtuzumab, natalizumab and ocrelizumab. The publication date of included studies ranged from 2006 to 2024. The majority of case reports and series described the occurrence of late-onset hematological disorders (events that occurred more than 30 days after the first DMT administration), mainly represented by case of neutropenia, autoimmune hemolytic anemia and immune thrombocytopenia. All cases reported a favorable outcome, apart one case report that described a fatal case. Among included cases, 4 articles, all related to natalizumab, described the occurrence of myeloid disorders in 13 newborns from mother receiving the DMT.DiscussionConsidering the limitations identified in the majority of included studies, further ad hoc studies are strongly needed to better evaluate the hematological disorders of DMTs. Meantime, the strict monitoring of treated patients for the occurrence of these toxicities should be highly recommended.
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Affiliation(s)
- Cristina Scavone
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Valerio Liguori
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | | | | | - Maria Giuseppa Sullo
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Vincenzo Andreone
- Neurological Clinic and Stroke Unit, “A. Cardarelli” Hospital, Naples, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
| | - Giorgia Teresa Maniscalco
- Multiple Sclerosis Regional Center, “A. Cardarelli” Hospital, Naples, Italy
- Neurological Clinic and Stroke Unit, “A. Cardarelli” Hospital, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Regional Center of Pharmacovigilance and Pharmacoepidemiology of Campania Region, Naples, Italy
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2
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Wright SL, Thompson AJ. Managing patients with late-onset neutropenia during treatment with ocrelizumab. Mult Scler 2024; 30:134. [PMID: 37888826 DOI: 10.1177/13524585231206219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Affiliation(s)
- Sarah L Wright
- Department of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
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3
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Alabdulqader RA, Alnasser W, Aljubran HJ, Alkhulaif HH. A Case of Late-Onset Neutropenia in Relapsing-Remitting Multiple Sclerosis Following Ocrelizumab Therapy. Cureus 2024; 16:e51729. [PMID: 38187018 PMCID: PMC10770766 DOI: 10.7759/cureus.51729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 01/09/2024] Open
Abstract
Ocrelizumab, a monoclonal antibody, has proven effective in treating both primary progressive and relapsing-remitting multiple sclerosis. Common adverse effects observed in clinical studies include flushing, sore throat, pruritus, and rash. This abstract discusses a case of severe, late-onset neutropenia in a patient with relapsing-remitting multiple sclerosis undergoing ocrelizumab treatment. The neutropenia emerged 46 days following the patient's most recent ocrelizumab dose. The patient responded well to treatment with intravenous meropenem and filgrastim. This rare and unforeseen adverse effect highlights the importance of regular blood monitoring for early detection of severe neutropenia in patients treated with ocrelizumab.
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Affiliation(s)
| | - Wafa Alnasser
- Infection Control, Imam Abdulrahman Bin Faisal Hospital, Dammam, SAU
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4
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Pang V, Seery N, Wesselingh R, Yeh W, Zhong M, Tan T, Dwyer C, Nesbitt C, Rath L, Perera D, Bridge F, Skibina O, Bosco JJ, Jokubaitis V, Marriott M, Butkueven H, Van Der Walt A, Massey J, Sutton I, Monif M. Neutropaenia complications from Ocrelizumab and Rituximab treatment. Mult Scler Relat Disord 2024; 81:105147. [PMID: 38043368 DOI: 10.1016/j.msard.2023.105147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 11/11/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023]
Abstract
Ocrelizumab is an anti-CD20 monoclonal antibody (mAb) that has been shown in phase 3 clinical trials to reduce relapses and disease progression in multiple sclerosis (MS) patients. Prior to the approval of ocrelizumab, rituximab, a chimeric anti-CD20 mAb was used to treat MS. Rituximab is still used to treat MS in many countries outside of Australia and remains mainstay of treatment of many non-MS neuroimmunological and systemic inflammatory diseases. Rituximab is currently used in neuromyelitis optica spectrum disorder (NMOSD) and autoimmune encephalitis, in addition to its widespread usage in hematological malignancies and systemic inflammatory diseases. Ocrelizumab is currently approved in Australia for treatment of relapsing-remitting MS (RRMS). Neutropaenia is a rare complication of both ocrelizumab and rituximab treatment. This case series reports 12 patients who have experienced neutropaenia following ocrelizumab or rituximab treatment and aims to characterize the clinical parameters of neutropaenia experienced by these patients, including the severity and duration of neutropaenia, length of hospital admission, the types of subsequent infections experienced and types of treatment necessary before patients reached count recovery. The unpredictability of neutropaenia and potential for serious infections highlight the need for continued hematological monitoring for patients on B-cell depleting therapies and calls for careful patient counselling to provide guidance on whether to continue such therapies in patients who have experienced related neutropaenia.
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Affiliation(s)
- Venus Pang
- Department of Neuroscience Monash University, Melbourne, Australia
| | - Nabil Seery
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Robb Wesselingh
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Wei Yeh
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Michael Zhong
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Tracie Tan
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Chris Dwyer
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Cassie Nesbitt
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Louise Rath
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Deborah Perera
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Francesca Bridge
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Olga Skibina
- Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Julian J Bosco
- Department of Allergy, asthma, Immunology, Alfred Hospital, Melbourne, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Mark Marriott
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Helmut Butkueven
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Anneke Van Der Walt
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - Mastura Monif
- Department of Neuroscience Monash University, Melbourne, Australia; Department of Neurology, Alfred Hospital, Melbourne, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.
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5
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Hess F, Uibel P, Berthele A, Hemmer B. [Ocrelizumab-associated severe neutropenia: an underestimated complication of treatment of multiple sclerosis with anti-CD20 antibodies?]. DER NERVENARZT 2023; 94:1153-1156. [PMID: 37294304 PMCID: PMC10252158 DOI: 10.1007/s00115-023-01507-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Felix Hess
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland.
| | - Paula Uibel
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - Achim Berthele
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - Bernhard Hemmer
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
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6
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Alba Suárez EM, Tallón Barranco A, Puertas Muñoz I, Chamorro Hernández B, Robles Marhuenda Á. Non-late-onset neutropaenia following treatment of multiple sclerosis with ocrelizumab. Neurologia 2023; 38:463-466. [PMID: 37659836 DOI: 10.1016/j.nrleng.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/01/2021] [Indexed: 09/04/2023] Open
Abstract
Late-onset neutropaenia is defined as an absolute neutrophil count of <1.5×103cells/μL starting>4 weeks after the last dose of rituximab, in the absence of other identifiable causes. Late-onset neutropaenia is a rare adverse reaction to rituximab (observed in approximately 5% of patients). Rheumatic diseases constitute the main indication for rituximab; in these patients, neutropaenia appears after a mean of>28 days. Ocrelizumab is another monoclonal antibody that binds to CD20 (a glycosylated phosphoprotein mainly expressed on the membranes of B-lymphocytes); in January 2018, it was approved for the treatment of relapsing-remitting and primary progressive multiple sclerosis. We present a case of neutropaenia following intravenous infusion of ocrelizumab in a patient with primary progressive multiple sclerosis who presented with neutropaenic fever, herpetic stomatitis, and ecthyma gangrenosum only 20 days after infusion.
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Affiliation(s)
- E M Alba Suárez
- Servicio de Neurología Hospital Universitario La Paz, Spain.
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7
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de Sèze J, Maillart E, Gueguen A, Laplaud DA, Michel L, Thouvenot E, Zephir H, Zimmer L, Biotti D, Liblau R. Anti-CD20 therapies in multiple sclerosis: From pathology to the clinic. Front Immunol 2023; 14:1004795. [PMID: 37033984 PMCID: PMC10076836 DOI: 10.3389/fimmu.2023.1004795] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 02/13/2023] [Indexed: 04/11/2023] Open
Abstract
The immune system plays a significant role in multiple sclerosis. While MS was historically thought to be T cell-mediated, multiple pieces of evidence now support the view that B cells are essential players in multiple sclerosis pathogenic processes. High-efficacy disease-modifying therapies that target the immune system have emerged over the past two decades. Anti-CD20 monoclonal antibodies selectively deplete CD20+ B and CD20+ T cells and efficiently suppress inflammatory disease activity. These monotherapies prevent relapses, reduce new or active magnetic resonance imaging brain lesions, and lessen disability progression in patients with relapsing multiple sclerosis. Rituximab, ocrelizumab, and ofatumumab are currently used in clinical practice, while phase III clinical trials for ublituximab have been recently completed. In this review, we compare the four anti-CD20 antibodies in terms of their mechanisms of action, routes of administration, immunological targets, and pharmacokinetic properties. A deeper understanding of the individual properties of these molecules in relation to their efficacy and safety profiles is critical for their use in clinical practice.
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Affiliation(s)
- Jérôme de Sèze
- Department of Neurology, Hôpital de Hautepierre, Clinical Investigation Center, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- Fédération de Médecine Translationelle, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- *Correspondence: Jérôme de Sèze,
| | - Elisabeth Maillart
- Department of Neurology, Pitié Salpêtrière Hospital, Paris, France
- Centre de Ressources et de Compétences Sclérose en Plaques, Paris, France
| | - Antoine Gueguen
- Department of Neurology, Rothschild Ophthalmologic Foundation, Paris, France
| | - David A. Laplaud
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre d’Investigation Clinique (CIC), Center for Research in Transplantation and Translational Immunology, UMR, UMR1064, Nantes, France
| | - Laure Michel
- Clinical Neuroscience Centre, CIC_P1414 Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes University Hospital, Rennes University, Rennes, France
- Microenvironment, Cell Differentiation, Immunology and Cancer Unit, Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes I University, French Blood Agency, Rennes, France
- Neurology Department, Rennes University Hospital, Rennes, France
| | - Eric Thouvenot
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nîmes, University of Montpellier, Nîmes, France
- Institut de Génomique Fonctionnelle, UMR, Institut National de la Santé et de la Recherche Médicale (INSERM), University of Montpellier, Montpellier, France
| | - Hélène Zephir
- University of Lille, Institut National de la Santé et de la Recherche Médicale (INSERM) U1172, Centre Hospitalier Universitaire (CHU), Lille, France
| | - Luc Zimmer
- Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Institut National de la Santé et de la Recherche Médicale (INSERM), CNRS, Lyon Neuroscience Research Center, Lyon, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose En Plaques (CRC-SEP) and Department of Neurology, Centre Hospitalier Universitaire (CHU) Toulouse Purpan – Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Roland Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, Institut National de la Santé et de la Recherche Médicale (INSERM), UPS, Toulouse, France
- Department of Immunology, Toulouse University Hospital, Toulouse, France
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8
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Ren J, Wang J, Liu R, Guo J, Yao Y, Luo J, Hao H, Gao F. Case report: Persistent hypogammaglobulinemia in thymoma-associated myasthenia gravis: the impact of rituximab or Good's syndrome? Front Neurol 2023; 14:1152992. [PMID: 37213908 PMCID: PMC10196171 DOI: 10.3389/fneur.2023.1152992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
Introduction Rituximab (RTX) showed good efficacy and safety for patients with myasthenia gravis. However, the percentage of peripheral CD20+ B cell may be absent for years after low dose of RTX treatment. Persistent hypogammaglobulinemia and opportunistic infection may occur in patients under treatment of RTX with thymoma relapse. Case representation We report a case of refractory myasthenia gravis. After two doses of 100 mg rituximab, the patient developed transient neutropenia. The peripheral blood CD20+ B cell percentage was 0 more than 3 years. Eighteen months later, the patient's symptoms relapsed with thymoma recurred. She had persistent hypogammaglobulinemia and multiple opportunistic infections. Conclusion In MG patient under B cell depletion therapy had thymoma relapse, Good's syndrome may induce prolonged B cell depletion, hypogammaglobulinemia and opportunistic infections.
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9
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Trautmann A, Boyer O, Hodson E, Bagga A, Gipson DS, Samuel S, Wetzels J, Alhasan K, Banerjee S, Bhimma R, Bonilla-Felix M, Cano F, Christian M, Hahn D, Kang HG, Nakanishi K, Safouh H, Trachtman H, Xu H, Cook W, Vivarelli M, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2023; 38:877-919. [PMID: 36269406 PMCID: PMC9589698 DOI: 10.1007/s00467-022-05739-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 01/19/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent pediatric glomerular disease, affecting from 1.15 to 16.9 per 100,000 children per year globally. It is characterized by massive proteinuria, hypoalbuminemia, and/or concomitant edema. Approximately 85-90% of patients attain complete remission of proteinuria within 4-6 weeks of treatment with glucocorticoids, and therefore, have steroid-sensitive nephrotic syndrome (SSNS). Among those patients who are steroid sensitive, 70-80% will have at least one relapse during follow-up, and up to 50% of these patients will experience frequent relapses or become dependent on glucocorticoids to maintain remission. The dose and duration of steroid treatment to prolong time between relapses remains a subject of much debate, and patients continue to experience a high prevalence of steroid-related morbidity. Various steroid-sparing immunosuppressive drugs have been used in clinical practice; however, there is marked practice variation in the selection of these drugs and timing of their introduction during the course of the disease. Therefore, international evidence-based clinical practice recommendations (CPRs) are needed to guide clinical practice and reduce practice variation. The International Pediatric Nephrology Association (IPNA) convened a team of experts including pediatric nephrologists, an adult nephrologist, and a patient representative to develop comprehensive CPRs on the diagnosis and management of SSNS in children. After performing a systematic literature review on 12 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, recommendations were formulated and formally graded at several virtual consensus meetings. New definitions for treatment outcomes to help guide change of therapy and recommendations for important research questions are given.
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Affiliation(s)
- Agnes Trautmann
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Olivia Boyer
- grid.50550.350000 0001 2175 4109Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Children’s Hospital, APHP, Paris, France
| | - Elisabeth Hodson
- grid.413973.b0000 0000 9690 854XCochrane Kidney and Transplant, Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
| | - Arvind Bagga
- grid.413618.90000 0004 1767 6103Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Debbie S. Gipson
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Susan Samuel
- grid.22072.350000 0004 1936 7697Section of Pediatric Nephrology, Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Jack Wetzels
- grid.10417.330000 0004 0444 9382Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Khalid Alhasan
- grid.56302.320000 0004 1773 5396Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sushmita Banerjee
- grid.414710.70000 0004 1801 0469Department of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Rajendra Bhimma
- grid.16463.360000 0001 0723 4123University of KwaZulu-Natal, Durban, South Africa
| | - Melvin Bonilla-Felix
- grid.267034.40000 0001 0153 191XDepartment of Pediatrics, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
| | - Francisco Cano
- grid.443909.30000 0004 0385 4466Department of Pediatric Nephrology, Luis Calvo Mackenna Children’s Hospital, University of Chile, Santiago, Chile
| | - Martin Christian
- Children’s Kidney Unit, Nottingham Children’s Hospital, Nottingham, UK
| | - Deirdre Hahn
- grid.413973.b0000 0000 9690 854XDivision of Pediatric Nephrology, Department of Paediatrics, The Children’s Hospital at Westmead, Sydney, Australia
| | - Hee Gyung Kang
- grid.31501.360000 0004 0470 5905Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital & Seoul National University College of Medicine, Seoul, Korea
| | - Koichi Nakanishi
- grid.267625.20000 0001 0685 5104Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hesham Safouh
- grid.7776.10000 0004 0639 9286Pediatric Nephrology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Howard Trachtman
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Hong Xu
- grid.411333.70000 0004 0407 2968Department of Nephrology, Children’s Hospital of Fudan University, Shanghai, China
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Somerset, UK
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Rome, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover and Center for Rare Diseases, Hannover Medical School, Hannover, Germany.
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Bhandari S, Baral MR, Barbery M, Rudinskaya A, Sostin O. Hematologic side effects of biologics and kinase inhibitors used in rheumatologic diseases: a review of the current evidence. Ann Hematol 2022; 101:1897-1904. [PMID: 35759025 PMCID: PMC9243812 DOI: 10.1007/s00277-022-04896-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
Treatment options for various rheumatologic diseases have been limited until the introduction of biologic agents and kinase inhibitor therapy in recent decades. Since their arrival, they have steadily been integrated into routine management. Given their wide use and overall successful outcomes, it becomes increasingly pertinent for clinicians to readily identify their side effects. Their effects can involve multiple organ systems, including hematologic. This review aims to identify and classify the range of hematologic effects associated with individual biologics and kinase inhibitors used for treatment of rheumatologic diseases.
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Affiliation(s)
| | - Maun Ranjan Baral
- Department of Medicine, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Matthew Barbery
- Department of Medicine, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Alla Rudinskaya
- Department of Rheumatology, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Oleg Sostin
- Department of Research, Danbury Hospital-Nuvance Health, Danbury, CT, USA
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11
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Rauniyar R, Rauniyar R, Agrawal A, Yadav S, Avula S. Severe late-onset neutropenia induced by ocrelizumab in a multiple sclerosis patient: A case report. Clin Case Rep 2022; 10:e05299. [PMID: 35079395 PMCID: PMC8770231 DOI: 10.1002/ccr3.5299] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 11/12/2022] Open
Abstract
Ocrelizumab is a recombinant humanized antibody targeted against CD-20 molecule, which was approved for the treatment of relapsing and primary progressive multiple sclerosis. Common adverse events of ocrelizumab include infusion-related reactions like rash, pruritus, and flushing. Late-onset neutropenia (LON) is a rarely reported complication of ocrelizumab therapy. We report a case of severe late-onset neutropenia in a patient with primary progressive multiple sclerosis treated with ocrelizumab with neutropenia occurring 3 months after the last dose received treated with empirical broad-spectrum intravenous antibiotics and filgrastim. Severe late-onset neutropenia is a rare unpredictable adverse event and outlines the importance of regular routine blood workup for detecting severe neutropenia early in its course.
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Affiliation(s)
- Robin Rauniyar
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Rahul Rauniyar
- Internal MedicineThe Wright Center for Graduate Medical EducationScrantonPennsylvaniaUSA
| | - Ankita Agrawal
- Nepal Army Institute of Health SciencesTribhuvan UniversityKathmanduNepal
| | - Shikha Yadav
- Nepalgunj Medical CollegeKathmandu UniversityKathmanduNepal
| | - Sreekant Avula
- Internal MedicineThe Wright Center for Graduate Medical EducationScrantonPennsylvaniaUSA
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12
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Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
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Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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13
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Mancinelli CR, Rossi ND, Capra R. Ocrelizumab for the Treatment of Multiple Sclerosis: Safety, Efficacy, and Pharmacology. Ther Clin Risk Manag 2021; 17:765-776. [PMID: 34354358 PMCID: PMC8331077 DOI: 10.2147/tcrm.s282390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022] Open
Abstract
The success of selective B-cells depleting therapies, as the anti-CD20 antibodies, in patients with multiple sclerosis (MS) has confirmed that B-cells are critical in the immune pathogenesis of the disease. Ocrelizumab, a humanized monoclonal antibody that selectively targets CD20+ B-cells, profoundly suppresses acute inflammatory disease activity, representing a highly effective therapy for relapsing-remitting multiple sclerosis (RRMS). It is also the first proven therapy able to slow disability progression in primary progressive multiple sclerosis (PPMS), particularly in patients with signs of acute radiological activity before being enrolled. Effectiveness has widely been demonstrated in randomized clinical trials (RCTs), and recently confirmed in open-label extension trials. Here, we review the role of B-cells in MS, the mechanism of action of ocrelizumab, its pharmacokinetics and pharmacodynamics, and the clinical data supporting its use, as well as safety data. We focus on issues related to the maintenance of immunocompetence, essential to ensure an immune response to either a primary infection or a vaccination. Lastly, we discuss about the possible role of ocrelizumab as an exit strategy from natalizumab-treated patients at risk of developing multifocal progressive leukoencephalopathy. In view of using ocrelizumab chronically, collecting long-term safety data and finding strategies to minimize adverse events will be extremely relevant.
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Affiliation(s)
| | - Nicola De Rossi
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Brescia, Italy
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14
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Late-onset neutropenia (LON) recur in a MS patient after the second cycle of ocrelizumab: a case report. Neurol Sci 2021; 42:3933-3935. [PMID: 34170432 DOI: 10.1007/s10072-021-05379-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/03/2021] [Indexed: 12/23/2022]
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15
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Rituximab- and ocrelizumab-induced early- and late-onset neutropenia in a multiple sclerosis patient. Neurol Sci 2021; 42:3893-3895. [PMID: 34075515 DOI: 10.1007/s10072-021-05357-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
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16
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Baird-Gunning J, Yun J, Stevenson W, Ng K. Severe Delayed-Onset Neutropenia Induced by Ocrelizumab. Neurohospitalist 2021; 11:59-61. [PMID: 33868559 DOI: 10.1177/1941874420936438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Ocrelizumab is an anti-CD20 monoclonal antibody that has been shown to reduce disability progression in primary progressive multiple sclerosis (MS). The adverse event profile is still being determined through postmarketing surveillance and case reports. Objective To report a case of severe late-onset neutropenia associated with ocrelizumab in a patient with primary progressive MS. Methods Case report. Result A 34-year-old male with primary progressive MS developed severe late-onset neutropenia 42 days after infusion of ocrelizumab, which necessitated hospital admission and administration of broad-spectrum antibiotics and granulocyte colony-stimulating factor. Conclusion Late-onset neutropenia is a rare complication of ocrelizumab. Patients should be counseled to present for urgent evaluation if they develop fever.
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Affiliation(s)
| | - James Yun
- Nepean Hospital, Nepean Hospital, Penrith, New South Wales, Australia
| | - William Stevenson
- Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Karl Ng
- Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
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17
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Segelmark L, Flores-Suárez LF, Mohammad AJ. Severe infections in patients with ANCA associated vasculitis treated with rituximab. Rheumatology (Oxford) 2021; 61:205-212. [PMID: 33757116 DOI: 10.1093/rheumatology/keab293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab (RTX) is an anti-CD20 antibody that selectively depletes B-cells and has emerged as a therapy for ANCA-associated vasculitis (AAV) during the past decade. This study sought to quantify, and determine potential risk factors for, severe infections in AAV patients treated with RTX at rheumatology clinics in Mexico City, Mexico and Lund, Sweden. METHODS The study consisted of a retrospective case-record review (2005-2015) with standardized data collection related to the occurrence of severe infection in 46 patients with AAV in Mexico City (n = 20) and Lund (n = 26) treated with RTX during their disease course. Median duration of follow-up from first RTX dose to death or end of study was 26 months. RESULTS Eleven (24%) patients suffered a total of 18 severe infections (infection rate of 11.5/100 patient-years). Thirteen of the 18 infections (72%) occurred within the first year of treatment. Risk factors for severe infection were older age at RTX initiation and absence of ENT-involvement at diagnosis. In multivariate analyses, age at RTX infusion was the only independent factor predicting severe infection. Four patients (9%) died during follow-up, all as a result of infection. CONCLUSIONS Severe infections are common following RTX treatment, and mortality due to infection is a major concern. Most severe infections occur within the first year of RTX treatment. The negative correlation of ENT involvement with severe infection might reflect GPA phenotype heterogeneity. Older age at time of RTX treatment independently predicts severe infections.
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Affiliation(s)
- Leo Segelmark
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - L F Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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18
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Alba Suárez EM, Tallón Barranco A, Puertas Muñoz I, Chamorro Hernández B, Robles Marhuenda Á. Non-late-onset neutropaenia following treatment of multiple sclerosis with ocrelizumab. Neurologia 2021; 38:S0213-4853(21)00026-8. [PMID: 33726971 DOI: 10.1016/j.nrl.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/17/2020] [Accepted: 01/01/2021] [Indexed: 10/21/2022] Open
Abstract
Late-onset neutropaenia is defined as an absolute neutrophil count of <1.5×103cells/μL starting>4 weeks after the last dose of rituximab, in the absence of other identifiable causes. Late-onset neutropaenia is a rare adverse reaction to rituximab (observed in approximately 5% of patients). Rheumatic diseases constitute the main indication for rituximab; in these patients, neutropaenia appears after a mean of>28 days. Ocrelizumab is another monoclonal antibody that binds to CD20 (a glycosylated phosphoprotein mainly expressed on the membranes of B-lymphocytes); in January 2018, it was approved for the treatment of relapsing-remitting and primary progressive multiple sclerosis. We present a case of neutropaenia following intravenous infusion of ocrelizumab in a patient with primary progressive multiple sclerosis who presented with neutropaenic fever, herpetic stomatitis, and ecthyma gangrenosum only 20 days after infusion.
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Affiliation(s)
- E M Alba Suárez
- Servicio de Neurología Hospital Universitario La Paz, Spain.
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19
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Zonozi R, Wallace ZS, Laliberte K, Huizenga NR, Rosenthal JM, Rhee EP, Cortazar FB, Niles JL. Incidence, Clinical Features, and Outcomes of Late-Onset Neutropenia From Rituximab for Autoimmune Disease. Arthritis Rheumatol 2020; 73:347-354. [PMID: 32892495 DOI: 10.1002/art.41501] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 08/20/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Late-onset neutropenia (LON) is an underrecognized complication of rituximab treatment. We undertook this study to describe its incidence, risk factors, clinical features, management, and recurrence. METHODS We conducted a single-center retrospective cohort study of 738 adult patients with autoimmune disease who were treated with rituximab to induce continuous B cell depletion. The primary outcome measure was LON, defined as an unexplained absolute neutrophil count of <1,000 cells/µl during B cell depletion. Secondary outcome measures included incidental diagnosis, fever, sepsis, filgrastim use, and recurrent LON. We assessed predictors of LON using Cox proportional hazards regression models. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. RESULTS We identified 107 episodes of LON in 71 patients. The cumulative incidence at 1 year of B cell depletion therapy was 6.6% (95% CI 5.0-8.7). The incidence rate during the first year was higher compared to thereafter (7.2 cases per 100 person-years [95% CI 5.4-9.6] versus 1.5 cases per 100 person-years [95% CI 1.0-2.3]). Systemic lupus erythematosus and combination therapy with cyclophosphamide were each independently associated with an increased risk of LON (adjusted HR 2.96 [95% CI 1.10-8.01] and 1.98 [95% CI 1.06-3.71], respectively). LON was not observed in minimal change disease or focal segmental glomerulosclerosis. The majority of episodes (59.4%) were asymptomatic. Fever and sepsis complicated 31.3% and 8.5% of episodes, respectively. Most patients (69%) were treated with filgrastim. Rituximab rechallenge occurred in 87% of patients, of whom 21% developed recurrent LON. CONCLUSION LON is common and often incidental. Most cases are reversible and respond well to filgrastim. However, LON can be associated with serious infections and thus warrants vigilant monitoring.
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Affiliation(s)
| | | | | | | | | | | | - Frank B Cortazar
- Massachusetts General Hospital, Boston, and New York Nephrology Vasculitis and Glomerular Center, Albany
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20
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Klein A, Molad Y. Hematological Manifestations among Patients with Rheumatic Diseases. Acta Haematol 2020; 144:403-412. [PMID: 33221805 DOI: 10.1159/000511759] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/22/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias. SUMMARY The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.
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Affiliation(s)
- Alina Klein
- Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel,
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Alfano G, Giaroni F, Fontana F, Neri L, Mosconi G, Mussini C, Guaraldi G, Cappelli G. Rituximab in people living with HIV affected by immune-mediated renal diseases: a case-series. Int J STD AIDS 2020; 31:1426-1431. [PMID: 33104497 DOI: 10.1177/0956462420946662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Over the last two decades, rituximab (RTX) has played an important role in the treatment of some lymphoproliferative malignancies and immune-mediated diseases. RTX administration is generally safe and well-tolerated, but side effects including late-onset neutropenia, hypogammaglobulinemia, hepatitis B reactivation and rare cases of progressive multifocal leukoencephalopathy have been observed after its administration. Although there are no absolute contraindications regarding its use in people living with HIV (PLWH), the prescription of this drug has been principally limited in patients with oncohematological diseases. In this report, we described the outcome of four PLWH who underwent RTX therapy after the diagnosis of immune-mediated renal disease. The main RTX-associated adverse effects were leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts. In addition, two of the four patients experienced pneumonia requiring hospitalization within six months from the last RTX infusion. We suggest that RTX should be used with caution in PLWH until further evidence emerges on its safety profile in this vulnerable population.
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Affiliation(s)
- G Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - F Giaroni
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - F Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - L Neri
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy
| | - G Mosconi
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy.,Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - C Mussini
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Guaraldi
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
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22
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Bigot W, Viallard JF, Sellam J, Dellal A, Retbi A, Gobert D, Malard F, Mohty M, Mekinian A, Fain O. Efficacy and safety of rituximab for autoimmune neutropenia: a French case series and literature review. Rheumatology (Oxford) 2020; 59:2637-2640. [DOI: 10.1093/rheumatology/keaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/09/2019] [Accepted: 12/30/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- William Bigot
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (DHU i2B), Paris
| | | | - Jérémie Sellam
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | | | - Aurélie Retbi
- Hôpital Saint Antoine, Sorbonne Universités, AP-HP, Paris, France
| | - Delphine Gobert
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | - Florent Malard
- Service de Rhumatologie, Hôpital Montfermeil, Monfermeil
| | - Mohamad Mohty
- Service de Rhumatologie, Hôpital Montfermeil, Monfermeil
| | - Arsène Mekinian
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | - Olivier Fain
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
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23
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Caldito NG, Shirani A, Salter A, Stuve O. Adverse event profile differences between rituximab and ocrelizumab: Findings from the FDA Adverse Event Reporting Database. Mult Scler 2020; 27:1066-1076. [PMID: 32820687 DOI: 10.1177/1352458520949986] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rituximab and ocrelizumab are anti-CD20 monoclonal antibodies that have shown a marked reduction in multiple sclerosis (MS) inflammatory activity. However, their real-world safety profile has not been adequately compared. OBJECTIVE To investigate the adverse event (AE) profile of rituximab and ocrelizumab reported to the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS The FAERS database was filtered by indication (MS) and drug (rituximab or ocrelizumab). Disproportionality analyses including but not limited to reporting odds ratio (ROR) were conducted to identify drug-AE associations. A signal was detected if the lower limit of the 95% confidence interval of ROR (ROR025) exceeded 1. RESULTS There were 623 and 7948 reports for rituximab and ocrelizumab, respectively. The most frequent AEs with rituximab and ocrelizumab were infusion-related reaction (4.82%) and urinary tract infection (10.52%), respectively. The strongest drug-AE association for rituximab and ocrelizumab were ear pruritus (ROR025: 47.53) and oral herpes (ROR025: 38.99), respectively. Ocrelizumab was associated with an almost two times higher frequency of infections than rituximab (21.93% vs 11.05%, respectively). CONCLUSION This study revealed differences in reporting AEs between rituximab and ocrelizumab. Infections were reported more frequently with ocrelizumab. Although speculative, a potentially different or more extensive B-cell depletion by ocrelizumab might explain these findings. Additional pharmacovigilance studies need to be performed to better characterize differences in the AE profile in B-cell-depleting therapies.
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Affiliation(s)
- Natalia Gonzalez Caldito
- Department of Neurology & Neurotherapeutics, Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Afsaneh Shirani
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Olaf Stuve
- Department of Neurology & Neurotherapeutics, Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA/Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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24
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Late-onset neutropenia in a multiple sclerosis patient after first dose ocrelizumab switched from rituximab. Mult Scler Relat Disord 2020; 43:102155. [DOI: 10.1016/j.msard.2020.102155] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/16/2020] [Accepted: 04/25/2020] [Indexed: 11/19/2022]
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25
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Rituximab and immune thrombocytopenia in adults: The state of knowledge 20 years later. Rev Med Interne 2020; 42:32-37. [PMID: 32680716 DOI: 10.1016/j.revmed.2020.05.016] [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: 03/05/2020] [Accepted: 05/23/2020] [Indexed: 01/19/2023]
Abstract
Rituximab has been used for immune thrombocytopenia (ITP) for almost 20 years and is now considered a valid off-label second-line treatment. About 60% to 70% of patients with ITP show initial response to rituximab, but in half of these patients, the disease will eventually relapse. Therefore, in 30% of patients with persistent or chronic ITP, one course of rituximab at 375 mg/m2/week for 4 weeks or 2 fixed 1000-mg rituximab infusions allows for a sustained response rate at 5 years. Unfortunately, to date, no robust predictor of long-term sustained response has been found to assist the physician in deciding to treat with rituximab on an individual basis, and the choice of rituximab or another second-line treatment must be individualized and shared with the patient. Retreatment with rituximab has been found efficient, with a similar or higher magnitude and duration of response in most patients. Rituximab is usually well tolerated, with mainly mild and easily manageable infusion-related adverse events. Severe infections are uncommon, including in the long-term, and occur in patients with at least another contributing factor in more than two thirds. Several issues remain to be resolved. Indeed, head-to-head comparisons with other and new treatments in ITP and robust predictors of long-term response are urgently needed to better determine the position of rituximab in the therapeutic armamentarium for adult ITP. Additionally, the place of combination therapies, maintenance therapy with rituximab and rituximab in newly-diagnosed ITP deserve additional studies.
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26
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Hellgren J, Risedal A, Källén K. Rituximab in multiple sclerosis at general hospital level. Acta Neurol Scand 2020; 141:491-499. [PMID: 31990978 DOI: 10.1111/ane.13225] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The use of rituximab (RTX) in multiple sclerosis (MS) is a rapidly increasing choice of disease-modifying therapy. Efficacy outside specialized university hospital-based care is not yet systematically investigated. Our aim was to evaluate off-label RTX treatment for MS at a general hospital in Sweden. MATERIALS AND METHODS Subjects with definite MS with at least one rituximab infusion were eligible for inclusion in this retrospective, observational study. Effect was evaluated by monitoring clinical disability, annual relapse rate, new lesions on MRI, and safety by the incidence and severity of adverse events. RESULTS Among the 83 included subjects, 15 had clinical worsening of disease during the median 23.5 (1-76) months of follow-up after RTX initiation: 7/66 with relapsing-remitting multiple sclerosis (RRMS) and 8/17 with progressive subtypes (PMS). Cumulative survival without worsening was 86% in RRMS and 30% in PMS. The annual relapse rate before RTX vs follow-up dropped from 0.38 to 0.05 (P < .00001). Subjects with new enhancing lesions on MRI during the first year before RTX initiation vs the year after dropped from 0.94 to 0.024 (P < .00001) and was only seen in RRMS (1.05-0.31, P = .00003). Adverse events were mainly mild. Thirty-six out of 53 non-infusion-related adverse events were infections, of which four were serious, including a case of pneumonia with concomitant late-onset neutropenia. CONCLUSIONS Rituximab was as effective and safe when given at a general hospital outpatient clinic compared with results from previous university hospital-based studies. Vigilance is required concerning severe adverse events.
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Affiliation(s)
- Johan Hellgren
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
| | - Anette Risedal
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
| | - Kristina Källén
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
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27
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Abstract
INTRODUCTION Rituximab, an anti-B-cell biological therapy, has been investigated in several clinical trials on antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). AREAS COVERED In this paper, the clinical trials and open-label studies on rituximab efficacy and safety in treating AAVs are reviewed. EXPERT OPINION Rituximab achieved high remission-induction and sustained-maintenance rates for patients with these severe diseases, thereby challenging the cornerstone treatment of corticosteroids and cyclophosphamide followed by azathioprine. Rituximab should be used as first-line therapy with corticosteroids to induce remission of severe AAVs, especially in situations in which cyclophosphamide may be problematic (relapse after cyclophosphamide, women of childbearing age, risk of malignancy). Cyclophosphamide indications are likely to be restricted in the future. Whenever possible, rituximab should be preferred to azathioprine to maintain remission. The current maintenance regimen has been extended to at least 18 months but its optimal duration remains unknown and recent data suggest the possibility to extend treatment to 4 years. Future challenges include defining the best dose regimen: at present, different schedules are used as alternatives to those recognized as standards by health authorities. In addition, it remains to identify which patients will benefit the most from long-term retreatment: potentially those with relapsing disease or anti-proteinase-3 ANCA-positivity.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion , Saint-Denis, France
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes , Paris, France
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28
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Late onset absolute neutropenia associated with ocrelizumab treatment in multiple sclerosis: A case report and review of the literature. J Neurol Sci 2020; 409:116603. [DOI: 10.1016/j.jns.2019.116603] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022]
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Deshayes S, Khellaf M, Zarour A, Layese R, Fain O, Terriou L, Viallard J, Cheze S, Graveleau J, Slama B, Audia S, Cliquennois M, Ebbo M, Le Guenno G, Salles G, Bonmati C, Teillet F, Galicier L, Lambotte O, Hot A, Lefrère F, Mahévas M, Canoui‐Poitrine F, Michel M, Godeau B. Long-term safety and efficacy of rituximab in 248 adults with immune thrombocytopenia: Results at 5 years from the French prospective registry ITP-ritux. Am J Hematol 2019; 94:1314-1324. [PMID: 31489694 DOI: 10.1002/ajh.25632] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 01/19/2023]
Abstract
Rituximab is a second-line option in adults with immune thrombocytopenia (ITP), but the estimated 5-year response rate, only based on pooled retrospective data, is about 20%, and no studies have focused on long-term safety. We conducted a prospective multicenter registry of 248 adults with ITP treated with rituximab with 5 years of follow-up to assess its long-term safety and efficacy. The median follow-up was 68.4 [53.7-78.5] months. The incidence of severe infections was only 2/100 patient-years. Profound hypogammaglobulinemia (<5 g/L) developed in five patients at 15 to 31 months after the last rituximab infusion. In total, 25 patients died at a median age of 80 [69.5-83.9] years, corresponding to a mortality rate of 2.3/100 patient-years. Only three deaths related to infection that occurred 12 to 14 months after rituximab infusions could be due in part to rituximab. At 60 months of follow-up, 73 (29.4%) patients had a sustained response. On univariate and multivariate analysis, the only factor significantly associated with sustained response was a previous transient response to corticosteroids (P = .022). Overall, 24 patients with an initial response and then relapse received retreatment with rituximab, which gave a response in 92%, with a higher duration of response in 54%. As a result of its safety profile and its sustained response rate, rituximab remains an important option in the current therapeutic armamentarium for adult ITP. Retreatment could be an effective and safe option.
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Affiliation(s)
- Samuel Deshayes
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Médecine Interne Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Mehdi Khellaf
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Anissa Zarour
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Richard Layese
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Olivier Fain
- Service de Médecine Interne, Hôpital Saint‐Antoine, Assistance Publique‐Hôpitaux de Paris Sorbonne Université Paris France
| | - Louis Terriou
- Service de Médecine Interne Centre Hospitalier Régional Universitaire de Lille Lille France
| | - Jean‐François Viallard
- Département de Médecine Interne et Maladies Infectieuses Centre Hospitalier Universitaire Haut Lévêque, Université de Bordeaux Pessac France
| | - Stéphane Cheze
- Service d'Hématologie Clinique Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Julie Graveleau
- Service de Médecine Interne Centre Hospitalier Universitaire de Nantes Nantes France
| | - Borhane Slama
- Service d'Hématologie Centre Hospitalier d'Avignon Avignon France
| | | | - Manuel Cliquennois
- Département d'Hématologie Groupe Hospitalier de l'Institut Catholique de Lille Lille France
| | - Mikael Ebbo
- Service de Médecine Interne Hôpital de la Timone, Assistance Publique‐Hôpitaux de Marseille, Université Aix‐Marseille Marseille France
| | - Guillaume Le Guenno
- Service de Médecine Interne Centre Hospitalier Universitaire Estaing Clermont Ferrand France
| | - Gilles Salles
- Service d'Hématologie Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre‐Bénite, University Claude Bernard Lyon 1 Lyon France
| | - Caroline Bonmati
- Service d'Hématologie Centre Hospitalier Universitaire de Nancy Nancy France
| | - France Teillet
- Département d'Immuno‐Hématologie Centre Hospitalier Universitaire Louis Mourier, Assistance Publique‐Hôpitaux de Paris Colombes France
| | - Lionel Galicier
- Service d'Immuno‐Pathologie Centre Hospitalier Universitaire Saint‐Louis, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Olivier Lambotte
- Service de Médecine Interne Centre Hospitalier Universitaire Bicêtre, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Arnaud Hot
- Service de Médecine Interne Groupement Hospitalier Edouard Herriot Lyon France
| | - François Lefrère
- Service d'Hématologie Centre Hospitalier Universitaire Necker, Assistance Publique‐ Hôpitaux de Paris Paris France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Florence Canoui‐Poitrine
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Marc Michel
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
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Schultz B, Culton D. A case of late-onset neutropenia secondary to rituximab in a patient with mucous membrane pemphigoid. JAAD Case Rep 2019; 5:715-719. [PMID: 31440566 PMCID: PMC6698445 DOI: 10.1016/j.jdcr.2019.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Brittney Schultz
- Departments of Dermatology and Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Donna Culton
- Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina
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31
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Daneshpazhooh M, Balighi K, Mahmoudi H, Tavakolpour S, Abedini R, Soori T, Ehsani A, Ghiasi M, Noormohammadpour P, Ghandi N, Lajevardi V, Sadeghinia A, Nasimi M, Azizpour A, Chams‐Davatchi C. Iranian guideline for rituximab therapy in pemphigus patients. Dermatol Ther 2019; 32:e13016. [DOI: 10.1111/dth.13016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/18/2019] [Accepted: 06/23/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Robabeh Abedini
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Tahereh Soori
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Amir‐Houshang Ehsani
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Maryam Ghiasi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Pedram Noormohammadpour
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Narges Ghandi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Vahideh Lajevardi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Ali Sadeghinia
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Maryam Nasimi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Arghavan Azizpour
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
| | - Cheyda Chams‐Davatchi
- Autoimmune Bullous Diseases Research CenterRazi Hospital, Tehran University of Medical Sciences Tehran Iran
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Fukui KO, Shoji K, Nagai Y, Shindo T, Hikosaka M, Kuwahara K, Ishiguro A, Miyairi I. Ecthyma gangrenosum in a 3-year-old boy post-heart transplantation. Transpl Infect Dis 2019; 21:e13131. [PMID: 31216602 DOI: 10.1111/tid.13131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/25/2019] [Accepted: 06/09/2019] [Indexed: 11/27/2022]
Abstract
Ecthyma gangrenosum (EG) is a serious bacterial infection in immunocompromised patients. EG in transplant recipients is rarely reported and may go unrecognized, which may delay initiation of appropriate treatment. We report a case of EG in a pediatric heart transplant recipient who was treated successfully with antibiotics and surgical debridement.
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Affiliation(s)
- Kana Okazaki Fukui
- Center of Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, Department Medical Subspecialties, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Yusa Nagai
- Center of Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Takahiro Shindo
- Division of Cardiology, Department Medical Subspecialties, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Makoto Hikosaka
- Division of Plastic Surgery, Department of Surgical Subspecialties, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Kosuke Kuwahara
- Division of Plastic Surgery, Department of Surgical Subspecialties, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Akira Ishiguro
- Center of Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department Medical Subspecialties, National Center for Child Health and Development, Setagaya-ku, Japan.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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33
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Lucchini E, Zaja F, Bussel J. Rituximab in the treatment of immune thrombocytopenia: what is the role of this agent in 2019? Haematologica 2019; 104:1124-1135. [PMID: 31126963 PMCID: PMC6545833 DOI: 10.3324/haematol.2019.218883] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/09/2019] [Indexed: 01/19/2023] Open
Abstract
The use of rituximab for the treatment of immune thrombocytopenia was greeted enthusiastically: it led to up to 60% response rates, making it, nearly 20 years ago, the main alternative to splenectomy, with far fewer side effects. However, long-term follow-up data showed that only 20-30% of patients maintained the remission. No significant changes have been registered using different dose schedules and timing of administration, while the combination with other drugs seemed promising. Higher response rates have been observed in young women before the chronic phase, but apart from that, other clinical factors or biomarkers predictive of response are still lacking. In this review we examine the historical and current role of rituximab in the management of immune thrombocytopenia, 20 years after its first use for the treatment of autoimmune diseases.
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Affiliation(s)
- Elisa Lucchini
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
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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: 26] [Impact Index Per Article: 5.2] [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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35
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Cohen BA. Late-onset neutropenia following ocrelizumab therapy for multiple sclerosis. Neurology 2019; 92:435-436. [PMID: 30635476 DOI: 10.1212/wnl.0000000000006924] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 12/14/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bruce A Cohen
- From Davee Dept of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
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36
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Fragoulis GE, Paterson C, Gilmour A, Derakhshan MH, McInnes IB, Porter D, Siebert S. Neutropaenia in early rheumatoid arthritis: frequency, predicting factors, natural history and outcome. RMD Open 2018; 4:e000739. [PMID: 30402267 PMCID: PMC6203094 DOI: 10.1136/rmdopen-2018-000739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/06/2018] [Accepted: 08/16/2018] [Indexed: 12/30/2022] Open
Abstract
Objectives To determine the frequency, severity and natural history of neutropaenia in early rheumatoid arthritis (RA), explore its associations with clinical features and assess its impact on clinical management. Methods The Scottish Early Rheumatoid Arthritis inception cohort prospectively recruited patients with newly diagnosed RA and followed them up every 6 months. Patients with RA who developed at least one episode of neutropaenia (grade 1: <2.0×10^9/L; grade 2: <1.5×10^9/L; grade 3: <1.0×10^9/L; grade 4: <0.5×10^9/L) were compared with those who did not. Comparisons were also made between patients who experienced one or more episodes of neutropaenia and between patients with different neutropaenia grades. Results 77 neutropaenia episodes were recorded in 58 of 771 (7.5%) patients with RA, who were followed up for a median (range) of 18 (6-48) months. Neutropaenia occurred at a median (range) of 12 (0-120) months after RA diagnosis. The majority had mild neutropaenia (grade 1: n=42; grade 2: n=14; grade 3: n=1; grade 4: n=1). Neutropaenia was transient (single episode) in the majority (44; 75.8%) of cases but led to treatment discontinuation in 14 (24.1%) patients. Patients who developed neutropaenia were more likely to be female (p=0.01) and non-smokers (p=0.007) and had lower baseline neutrophil levels (p<0.0001). Binomial regression analysis confirmed the latter (p<0.0001, B: -0.491) as neutropaenia predictor. The rate of infections did not differ between patients who developed neutropaenia and those who did not (p=0.878). Conclusion Neutropaenia was a common finding in this cohort. It was usually mild, transient and not associated with increased infection rates. Neutropaenia occurrence was associated with non-smoking, female gender and lower baseline neutrophil levels.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Caron Paterson
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Ashley Gilmour
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Mohammad H Derakhshan
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Duncan Porter
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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Abstract
Most glomerular diseases are immunologically mediated disorders of the kidney and are common causes of ESKD. In addition to supportive therapy, a wide range of immunosuppressive agents are used in the management of patients with these conditions. Immunosuppression requires a careful balance of risk and benefits, and many of these agents have a narrow therapeutic window and require close monitoring. This review describes the side effects of immunosuppressive agents used in recent randomized, controlled trials of glomerular disease, and highlights some of the key adverse events that determine the choice and prescription of these medications.
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Affiliation(s)
- J Ashley Jefferson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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38
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Parodis I, Söder F, Faustini F, Kasza Z, Samuelsson I, Zickert A, Svenungsson E, van Vollenhoven RF, Malmström V, Wermeling F, Gunnarsson I. Rituximab-mediated late-onset neutropenia in systemic lupus erythematosus – distinct roles of BAFF and APRIL. Lupus 2018; 27:1470-1478. [DOI: 10.1177/0961203318777116] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective Rituximab-mediated late-onset neutropenia (LON) has been described in various diseases. We investigated its occurrence, consequences and contributing factors in patients with systemic lupus erythematosus (SLE). Methods Rituximab-treated patients from the Karolinska University Hospital ( n = 107) were surveyed. LON was defined as an absolute neutrophil count <1500 cells/μl, occurring four weeks to two years following rituximab treatment, or later during sustained B-cell depletion. Serum levels of B-cell-related cytokines and growth factors of the myeloid lineage were determined using enzyme-linked immunosorbent assay. Results Thirty-two patients (29.9%) developed LON after a median time of 201.5 days. Thirteen patients were admitted to the hospital; 10 due to fever. Three patients developed critical conditions. BAFF levels increased from baseline (median: 0.62 ng/ml) to the post-treatment evaluation (median: 1.16 ng/ml; p < 0.001); post-treatment levels were higher in the LON group ( p = 0.021). APRIL levels were higher in the LON group both at baseline (median: 1.54 versus 1.15 ng/ml; p = 0.027) and post-treatment (median: 2.39 versus 1.11 ng/ml; p = 0.011). IL-6 and GM-CSF levels decreased in the non-LON group ( p < 0.001), but not in LON patients. High baseline disease activity predicted LON development (OR: 4.1; 95% CI: 1.1–15.2 for SLEDAI-2K > 8). No association with neutropenia prior to rituximab treatment was documented. Conclusion Post-rituximab LON was a common complication. Although the phenomenon was predominantly self-limiting, several patients developed severe conditions. Distinct roles of BAFF and APRIL are implicated: BAFF may contribute to LON development, whereas high APRIL levels may be predictive. Rituximab-treated SLE patients should be monitored for neutrophil counts, fever and infections.
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Affiliation(s)
- I Parodis
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - F Söder
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - F Faustini
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Z Kasza
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - I Samuelsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Zickert
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - E Svenungsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - R F van Vollenhoven
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - V Malmström
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - F Wermeling
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - I Gunnarsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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39
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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