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Klaus R, Kanzelmeyer N, Haffner D, Lange-Sperandio B. Outcome of rituximab treatment in children with non-dialysis-dependent anti-GBM disease. Pediatr Nephrol 2024:10.1007/s00467-024-06512-4. [PMID: 39320552 DOI: 10.1007/s00467-024-06512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/13/2024] [Accepted: 08/19/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Anti-GBM disease is a rare vasculitis mediated by pathogenic antibodies against collagen IV. Anti-GBM disease presents with rapid progressive glomerulonephritis and leads to kidney failure if untreated. KDIGO recommends plasma exchanges (PEX) for antibody elimination and steroids plus cyclophosphamide (CTX) to suppress antibody production. CTX is associated with severe side effects including gonadal toxicity. Rituximab (RTX) and mycophenolate mofetil (MMF) might be a less toxic but equally efficient alternative to CTX. Studies in pediatric anti-GBM disease patients receiving RTX and MMF instead of CTX are lacking. METHODS A retrospective survey in 8 tertiary German centers was performed. The clinical data of patients diagnosed between 2014 and 2022 were collected and analyzed. RESULTS Five adolescent patients treated with PEX and RTX and/or MMF due to anti-GBM disease were analyzed. All patients had anti-GBM antibodies, hematuria, glomerular proteinuria, and pulmonary hemorrhage. eGFR was 124 ml/min/1.73 m2 (range 47-162), and all patients were non-dialysis-dependent but with relevant histological kidney affection (mean crescents on kidney biopsy 77%). Antibody clearance was achieved after 13 PEX cycles (range 6-31). Four out of 5 patients received methylprednisolone pulses. All patients received oral prednisolone and MMF, and four patients received a median of 4 RTX doses (range 2-4). After a mean follow-up of 27 months, 4/5 patients had conserved or improved kidney function, while one patient (20%) developed kidney failure. CONCLUSIONS In this small series of pediatric non-dialysis-dependent anti-GBM disease patients, first-line treatment with RTX and MMF showed a favorable kidney outcome in 4/5 cases and had an acceptable side effect profile.
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Affiliation(s)
- Richard Klaus
- Department of Pediatrics, Dr. v. Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nele Kanzelmeyer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Bärbel Lange-Sperandio
- Department of Pediatrics, Dr. v. Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany.
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2
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Mu F, Bai X, Lou Y, Luo P, Guo Q. Rituximab alleviates pediatric systemic lupus erythematosus associated refractory immune thrombocytopenia: a case-based review. Immunol Res 2024; 72:503-511. [PMID: 38279058 DOI: 10.1007/s12026-024-09454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/10/2024] [Indexed: 01/28/2024]
Abstract
A complication of pediatric systemic lupus erythematosus (pSLE) is immune thrombocytopenia (ITP). Although corticosteroids and immunoglobulins are frequently used as preliminary treatments, some patients do not respond to them. Rituximab has been reported to be safe and effective in the treatment of pSLE complicated with refractory ITP. Research is currently underway to determine the optimal rituximab dose for these individuals. We report a case of a child with SLE-associated ITP (SLE-ITP) who was successfully treated with rituximab. Rituximab is likely the most viable therapeutic option for refractory SLE-ITP. Furthermore, a comprehensive review of the relevant literature was performed and a concise overview of the pathogenesis and available treatment modalities for pediatric patients diagnosed with SLE and concurrent ITP was provided.
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Affiliation(s)
- Fangxin Mu
- Department of Nephrology and Rheumatology, The Second Hospital of Jilin University, Changchun, Jilin, 130041, China
| | - Xue Bai
- Department of Nephrology and Rheumatology, The Second Hospital of Jilin University, Changchun, Jilin, 130041, China
| | - Yan Lou
- Department of Nephrology and Rheumatology, The Second Hospital of Jilin University, Changchun, Jilin, 130041, China
| | - Ping Luo
- Department of Nephrology and Rheumatology, The Second Hospital of Jilin University, Changchun, Jilin, 130041, China
| | - Qiaoyan Guo
- Department of Nephrology and Rheumatology, The Second Hospital of Jilin University, Changchun, Jilin, 130041, China.
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3
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Ünal A, Leventoğlu E, Bakkaloğlu SA. Rituximab use in paediatric nephrology practice in Türkiye: TRTX. Nephrology (Carlton) 2024; 29:259-267. [PMID: 38113869 DOI: 10.1111/nep.14265] [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: 09/16/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023]
Abstract
AIM Rituximab (RTX) is a genetically engineered chimeric monoclonal antibody which binds directly to CD20 antigen and mediates inhibition of B cell development. Although RTX has been widely used in paediatric nephrology, there is no routine protocol for its use. In this study, paediatric nephrologists in Türkiye were asked to fill out a questionnaire to understand their practice in using RTX. This study aimed to determine common practices and clarify the uncertainties regarding the use of RTX in paediatric nephrology. METHODS This was a nationwide, multicenter, retrospective cohort study based on data evaluating the use of RTX in paediatric nephrology practice. An online questionnaire was sent to all paediatric nephrology centers in Türkiye. The questionnaire forms included information about how many patients in total applied RTX treatment, for which indications they use RTX, and whether they made any preparations before using RTX. RESULTS According to this survey on RTX use in Türkiye, paediatric nephrologists use it most commonly in SSNS and followed by SRNS, ABMR, SLE and AAV, respectively. Dosing was highly standard but there is significant heterogeneity in pre-exposure tests and patient monitoring in the clinical practice of RTX. Also, the rate of encountering RTX-related allergic and infectious side effects at least once during the professional experience of our physicians can be quite high. CONCLUSION There is an increasing need for the preparation of a guideline on the indications for RTX use for each diagnosis, posology, and the practices to be performed before and after infusion.
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Affiliation(s)
- Ahmet Ünal
- Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Emre Leventoğlu
- Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
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4
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Labouret M, Trebossen V, Ntorkou A, Bartoli S, Aubart M, Auvin S, Bader-Meunier B, Baudouin V, Corseri O, Dingulu G, Ducrocq C, Dumaine C, Elmaleh M, Fabien N, Faye A, Hau I, Hentgen V, Kwon T, Meinzer U, Ouldali N, Parmentier C, Pouletty M, Renaldo F, Savioz I, Benoist JF, Le Roux E, Ellul P, Melki I. Juvenile neuropsychiatric systemic lupus erythematosus: A specific clinical phenotype and proposal of a probability score. Lupus 2024; 33:328-339. [PMID: 38315109 DOI: 10.1177/09612033241229022] [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] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Juvenile systemic lupus erythematosus (j-SLE) is a rare chronic auto-immune disease involving several organs. Neuropsychiatric (NP) SLE (NPSLE) is frequent in j-SLE and associated with increased morbidity/mortality. Although NPSLE classification criteria exist, attributing NP features to j-SLE remains a major challenge. The study objective is to thoroughly describe j-NPSLE patients and assist in their diagnosis. METHODS This is a 4-year retrospective monocentric study of j-SLE patients. NP events were attributed to j-SLE using standardised diagnostic criteria and multidisciplinary paediatric clinical expertise. Clinical features, brain magnetic resonance imaging (MRI)s and samples analysis including cerebrospinal fluid were assessed. A risk of j-NPSLE score was developed based on multivariable logistic regression analysis. RESULTS Of 39 patients included, 44% were identified as having j-NPSLE. J-NPSLE diagnosis was established at the onset of j-SLE in 59% of patients. In addition to frequent kidney involvement (76%) and chilblains (65%), all j-NPSLE patients displayed psychiatric features: cognitive symptoms (82%), hallucinations (76%), depressed mood (35%), acute confused state (18%) and catatonia (12%). Neurological involvement was often mild and nonspecific, with headache (53%) in about half of the patients. The main features reported on brain MRI were nonspecific T2/FLAIR white matter hyperintensities (65%), and cerebral atrophy (88%). Upon immunosuppressive treatment, clinical improvement of NP features was observed in all j-NPSLE patients. The score developed to attribute j-NPSLE probability, guide further investigations and appropriate treatments is based on hallucinations, memory, sleep and renal involvement (Sensitivity: 0.95 Specificity: 0.85). Cerebrospinal fluid (CSF) neopterin assessment increases the score sensitivity and specificity. CONCLUSION Physicians should carefully and systematically assess the presence of NP features at diagnosis and early stages of j-SLE. For j-NPSLE patients with predominant psychiatric features, a multidisciplinary collaboration, including psychiatrists, is essential for the diagnosis, management and follow-up.
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Affiliation(s)
- Mathilde Labouret
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Sorbonne Université, Paris, France
| | - Vincent Trebossen
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Alexandra Ntorkou
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Sophie Bartoli
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Mélodie Aubart
- Paediatric Neurology Department, Necker-Enfants Malades Hospital, University of Paris-Cité, AP-HP, Paris, France
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, French Institute of Health and Medical Research U1163, Imagine Institute, University of Paris-Cité, Paris, France
| | - Stéphane Auvin
- Department of Paediatric Neurology, Center for Rare Epilepsies & Epilepsy Unit, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Institut Universitaire de France (IUF), Paris, France
| | - Brigitte Bader-Meunier
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Laboratory of Immunogenetics of Paediatric Autoimmune Diseases, Imagine Institute, INSERM UMR 1163, Université Paris Cité, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Olivier Corseri
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Glory Dingulu
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Camille Ducrocq
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Cécile Dumaine
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Monique Elmaleh
- Department of Paediatric Radiology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Nicole Fabien
- Immunology Department, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Albert Faye
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- UMR1123 Inserm, Université Paris Cité, Paris, France
| | - Isabelle Hau
- Department of General Paediatrics, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Véronique Hentgen
- Department of General Paediatrics, French Reference centre for Autoinflammatory diseases and amyloidosis (CEREMAIA), Versailles Hospital, Le Chesnay, France
| | - Théresa Kwon
- Department of Paediatric Nephrology, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
| | - Ulrich Meinzer
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
- Center for Research on Inflammation, INSERM, Université Paris Cité, Paris, France
- Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France
| | - Naim Ouldali
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Université Paris Cité, UFR de Médecine Paris Nord, Paris, France
| | - Cyrielle Parmentier
- Department of Paediatric Nephrology, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Marie Pouletty
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Florence Renaldo
- Department of Paediatric Neurology, Center for Neurogenetic Diseases, Armand-Trousseau Childrens' Hospital, AP-HP, Paris, France
| | - Isabelle Savioz
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
| | - Jean-François Benoist
- Metabolic Biochemistry Laboratory, Reference Centre for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, AP-HP, Paris, France
- Université Paris Saclay, UFR Pharmacie, France
| | - Enora Le Roux
- UMR1123 Inserm, Université Paris Cité, Paris, France
- Unité d'Épidémiologie Clinique, Inserm, CIC 1426, Robert Debré Mother-Child University Hospital, Nord-Université Paris Cité, AP-HP, Paris, France
| | - Pierre Ellul
- Department of Child and Adolescent Psychiatry, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Immunology-Immunopathology-Immunotherapy (i3), Sorbonne Université, Paris, France
| | - Isabelle Melki
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Department of Paediatric Haematology-Immunology And Rheumatology, Necker-Enfants-Malades University Hospital, Reference Centre for Rheumatic, AutoImmune and Systemic Diseases in Children (RAISE), AP-HP, Paris, France
- Imagine Institute, Laboratory of Neurogenetics and Neuroinflammation, INSERM UMR 1163, Université Paris Cité, Paris, France
- Paediatrics, Rheumatology and Paediatric Internal Medicine, Children's Hospital, Bordeaux, France
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Kalashnikova E, Isupova E, Gaidar E, Sorokina L, Kaneva M, Masalova V, Dubko M, Kornishina T, Lubimova N, Kuchinskaya E, Chikova I, Raupov R, Kalashnikova O, Kostik M. BCD020 rituximab bioanalog compared to standard treatment in juvenile systemic lupus erythematosus: The data of 12 months case-control study. World J Clin Pediatr 2024; 13:89049. [PMID: 38596443 PMCID: PMC11000064 DOI: 10.5409/wjcp.v13.i1.89049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/02/2024] [Accepted: 01/30/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is the most frequent and serious systemic connective tissue disease. Nowadays there is no clear guidance on its treatment in childhood. There are a lot of negative effects of standard-of-care treatment (SOCT), including steroid toxicity. Rituximab (RTX) is the biological B-lymphocyte-depleting agent suggested as a basic therapy in pediatric SLE. AIM To compare the benefits of RTX above SOCT. METHODS The data from case histories of 79 children from the Saint-Petersburg State Pediatric Medical University from 2012 to 2022 years, were analyzed. The diagnosis of SLE was established with SLICC criteria. We compared the outcomes of treatment of SLE in children treated with and without RTX. Laboratory data, doses of glucocorticosteroids, disease activity measured with SELENA-SLEDAI, and organ damage were assessed at the time of initiation of therapy and one year later. RESULTS Patients, treated with RTX initially had a higher degree of disease activity with prevalence of central nervous system and kidney involvement, compared to patients with SOCT. One year later the disease characteristics became similar between groups with a more marked reduction of disease activity (SELENA-SLEDAI activity index) in the children who received RTX [-19 points (17; 23) since baseline] compared to children with SOCT [-10 (5; 15.5) points since baseline, P = 0.001], the number of patients with active lupus nephritis, and daily proteinuria. During RTX therapy, infectious diseases had three patients; one patient developed a bi-cytopenia. CONCLUSION RTX can be considered as the option in the treatment of severe forms of SLE, due to its ability to arrest disease activity compared to SOCT.
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Affiliation(s)
- Elvira Kalashnikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Eugenia Isupova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Ekaterina Gaidar
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Lyubov Sorokina
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Maria Kaneva
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Vera Masalova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Margarita Dubko
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Tatiana Kornishina
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Natalia Lubimova
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
| | - Ekaterina Kuchinskaya
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
| | - Irina Chikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Rinat Raupov
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
- Department of Rheumatology, Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery, Saint-Petetrsburg 197136, Russia
| | - Olga Kalashnikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Mikhail Kostik
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
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6
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Elshaer R, Jaber S, Odeh N, Arbili L, Al-Mayouf SM. Safety and efficacy of biologics in childhood systemic lupus erythematosus: a critical systematic review. Clin Rheumatol 2024; 43:863-877. [PMID: 38079010 DOI: 10.1007/s10067-023-06833-z] [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: 08/18/2023] [Revised: 10/20/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
Biologic agents are increasingly being used to treat adult patients with systemic lupus erythematosus (SLE). However, the available data on biologic agents' use in childhood-onset SLE (cSLE) remains limited. To collate available evidence related to the efficacy and safety of using biologic agents in cSLE. The study followed the PRISMA checklist for reporting the data and conducted a thorough search using PubMed, Cochrane Library, and Scopus from January 2005 to August 2023. Only articles meeting specific criteria were included, focusing on cSLE, the use of biologic agents, and having outcome measures at six- and 12-month follow-ups for safety and efficacy. Case reports were excluded, and four independent reviewers screened the articles for accuracy, with a fifth reviewer resolving any discrepancies that arose to achieve a consensus. The final selection included 18 studies with a total of 593 patients treated with biologic agents for severe and/ or refractory cSLE. The most common indication for using biologic agents was lupus nephritis. Rituximab was used in 12 studies, while belimumab was used in six studies. The studies evaluated the efficacy of biologic agents based on SLE disease activity scores, laboratory parameter improvements, and reduced corticosteroid dosage. Positive outcomes were reported, with improvements in renal, hematologic, and immunologic parameters along with mild adverse effects, mostly related to mild infections and infusion reactions. Belimumab and rituximab have shown promise as potential treatments for severe and refractory cSLE cases, leading to decreased disease activity and complete or partial remission in many patients with an acceptable safety profile. However, further research is needed to better understand their benefits and potential risks in these patients. Key Points • This review emphasizes the lack of sufficient randomized controlled trials exploring the use of biologics in childhood systemic lupus erythematosus (cSLE). • Treatment plans for cSLE are being derived from those used for adult systemic lupus erythematosus. • According to current evidence, belimumab and rituximab can be potential treatment options for refractory and severe cases of cSLE. • Additional studies are required to reach more definitive conclusions.
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Affiliation(s)
- Rawan Elshaer
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Samar Jaber
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nour Odeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Lana Arbili
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sulaiman M Al-Mayouf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Alfaisal University, Po Box 3354, 11211, Riyadh, Saudi Arabia.
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7
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Lin TW, Lin YT, Hu YC, Yu HH, Chiang BL. Rituximab as an effective add-on maintenance therapy for disease activities in childhood-onset systemic lupus erythematosus. Lupus Sci Med 2024; 11:e000987. [PMID: 38242722 PMCID: PMC10806525 DOI: 10.1136/lupus-2023-000987] [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: 06/27/2023] [Accepted: 12/23/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that can result in high morbidity if not treated. This retrospective study aimed to evaluate the outcomes of rituximab treatment in a paediatric SLE cohort in Taiwan. METHODS The medical records of paediatric patients diagnosed with SLE at the National Taiwan University Hospital between January 1992 and August 2022 who received rituximab as maintenance therapy between January 2015 and August 2022 were retrospectively reviewed. To enhance our analysis, we included a contemporary comparison group, matching in case number and demographic characteristics. This study aimed to describe the indications, efficacy and safety of rituximab in the treatment of paediatric SLE and to analyse the factors associated with disease outcomes. RESULTS The study included 40 rituximab-treated patients with a median age of 14.3 years at the time of disease diagnosis. In the rituximab-treated cohort, the median score on the Systemic Lupus Erythematosus Disease Activity Index 2000 decreased from 8 before rituximab administration to 4 after 2 years. The levels of C3 and C4 increased and anti-double stranded DNA (anti-dsDNA) levels decreased significantly within 6 months. The equivalent oral prednisolone dose halved after 6 months. Finally, 8 (20%) patients achieved disease control and 35 (87.5%) patients had no flare-ups during the follow-up period (median, 2 years). Those patients who achieved disease control had a significantly shorter interval between diagnosis and rituximab administration. In terms of adverse effects, only one patient developed hypogammaglobulinaemia that required intravenous immunoglobulin (IVIG) replacement. Compared with the comparison group (n=53), the rituximab-treated cohort exhibited superior disease outcomes and a reduced incidence of flare-ups. CONCLUSIONS This study provides real-world data and illuminates rituximab's role in maintaining disease stability among patients with paediatric-onset SLE who are serologically active without major clinical deterioration. Most importantly, no mortality or development of end-stage renal disease was observed in the rituximab-treated cohort.
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Affiliation(s)
- Ting-Wei Lin
- Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tsan Lin
- Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Chiao Hu
- Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Hui Yu
- Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, College of Life Science, National Taiwan University, Taipei, Taiwan
- Medical Research, National Taiwan University Hospital, Taipei, Taiwan
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8
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Natoli V, Charras A, Hahn G, Hedrich CM. Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus (jSLE). Mol Cell Pediatr 2023; 10:5. [PMID: 37556020 PMCID: PMC10412509 DOI: 10.1186/s40348-023-00161-7] [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: 04/27/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a rare autoimmune/inflammatory disease with significant morbidity and mortality. Approximately 15-20% of SLE patients develop the disease during childhood or adolescence (juvenile-onset SLE/jSLE). Patients with jSLE exhibit more variable and severe disease when compared to patients with disease-onset during adulthood. Neuropsychiatric (NP) involvement is a clinically heterogenous and potentially severe complication. Published reports on the incidence and prevalence of NP-jSLE are scarce, and the exact pathophysiology is poorly understood.This manuscript provides a review of the existing literature, suggesting NP involvement in 13.5-51% of jSLE patients. Among patients with NP-jSLE affecting the CNS, we propose two main subgroups: (i) a chronic progressive, predominantly type 1 interferon-driven form that poorly responds to currently used treatments, and (ii) an acutely aggressive form that usually presents early during the disease that may be primarily mediated by auto-reactive effector lymphocytes. While this hypothesis requires to be tested in large collaborative international cohort studies, it may offer future patient stratification and individualised care.
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Affiliation(s)
- Valentina Natoli
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Amandine Charras
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gabriele Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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9
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Brunner HI, Vadhariya A, Dickson C, Crandall W, Kar-Chan Choong C, Birt JA, Ruperto N, Ramanan AV. Treatment patterns in paediatric and adult patients with SLE: a retrospective claims database study in the USA. Lupus Sci Med 2023; 10:e000817. [PMID: 37429670 DOI: 10.1136/lupus-2022-000817] [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: 08/30/2022] [Accepted: 06/07/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To assess real-world treatment regimens and patterns in childhood-onset SLE (cSLE) and adult-onset SLE (aSLE) cohorts, including similarities in treatments, duration of use and adherence. METHODS This retrospective study utilised data from Merative L.P. MarketScan Research Databases (USA). Index date was the date of first SLE diagnosis (2010-2019). Patients aged <18 years (cSLE) and ≥18 years (aSLE) at index date with confirmed SLE diagnosis and ≥12 months continuous enrolment during pre-index and post-index periods were included. The cohorts were stratified based on the presence (existing) or absence (new) of pre-index SLE. Primary outcomes (post-index period) included treatment regimens (all patients), and adherence (proportion of days covered (PDC)) and discontinuation of therapies initiated within 90 days of diagnosis (new patients). Univariate comparisons between cSLE and aSLE cohorts were performed using Wilcoxon rank-sum and χ2 (or Fisher's exact) tests. RESULTS cSLE cohort included 1275 patients (mean age=14.1 years) and aSLE cohort included 66 326 patients (mean age=49.7 years). Antimalarials and glucocorticoids were commonly used among new (cSLE=64.4%/62.0%; aSLE=51.8%/49.7%) and existing (cSLE=68.6%/58.9%; aSLE=63.8%/51.3%) patients in both cohorts. Median oral glucocorticoid dose (prednisone equivalent) was higher in cSLE vs aSLE (new=22.1 vs 14.0 mg/day; existing=14.4 vs 12.3 mg/day; p<0.05). Mycophenolate mofetil use was higher in patients with cSLE vs aSLE (new=26.2% vs 5.8%; existing=37.6% vs 11.0%; p<0.0001). Compared with aSLE, more patients used combination therapies in cSLE (p<0.0001). Median PDC was higher in cSLE vs aSLE for antimalarials (0.9 vs 0.8; p<0.0001) and oral glucocorticoids (0.6 vs 0.3; p<0.0001). Treatment discontinuation was lower in cSLE vs aSLE for antimalarials (25.0% vs 33.1%; p<0.0001) and oral glucocorticoids (56.6% vs 71.2%; p<0.0001). CONCLUSIONS Management of cSLE and aSLE includes the same medication classes; differences include more intensive use of therapy in cSLE, warranting the need for approved safe medications for cSLE.
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Affiliation(s)
- Hermine I Brunner
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | | | | | - Julie A Birt
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOC Gaslini Trial Centre/Servizio di Sperimentazioni Cliniche Pediatriche, PRINTO, Genova, Italy
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
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10
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Balevic SJ, Niu J, Chen J, Green D, McMahon A, Hornik CP, Schanberg L, Glaser R, Gonzalez D, Burckart GJ. Extrapolation of Adult Efficacy Data to Pediatric Systemic Lupus Erythematosus: Evaluating Similarities in Exposure-Response. J Clin Pharmacol 2023; 63:105-118. [PMID: 35968821 PMCID: PMC9771895 DOI: 10.1002/jcph.2139] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/07/2022] [Indexed: 12/24/2022]
Abstract
To streamline drug development, the United States Food and Drug Administration (FDA) can consider the extrapolation of adult efficacy data to children when the disease and drug effects are sufficiently similar. This study explored whether the relationship between drug exposure and response for selected drugs in systemic lupus erythematosus (SLE) was sufficiently similar to support a consideration of the extrapolation of adult efficacy data to children of ≥5 years of age. An exposure-response analysis of drugs used to treat SLE was conducted using published exposure versus response and efficacy versus time data. Statistical analyses included noncompartmental analysis of a drug's area under the effect curve and direct Imax pharmacodynamic (PD) modeling. Six drugs were included: azathioprine, belimumab, cyclophosphamide, hydroxychloroquine, mycophenolate/mycophenolic acid, and rituximab. For belimumab, the net change in responders at week 52 (the primary end point) was nearly identical between 1 adult trial and the pediatric trial. For mycophenolate, PD modeling suggested no significant differences in exposure and SLE disease activity between adults and children. For azathioprine, cyclophosphamide, hydroxychloroquine, and rituximab the data were not sufficient to quantitatively characterize the exposure-response relationship, but the clinical or pharmacologic response between children and adults was similar overall. Adult SLE data should be leveraged to guide pediatric drug development programs and identify areas with residual uncertainty regarding the effectiveness or safety of a drug in children. The degree to which efficacy extrapolation can reduce clinical trial requirements in pediatric SLE should be individualized for each new drug product, depending in part on the mechanism of action of the drug and the similarity of disease manifestations in children and adults.
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Affiliation(s)
| | - Jing Niu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, MD
| | - Jianmeng Chen
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, MD
| | - Dionna Green
- Office of Pediatric Therapeutics, Office of the Commissioner, United States Food and Drug Administration (FDA), Silver Spring, MD
| | - Ann McMahon
- Office of Pediatric Therapeutics, Office of the Commissioner, United States Food and Drug Administration (FDA), Silver Spring, MD
| | | | - Laura Schanberg
- Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Rachel Glaser
- Division of Rheumatology and Transplant Medicine, Office of Immunology and Inflammation, Office of New Drugs, CDER, FDA, Silver Spring, MD
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, MD
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11
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Ramdas S, Della Marina A, Ryan MM, McWilliam K, Klein A, Jacquier D, Alabaf S, Childs AM, Parasuraman D, Beeson D, Palace J, Jungbluth H. Rituximab in juvenile myasthenia gravis-an international cohort study and literature review. Eur J Paediatr Neurol 2022; 40:5-10. [PMID: 35835035 DOI: 10.1016/j.ejpn.2022.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
Abstract
Juvenile myasthenia gravis (JMG) is a rare, antibody-mediated disorder of the neuromuscular junction. Treatment strategies in JMG are largely informed by adult MG treatments as the pathophysiology is similar. Rituximab is increasingly considered as a treatment option in refractory JMG but has not yet been systematically investigated in this patient group We conducted a retrospective study from five international centres with expertise in paediatric myasthenia. 10 JMG patients treated with rituximab were identified. Following rituximab treatment all patients had a reduction in JMG-related hospital admissions. At 24 month follow up, 6 patients (60%) had achieved complete stable remission or pharmacological remission and 7 patients were able to reduce immunomodulatory treatment(s). The main side-effect was infusion-related reactions (30%) which resolved in all patients with symptomatic treatment. We compared our cohort to previously reported JMG cases treated with rituximab and noted similar response rates but a slightly higher side-effect profile. Rituximab is a safe and effective treatment option in moderate to severe JMG and most patients have an improvement in MG symptoms post treatment.
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Affiliation(s)
- Sithara Ramdas
- MDUK Neuromuscular Centre, Department of Paediatrics, University of Oxford, United Kingdom; Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Adela Della Marina
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Children's Hospital, University of Duisburg-Essen, Germany.
| | - Monique M Ryan
- Neurology Department, Royal Children's Hospital, Melbourne, Australia.
| | - Kenneth McWilliam
- Department of Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, United Kingdom.
| | - Andrea Klein
- Department of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland; University Children's Hospital Bern, Inselspital, Bern, Switzerland.
| | - David Jacquier
- Paediatric Neurology and Neurorehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland.
| | - Setareh Alabaf
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Anne-Marie Childs
- Department of Paediatric Neurology, Leeds Teaching Hospitals, United Kingdom.
| | - Deepak Parasuraman
- Department of Paediatrics, Heartlands Hospital, Birmingham, United Kingdom.
| | - David Beeson
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, FoLSM, King's College, London, UK.
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12
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Ding Y, Qian J, Zhang S, Xu D, Leng X, Zhao J, Wang Q, Zhang W, Tian X, Li M, Zeng X. Immunosuppressive therapy in patients with connective tissue disease-associated pulmonary arterial hypertension: A systematic review. Int J Rheum Dis 2022; 25:982-990. [PMID: 35699128 DOI: 10.1111/1756-185x.14368] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/14/2022] [Accepted: 05/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES It is currently accepted that inflammation plays an important role in the pathogenesis of connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH). However, the efficacy of immunosuppressive therapy remains anecdotal. The objective of this systematic review was to evaluate the efficacy of immunosuppressive therapy in patients with CTD-PAH and to further assess whether response differs between CTD subtypes and clinical features. METHODS We systematically searched studies reporting the treatment response of immunosuppressants and biological agents in CTD-PAH from PUBMED, EMBASE, the Cochrane Library, and Scopus. Studies had to report treatment regime and response criteria. The risk of bias was assessed using the Newcastle-Ottawa scale. RESULTS Seven independent cohorts, 1 trial, and 1 case-series encompassing 439 patients with CTD-PAH were included. Patients were divided into 2 groups according to the therapeutic regimen. There were 146 patients in the immunosuppressants group with better heart function at baseline and 52.1% (76/146) of them were responders. There were 236 patients treated with immunosuppressants combined with PAH-specific therapy who showed more severity at baseline and 41.1% (97/236) of them were responders. Among different CTD subtypes, patients with systemic lupus erythematosus-associated PAH (SLE-PAH) showed a better response to immunosuppressants (response rate 48.1%). What is more, 1 randomized controlled trial showed the potential therapeutic value of rituximab (n = 57) in CTD-PAH patients. CONCLUSIONS Current studies support the use of immunosuppressive therapy in CTD-PAH, especially in SLE-PAH. Further studies on biological agents and the therapeutic effect of different immunosuppressants are still needed.
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Affiliation(s)
- Yufang Ding
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Junyan Qian
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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13
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Cheetham TD, Cole M, Abinun M, Allahabadia A, Barratt T, Davies JH, Dimitri P, Drake A, Mohamed Z, Murray RD, Steele CA, Zammitt N, Carnell S, Prichard J, Watson G, Hambleton S, Matthews JNS, Pearce SHS. Adjuvant Rituximab-Exploratory Trial in Young People With Graves Disease. J Clin Endocrinol Metab 2022; 107:743-754. [PMID: 34687316 PMCID: PMC8851941 DOI: 10.1210/clinem/dgab763] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Remission rates in young people with Graves hyperthyroidism are less than 25% after 2 years of thionamide antithyroid drug (ATD). OBJECTIVE We explored whether rituximab (RTX), a B-lymphocyte-depleting agent, would increase remission rates when administered with a short course of ATD. METHODS This was an open-label, multicenter, single-arm, phase 2 trial in young people (ages, 12-20 years) with Graves hyperthyroidism. An A'Hern design was used to distinguish an encouraging remission rate (40%) from an unacceptable rate (20%). Participants presenting with Graves hyperthyroidism received 500 mg RTX and 12 months of ATD titrated according to thyroid function. ATDs were stopped after 12 months and primary outcome assessed at 24 months. Participants had relapsed at 24 months if thyrotropin was suppressed and free 3,5,3'-triiodothyronine was raised; they had received ATD between months 12 and 24; or they had thyroid surgery/radioiodine. RESULTS A total of 27 participants were recruited and completed the trial with no serious side effects linked to treatment. Daily carbimazole dose at 12 months was less than 5 mg in 21 of 27 participants. Thirteen of 27 participants were in remission at 24 months (48%, 90% one-sided CI, 35%-100%); this exceeded the critical value (9) for the A'Hern design and provided evidence of a promising remission rate. B-lymphocyte count at 28 weeks, expressed as a percentage of baseline, was related to likelihood of remission. CONCLUSION Adjuvant RTX, administered with a 12-month course of ATD, may increase the likelihood of remission in young people with Graves hyperthyroidism. A randomized trial of adjuvant RTX in young people with Graves hyperthyroidism is warranted.
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Affiliation(s)
- Tim D Cheetham
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Paediatric Endocrinology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP, UK
- Correspondence: Tim D. Cheetham, MD, Newcastle University, c/o Department of Paediatric Endocrinology, Office Block 1, Level 3, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
| | - Michael Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Mario Abinun
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Amit Allahabadia
- Academic Directorate of Diabetes and Endocrinology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Tim Barratt
- University of Birmingham, Diabetes Unit, Birmingham Children’s Hospital, Birmingham, B4 6NH, UK
- Birmingham Children’s Hospital, Birmingham, B46NH, UK
| | - Justin H Davies
- Department of Paediatric Endocrinology, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Paul Dimitri
- The Department of Paediatric Endocrinology, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Amanda Drake
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, EH16 4TJ, UK
| | | | - Robert D Murray
- Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, LS97TF, UK
| | - Caroline A Steele
- Children and Adolescent services, Leeds Teaching Hospitals NHS Trust, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Jonathan Prichard
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Gillian Watson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Sophie Hambleton
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - John N S Matthews
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
- School of Mathematics, Statistics & Physics, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
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14
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Sinha R, Agrawal N, Xue Y, Chanchlani R, Pradhan S, Raina R, Marks SD. Use of rituximab in paediatric nephrology. Arch Dis Child 2021; 106:1058-1065. [PMID: 34112638 PMCID: PMC8543203 DOI: 10.1136/archdischild-2020-321211] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/27/2021] [Accepted: 03/10/2021] [Indexed: 11/03/2022]
Abstract
Rituximab is a chimeric monoclonal antibody capable of depleting B cell populations by targeting the CD20 antigen expressed on the cell surface. Its use in oncology, initially in B cell lymphoma and post-transplant lymphoproliferative disorders, predates its current utility in various fields of medicine wherein it has become one of the safest and most effective antibody-based therapies. It was subsequently found to be effective for rheumatological conditions such as rheumatoid arthritis and antineutrophil cytoplasmic antibody-associated vasculitis. Over the past decade, rituximab has generated a lot of interest in nephrology and has become an emerging or accepted therapy for multiple renal conditions, including systemic lupus erythematosus, lupus nephritis, vasculitis, nephrotic syndrome and in different scenarios before and after kidney transplantation. This review outlines its current use in paediatric nephrology practice, focusing on the knowledge required for general paediatricians who may be caring for children prescribed this medication and reviewing them on a shared care basis.
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Affiliation(s)
- Rajiv Sinha
- ICH, Institute of Child Health, Kolkata, India
| | - Nirav Agrawal
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Yuanxin Xue
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Subal Pradhan
- Department of Pediatrics, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics(SVPPGIP), Cuttack, Odisha, India
| | - Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK .,NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
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15
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Gilbert M, Goilav B, Hsu JJ, Nietert PJ, Meidan E, Chua A, Ardoin SP, Wenderfer SE, von Scheven E, Ruth NM. Differences in rituximab use between pediatric rheumatologists and nephrologists for the treatment of refractory lupus nephritis and renal flare in childhood-onset SLE. Pediatr Rheumatol Online J 2021; 19:137. [PMID: 34461932 PMCID: PMC8404338 DOI: 10.1186/s12969-021-00627-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Consensus treatment plans have been developed for induction therapy of newly diagnosed proliferative lupus nephritis (LN) in childhood-onset systemic lupus erythematosus. However, patients who do not respond to initial therapy, or who develop renal flare after remission, warrant escalation of treatment. Our objective was to assess current practices of pediatric nephrologists and rheumatologists in North America in treatment of refractory proliferative LN and flare. METHODS Members of Childhood Arthritis and Rheumatology Research Alliance (CARRA) and the American Society for Pediatric Nephrology (ASPN) were surveyed in November 2015 to assess therapy choices (other than modifying steroid dosing) and level of agreement between rheumatologists and nephrologists for proliferative LN patients. Two cases were presented: (1) refractory disease after induction treatment with corticosteroid and cyclophosphamide (CYC) and (2) nephritis flare after initial response to treatment. Survey respondents chose treatments for three follow up scenarios for each case that varied by severity of presentation. Treatment options included CYC, mycophenolate mofetil (MMF), rituximab (RTX), and others, alone or in combination. RESULTS Seventy-six respondents from ASPN and foty-one respondents from CARRA represented approximately 15 % of the eligible members from each organization. Treatment choices between nephrologists and rheumatologists were highly variable and received greater than 50 % agreement for an individual treatment choice in only the following 2 of 6 follow up scenarios: 59 % of nephrologists, but only 38 % of rheumatologists, chose increasing dose of MMF in the case of LN refractory to induction therapy with proteinuria, hematuria, and improved serum creatinine. In a follow up scenario showing severe renal flare after achieving remission with induction therapy, 58 % of rheumatologists chose CYC and RTX combination therapy, whereas the top choice for nephrologists (43 %) was CYC alone. Rheumatologists in comparison to nephrologists chose more therapy options that contained RTX in all follow up scenarios except one (p < 0.05). CONCLUSIONS Therapy choices for pediatric rheumatologists and nephrologists in the treatment of refractory LN or LN flare were highly variable with rheumatologists more often choosing rituximab. Further investigation is necessary to delineate the reasons behind this finding. This study highlights the importance of collaborative efforts in developing consensus treatment plans for pediatric LN.
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Affiliation(s)
- Mileka Gilbert
- Medical University of South Carolina, 135 Rutledge Ave, MSC 561, Charleston, SC, 29425, USA.
| | - Beatrice Goilav
- grid.414114.50000 0004 0566 7955The Children’s Hospital at Montefiore, 111 East 210th Street, Bronx, NY 10467 USA
| | - Joyce J. Hsu
- grid.168010.e0000000419368956Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305 USA
| | - Paul J. Nietert
- grid.259828.c0000 0001 2189 3475Medical University of South Carolina, 135 Rutledge Ave, MSC 561, Charleston, SC 29425 USA
| | - Esra Meidan
- grid.38142.3c000000041936754XHarvard Medical School, 300 Longwood Ave, Boston, MA 02115 USA
| | - Annabelle Chua
- grid.26009.3d0000 0004 1936 7961Duke University, Box 3959, 2301 Erwin Road, Durham, NC 27710 USA
| | - Stacy P. Ardoin
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43221 USA
| | - Scott E. Wenderfer
- grid.39382.330000 0001 2160 926XBaylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Emily von Scheven
- grid.266102.10000 0001 2297 6811University of California San Francisco, 550 16th Street, 4th floor, San Francisco, CA 94158 USA
| | - Natasha M. Ruth
- grid.259828.c0000 0001 2189 3475Medical University of South Carolina, 135 Rutledge Ave, MSC 561, Charleston, SC 29425 USA
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Kishi T, Sakai R, Tani Y, Nagata S, Katsumata Y, Miyamae T, Harigai M. Trends in actual medication use for child-onset systemic lupus erythematosus using the Japanese health insurance database 2009-18. Mod Rheumatol 2021; 32:565-570. [PMID: 34908147 DOI: 10.1093/mr/roab038] [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: 04/21/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Immunosuppressive therapy is the mainstay of treatment for child-onset systemic lupus erythematosus (cSLE). Since epidemiological data on Japanese cSLE patients are not available, we evaluated the trends in how treatment choices have changed over time in Japan. METHODS Using the Japanese health insurance database provided by Medical Data Vision Co., Ltd, we identified cSLE patients and evaluated changes in the use of corticosteroids and immunosuppressive medications and maximum daily doses of prednisolone from 2009 to 2018. RESULTS Of 182 cSLE patients, 86% were female, and the median age was 14 years. Oral prednisolone was used in more than 97% of cSLE patients during the study period, and the median of the maximum daily dose in each patient decreased over time. Intravenous cyclophosphamide was used less frequently after 2016, while mycophenolate mofetil and hydroxychloroquine were used frequently after 2016. The use of mizoribine reduced after 2014, whereas the other immunosuppressive medications showed no significant change over time; the use of biological agents was very limited. CONCLUSIONS Oral prednisolone was the mainstay of treatment for cSLE, and the maximum daily dose has reduced over the past decade. The most frequently prescribed immunosuppressive therapy has shifted to mycophenolate mofetil over time.
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Affiliation(s)
- Takayuki Kishi
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Ryoko Sakai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yumi Tani
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Satoru Nagata
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Sawhney S, Agarwal M. Rituximab use in pediatric systemic lupus erythematosus: Indications, efficacy and safety in an Indian cohort. Lupus 2021; 30:1829-1836. [PMID: 34315295 DOI: 10.1177/09612033211034567] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Children with systemic lupus erythematosus have a more challenging and difficult course as compared to their adult counterparts. Today, the aim of therapy for any child with lupus is to keep the child in a state of sustained remission with minimal or no use of steroids. This laudable goal is often difficult to achieve for the child with lupus. In addition to the use of disease modifying agents, sometimes in combination, Rituximab (RTX) is also used as an off-label indication to manage such patients.Objectives: To study the use, efficacy and safety of RTX in a cohort of patients with pediatric lupus followed at a single tertiary level center in Northern India.Methods: This paper is a retrospective review looking at the use of RTX in children with systemic lupus at a tertiary level pediatric rheumatology center in North India over a period of seventeen years. This paper describes the indications, use, efficacy and safety of RTX in childhood systemic lupus erythematosus.Results: RTX was used in 17 of 225 pediatric lupus patients (7.5%), with the most common indication being resistant renal disease (53%). Significant improvement was seen in all domains studied: The mean SLEDAI was 16.25 prior to RTX and reduced to 1.43 six months after the RTX (p value 0.001), steroid use dropped from 100% pre- RTX to 33% at 2 years, there was a sustained reduction in proteinuria in the patients with nephritis from a mean urine spot protein creatinine ratio of 3.1 pre RTX to 0.4 at one year post RTX (p= .006). Finally, 82% of the children had no flare during the follow up (median 24 months). No patient had any adverse event.Conclusions: This study confirms that RTX is very effective in childhood lupus and can be safely used even in a country with a very high burden of infectious diseases. This data adds to the scarce literature in this area from the developing world.
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Affiliation(s)
- Sujata Sawhney
- Division of Pediatric Rheumatology, 28928Sir Ganga Ram Hospital, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Manjari Agarwal
- Division of Pediatric Rheumatology, 28928Sir Ganga Ram Hospital, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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18
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McAtee CL, Lubega J, Underbrink K, Curry K, Msaouel P, Barrow M, Muscal E, Lotze T, Srivaths P, Forbes LR, Allen C, Bernhardt MB. Association of Rituximab Use With Adverse Events in Children, Adolescents, and Young Adults. JAMA Netw Open 2021; 4:e2036321. [PMID: 33533931 PMCID: PMC7859842 DOI: 10.1001/jamanetworkopen.2020.36321] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Rituximab is among the most frequently used immunotherapies in pediatrics. Few studies have reported long-term adverse events associated with its use for children. OBJECTIVE To describe the use of rituximab and to assess whether its use is associated with short- or long-term adverse events, infections, or time to immune reconstitution in a diverse group of young people. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 468 patients aged younger than 21 years who received rituximab for diverse indications between October 1, 2010, and December 31, 2017, at Texas Children's Hospital, a large pediatric referral hospital. Patterns of adverse events, infections, and immune recovery are described. Data analyses were conducted from December 2019 to June 2020. EXPOSURE One or more doses of rituximab. MAIN OUTCOMES AND MEASURES Adverse drug events (eg, anaphylaxis), incidence of mild and severe infections, and time to recovery of B lymphocyte subset counts and immunoglobulin levels. Survival models and logistic regression analyses and were used to identify associated risk factors of infectious and noninfectious adverse drug events. RESULTS We identified 468 patients receiving at least 1 dose of rituximab. The total follow-up time was 11 713 person-months. Of the 468 patients, 293 (62.6%) were female, the median (interquartile range) age at receipt of dose was 14.3 (9.9-16.8) years, and 209 (44.7%) were self-reported White Hispanic. Adverse events associated with rituximab infusion occurred in 72 patients (15.4%), and anaphylaxis occurred in 17 patients (3.6%). Long-term adverse events, such as prolonged neutropenia and leukoencephalopathy, were absent. Infections occurred in 224 patients (47.9%); 84 patients (17.9%) had severe infections, and 3 patients (0.6%) had lethal infections. Concurrent use of intravenous chemotherapy, treatment of systemic lupus erythematosus, neutropenia, and use of intravenous immunoglobulin were associated with increased risk of infection. Among 135 patients (28.8%) followed up to B cell count recovery, CD19+ or CD20+ cell numbers normalized in a median of 9.0 months (interquartile range, 5.9-14.4 months) following rituximab use; 48 of 95 patients (51%) evaluated beyond a year had low-for-age B cell counts. Recovery of CD27+ memory B cell number occurred in a median of 15.7 months (interquartile range, 6.0-22.7 months). Among patients with normal baseline values, low immunoglobulin G (IgG) levels developed in 67 of 289 patients (23.2%) and low IgM levels in 118 of 255 patients (40.8%); of these patients evaluated beyond 12 months from rituximab, 16 of 117 (13.7%) had persistently low IgG and 37 (33.9%) of 109 had persistently low IgM. CONCLUSIONS AND RELEVANCE Rituximab is well tolerated among young people and is associated with few serious adverse events, but infections are common, corresponding to a prolonged period of B cell count recovery often lasting for longer than a year. Further examination of strategies to prevent infections following rituximab should be pursued.
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Affiliation(s)
- Casey Lee McAtee
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joseph Lubega
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kristen Underbrink
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kristen Curry
- Department of Pharmacy, Texas Children’s Hospital, Houston
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Martha Barrow
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Eyal Muscal
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Timothy Lotze
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Poyyapakkam Srivaths
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Lisa R. Forbes
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Carl Allen
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - M. Brooke Bernhardt
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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19
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Liccioli G, Simonini G, Melani F, Giovannini M, Ricci S, Sarti L, Cavallin M, Barni S, Marrani E, Mori F. Hypersensitivity to Rituximab in Children. Pharmacology 2020; 106:341-344. [PMID: 33202411 DOI: 10.1159/000511458] [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: 08/11/2020] [Accepted: 09/03/2020] [Indexed: 11/19/2022]
Abstract
Biological agents have had an increased usage during the past years, also in pediatric population. Monoclonal antibodies can cause adverse drug reactions with different pathomechanisms, including type I IgE-mediated hypersensitivity reactions (HR). In this report, we describe 2 children who had a diagnosis of anaphylaxis to rituximab (RTX), confirmed by positive in vivo tests in both cases and elevated tryptase value in one case. We also made a review of the few cases of HR to RTX in pediatric population reported in literature and discuss differential diagnosis and utility of allergy investigations.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy,
| | - Gabriele Simonini
- Rheumatology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Federico Melani
- Child Neurology Unit and Laboratories, Neuroscience Department, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Silvia Ricci
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mara Cavallin
- Child Neurology Unit and Laboratories, Neuroscience Department, Meyer Children's University Hospital, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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20
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Kianfar N, Dasdar S, Mahmoudi H, Tavakolpour S, Balighi K, Daneshpazhooh M. Rituximab in childhood and juvenile autoimmune bullous diseases as first-line and second-line treatment: a case series of 13 patients. J DERMATOL TREAT 2020; 33:869-874. [DOI: 10.1080/09546634.2020.1788702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nika Kianfar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shayan Dasdar
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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21
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Nasonov EL, Beketova TV, Ananyeva LP, Vasilyev VI, Solovyev SK, Avdeeva AS. PROSPECTS FOR ANTI-B-CELL THERAPY IN IMMUNO-INFLAMMATORY RHEUMATIC DISEASES. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-3-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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22
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Tao MJ, Cheng P, Jin LR, Zhou J, Shi W, Peng H, Xu L, Li Z, Yuan H. The safety and efficacy of biologic agents in treatment of systemic lupus erythematosus: A network meta-analysis. Pak J Med Sci 2019; 35:1680-1686. [PMID: 31777515 PMCID: PMC6861478 DOI: 10.12669/pjms.35.6.771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective: Previous studies have shown that biologic agents out of the nine medicines might be beneficial for the treatment of SLE. The aim of this study was to evaluate the most effective medication of six biologic agents in treatment of SLE using network meta-analysis (NMA). The performance of these processes is ranked according to the results of this analysis. Methods: Multiple databases including PubMed, EMBASE and Cochrane Library was used to identify applicable articles and collect relevant data to analyzed by using STATA (13.0) software. The papers included in this study were divided into control group (placebo) and observation group (one of the six medicines). Results: A total of 21 eligible RCTs of biologic agents were identified, a total of 995 papers were included, and the results showed that the belimumab had the highest probability of being the most clinically efficacious intervention, with a surface under the cumulative ranking (SUCRA) curve of 75.0, was significantly superior (P < 0.05) to placebo alone. The blisibimod was the worst, with a SUCRA value of 29.4. The other biologic agents (atacicept, blisibimod, epratuzumab, rituximab, tabalumab) were insignificantly superior (P > 0.05) to placebo alone. Conclusions: Belimumab had the highest probability of being the best treatment for SLE compared with the other biologic agents (atacicept, blisibimod, epratuzumab, rituximab, tabalumab). The other biologic agents indicated an insignificant difference in efficacy for the treatment of SLE compared with placebo.
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Affiliation(s)
- Meng-Jun Tao
- Meng-Jun Tao, Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, PR China
| | - Ping Cheng
- Ping Cheng, Administration Office of Education Cluster, Yijishan Hospital of Wannan Medical College,Wuhu, P.R. China
| | - Lai-Run Jin
- Lai-Run Jin, Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, PR China
| | - Jun Zhou
- Jun Zhou, Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, PR China
| | - Wei Shi
- Wei Shi, Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, PR China
| | - Hui Peng
- Hui Peng, Administration Office of Hospital Admission and Discharge, Yijishan Hospital of Wannan Medical College, Wuhu, P.R. China
| | - Liang Xu
- Liang Xu, Department of Rheumatology, Yijishan Hospital of Wannan Medical College, Wuhu, P.R. China
| | - Zhi Li
- Zhi Li, Department of Rheumatology, Yijishan Hospital of Wannan Medical College, Wuhu, P.R. China
| | - Hui Yuan
- Hui Yuan, Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, PR China
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23
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Mitchell C, Crayne CB, Cron RQ. Patterns of B Cell Repletion Following Rituximab Therapy in a Pediatric Rheumatology Cohort. ACR Open Rheumatol 2019; 1:527-532. [PMID: 31777835 PMCID: PMC6858005 DOI: 10.1002/acr2.11074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022] Open
Abstract
Objective To investigate the association between demographic characteristics, disease characteristics, the number of rituximab (RTX) rounds, and concurrent immunosuppression on B cell level repletion following RTX therapy. Methods A retrospective chart review of 112 children who met inclusion criteria and were treated with RTX at a single institution was performed. Demographic, clinical, and laboratory data were extracted and compared. CD19 levels were reviewed at 6 and 12 months post‐RTX with depletion defined as fewer than 10 cells/μL and complete repopulation to normal levels defined as 170 cells/μL or more. Results Among patients with CD19 levels, 48% of patients remained depleted at 6 months, 89% were repleted with 10 cells/μL or more by 12 months, and 46% remained below normal levels at 12 months following infusion. There was no significant association between the number of RTX rounds or underlying disease and persistent depletion below normal levels at 12 months following RTX infusion. Depletion at 6 months was associated with a 79% chance of persistent depletion below normal levels at 12 months. The association between concurrent cyclophosphamide (CYC) and repletion of 10 cells/μL or more at 6 (P = 0.091) and 12 months (P = 0.087) trended toward significance with no significant association between CYC and persistent depletion below normal levels. Conclusion RTX therapy for pediatric rheumatic diseases is well‐tolerated and results in variable repletion and normalization of B cell numbers at 6 and 12 months. B cell repletion in children is variable and independent of underlying disease and of the number of RTX infusions.
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24
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Fragoso YD, Sousa NAC, Saad T, Alves-Leon SV, Pimentel MLV, Goncalves MVM, Stella CV, Diniz DS, Santos GC, Gomes S, Adoni T, Anacleto A, Claudino R, Malfetano FR, Winckler TCD, Damasceno A, Eboni ACB, Farinhas JGD, Mota RSDS. Clinical Characteristics of Patients With Neuromyelitis Optica Spectrum Disorders With Early Onset. J Child Neurol 2019; 34:487-490. [PMID: 31012355 DOI: 10.1177/0883073819842421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neuromyelitis optica spectrum disorder is a severe and disabling disease that manifests with severe relapses of optic neuritis, longitudinally extensive myelitis, and/or brainstem syndromes. The disease is complex and, although onset typically occurs in middle age, children and adolescents may be affected. The present study adds to the literature through detailed clinical data from 36 Brazilian patients with neuromyelitis optica spectrum disorder starting before age 21. This was a retrospective assessment of medical records from 14 specialized units in Brazil. The results showed that the course of neuromyelitis optica spectrum disorder was worse in patients with disease onset before the age of 12 years. Gender and ethnic background did not influence disability accumulation. Over a median period of 8 years, 14% of the patients who presented the initial symptoms of neuromyelitis optica spectrum disorder before the age of 21 years died. In conclusion, the present study adds to the reports from other authors examining the severity of early-onset neuromyelitis optica spectrum disorder.
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Affiliation(s)
- Yara Dadalti Fragoso
- 1 Department of Neurology, Universidade Metropolitana de Santos, Santos, SP, Brazil
| | | | - Tania Saad
- 3 Neuropediatric Division, Fernandes Figueira Institute - FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | | | - Maria Lucia V Pimentel
- 5 Department of Neurology, Santa Casa Misericordia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Carla Vieira Stella
- 7 Department of Neurology, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Gutemberg C Santos
- 9 Department of Neurology, Universidade Estacio de Sa, Rio de Janeiro, RJ, Brazil
| | - Sidney Gomes
- 10 Department of Neurology, Hospital Beneficencia Portuguesa de Sao Paulo and Hospital Paulistano, Sao Paulo, SP, Brazil
| | - Tarso Adoni
- 11 Department of Neurology, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | - Andrea Anacleto
- 1 Department of Neurology, Universidade Metropolitana de Santos, Santos, SP, Brazil
| | - Rinaldo Claudino
- 12 Department of Neurology, Universidade Federal de Santa Catarina, Florianopolis, SC, Brazil
| | | | | | - Alfredo Damasceno
- 7 Department of Neurology, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Audred C Biondo Eboni
- 6 Department of Neurology, Universidade da Regiao de Joinville, Joinville, SC, Brazil
| | - João Gabriel D Farinhas
- 4 Department of Neurology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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25
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Herrada AA, Escobedo N, Iruretagoyena M, Valenzuela RA, Burgos PI, Cuitino L, Llanos C. Innate Immune Cells' Contribution to Systemic Lupus Erythematosus. Front Immunol 2019; 10:772. [PMID: 31037070 PMCID: PMC6476281 DOI: 10.3389/fimmu.2019.00772] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/25/2019] [Indexed: 01/29/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the presence of autoantibodies against nuclear antigens, immune complex deposition, and tissue damage in the kidneys, skin, heart and lung. Because of the pathogenic role of antinuclear antibodies and autoreactive T cells in SLE, extensive efforts have been made to demonstrate how B cells act as antibody-producing or as antigen-presenting cells that can prime autoreactive T cell activation. With the discovery of new innate immune cells and inflammatory mediators, innate immunity is emerging as a key player in disease pathologies. Recent work over the last decade has highlighted the importance of innate immune cells and molecules in promoting and potentiating SLE. In this review, we discuss recent evidence of the involvement of different innate immune cells and pathways in the pathogenesis of SLE. We also discuss new therapeutics targets directed against innate immune components as potential novel therapies in SLE.
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Affiliation(s)
- Andrés A Herrada
- Lymphatic and Inflammation Research Laboratory, Facultad de Ciencias de la Salud, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Talca, Chile
| | - Noelia Escobedo
- Lymphatic and Inflammation Research Laboratory, Facultad de Ciencias de la Salud, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Talca, Chile
| | - Mirentxu Iruretagoyena
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo A Valenzuela
- Laboratorio de Enfermedades Autoinmunes Oculares y Sistémicas, Departamento de Oftalmología, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Departamento de Ciencias Químicas y Biológicas, Facultad de Salud, Universidad Bernardo O'Higgins, Santiago, Chile
| | - Paula I Burgos
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Loreto Cuitino
- Laboratorio de Enfermedades Autoinmunes Oculares y Sistémicas, Departamento de Oftalmología, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Servicio de Oftalmología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Carolina Llanos
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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26
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Nalakonda G, Islam M, Chukwu VE, Soliman A, Munim R, Abukraa I. Psycho-rheumatic Integration in Systemic Lupus Erythematosus: An Insight into Antibodies Causing Neuropsychiatric Changes. Cureus 2018; 10:e3091. [PMID: 30324045 PMCID: PMC6171782 DOI: 10.7759/cureus.3091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The main purpose of this paper is to bring together all the antibodies and markers related to neurological and psychiatric manifestations in systemic lupus erythematosus and also the pharmacology that could help treat these symptoms. Existing research data regarding specific antibodies involved in the disease process and drugs that were being studied was collected and analyzed. After reviewing the studies published by various authors, symptoms were shown to be mainly caused by antibodies against N-methyl-D-aspartate receptor (NMDAR) antibodies, anti-endothelial, anti-ribosomal P, antiphospholipid antibodies, cytokines like interferons and chemokines. The monoclonal antibody rituximab has shown to be beneficial in some of the cases. Based on all the articles reviewed, the antibodies and cytokines showed the most effective evidence in causing the different manifestations of neuropsychiatric systemic lupus erythematosus (NPSLE), but studies regarding the drugs being effective against all the symptoms are inconclusive as there are very few studies. Further research to support the drug’s effectiveness in managing the symptoms is needed. More studies are needed regarding early diagnosis of NPSLE using the antibodies as biomarkers as it could help in preventing these manifestations.
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Affiliation(s)
- Gouthami Nalakonda
- Medical Student, Chalmeda Anandrao Institute of Medical Sciences, Karimnagar, IND
| | - Mimsa Islam
- Internal Medicine, Sir Salimullah Medical College, Dhaka, USA
| | | | | | - Rujina Munim
- Miscellaneous, Sylhet Mag Osmani Medical College and Hospital, Sylhet, BGD
| | - Inas Abukraa
- Faculty of Medicine, Tripoli University, Tripoli, LBY
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27
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Sciascia S, Radin M, Roccatello D, Sanna G, Bertolaccini ML. Recent advances in the management of systemic lupus erythematosus. F1000Res 2018; 7:F1000 Faculty Rev-970. [PMID: 30026918 PMCID: PMC6039948 DOI: 10.12688/f1000research.13941.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease presenting highly heterogeneous clinical manifestations and multi-systemic involvement. Patients are susceptible to relapse- and remission, thus making management challenging. Moreover, a considerable number of side effects may occur with conventional therapies; therefore, there is clearly a need for new therapeutic strategies. Since the pathogenesis of SLE is highly complex, it is far from being fully understood. However, greater understanding of the pathways and of the cellular and molecular mediators involved in SLE is being achieved. Emerging evidence has allowed the development of new biological therapeutic options targeting crucial molecular mediators involved in the pathogenesis of SLE. This literature review analyzes the availability of biological and target-directed treatments, phase II and III trials, and new therapies that are being developed for the treatment of SLE.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Giovanni Sanna
- Louise Coote Lupus Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King’s College London, London, UK
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Harry O, Yasin S, Brunner H. Childhood-Onset Systemic Lupus Erythematosus: A Review and Update. J Pediatr 2018; 196:22-30.e2. [PMID: 29703361 DOI: 10.1016/j.jpeds.2018.01.045] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Onengiya Harry
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shima Yasin
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Vinod SS, Reed AB, Maxwell J, Cron RQ, Stoll ML. Pediatric rheumatology infusion center: report on therapeutic protocols and infusions given over 4 Years with focus on adverse events over 1 Year. Pediatr Rheumatol Online J 2018; 16:16. [PMID: 29523211 PMCID: PMC5845357 DOI: 10.1186/s12969-018-0234-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children with chronic rheumatic disease often require intravenous (IV) therapy. Our center has instituted standardized protocols for use of IV medications in rheumatology patients. Herein, we introduce the therapeutic protocols and report on their short-term safety. METHODS This was an institutional review board (IRB) approved retrospective chart review of all patients who had received IV infusions between the years 2012 and 2015 at a single center, prescribed by a pediatric rheumatologist. Infusion medications included abatacept, belimumab, cyclophosphamide, immune globulin, infliximab, methylprednisolone, N-acetylcysteine, pamidronate disodium, rituximab, and tocilizumab. For calendar year 2015, all adverse infusions reactions were recorded along with treatment strategies used to manage them, and outcomes. Rates of adverse events were calculated per infusion medication. RESULTS During calendar years 2012-2015, 7585 IV infusions were administered to 398 unique patients. In the year 2015, 2187 infusions were administered to 224 patients, with 34 patients experiencing 41 infusion reactions (1.9% of all infusions). Rituximab had the highest rate of adverse drug reactions with 10 patients experiencing reactions during 106 infusions (9.4%). None of the reactions were life-threatening, and only 6 resulted in discontinuation of therapy. CONCLUSIONS In a recent 4-year span, the UAB Pediatric Rheumatology Infusion Center has given thousands of IV infusions with minimal adverse reactions over a one-year reporting period. The combination of standard infusion protocols, experience of and communication between physicians and nurses who staff the center, and safety of the medications themselves, allows for safe IV administration of a variety of therapies for pediatric rheumatology patients. TRIAL REGISTRATION Not applicable; this was a retrospective study.
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Affiliation(s)
- Surabhi S. Vinod
- 0000000106344187grid.265892.2Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL USA
| | - Annelle B. Reed
- 0000 0004 0436 8398grid.413963.aDivision of Pediatric Rheumatology, Children’s of Alabama, Birmingham, AL 35233-1711 USA
| | - Jamelle Maxwell
- 0000 0004 0436 8398grid.413963.aDivision of Pediatric Rheumatology, Children’s of Alabama, Birmingham, AL 35233-1711 USA
| | - Randy Q. Cron
- 0000000106344187grid.265892.2Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL USA ,0000 0004 0436 8398grid.413963.aDivision of Pediatric Rheumatology, Children’s of Alabama, Birmingham, AL 35233-1711 USA
| | - Matthew L. Stoll
- 0000000106344187grid.265892.2Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL USA ,0000 0004 0436 8398grid.413963.aDivision of Pediatric Rheumatology, Children’s of Alabama, Birmingham, AL 35233-1711 USA
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Speth F, Hinze C, Häfner R. Combination of ofatumumab and fresh frozen plasma in hypocomplementemic systemic lupus erythematosus: a case report. Lupus 2018; 27:1395-1396. [PMID: 29439647 DOI: 10.1177/0961203318756289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- F Speth
- 1 Department of Pediatric Rheumatology, Universitatsmedizin Rostock Kinder und Jugendklinik, Rostock, Germany
| | - C Hinze
- 2 Department of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Germany
| | - R Häfner
- 3 Children's Hospital, German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
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McGinley M, Rossman IT. Bringing the HEET: The Argument for High-Efficacy Early Treatment for Pediatric-Onset Multiple Sclerosis. Neurotherapeutics 2017; 14:985-998. [PMID: 28895071 PMCID: PMC5722772 DOI: 10.1007/s13311-017-0568-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Pediatric-onset multiple sclerosis (POMS) is rarer than adult-onset disease, and represents a different diagnostic and treatment challenge to clinicians. We review POMS clinical and radiographic presentations, and explore important differences between POMS and adult-onset MS natural histories and long-term outcomes. Despite having more active disease, current treatment guidelines for patients with POMS endorse the off-label use of lower-efficacy disease-modifying therapies (DMTs) as first line. We review the available MS DMTs, their evidence for use in POMS, and the contrasting treatment strategies of high-efficacy early treatment and escalation therapy. We introduce a new treatment approach, the "high-efficacy early treatment", or HEET strategy, based on using directly observed, high-efficacy intravenously infused DMTs as first-line therapies. Like other proposed POMS treatment strategies, HEET will need to be prospectively studied, and all treatment decisions should be determined by an experienced neurologist, the patient, and his/her parents.
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Affiliation(s)
- Marisa McGinley
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue U10, Cleveland, OH, 44195, USA
| | - Ian T Rossman
- NeuroDevelopmental Science Center, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA.
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