Prolonged treatment with rituximab in patients with refractory pemphigus vulgaris

Brain abscess following rituximab infusion in a patient with pemphigus vulgaris

Patient: Female, 52

Final Diagnosis: Brain abscess

Symptoms: Fever • headache • weakness, left sided

Medication: Prednisolone • Azathioprine • Rituximab

Clinical Procedure: Stereotactic brain biopsy and LP

Specialty: Neurology

Rituximab in the treatment of pemphigus vulgaris

INTRODUCTION

Rituximab is increasingly used in patients with pemphigus vulgaris (PV) who are nonresponders to conventional therapy.

METHODS

A PubMed search was conducted using the words pemphigus vulgaris and rituximab therapy from papers published between 2000 and 2012. Two protocols were used. In the lymphoma protocol, patients received four weekly infusions of rituximab (dose 375 mg/m(2)). The rheumatoid arthritis (RA) protocol consisted of two infusions of 1,000 mg each 15 days apart. The variables recorded from each study included clinical remission off or on therapy, relapse rate, incidence of serious adverse events, concomitant therapies, duration of follow-up, and when available, levels of B cells and autoantibodies.

RESULTS

Forty-two studies were found, which reported 272 patients; 180 were treated by the lymphoma protocol and 92 by the RA protocol. Both protocols were effective in treating recalcitrant PV. The lymphoma protocol had a lower response rate, relapse rate and serious infections, but higher mortality, and there were nonresponders. The RA protocol produced a higher response rate, relapse rate, number of infections, but lower mortality rate, and lacked nonresponders. The cumulative follow-up for patients treated with the lymphoma protocol was 15.44 months (range 1-41) and 21.04 months (range 8.35-29) for the RA protocol. A major concern in both protocols was the high infection rates, some of which were fatal. A different protocol using a combination of rituximab with intravenous immunoglobulin in a defined manner with a definitive endpoint, used in a limited cohort of patients, showed promising results.

CONCLUSION

Neither protocol produced a sustained clinical remission and both required continued systemic therapy. Before initiation of treatment, physicians should have a specific goal and endpoint and be aware of its potential side effects and lack of information on its long-term effects. Patients should be carefully monitored during and after therapy.

Relevance of rituximab therapy in pemphigus vulgaris: analysis of current data and the immunologic basis for its observed responses

Treatment of pemphigus vulgaris (PV) patients with rituximab therapy has not been critically evaluated. This article will provide in significant detail the available data to date, in order to provide a clinical and immunologic basis for clinicians to decide how best to treat recalcitrant PV patients with rituximab. PV is an autoimmune blistering disorder that affects the skin and mucous membranes. The immunopathology is well characterized, including the target antigens. PV patients have traditionally been treated with systemic corticosteroids and adjuvant immunosuppressive therapies. Clinical remission has been achieved in roughly 30% of patients. However, many patients experience severe side effects from this immunosuppression, including death. B-cell depletion therapy with rituximab therapy has been used to treat several autoimmune diseases including PV. In this article, we examined the data on 153 patients with PV who have been treated with rituximab. Our focus is on the clinical response of the patients with emphasis on adjuvant therapies, dosing regimens, potential adverse events and mechanism of action related to B-cell modulation during therapy. Importantly, the use of rituximab has increased clinical remission rates to 65% including many patients who were able to discontinue all systemic medications. Finally, an expert commentary is provided, which includes suggestions for optimizing current therapy and recommends the future direction of the field. The authors strongly endorse the use of rituximab in treatment of PV patients, particularly those nonresponsive to or who develop serious side effects to conventional therapy. Proper monitoring of patients including peripheral B-cell counts and overt signs of infection are warranted, given the potential for prolonged B-cell depletion.