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Venturelli V, Isenberg DA. Targeted Therapy for SLE-What Works, What Doesn't, What's Next. J Clin Med 2023; 12:jcm12093198. [PMID: 37176637 PMCID: PMC10179673 DOI: 10.3390/jcm12093198] [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: 03/28/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
For many years, the failure of randomized controlled trials (RCTs) has prevented patients with systemic lupus erythematosus (SLE) from benefiting from biological drugs that have proved to be effective in other rheumatological diseases. Only two biologics are approved for SLE, however they can only be administered to a restricted proportion of patients. Recently, several phase II RCTs have evaluated the efficacy and safety of new biologics in extra-renal SLE and lupus nephritis. Six drug trials have reported encouraging results, with an improvement in multiple clinical and serological outcome measures. The possibility of combining B-cell depletion and anti-BLyS treatment has also been successfully explored.
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Affiliation(s)
- Veronica Venturelli
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, 44124 Cona, Italy
| | - David Alan Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London WC1E 6JF, UK
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Choi SJ, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Initial Preserved Renal Function as a Predictor of Favorable Renal Response to Rituximab in Refractory or Relapsing Lupus Nephritis: A Single-center Cohort Study in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:22-32. [PMID: 37476702 PMCID: PMC10324915 DOI: 10.4078/jrd.2022.29.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Previous studies investigating the beneficial effect of rituximab on lupus nephritis (LN) reported controversial results There have been few reports of renal response to rituximab according to renal function We investigated the efficacy of rituximab in refractory/relapsing LN and the role of renal function as a predictor of renal response. METHODS From 2016 to 2019, we retrospectively reviewed 22 patients with refractory/relapsing LN receiving rituximab Renal responses (complete and partial) at 6 and 12 months were compared between normal (glomerular filtration rate [GFR]≥90 mL/min/173 m2, n=11) and decreased (GFR<90 mL/min/173 m2, n=11) GFR groups Multivariate Cox regression analysis was used to assess predictors of renal response. RESULTS At baseline, the decreased GFR group had a higher urine proteinuria to creatinine ratio (p=0008) and proportion of refractory LN (p=0010) and previous cyclophosphamide therapy (p=0035) than the normal GFR group The overall renal response rate was 455% (10 patients) at 6 months and 545% (12 patients) at 12 months Renal response rates were higher in the normal GFR group (818% and 909% at 6 and 12 months, respectively) than in the decreased GFR group (91% and 182% at 6 and 12 months, respectively; p<0001) Normal GFR and anti-La were associated with renal response to rituximab, with hazard ratios of 9256 (p=0008) and 5478 (p=0041), respectively. CONCLUSION Rituximab is an effective therapy for refractory/relapsing LN, particularly in patients with preserved renal function.
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Affiliation(s)
- Su Jin Choi
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Rheumatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Tsang-A-Sjoe MWP, Bultink IEM. New developments in systemic lupus erythematosus. Rheumatology (Oxford) 2021; 60:vi21-vi28. [PMID: 34951924 PMCID: PMC8709564 DOI: 10.1093/rheumatology/keab498] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
In this review, the results of recent and ongoing clinical trials in patients with SLE are discussed. After many unsuccessful trials in the past decade, belimumab was the first biologic specifically designed for SLE that met its primary end point. At the same time, studies on the pathophysiology of SLE have further elucidated the pathways involved in the disease, which has led to the identification of new possible therapeutics and has encouraged the initiation of new trials. These new drugs include biologics that target B cells, T cells and type 1 interferons, and small molecules that inhibit kinases. Other therapeutics aim to restore immunological balance by restoring tolerance. Results from phase II and even phase III trials are promising and it is likely that some of the therapeutics discussed will receive approval in the following years. Hopefully, this will allow for more tailor-made medicine for SLE patients in the future.
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Affiliation(s)
- Michel W. P. Tsang-A-Sjoe
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Irene E. M. Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Goulden B, Isenberg D. Anti-IFNαR Mabs for the treatment of systemic lupus erythematosus. Expert Opin Biol Ther 2020; 21:519-528. [PMID: 33085537 DOI: 10.1080/14712598.2021.1841164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The type 1 interferon pathway is known to play a role in the immunopathology of systemic lupus erythematosus (SLE). As a result, biologic agents targeting this pathway have been developed and are currently being investigated in clinical trials. AREAS COVERED We review the biologic agents which have been developed to antagonize type I interferons in SLE. We focus on anifrolumab, a type I interferon receptor antagonist, and consider the complexities of defining efficacy in SLE clinical trials. EXPERT OPINION Anifrolumab shows promise as an addition to the SLE therapeutic armamentarium. Despite discordant results between its two phase III studies, there is a convincing suggestion of benefit in both trials to encourage the view that this approach might be effective. Data acquired thus far look particularly useful for cutaneous disease. We await data on its effect on renal, pulmonary, cardiac, and central nervous system involvement, on patient reported outcomes, and its safety and efficacy with long-term use.
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Affiliation(s)
- Bethan Goulden
- Rheumatology Department, University College London, London, UK
| | - David Isenberg
- Rheumatology Department, University College London, London, UK
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Murphy G, Isenberg DA. New therapies for systemic lupus erythematosus - past imperfect, future tense. Nat Rev Rheumatol 2020; 15:403-412. [PMID: 31165780 DOI: 10.1038/s41584-019-0235-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The failure of many new, mostly biologic, drugs to meet their primary end points in double-blind clinical trials in patients with systemic lupus erythematosus (SLE) has caused a profound sense of disappointment among both physicians and patients. Arguably, the success of B cell depletion with rituximab in open-label clinical trials, the approval of belimumab (which blocks B cell-activating factor (BAFF)) for use in patients with lupus nephritis in the USA and in difficult-to-treat patients with SLE in the UK and the recognition that clinical trial design can be improved have given some cause for hope. However, changes to therapies in current use and the development of new approaches are urgently needed. The results of the latest studies investigating the use of several new approaches to treating SLE are discussed in this Review, including: fully humanized anti-CD20 and anti-CD19 monoclonal antibodies; inhibition of tyrosine-protein kinase BTK; CD40 ligand blockade; interfering with the presentation of antigen to autoreactive T cells using a peptide approach; a receptor decoy approach using an analogue of Fcγ receptor IIB; dual blockade of IL-12 and IL-23; and inhibition of Janus kinases.
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Affiliation(s)
- Grainne Murphy
- Department of Rheumatology, Cork University Hospital, Cork, Ireland
| | - David A Isenberg
- Centre for Rheumatology/Division of Medicine, University College London, London, UK.
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Hennessey A, Lukawska J, Cambridge G, Isenberg D, Leandro M. Adverse infusion reactions to rituximab in systemic lupus erythematosus: a retrospective analysis. BMC Rheumatol 2019; 3:32. [PMID: 31485560 PMCID: PMC6714312 DOI: 10.1186/s41927-019-0082-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 07/24/2019] [Indexed: 01/09/2023] Open
Abstract
Background To undertake a retrospective review of patients with SLE who had received Rituximab in order to determine the rates and associated patient characteristics of clinically significant adverse infusion reactions. Methods A descriptive analysis was undertaken of each infusion reaction, which was then assessed using the clinical information available to hypothesise on the possible underlying mechanism(s). Results Records of 136 SLE patients previously treated with 481 individual infusions of Rituximab were reviewed. A total of 22 patients (17.6%) had 28 (5.8% of total infusions) documented clinically significant adverse infusion reactions. Average age at first Rituximab infusion in patients without a reaction was 37 years (range 16–73) compared with 30 years (range 18–56) in those with a reaction. A high proportion of men (18.2%) experienced an infusion reaction. Severity and type of reaction varied. 6.4% of those who had a reaction were not retreated. Conclusions While Rituximab remains an important tool in the treatment of SLE it is important to be aware that rates of infusion reactions may be more significant in SLE than in other diseases. A prospective study is required to better characterise the reactions.
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Affiliation(s)
- Ashleigh Hennessey
- Rheumatology Department, Royal Brisbane and Women's Hopsital, Herston, Brisbane, Queensland 4006 Australia.,2University of Queensland School of Medicine, Herston, Brisbane, Queensland 4006 Australia
| | - Joanna Lukawska
- 3Allergy Medicine, University College London Hospitals, London, UK
| | - Geraldine Cambridge
- 4Centre for Rheumatology and Bloomsbury Rheumatology Unit, University College London, London, UK
| | - David Isenberg
- 5Division of Rheumatology, Department of Medicine, University College London Hospitals & Centre for Rheumatology, London, UK.,6Bloomsbury, Rheumatology Unit, University College London, London, UK
| | - Maria Leandro
- 5Division of Rheumatology, Department of Medicine, University College London Hospitals & Centre for Rheumatology, London, UK.,6Bloomsbury, Rheumatology Unit, University College London, London, UK
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Sin FE, Isenberg D. An evaluation of voclosporin for the treatment of lupus nephritis. Expert Opin Pharmacother 2018; 19:1613-1621. [DOI: 10.1080/14656566.2018.1516751] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Fang En Sin
- Rheumatology Department, University College Hospital London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Iwata S, Saito K, Hirata S, Ohkubo N, Nakayamada S, Nakano K, Hanami K, Kubo S, Miyagawa I, Yoshikawa M, Miyazaki Y, Yoshinari H, Tanaka Y. Efficacy and safety of anti-CD20 antibody rituximab for patients with refractory systemic lupus erythematosus. Lupus 2018; 27:802-811. [DOI: 10.1177/0961203317749047] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective We examined the efficacy and safety of rituximab in patients with refractory systemic lupus erythematosus (SLE). Methods The study enrolled 63 SLE patients who were treated with rituximab between 2002 and 2015. The participants underwent a battery of tests before treatment and at one year. Treatment ranged from two to four times at 500 or 1000 mg. Results Baseline characteristics were males:females = 6:57, age 33.9 years, and disease duration 87.2 months. The primary endpoint: The rate of major clinical response (MCR) was 60% while the partial clinical response (PCR) was 25%. Thirty of 36 (83%) patients with lupus nephritis (WHO II: 2, III: 5, IV: 22, V: 4, IV+V: 2, not assessed: 1) and 22 of 24 patients (92%) with neuropsychiatric SLE, who could be followed at one year, showed changes from BILAG A or B score to C or D score at one year. Multivariate analysis identified high anti-dsDNA antibody and shorter disease duration as significant determinants of MCR at one year. Repeat examination was conducted at five years. Primary failure was recorded in 8.8% and secondary failure in 32.4% (time to relapse: 24.4 months). Rituximab was well tolerated although 65 adverse events, mostly infections, were recorded within one year. Conclusion Rituximab is potentially efficacious for the treatment of patients with refractory SLE.
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Affiliation(s)
- S Iwata
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - K Saito
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - S Hirata
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - N Ohkubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - S Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - K Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - K Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - S Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - I Miyagawa
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - M Yoshikawa
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - Y Miyazaki
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - H Yoshinari
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | - Y Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational & Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
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Aguiar R, Araújo C, Martins-Coelho G, Isenberg D. Use of Rituximab in Systemic Lupus Erythematosus: A Single Center Experience Over 14 Years. Arthritis Care Res (Hoboken) 2017; 69:257-262. [DOI: 10.1002/acr.22921] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/16/2016] [Accepted: 04/19/2016] [Indexed: 01/03/2023]
Affiliation(s)
- R. Aguiar
- Centro Hospitalar do Baixo Vouga EPE; Aveiro Portugal
| | - C. Araújo
- Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central EPE; Lisbon Portugal
| | - G. Martins-Coelho
- Baixo Vouga Group of Primary Care Centers and University of Porto Medical School; Porto Portugal
| | - D. Isenberg
- Centre for Rheumatology Research, University College of London Hospital; London UK
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Mota P, Reddy V, Isenberg D. Improving B-cell depletion in systemic lupus erythematosus and rheumatoid arthritis. Expert Rev Clin Immunol 2016; 13:667-676. [PMID: 27841031 DOI: 10.1080/1744666x.2017.1259068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Rituximab-based B-cell depletion (BCD) therapy is effective in refractory rheumatoid arthritis (RA) and although used to treat patients with refractory systemic lupus erythematosus (SLE) in routine clinical practice, rituximab failed to meet the primary endpoints in two large randomised controlled trials (RCTs) of non-renal (EXPLORER) and renal (LUNAR) SLE. Areas covered: We review how BCD could be improved to achieve better clinical responses in RA and SLE. Insights into the variability in clinical response to BCD in RA and SLE may help develop new therapeutic strategies. To this end, a literature search was performed using the following terms: rheumatoid arthritis, systemic erythematosus lupus, rituximab and B-cell depletion. Expert commentary: Poor trial design may have, at least partly, contributed to the apparent lack of response to BCD in the two RCTs of patients with SLE. Enhanced B-cell depletion and/or sequential therapy with belimumab may improve clinical response at least in some patients with SLE.
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Affiliation(s)
- Pedro Mota
- a Department of Internal Medicine , Hospital da Luz , Lisbon , Portugal
| | - Venkat Reddy
- b Centre for Rheumatology, Division of Medicine , University College London , London , UK
| | - David Isenberg
- b Centre for Rheumatology, Division of Medicine , University College London , London , UK
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Isenberg DA, Merrill JT. Why, why, why de-lupus (does so badly in clinical trials). Expert Rev Clin Immunol 2016; 12:95-8. [PMID: 26786849 DOI: 10.1586/1744666x.2016.1112270] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David A Isenberg
- a Centre for Rheumatology, Department of Medicine , University College London , London , UK
| | - Joan T Merrill
- b Clinical Pharmacology Research Program , Oklahoma Medical Research Foundation , Oklahoma City , OK , USA
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