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Abstract
BACKGROUND Thyroid-associated ophthalmopathy (TAO) is the most frequent extrathyroidal manifestation of Graves' disease, affecting up to 50% of patients. It has a great impact on quality of life. Rituximab (RTX) is a human/murine chimeric monoclonal antibody that targets the CD20 receptor on B-lymphocytes. Preliminary work has shown that blocking this CD20 receptor with RTX may affect the clinical course of TAO by reducing inflammation and the degree of proptosis. OBJECTIVES: This review update, originally published in 2013, assesses the efficacy and safety of using RTX for the treatment of TAO. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 2), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Science Information database (LILACS), the ISRCTN registry, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (WHO ICTRP). There were no language restrictions in the electronic search for trials. We last searched the electronic databases on 22 February 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of RTX administered by intravenous infusion using any dosage regimen for the treatment of active TAO in adults, compared to placebo or glucocorticoids treatment. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently scanned titles and abstracts, and screened full-text reports of potentially relevant studies. The outcomes of interest in this review were: clinical activity score (CAS), NOSPECS severity scale, proptosis (mm), palpebral aperture (mm), extraocular motility (degrees or diplopia rating scale), quality of life and adverse effects. MAIN RESULTS We identified two studies that met the inclusion criteria in this updated review. Across both studies, the mean age of participants was 55 years and 77% were women. RTX compared to intravenous methylprednisolone (IVMP) One study, conducted in Italy, compared RTX (n = 15 after one participant withdrew) with IVMP (n = 16) for active TAO (CAS ≥ 3 out of 7 or 4 out of 10). We judged this study to be at low risk of bias in most domains, but it was stopped early because of disease reactivation in the comparator group (5/16 participants). This study provided low-certainty evidence that RTX may result in CAS improvement at 24 weeks compared to IVMP (15/15 versus 12/16 improved by ≥ 2 points; risk ratio (RR) 1.32, 95% confidence interval (CI) 0.98 to 1.78). Only very low-certainty evidence was available for the other outcomes: NOSPECS improvement by 2 or more classes (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); proptosis improvement by 2 mm or more (0/15 versus 1/16; RR 0.35, 95% CI 0.02 to 8.08); palpebral aperture improvement by 3 mm or more (2/15 versus 0/16; RR 5.31, 95% CI 0.28 to 102.38); motility improvement by 1 class or more (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); and improvement on the Graves' ophthalmopathy QoL scale by at least 6 points for "functioning" (5/14 versus 8/13; RR 0.58, 95% CI 0.25 to 1.32), and "appearance" (9/14 versus 6/13; RR 1.39, 95% CI 0.69 to 2.82). Adverse events were more common in the RTX group (RR 1.39, 95% CI 0.90 to 2.13; low-certainty evidence). Minor adverse effects (mild infusion reactions) were observed in most people receiving RTX at first infusion. Two participants experienced a major infusion reaction, likely cytokine release syndrome. RTX compared to placebo One study, conducted in the USA, enrolled 25 participants with active TAO (CAS ≥ 4 out of 7), comparing RTX (13 participants) to placebo. We judged this study to be at low risk of bias in most domains, but it was stopped early due to recruitment issues. It provided very low-certainty evidence on the following outcomes at 24 weeks: CAS improvement by 2 or more points (4/13 RTX versus 3/12 placebo; RR 1.23, 95% CI 0.34 to 4.40); NOSPECS improvement by 2 or more classes (2/13 versus 2/12; RR 0.92, 95% CI 0.15 to 5.56); proptosis improvement by 2 mm or more (2/13 versus 4/12; RR 0.46, 95% CI 0.10 to 2.08); palpebral aperture median change (0 mm in RTX group, in both eyes separately, versus -0.5 mm and 0.5 mm in placebo group right and left eye, respectively); motility median diplopia score (3 versus 2.5); SF-12 physical component median score (45.9 versus 40.3) and mental component median score (52.8 versus 46.1). More participants in the RTX group experienced adverse effects (8/13 versus 3/12; RR 2.46, 95% CI 0.84 to 7.18). AUTHORS' CONCLUSIONS: There is currently insufficient evidence to support the use of RTX in people with TAO. Future studies investigating RTX in people with active TAO may need to be multi-centre in order to recruit enough participants to make an adequate judgement on the efficacy and safety of this novel therapy.
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Affiliation(s)
- Swan Kang
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Neda Minakaran
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Daniel G Ezra
- Moorfields and UCL Institute of Ophthalmology BMRC, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Wang Y, Hu H, Chen L, Zhang H, Yang T, Xu X, Chen H. Observation study of using a small dose of rituximab treatment for thyroid-associated ophthalmopathy in seven Chinese patients: One pilot study. Front Endocrinol (Lausanne) 2022; 13:1079852. [PMID: 36743915 PMCID: PMC9889535 DOI: 10.3389/fendo.2022.1079852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To report the efficacy, long-term safety, and tolerability of using a small dose (125 mg/m2 weekly for 4 weeks) of rituximab to treat Chinese patients with thyroid-associated ophthalmopathy (TAO). METHODS Seven patients with active moderate-to-severe TAO were prospectively recruited in this study. A small dose of rituximab (125mg/m2 body surface area) was given weekly with a duration of four weeks. Thyroid function, thyrotropin receptor antibody (TRAb), B cell and T cell subsets, ophthalmological examination, magnetic resonance imaging derived parameters, and adverse reactions were recorded at each visit. RESULTS Seven patients were followed for an average of 224 weeks. B-cell depletion was observed in all patients following rituximab infusion. The clinical activity score (CAS) decreased from 4.86 ± 0.69 to 3.00 ± 0.82 at 5 weeks after treatment (P = 0.033) and remained significantly lower than baseline values at the end of follow-up (P = 0.001). Compared to baseline values, significant decreases in exophthalmos of the right eye, the thickness of extraocular muscles with maximum signal intensity, and the highest signal intensity ratio (SIR) of extraocular muscle to ipsilateral temporal muscle values were observed at the last follow-up (all P < 0.05). Disease progressions or recurrences were not observed during follow-up. Only mild fatigue was observed after the first infusion as a side effect (n = 1). CONCLUSION Small dose of rituximab may be a promising option with adequate safety, tolerability, and long-term efficacy for patients with active moderate-to-severe TAO.
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Affiliation(s)
- Yueyue Wang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Hu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Chen
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Haitao Zhang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Yang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoquan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Xiaoquan Xu, ; Huanhuan Chen,
| | - Huanhuan Chen
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Xiaoquan Xu, ; Huanhuan Chen,
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Chen J, Chen G, Sun H. Intravenous rituximab therapy for active Graves' ophthalmopathy: a meta-analysis. Hormones (Athens) 2021; 20:279-286. [PMID: 33783712 DOI: 10.1007/s42000-021-00282-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/14/2021] [Indexed: 01/03/2023]
Abstract
AIM The successful treatment of Graves' ophthalmopathy (GO) remains a challenge, while the efficacy of rituximab (RTX) is at present controversial. The aim of this meta-analysis was to investigate the potential impact of intravenous RTX therapy in patients with GO. METHODS We performed a search in the PubMed, Embase, and Web of Science databases for relevant studies published before July 2020. The primary outcome was the change of clinical activity score (CAS), and secondary outcomes were the change of proptosis and TSH receptor antibodies (TRAb). A meta-analysis was conducted to calculate the standard mean difference (SMD) for these outcomes by using fixed- or random-effect models. RESULTS Analysis of outcomes in 152 patients collected from 12 published articles was conducted. Compared to baseline value, CAS was significantly decreased at 1, 6, 12, and >12 months after RTX treatment. For proptosis, the results revealed no significant decrease at 1-3, 6, and ≥12 months. Moreover, the pooled analysis employed in this meta-analysis showed no significant difference of TRAb at 1 month, but significant declines were observed at 6 and ≥12 months. CONCLUSION Our results strongly suggest that intravenous RTX treatment has an acute and long-lasting beneficial effect on decreasing both CAS and TRAb. The study also indicates that the effect of RTX on proptosis is limited. There is evidently a need to investigate the mechanism behind RTX ineffectiveness on proptosis and explore other therapeutic regimens for the reduction of proptosis.
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Affiliation(s)
- Jing Chen
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Ophthalmology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Gang Chen
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China.
- Fujian Provincial Key Laboratory of Medical Analysis, Fujian Academy of Medical Sciences, Fuzhou, 350001, Fujian, China.
| | - Huilan Sun
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Ophthalmology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China.
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Thyroid eye disease: current and potential medical management. Int Ophthalmol 2020; 40:1035-1048. [PMID: 31919775 DOI: 10.1007/s10792-019-01258-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 12/28/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Thyroid eye disease (TED) is the most frequent extra-thyroid manifestation of Graves' disease and it is more frequent in middle age and in female gender. Nowadays, the causal mechanisms of this disease are not completely understood, but the current available studies suggest that the main causative factor is the thyroid stimulating hormone receptor. MATERIALS AND METHODS To collect reports on TED medical management, a thorough literature search was performed in PubMed database. An additional search was made in Google Scholar to complete the collected items. RESULTS Among the indentified risk factors, tobacco habit is the most relevant. The main criteria to choose a suitable treatment are the activity and severity of the disease. Support measures can be used to improve the patient's symptoms in any phase of the disease. There is a large number of drugs proposed to manage TED, although with different reported rates of success. CONCLUSIONS Currently, the drugs of choice are corticosteroids in moderate-to-severe and in sight-threatening forms. The main problem of corticosteroids is their spectrum of side effects. Therefore, other alternatives are being suggested for medical management of this disease. The efficacy of these alternatives remains unclear.
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Insull EA, Sipkova Z, David J, Turner HE, Norris JH. Early low-dose rituximab for active thyroid eye disease: An effective and well-tolerated treatment. Clin Endocrinol (Oxf) 2019; 91:179-186. [PMID: 30864162 DOI: 10.1111/cen.13970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thyroid eye disease (TED) is an autoimmune inflammatory disease that can be disfiguring and potentially sight threatening. Suppression of inflammation in active disease can reduce the risk of visual loss and limit long-term sequelae. Current management involves inflammation suppression using glucocorticoids. The aim of this study was to evaluate the efficacy of early disease intervention with targeted immunomodulatory therapy to alter disease course. This paper reports the efficacy of low-dose rituximab in reducing clinical activity in TED in a small population. METHODS A retrospective audit of consecutive patients with active TED managed primarily with a 100 mg rituximab infusion. Further glucocorticoid or steroid-sparing agents were prescribed if clinically indicated. Clinical activity score, VISA overall severity score and Oxford Quality of Life score were recorded at each visit as well as TSH receptor antibody levels (TRAb), B cell subsets and adverse reactions. RESULTS Twelve patients had mean follow-up of 6.3 months. Clinical activity scores significantly decreased (mean score 5.08 to 1.58; P < 0.001), VISA overall severity scores reduced by 50% from 12 to 6, P < 0.001 and the mean cumulative dose of IV methylprednisolone was 2.3 g. 100 mg rituximab induced significant CD19+ B cell depletion (n = 8, P < 0.001). There was no significant reduction in serum TRAb (n = 8, P = 0.06). A transient infusion-related rash was the only adverse effect, n = 4. QoL scores did not differ markedly before and after treatment. CONCLUSION Low-dose rituximab is an efficacious, well-tolerated and safe treatment for active TED; reducing disease activity and allowing reduced administration of systemic steroid.
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Affiliation(s)
| | - Zuzana Sipkova
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Joel David
- Rheumatology Department, John Radcliffe Hospital, Oxford, UK
| | - Helen E Turner
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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Chen G, Ding Y, Li Q, Li Y, Wen X, Ji X, Bi S, Chen J, Xu J, Chen R, Ye H, Wei L, Yang H. Defective Regulatory B Cells Are Associated with Thyroid Associated Ophthalmopathy. J Clin Endocrinol Metab 2019; 104:4067-4077. [PMID: 30888403 DOI: 10.1210/jc.2018-01812] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 03/13/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE To investigate the change of IL-10 producing regulatory B cells (Bregs), which function to suppress peripheral immune responses, in patients with thyroid associated ophthalmopathy (TAO). METHODS Peripheral blood mononuclear cells (PBMCs) were isolated from healthy controls (N=54), patients with Grave's disease (N=26), and TAO patients (N=125), and stimulated with CpG/CD40L. The frequency of IL-10 producing Bregs and the expression of IL-10 in response to thyroid-stimulating hormone (TSH) stimulation were measured by flow cytometry. CD4+ T cells were cultured with Breg-depleted PBMCs to elucidate the function of Bregs in TAO patients. The potential immunoregulatory mechanism was also investigated by western blot and chromatin immunoprecipitation assays. RESULTS Active TAO patients had higher baseline levels of Bregs in their peripheral blood than both healthy controls and inactive patients. TSH promoted Bregs. Bregs from TAO patients were defective in suppressing the activation of IFN-γ+ and IL-17+ T cells in vitro. CONCLUSIONS We found that regulatory B cells in TAO patients are functionally defective, suggesting the defective Bregs might be responsible for the pathogenesis of TAO.
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Affiliation(s)
- Guo Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yungang Ding
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Qian Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
- Ningxia Eye Hospital, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Clinical Research Center of Blinding Eye Diseases, the First Clinical College of Northwest University for Nationalities, the Cooperative Teaching Hospital of North Minzu University, Yinchuan 750001, Ningxia Hui Autonomous Region, China
| | | | - Xiaofeng Wen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xian Ji
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | | | - Jingqiao Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Jianan Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Rongxin Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Huijing Ye
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lai Wei
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Huasheng Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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Shen WC, Lee CH, Loh EW, Hsieh AT, Chen L, Tam KW. Efficacy and Safety of Rituximab for the Treatment of Graves' Orbitopathy: A Meta-analysis of Randomized Controlled Trials. Pharmacotherapy 2019; 38:503-510. [PMID: 29601105 DOI: 10.1002/phar.2111] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE To investigate the efficacy and safety of rituximab in patients with Graves' orbitopathy (GO). DESIGN Systematic review and meta-analysis of four randomized controlled trials. PATIENTS A total of 293 patients with GO who received rituximab or control (either glucocorticoids, the established first-line therapy [three trials], or saline [one trial]). MEASUREMENTS AND RESULTS Relevant studies published before February 2018 were identified from the PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random-effects model. Treatment efficacy was assessed by measuring the following outcomes: clinical activity score (CAS), sight visual acuity reduction (NOSPECS) score, proptosis, diplopia, changes in eye volume, quality of life, and adverse events. In the four included trials, 113 patients in the rituximab group and 108 patients in the control group were evaluated. Compared with the control group, CAS (weighted mean difference 0.57, 95% confidence interval 0.25-0.89) was significantly reduced at 24 weeks in the rituximab group. Compared with the control group, considerable proptosis reduction was also observed in the rituximab group; however, the difference was not significant. The proportion of adverse events in the rituximab group was not significantly higher than that in the glucocorticoid control group, but one of the included trials indicated that the rituximab group had more serious adverse events than the saline control group. CONCLUSION Rituximab is a relatively safe and viable treatment that is superior to glucocorticoids or saline for patients with moderate to severe GO. However, the incidence of serious adverse events was disparate among the included trials. Additional studies involving a larger sample size and investigating the optimal rituximab dosage, frequency, and method of administration are warranted.
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Affiliation(s)
- Wan-Chen Shen
- Department of Pharmacy, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chia-Hwa Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Comprehensive Cancer Center of Taipei Medical University, Taipei, Taiwan.,Department of Laboratory Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
| | - El-Wui Loh
- Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - An-Tsz Hsieh
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lawrence Chen
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
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Tang F, Chen X, Mao Y, Wan S, Ai S, Yang H, Liu G, Zou Y, Lin M, Dan L. Orbital fibroblasts of Graves' orbitopathy stimulated with proinflammatory cytokines promote B cell survival by secreting BAFF. Mol Cell Endocrinol 2017; 446:1-11. [PMID: 28087387 DOI: 10.1016/j.mce.2017.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/30/2016] [Accepted: 01/09/2017] [Indexed: 12/11/2022]
Abstract
The success of rituximab for the treatment of active Graves' orbitopathy (GO) suggests that B cells play a critical role in intraorbital inflammation. B cell activating factor (BAFF) and its homolog a proliferation-inducing ligand (APRIL) are critical for B cell survival. However, the contribution of BAFF/APRIL to GO remains unclear. We sought to determine the role of BAFF/APRIL in the orbits of GO, and found that BAFF was markedly upregulated, while APRIL was not. Additionally, cultured GO orbital fibroblasts (GO-OFs)2 expressing BAFF were induced to produce a large amount of BAFF. In contrast, a weak APRIL expression was detected in the OFs, and they exhibited a slight response to stimulation. Notably, pretreated GO-OFs promoted B cell survival, and this effect was significantly inhibited by a BAFF-R neutralizing antibody. This study indicates that OFs from GO can express BAFF and mediate the intraorbital survival of B cells via BAFF mechanism.
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Affiliation(s)
- Fen Tang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Xiaoqing Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Yuxiang Mao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Shangtao Wan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Siming Ai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Huasheng Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Guangming Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Yusha Zou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China
| | - Miaoli Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China.
| | - Liang Dan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, People's Republic of China.
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Şimşek T, Yıldırım N, Efe B, Kebapçı N. Rituximab Treatment in a Patient with Active Graves' Orbitopathy and Psoriasis. Turk J Ophthalmol 2017; 47:42-46. [PMID: 28182165 PMCID: PMC5282540 DOI: 10.4274/tjo.26780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/30/2015] [Indexed: 12/01/2022] Open
Abstract
Management of Graves’ orbitopathy remains an important therapeutic challenge. Current therapeutic modalities are unsatisfactory in about one third of patients. Rituximab is a monoclonal antibody against CD20 antigen that is expressed in mature and immature B cells. Early experience with rituximab suggests that it is a promising alternative therapy for Graves’ orbitopathy. Here we report a case of a 49-year-old woman with Graves’ orbitopathy and psoriasis. The patient received 2 infusions of 1 g rituximab 2 weeks apart. Although there was improvement in inflammatory signs of the disease, proptosis did not change after the treatment.
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Affiliation(s)
- Tülay Şimşek
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - Nilgün Yıldırım
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - Belgin Efe
- Eskişehir Osmangazi University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Eskişehir, Turkey
| | - Nur Kebapçı
- Eskişehir Osmangazi University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Eskişehir, Turkey
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Li J, Xiao Z, Hu X, Li Y, Zhang X, Zhang S, Gong W, Zhao J, Ye X. The Efficacy of Rituximab Combined with 131I for Ophthalmic Outcomes of Graves' Ophthalmopathy Patients. Pharmacology 2017; 99:144-152. [PMID: 28049190 DOI: 10.1159/000453618] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/18/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study is to examine the effectiveness of introducing both rituximab (RTX) and 131I for active Graves' ophthalmopathy (GO) with hyperthyroidism. METHODS In total, 217 patients suffering from active GO with hyperthyroidism were included in this research. All subjects were randomly assigned to 3 groups. Patients in group A solely received 131I treatment; group B1 underwent a methylprednisolone treatment in combination with 131I treatment; and group B2 received an RTX in combination with 131I treatment. Hyperthyroidism treatment outcomes, orbital volumetry, ophthalmic assessments, serum cytokine levels, and adverse effects were measured after treatment. RESULTS The orbital volumetry principle was significantly different from 24 weeks after the start of treatment among all 3 groups, and improvements in most ophthalmic parameters were regarded significantly different among 3 groups (all p < 0.05). The expression levels of miR-146a and most serum cytokines were regarded significantly different from 24 weeks after the start of treatment among 3 groups (all p < 0.05). CONCLUSIONS In comparison with other therapies, RTX treatment in combination with 131I treatment is considered to be more effective for hyperthyroidism with active GO.
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Affiliation(s)
- Jiagen Li
- Department of Thyroid Breast Surgery, Yinzhou Hospital of Ningbo University Medical College, Ningbo, China
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Liu X, Guo H, Liu J, Shi B. Clinical efficacy of combined rituximab treatment in a woman with severe Graves' ophthalmopathy. Exp Ther Med 2016; 12:1093-1096. [PMID: 27446325 DOI: 10.3892/etm.2016.3367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/11/2016] [Indexed: 11/06/2022] Open
Abstract
The present study reports the case of a female Chinese patient with Graves' disease (GD) and severe Graves' ophthalmopathy (GO) in its active phase, who was treated with propylthiouracil and oral prednisolone for 2 months at a local hospital. However, a lack of improvement in symptoms meant that the patient was transferred to the First Affiliated Hospital of Xi'an Jiaotong University (Xi'an, China), whereupon the patient received high-dose intravenous methylprednisolone pulse therapy, although with limited efficacy. Subsequently, rituximab (RTX; anti-CD20 monoclonal antibody) combined with orbital irradiation treatment was initiated. The patient responded positively to the combined treatment; the clinical symptoms and enlargement of the extraocular muscles were ameliorated, and there were marked decreases in the clinical activity and NOSPECS grading scores. Furthermore, the serum levels of anti-thyrotropin receptor antibodies (TRAb) were markedly decreased at 2 months following RTX therapy. The patient was maintained in a euthyroid state by treatment with methimazole during and following RTX therapy. It was concluded that RTX treatment may attenuate severe GO by depleting lymphocytes, and may promote the recovery of GD by reducing the serum levels of TRAb.
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Affiliation(s)
- Xiaomei Liu
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China; Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China
| | - Hui Guo
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Juan Liu
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Bingyin Shi
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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Ettl A. Endokrine Orbitopathie. SPEKTRUM DER AUGENHEILKUNDE 2015. [DOI: 10.1007/s00717-015-0279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ostrowski RA, Bussey MR, Shayesteh Y, Jay WM. Rituximab in the Treatment of Thyroid Eye Disease: A Review. Neuroophthalmology 2015; 39:109-115. [PMID: 27928343 DOI: 10.3109/01658107.2015.1039140] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/27/2015] [Accepted: 04/06/2015] [Indexed: 01/08/2023] Open
Abstract
Graves disease is an autoimmune thyroid disease classically characterised by a clinical triad consisting of hyperthyroidism, diffuse goitre, and thyroid eye disease. Thyroid eye disease is an immunologically mediated condition in which humoral immunity is thought to play a central role. Thyroid eye disease is traditionally treated with high-dose glucocorticosteroids and surgical orbital decompression. However, responses are inadequate and alternative treatment options are needed. Rituximab, an anti-CD20 monoclonal antibody, shows promise as a novel therapeutic option for thyroid eye disease. There are 43 cases of thyroid eye disease treated with rituximab in the medical literature, and larger studies are warranted to determine the long-term effectiveness of rituximab. Rituximab may represent an attractive new treatment option for thyroid eye disease, especially in the case of disease that is refractory to current treatment strategies.
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Affiliation(s)
- Rochella A Ostrowski
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA and
| | - Melissa R Bussey
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA and
| | - Yasmin Shayesteh
- Department of Ophthalmology, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA
| | - Walter M Jay
- Department of Ophthalmology, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA
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Savino G, Mandarà E, Gari M, Battendieri R, Corsello SM, Pontecorvi A. Intraorbital injection of rituximab versus high dose of systemic glucocorticoids in the treatment of thyroid-associated orbitopathy. Endocrine 2015; 48:241-7. [PMID: 24880619 DOI: 10.1007/s12020-014-0283-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/29/2014] [Indexed: 12/15/2022]
Abstract
The aim of the study was to compare, in a randomized prospective study, the efficacy and safety of intraorbital administration of low doses of RTX versus intravenous glucocorticoids (GCs) to treat patients affected by moderately severe thyroid-associated active orbitopathy. Twenty patients with active, moderately severe TAO, whose mean age was 56.7 years±10.2 SD participated in the study. Patients were randomly selected and treated with intraorbital injections of RTX or with i.v. GCs. Disease activity and severity were assessed by the Clinical Activity Score (CAS) and the NOSPECS. Computed tomography or magnetic resonance scans were performed in all patients. In the RTX group, full blood cell count and flow cytometric analysis on peripheral blood lymphocytes were done. The patients were followed for 20 months. In both groups, CAS and NOSPECS indexes were significantly reduced (p<0.005). In particular, CAS reduction was evident since the first follow-up with both treatments. Proptosis decreased significantly only in group B and diplopia showed no significant changes during follow-up times in both groups. Neither of the treatments affected the peripheral TRab. In group A, 5 weeks after the first injection, the CD20+ peripheral lymphocytes value was nearly zero. One patient treated with rituximab progressed to severe TAO (optic neuropathy) following the second injection so the treatment was discontinued. The data confirm the therapeutic efficacy of RTX in active TAO, even in low doses and locally administered. The efficacy on the inflammatory component of the disease is comparable to that of steroids and seems to be related with the reduction of peripheral CD20+ lymphocytes. Caution should be given to an accurate patient selection.
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Affiliation(s)
- Gustavo Savino
- Institute of Ophthalmology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy,
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Palau AEB, Morgan ML, Yalamanchili S, Lee AG. Neuro-Ophthalmology Annual Review. Asia Pac J Ophthalmol (Phila) 2014; 3:104-25. [PMID: 26107493 DOI: 10.1097/apo.0000000000000052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to update the practicing ophthalmologist on the English-language neuro-ophthalmology literature from the prior year. This study is a review of English-language literature from August 1, 2012, to August 1, 2013. The authors searched PubMed articles published from August 1, 2012, to August 1, 2013, limited to English-language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. We researched the following topics: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis and demyelinating disease including multiple sclerosis, lesions of the chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual functions, and neuroimaging advances. We intend to share clinically relevant literature of the past year with the practicing ophthalmologist. We aimed to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. We reviewed literature in the past year with a focus on relevance and novelty. This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.
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Affiliation(s)
- Angelina Espino Barros Palau
- From the *Department of Ophthalmology, Houston Methodist Hospital, Houston, TX; †Baylor College of Medicine, Houston, TX; ‡Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, Houston, TX; §University of Texas Medical Branch, Galveston, TX; ¶University of Texas M.D. Anderson Cancer Center, Houston, TX; and ∥The University of Iowa Hospitals and Clinics, Iowa City, IA
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Abstract
BACKGROUND Thyroid associated ophthalmopathy (TAO) is the most frequent extrathyroidal manifestation of Graves' disease, affecting up to 50% of patients, and has a great impact on quality of life. Rituximab is a human/murine chimeric monoclonal antibody that targets CD20, a transmembrane protein expressed on the surface of pre-B and mature B lymphocytes, but not on stem cells, pro-B lymphocytes or plasma cells. Preliminary work has shown that blocking the CD20 receptor on B-lymphocytes with rituximab affects the clinical course of TAO, by reducing inflammation and the degree of proptosis. OBJECTIVES The aim of this review was to investigate the effectiveness and safety of rituximab for the treatment of TAO. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to April 2013), EMBASE (January 1980 to April 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to April 2013), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the EU Clinical Trials Register (www.clinicaltrialsregister.eu). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 April 2013. We manually searched references of review articles and used the Science Citation Index to identify additional studies citing trials. We contacted the lead investigators of relevant trials on ClinicalTrials.gov and the WHO ICTRP for information and data from as yet unpublished clinical trials. We contacted experts in the field for information about any ongoing trials. We contacted the manufacturers of rituximab for details of any sponsored trials. SELECTION CRITERIA We sought to include randomised controlled trials (RCTs) of rituximab treatment by intravenous infusion for the treatment of patients with TAO, compared with placebo or intravenous glucocorticoid treatment. DATA COLLECTION AND ANALYSIS Two review authors independently scanned titles and abstracts, as well as independently screened the full reports of the potentially relevant studies. At each stage, the results were compared and disagreements were solved by discussion. MAIN RESULTS No studies were identified that met the inclusion criteria. There are three ongoing studies which are likely to meet inclusion criteria once published, and thus be included in future updates of this review. AUTHORS' CONCLUSIONS There is currently insufficient evidence to support the use of rituximab in patients with TAO. There is a need for large RCTs, investigating rituximab versus placebo or corticosteroids in patients with active TAO to make adequate judgement on the efficacy and safety of this novel therapy for this condition.
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Affiliation(s)
- Neda Minakaran
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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