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Liang H, Deng Z, Niu S, Kong W, Liu Y, Wang S, Li H, Wang Y, Zheng D, Liu D. Dosing optimization of rituximab for primary membranous nephropathy by population pharmacokinetic and pharmacodynamic study. Front Pharmacol 2024; 15:1197651. [PMID: 38595918 PMCID: PMC11002205 DOI: 10.3389/fphar.2024.1197651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 03/11/2024] [Indexed: 04/11/2024] Open
Abstract
Primary membranous nephropathy (PMN) is the most common cause for adult nephrotic syndrome. Rituximab has demonstrated promising clinical efficacy by random controlled trials and the off-label use is widely adopted in PMN. However, the standard dosage is borrowed from B cell lymphoma treatment with far more antigens and is oversaturated for PMN treatment, accompanied with additional safety risk and unnecessary medical cost. More than 15% serious adverse events were observed under standard dosage and low dose therapies were explored recently. Dose optimization by clinical trials is extremely time- and cost-consuming and can be significantly accelerated with the aid of model-informed drug development. Here, we aim to establish the first population pharmacokinetic and pharmacodynamic (PPK/PD) model for rituximab in PMN to guide its dosage optimization. Rituximab pharmacokinetic and pharmacodynamic data from 41 PMN patients in a retrospective study under a newly proposed monthly mini-dose were used to construct quantitative dose-exposure-response relationship via mechanistic target-mediated drug disposition (TMDD) model followed by regression between the reduction of anti-PLA2R titer and time after the treatment. The final model, validated by goodness-of-fit plots, visual predictive checks and bootstrap, was used to recommend the optimized dosing regimen by simulations. The model was well validated for PK/PD prediction. The systemic clearance and half-life are 0.54 L/h and 14.7 days, respectively. Simulation of a novel regimen (6 monthly doses of 100 mg) indicated the comparable ability and superior duration time of CD20+ B cell depletion compared with standard dosage, while the cumulative dosage and safety risk was significantly decreased. We established the first PPK/PD model and provide evidence to support the dosage optimization based on monthly mini-dose. Our study can also efficiently accelerate dosage optimization of novel anti-CD20 antibodies in PMN and other indications.
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Affiliation(s)
- Hao Liang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Zhenling Deng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Shu Niu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Weijie Kong
- Department of Nephrology, Peking University Third Hospital, Beijing, China
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Yang Liu
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Hohhot, China
| | - Song Wang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Haiyan Li
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Danxia Zheng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
- Institute of Medical Innovation, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Cardiovascular Receptors Research, Peking University Third Hospital, Beijing, China
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Guo Y, Remaily BC, Thomas J, Kim K, Kulp SK, Mace TA, Ganesan LP, Owen DH, Coss CC, Phelps MA. Antibody Drug Clearance: An Underexplored Marker of Outcomes with Checkpoint Inhibitors. Clin Cancer Res 2024; 30:942-958. [PMID: 37921739 PMCID: PMC10922515 DOI: 10.1158/1078-0432.ccr-23-1683] [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: 06/13/2023] [Revised: 08/23/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
Immune-checkpoint inhibitor (ICI) therapy has dramatically changed the clinical landscape for several cancers, and ICI use continues to expand across many cancer types. Low baseline clearance (CL) and/or a large reduction of CL during treatment correlates with better clinical response and longer survival. Similar phenomena have also been reported with other monoclonal antibodies (mAb) in cancer and other diseases, highlighting a characteristic of mAb clinical pharmacology that is potentially shared among various mAbs and diseases. Though tempting to attribute poor outcomes to low drug exposure and arguably low target engagement due to high CL, such speculation is not supported by the relatively flat exposure-response relationship of most ICIs, where a higher dose or exposure is not likely to provide additional benefit. Instead, an elevated and/or increasing CL could be a surrogate marker of the inherent resistant phenotype that cannot be reversed by maximizing drug exposure. The mechanisms connecting ICI clearance, therapeutic efficacy, and resistance are unclear and likely to be multifactorial. Therefore, to explore the potential of ICI CL as an early marker for efficacy, this review highlights the similarities and differences of CL characteristics and CL-response relationships for all FDA-approved ICIs, and we compare and contrast these to selected non-ICI mAbs. We also discuss underlying mechanisms that potentially link mAb CL with efficacy and highlight existing knowledge gaps and future directions where more clinical and preclinical investigations are warranted to clearly understand the value of baseline and/or time-varying CL in predicting response to ICI-based therapeutics.
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Affiliation(s)
- Yizhen Guo
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Bryan C. Remaily
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Justin Thomas
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Kyeongmin Kim
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Samuel K. Kulp
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Thomas A. Mace
- Department of Internal Medicine, Division of Rheumatology and Immunology, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Latha P. Ganesan
- Department of Internal Medicine, Division of Rheumatology and Immunology, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dwight H. Owen
- Division of Medical Oncology, Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Christopher C. Coss
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Mitch A. Phelps
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH
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Khoudour N, Delestre F, Jabot-Hanin F, Jouinot A, Nectoux J, Letouneur F, Izac B, Vidal M, Guillevin L, Puéchal X, Charles P, Terrier B, Blanchet B. Association Between Plasma Rituximab Concentration and the Risk of Major Relapse in Antineutrophil Cytoplasmic Antibody-Associated Vasculitides During Rituximab Maintenance Therapy. Arthritis Rheumatol 2023; 75:2003-2013. [PMID: 37134130 DOI: 10.1002/art.42556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE Interindividual variability in response to rituximab remains unexplored in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Rituximab pharmacokinetics (PK) and pharmacodynamics (PD) as well as genetic polymorphisms could contribute to variability. This ancillary study of the MAINRITSAN 2 trial aimed to explore the relationship between rituximab plasma concentration, genetic polymorphisms in PK/PD candidate genes, and clinical outcomes. METHODS Patients included in the MAINRITSAN2 trial (ClinicalTrials.gov identifier: NCT01731561) were randomized to receive a 500-mg fixed-schedule rituximab infusion or an individually tailored regimen. Rituximab plasma concentrations at month 3 (CM3) were assessed. DNA samples (n = 53) were genotyped for single-nucleotide polymorphisms within 88 putative PK/PD candidate genes. The relationship between PK/PD outcomes and genetic variants was investigated using logistic linear regression in additive and recessive genetic models. RESULTS One hundred and thirty-five patients were included. The frequency of underexposed patients (<4 μg/ml) in the fixed-schedule group was statistically lower compared to that in the tailored-infusion group (2.0% versus 18.0%; P = 0.02, respectively). Low rituximab plasma concentration at 3 months (CM3 <4 μg/ml) was an independent risk factor for major relapse (odds ratio 6.56 [95% confidence interval (95% CI) 1.26-34.09]; P = 0.025) at month 28 (M28). A sensitivity survival analysis also identified CM3 <4 μg/ml as an independent risk factor for major relapse (hazard ratio [HR] 4.81 [95% CI 1.56-14.82]; P = 0.006) and relapse (HR 2.70 [95% CI 1.02-7.15]; P = 0.046). STAT4 rs2278940 and PRKCA rs8076312 were significantly associated with CM3 but not with major relapse onset at M28. CONCLUSION These results suggest that drug monitoring could be useful to individualize the schedule of rituximab administration within the maintenance phase.
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Affiliation(s)
- Nihel Khoudour
- Department of Pharmacokinetics and Pharmacochemistry, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, CARPEM, Paris, France
| | - Florence Delestre
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fabienne Jabot-Hanin
- Bioinformatic Platform, INSERM UMR 1163, Institut Imagine, and Bioinformatics Core Facility, Structure Fédérative de Recherche Necker, INSERM US24/CNRS UMS 3633, Université Paris Cité, Paris, France
| | - Anne Jouinot
- Institut du Cancer Paris CARPEM, AP-HP, APHP Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, and INSERM U-1016, CNRS UMR-8104, Université Paris Cité, Institut Cochin, Paris, France
| | - Juliette Nectoux
- Fédération de Génétique et Médecine Génomique, Hôpital Cochin, AP-HP, Centre-Université Paris Cité, 27 rue du Faubourg-Saint-Jacques, Paris, France, and Université Paris Cité, Paris, France
| | - Franck Letouneur
- INSERM U-1016, CNRS UMR-8104, Université Paris Cité, Institut Cochin, Paris, France
| | - Brigitte Izac
- INSERM U-1016, CNRS UMR-8104, Université Paris Cité, Institut Cochin, Paris, France
| | - Michel Vidal
- Department of Pharmacokinetics and Pharmacochemistry, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, and Université Paris Cité, UMR8038 CNRS, U1268 INSERM, Faculté de Pharmacie, PRES Sorbonne Paris Cité, CARPEM, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Cité, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Cité, Paris, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Cité, Paris, France
| | - Benoit Blanchet
- Department of Pharmacokinetics and Pharmacochemistry, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, and Université Paris Cité, UMR8038 CNRS, U1268 INSERM, Faculté de Pharmacie, PRES Sorbonne Paris Cité, CARPEM, Paris, France
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Riva N, Brstilo L, Sancho-Araiz A, Molina M, Savransky A, Roffé G, Sanz M, Tenembaum S, Katsicas MM, Trocóniz IF, Schaiquevich P. Population Pharmacodynamic Modelling of the CD19+ Suppression Effects of Rituximab in Paediatric Patients with Neurological and Autoimmune Diseases. Pharmaceutics 2023; 15:2534. [PMID: 38004515 PMCID: PMC10674351 DOI: 10.3390/pharmaceutics15112534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/09/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Limited pharmacotherapy and the failure of conventional treatments in complex pathologies in children lead to increased off-label use of rituximab. We aimed to characterize the time course of CD19+ B lymphocytes (CD19+) under treatment with intravenous rituximab in children with neurologic and autoimmune diseases and to evaluate the impact of covariates (i.e., demographics, diagnosis and substitution between innovator and biosimilar product) on rituximab pharmacodynamics and disease activity. METHODS Pre- and post-drug infusion CD19+ in peripheral blood were prospectively registered. A population pharmacodynamic model describing the time course of CD19+ was developed with NONMEM v7.4. Simulations of three different rituximab regimens were performed to assess the impact on CD19+. Logistic regression analysis was performed to identify predictors of clinical response recorded through disease activity scores. RESULTS 281 measurements of CD19+ lymphocyte counts obtained from 63 children with neurologic (n = 36) and autoimmune (n = 27) diseases were available. The time course of CD19+ was described with a turn-over model in which the balance between synthesis and degradation rates is disrupted by rituximab, increasing the latter process. The model predicts half-lives (percent coefficient of variation, CV(%)) of rituximab and CD19+ of 11.6 days (17%) and 173.3 days (22%), respectively. No statistically significant effect was found between any of the studied covariates and model parameters (p > 0.05). Simulations of different regimens showed no clinically significant differences in terms of CD19+ repopulation times. A trend towards a lack of clinical response was observed in patients with lower CD19+ repopulation times and higher areas under the CD19+ versus time curve. CONCLUSIONS Rituximab pharmacodynamics was described in a real-world setting in children suffering from autoimmune and neurologic diseases. Diagnosis, substitution between innovator rituximab and its biosimilars or type of regimen did not affect rituximab-induced depletion of CD19+ nor the clinical response in this cohort of patients. According to this study, rituximab frequency and dosage may be chosen based on clinical convenience or safety reasons without affecting CD19+ repopulation times. Further studies in larger populations are required to confirm these results.
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Affiliation(s)
- Natalia Riva
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Sciences, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (A.S.-A.); (I.F.T.)
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (L.B.); (M.M.); (P.S.)
- National Council of Scientific and Technical Research (CONICET), Buenos Aires C1425 FQB, Argentina
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
| | - Lucas Brstilo
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (L.B.); (M.M.); (P.S.)
- National Council of Scientific and Technical Research (CONICET), Buenos Aires C1425 FQB, Argentina
| | - Aymara Sancho-Araiz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Sciences, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (A.S.-A.); (I.F.T.)
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (L.B.); (M.M.); (P.S.)
| | - Manuel Molina
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (L.B.); (M.M.); (P.S.)
| | - Andrea Savransky
- Neurology Service, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (A.S.); (S.T.)
| | - Georgina Roffé
- Laboratory of Cellular Immunology, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (G.R.); (M.S.)
| | - Marianela Sanz
- Laboratory of Cellular Immunology, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (G.R.); (M.S.)
| | - Silvia Tenembaum
- Neurology Service, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (A.S.); (S.T.)
| | - Maria M. Katsicas
- Immunology and Rheumatology Service, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina;
| | - Iñaki F. Trocóniz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Sciences, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (A.S.-A.); (I.F.T.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
- Institute of Data Science and Artificial Intelligence, DATAI, University of Navarra, 31009 Pamplona, Spain
| | - Paula Schaiquevich
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires C1245 CABA, Argentina; (L.B.); (M.M.); (P.S.)
- National Council of Scientific and Technical Research (CONICET), Buenos Aires C1425 FQB, Argentina
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Lobet S, Paintaud G, Azzopardi N, Passot C, Caulet M, Chautard R, Desvignes C, Capitain O, Tougeron D, Lecomte T, Ternant D. Relationship Between Cetuximab Target-Mediated Pharmacokinetics and Progression-Free Survival in Metastatic Colorectal Cancer Patients. Clin Pharmacokinet 2023; 62:1263-1274. [PMID: 37442917 DOI: 10.1007/s40262-023-01270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Cetuximab, an anti-epidermal growth factor receptor (EGFR) monoclonal immunoglobulin (Ig)G1 antibody, has been approved for the treatment of metastatic colorectal cancer (mCRC). The influence of target-antigen on cetuximab pharmacokinetics has never been investigated using target-mediated drug disposition (TMDD) modelling. This study aimed to investigate the relationship between cetuximab concentrations, target kinetics and progression-free survival (PFS). METHODS In this ancillary study (NCT00559741), 91 patients with mCRC treated with cetuximab were assessed. Influence of target levels on cetuximab pharmacokinetics was described using TMDD modelling. The relationship between cetuximab concentrations, target kinetics and time-to-progression (TTP) was described using a joint pharmacokinetic-TTP model, where unbound target levels were assumed to influence hazard of progression by an Emax model. Mitigation strategies of concentration-response relationship, i.e., time-varying endogenous clearance and mutual influences of clearance and time-to-progression were investigated. RESULTS Cetuximab concentration-time data were satisfactorily described using the TMDD model with quasi-steady-state approximation and time-varying endogenous clearance. Estimated target parameters were baseline target levels (R0 = 43 nM), and complex elimination rate constant (kint = 0.95 day-1). Estimated time-varying clearance parameters were time-invariant component of CL (CL0= 0.38 L/day-1), time-variant component of CL (CL1= 0.058 L/day-1) and first-order rate of CL1 decreasing over time (kdes = 0.049 day-1). Part of concentration-TTP was TTP-driven, where clearance and TTP were inversely correlated. In addition, increased target occupancy was associated with increased TTP. CONCLUSION This is the first study describing the complex relationship between cetuximab target-mediated pharmacokinetics and PFS in mCRC patients using a joint PK-time-to-progression model. Further studies are needed to provide a more in-depth description of this relationship.
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Affiliation(s)
- Sarah Lobet
- Inserm UMR 1069, Nutrition Croissance et Cancer (N2C), Tours University, Tours, France
| | - Gilles Paintaud
- EA4245 Transplantation, Immunologie, Inflammation (T2i), Tours University, Tours, France
- Centre Pilote de suivi Biologique des traitements par Anticorps (CePiBAc), Tours University Hospital, Tours, France
- Pharmacology-Toxicology Department, Tours University Hospital, Tours, France
| | | | - Christophe Passot
- Oncopharmacology-Pharmacogenetics Department INSERM U892, Institut de Cancérologie de l'Ouest site Paul Papin, Angers, France
| | - Morgane Caulet
- Gastroenterology and Digestive oncology Department, Tours University Hospital, Tours, France
| | - Romain Chautard
- Inserm UMR 1069, Nutrition Croissance et Cancer (N2C), Tours University, Tours, France
- Gastroenterology and Digestive oncology Department, Tours University Hospital, Tours, France
| | - Céline Desvignes
- EA4245 Transplantation, Immunologie, Inflammation (T2i), Tours University, Tours, France
- Centre Pilote de suivi Biologique des traitements par Anticorps (CePiBAc), Tours University Hospital, Tours, France
| | - Olivier Capitain
- Oncopharmacology-Pharmacogenetics Department INSERM U892, Institut de Cancérologie de l'Ouest site Paul Papin, Angers, France
| | - David Tougeron
- Gastroenterology Department, Poitiers University Hospital, Poitiers, France
- PRoDiCeT, Poitiers University, Poitiers, France
| | - Thierry Lecomte
- Inserm UMR 1069, Nutrition Croissance et Cancer (N2C), Tours University, Tours, France
- Gastroenterology and Digestive oncology Department, Tours University Hospital, Tours, France
| | - David Ternant
- EA4245 Transplantation, Immunologie, Inflammation (T2i), Tours University, Tours, France.
- Centre Pilote de suivi Biologique des traitements par Anticorps (CePiBAc), Tours University Hospital, Tours, France.
- Pharmacology-Toxicology Department, Tours University Hospital, Tours, France.
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Hartinger JM, Kratky V, Hruskova Z, Slanar O, Tesar V. Implications of rituximab pharmacokinetic and pharmacodynamic alterations in various immune-mediated glomerulopathies and potential anti-CD20 therapy alternatives. Front Immunol 2022; 13:1024068. [PMID: 36420256 PMCID: PMC9676507 DOI: 10.3389/fimmu.2022.1024068] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
The specific B-cell depleting anti-CD20 monoclonal antibody rituximab (RTX) is effective in terms of the treatment of various immune-mediated glomerulopathies. The administration of RTX has been shown to be reliable and highly effective particularly in patients with ANCA-associated vasculitis, which is manifested predominantly with non-nephrotic proteinuria. Stable long-term B-cell depletion is usually readily attained in such patients using standard dosing regimens. However, in patients with nephrotic syndrome and non-selective proteinuria, the RTX pharmacokinetics is altered profoundly and RTX does not maintain high enough levels for a sufficiently long period, which may render RTX treatment ineffective. Since complement-derived cytotoxicity is one of the important modes of action of RTX, hypocomplementemia, frequently associated with systemic lupus erythematodes, may act to hamper the efficacy of RTX in the treatment of patients with lupus nephritis. This review provides a description of RTX pharmacokinetics and pharmacodynamics in several selected glomerulopathies, as well as the impact of proteinuria, anti-drug antibodies and other clinical variables on the clearance and volume of distribution of RTX. The impact of plasmapheresis and peritoneal dialysis on the clearance of RTX is also discussed in the paper. A review is provided of the potential association between pharmacokinetic and pharmacodynamic alterations in various kidney-affecting glomerular diseases, the sustainability of B-cell depletion and the clinical efficacy of RTX, with proposals for potential dosing implications. The role of therapeutic drug monitoring in treatment tailoring is also discussed, and various previously tested RTX dosing schedules are compared in terms of their clinical and laboratory treatment responses. Since alternative anti-CD20 molecules may prove effective in RTX unresponsive patients, their pharmacokinetics, pharmacodynamics and current role in the treatment of glomerulopathies are also mentioned.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
- *Correspondence: Jan Miroslav Hartinger,
| | - Vojtech Kratky
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Ondrej Slanar
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
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