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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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2
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Apostolopoulou A, Fishman JA. The Pathogenesis and Diagnosis of Pneumocystis jiroveci Pneumonia. J Fungi (Basel) 2022; 8:1167. [PMID: 36354934 PMCID: PMC9696632 DOI: 10.3390/jof8111167] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 07/29/2023] Open
Abstract
Pneumocystis jiroveci remains an important fungal pathogen in immunocompromised hosts. The environmental reservoir remains unknown. Pneumonia (PJP) results from airborne transmission, including in nosocomial clusters, or with reactivation after an inadequately treated infection. Pneumocystis pneumonia most often occurs within 6 months of organ transplantation, with intensified or prolonged immunosuppression, notably with corticosteroids and following cytomegalovirus (CMV) infections. Infection may be recognized during recovery from neutropenia and lymphopenia. Invasive procedures may be required for early diagnosis and therapy. Despite being a well-established entity, aspects of the pathogenesis of PJP remain poorly understood. The goal of this review is to summarize the data on the pathogenesis of PJP, review the strengths and weaknesses of the pertinent diagnostic modalities, and discuss areas for future research.
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Affiliation(s)
- Anna Apostolopoulou
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jay A. Fishman
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- MGH Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Little JS, Weiss ZF, Hammond SP. Invasive Fungal Infections and Targeted Therapies in Hematological Malignancies. J Fungi (Basel) 2021; 7:1058. [PMID: 34947040 PMCID: PMC8706272 DOI: 10.3390/jof7121058] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023] Open
Abstract
The use of targeted biologic therapies for hematological malignancies has greatly expanded in recent years. These agents act upon specific molecular pathways in order to target malignant cells but frequently have broader effects involving both innate and adaptive immunity. Patients with hematological malignancies have unique risk factors for infection, including immune dysregulation related to their underlying disease and sequelae of prior treatment regimens. Determining the individual risk of infection related to any novel agent is challenging in this setting. Invasive fungal infections (IFIs) represent one of the most morbid infectious complications observed in hematological malignancy. In recent years, growing evidence suggests that certain small molecule inhibitors, such as BTK inhibitors and PI3K inhibitors, may cause an increased risk of IFI in certain patients. It is imperative to better understand the impact that novel targeted therapies might have on the development of IFIs in this high-risk patient population.
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Affiliation(s)
- Jessica S. Little
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Zoe F. Weiss
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Sarah P. Hammond
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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4
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Nelson BE, Tipton S, Venkatesan R. Early Onset Neutropenia due to Rituximab Therapy in Mantle Cell Lymphoma: A Case Report. J Hematol 2021; 10:136-138. [PMID: 34267851 PMCID: PMC8256914 DOI: 10.14740/jh814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/19/2021] [Indexed: 11/23/2022] Open
Abstract
Cases of late onset neutropenia (LON) after rituximab therapy have been documented, but few cases have been documented of early onset neutropenia (EON). We present a case report of a patient with mantle cell lymphoma who presented with EON, only 6 days after initiation of rituximab therapy, notable for the shortest duration to EON ever reported in literature. Throughout this paper, we explore the potential pathogenesis and incidence of EON with the help of our unique case.
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Affiliation(s)
| | - Shelby Tipton
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Rohit Venkatesan
- Department of Hematology & Oncology, MD Anderson Cancer Center, Houston, TX, USA
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Della Rocca AM, Leonart LP, Ferreira VL, Tonin FS, Steffenello-Durigon G, Del Moral JAG, Fernandez-Llimos F, Pontarolo R. Chemotherapy Treatments for Burkitt Lymphoma: Systematic Review of Interventional Studies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:514-525. [PMID: 33947633 DOI: 10.1016/j.clml.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/16/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Burkitt lymphoma (BL) is an aggressive hematologic cancer. This study synthetized the evidence about the efficacy and safety of chemotherapy treatments used in patients with BL using the World Health Organization classification. MATERIALS AND METHODS A systematic review of interventional studies was performed. A search was carried out in PubMed, Scopus, and Web of Science, with additional manual and gray literature searches. The methodological quality of articles was assessed with the Newcastle-Ottawa scale. RESULTS We identified 1358 studies; 9 nonrandomized studies satisfied the eligibility criteria (n = 544 patients). The BL epidemiologic variants were sporadic BL (44.5%), endemic BL (47.2%), and immunodeficiency-associated BL (8.3%). Regarding chemotherapy protocols, 4 groups were identified: based on CODOX-M/IVAC (n = 4), EPOCH (n = 1), BFM (n = 1), and simplified treatment schemes used in African countries (n = 3). Most studies had moderate quality. Empirically and qualitatively, the best options for adults with sporadic BL were 'DA-EPOCH-R' (7-year overall survival [OS], 100%; 95% confidence interval [CI], 82-100), 'HDR + LD into CODOX-M/IVAC' (2-year OS, 84%), and 'RD-CODOX-M/IVAC' (4-year progression-free survival, 92%; 95% CI, 77-100); in pediatric patients, the 'BFM-NHL-90-like' showed promising results (3-year OS, 90%). For immunodeficiency-associated BL, the 'SC-EPOCH-RR' demonstrated a good therapeutic profile (6-year OS, 90%; 95% CI, 60-98). The 'Malawi 2012-2014' (1-year OS, 73%; 95% CI, 61-85) could be the treatment choice in endemic BL (African countries). The main adverse events were hematologic. CONCLUSION Selecting chemotherapy protocols for BL should be grounded in its epidemiologic variants. Further studies with greater methodological quality are needed to strengthen the evidence.
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Affiliation(s)
- Ana M Della Rocca
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Letícia P Leonart
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Vinicius L Ferreira
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Giovanna Steffenello-Durigon
- Hematology Service, University Hospital Professor Polydoro Ernani de São Thiago, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Joanita A G Del Moral
- Hematology Service, University Hospital Professor Polydoro Ernani de São Thiago, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Fernando Fernandez-Llimos
- Center for Health Technology and Services Research (CINTESIS), Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.
| | - Roberto Pontarolo
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil; Department of Pharmacy, Federal University of Paraná, Curitiba, PR, Brazil.
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Srinivasan S, Roy Moulik N, Kc A, Narula G, Sankaran H, Prasad M, Dhamne C, Cheriyalinkal Parambil B, Shah S, Shet T, Sridhar E, Gujral S, Banavali S. Increased toxicities in children with Burkitt lymphoma treated with rituximab: Experience from a tertiary cancer center in India. Pediatr Blood Cancer 2020; 67:e28682. [PMID: 32865865 DOI: 10.1002/pbc.28682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Even though rituximab has emerged as standard of care for the management of high-risk pediatric Burkitt lymphoma (BL), its safety in children from the low-middle-income countries (LMICs) remains to be proven. We herein report our experience of using rituximab in children with BL. METHODS All patients diagnosed with BL between January 2015 and December 2017 were treated in a risk-stratified manner with either the modified MCP-842 or modified LMB protocol. Patients with poor response to MCP-842 were switched to the LMB-salvage regimen. In addition, rituximab was given to selected high-risk patients. RESULT Forty-two (49.4%) of 85 patients with BL received rituximab. The incidence of febrile neutropenia (90.5% vs 67.4%; P = 0.02), pneumonia (38.1% vs 11.6%; P = 0.005), intensive care unit admissions (54.5% vs 17.6%; P = 0.002), and toxic deaths (26.2% vs 9.3%; P = 0.04) was higher among BL patients who received rituximab. Pneumonia was fatal in 11 of 16 (69%) patients who received rituximab. On multivariate analysis, rituximab continued to be significantly associated with toxic deaths ( OR: 11.45 [95% CI: 1.87-70.07; P = 0.008]). The addition of rituximab to intensive chemotherapy resulted in an inferior one-year event-free survival (49.4% ± 8.1% vs 79.3% ± 6.5%; P = 0.025) and one-year overall survival (63.1% ± 8.5% vs 91.8% ± 4.5%; P = 0.007) with no improvement in one-year relapse-free survival (78.3% ± 7.3% vs 83.9% ± 6.0%; P = 0.817). CONCLUSION Rituximab was associated with increased toxicities and toxic deaths in our patients. The potential immunomodulatory effect of rituximab and increased susceptibility to infections in patients from LMICs have to be carefully considered while choosing this drug in the treatment of BL in resource-constrained settings.
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Affiliation(s)
- Shyam Srinivasan
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nirmalya Roy Moulik
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anand Kc
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Hari Sankaran
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Badira Cheriyalinkal Parambil
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sneha Shah
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tanuja Shet
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sumeet Gujral
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shripad Banavali
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Stocker N, Labopin M, Boussen I, Paccoud O, Bonnin A, Malard F, Amiel C, Gozlan J, Battipaglia G, Duléry R, Giannotti F, Ruggeri A, Gaugler B, Mohty M, Brissot E. Pre-emptive rituximab treatment for Epstein–Barr virus reactivation after allogeneic hematopoietic stem cell transplantation is a worthwhile strategy in high-risk recipients: a comparative study for immune recovery and clinical outcomes. Bone Marrow Transplant 2019; 55:586-594. [DOI: 10.1038/s41409-019-0699-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/03/2019] [Accepted: 08/10/2019] [Indexed: 12/13/2022]
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8
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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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9
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Shek D, Read SA, Ahlenstiel G, Piatkov I. Pharmacogenetics of anticancer monoclonal antibodies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2019; 2:69-81. [PMID: 35582142 PMCID: PMC9019180 DOI: 10.20517/cdr.2018.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/09/2019] [Accepted: 02/19/2019] [Indexed: 12/16/2022]
Abstract
Pharmacogenetics is the study of therapeutic and adverse responses to drugs based on an individual’s genetic background. Monoclonal antibodies (mAbs) are a rapidly evolving field in cancer therapy, however a number of newly developed and highly effective mAbs (e.g., anti-CTLA-4 and anti-PD-1) possess pharmacogenomic profiles that remain largely undefined. Since the first chemotherapeutic mAb Rituximab was approved in 1997 by the US Food and Drug Administration for cancer treatment, a broad number of other mAbs have been successfully developed and implemented into oncological practice. Nowadays, mAbs are considered as one of the most promising new approaches for cancer treatment. The efficacy of mAb treatment can however be significantly affected by genetic background, where genes responsible for antibody presentation and metabolism, for example, can seriously affect patient outcome. This review will focus on current anticancer mAb treatments, patient genetics that shape their efficacy, and the molecular pathways that bridge the two.
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Affiliation(s)
- Dmitrii Shek
- Blacktown Clinical School, Western Sydney University, Blacktown, NSW 2148, Australia
| | - Scott A Read
- Blacktown Clinical School, Western Sydney University, Blacktown, NSW 2148, Australia.,Storr Liver Centre, The Westmead Institute for Medical Research, The University of Sydney, Westmead, NSW 2145, Australia
| | - Golo Ahlenstiel
- Blacktown Clinical School, Western Sydney University, Blacktown, NSW 2148, Australia.,Storr Liver Centre, The Westmead Institute for Medical Research, The University of Sydney, Westmead, NSW 2145, Australia.,Blacktown Hospital, Blacktown, NSW 2148, Australia
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10
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Crayne CB, Eloseily E, Mannion ML, Azerf SP, Weiser P, Beukelman T, Stoll ML, Feig DI, Prescott Atkinson T, Cron RQ. Rituximab treatment for chronic steroid-dependent Henoch-Schonlein purpura: 8 cases and a review of the literature. Pediatr Rheumatol Online J 2018; 16:71. [PMID: 30428889 PMCID: PMC6236882 DOI: 10.1186/s12969-018-0285-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/25/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that is characterized by non-thrombocytopenic purpura, abdominal pain, arthritis, and glomerulonephritis. Typically, HSP is self-limited requiring only supportive care, but more severe cases may require corticosteroid (CS) treatment. Rarely, a subset of these patients has persistent rash, arthritis, abdominal involvement, or renal disease despite treatment with CS, or has disease recurrence on CS tapering. Refractory HSP has been effectively treated with a variety of CS sparing therapies. For life-threatening refractory HSP, the B cell depleting agent, rituximab (RTX), has been reported as beneficial for children with substantial renal or central nervous system involvement. However, RTX use for children with less severe HSP, but chronic CS dependent disease refractory to CS sparing immunomodulatory agents, has been less well explored. Herein, we describe 8 children treated with RTX for chronic refractory HSP and report a reduction in recurrent hospitalizations and eventual CS discontinuation. METHODS This is a retrospective analysis of eight children who were treated with RTX for chronic CS dependent HSP during the years 2006-2014 at a single institution. A chart review of the electronic medical record was performed to determine the presenting symptoms, the type and duration of treatment received, and the number of hospitalizations prior to and after RTX. The number of hospitalizations and oral corticosteroid burden were analyzed using the Wilcoxon signed rank test. RESULTS Prior to receiving RTX, seven patients had at least one hospitalization for HSP (median 1.5, range 0-3). Following RTX, only two patients were hospitalized, each a single time for recurrent abdominal pain. The median oral CS burden was 0.345 mg/kg/day before RTX and 0 mg/kg/day at 6 months (p = 0.078), 1 year (p = 0.0625), and 2 years (p = 0.03) following RTX infusion. Seven out of eight children met remission criteria, defined as no active rash, arthritis, nephritis (hematuria and proteinuria), or gastrointestinal distress following RTX. No serious adverse events were noted. CONCLUSION Overall, RTX effectively reduced the number of hospital admissions and oral CS burden. RTX also helped most all children achieve clinical remission. RTX appears to be an effective and safe alternative for chronic CS dependent and immunomodulatory refractory childhood HSP.
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Affiliation(s)
- Courtney B. Crayne
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Esraa Eloseily
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Melissa L. Mannion
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Saji P. Azerf
- 0000000106344187grid.265892.2School of Medicine, University of Alabama at Birmingham, 510 20th St S, #12, Birmingham, AL 35233 USA
| | - Peter Weiser
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Timothy Beukelman
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Matthew L. Stoll
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Daniel I. Feig
- 0000000106344187grid.265892.2Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave S, ACC 516, Birmingham, AL 35233 USA
| | - T. Prescott Atkinson
- 0000000106344187grid.265892.2Division of Allergy & Immunology, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave S, CPPN M20, Birmingham, AL 35233 USA
| | - Randy Quentin Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL, 35233, USA.
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11
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Khalil MAM, Khalil MAU, Khan TFT, Tan J. Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians. J Transplant 2018; 2018:9429265. [PMID: 30155279 PMCID: PMC6093016 DOI: 10.1155/2018/9429265] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 06/04/2018] [Accepted: 06/25/2018] [Indexed: 12/14/2022] Open
Abstract
Drug-induced hematological cytopenia is common in kidney transplantation. Various cytopenia including leucopenia (neutropenia), thrombocytopenia, and anemia can occur in kidney transplant recipients. Persistent severe leucopenia or neutropenia can lead to opportunistic infections of various etiologies. On the contrary, reducing or stopping immunosuppressive medications in these events can provoke a rejection. Transplant clinicians are often faced with the delicate dilemma of balancing cytopenia and rejection from adjustments of immunosuppressive regimen. Differentials of drug-induced cytopenia are wide. Identification of culprit medication and subsequent modification is also challenging. In this review, we will discuss individual drug implicated in causing cytopenia and correlate it with corresponding literature evidence.
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Affiliation(s)
| | | | - Taqi F. Taufeeq Khan
- King Salman Armed Forces Hospital, Tabuk King Abdul Aziz Rd., Tabuk 47512, Saudi Arabia
| | - Jackson Tan
- RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
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12
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Ghrenassia E, Mariotte E, Azoulay E. Rituximab-related Severe Toxicity. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7176228 DOI: 10.1007/978-3-319-73670-9_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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13
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Schoch LK, Asiama A, Zahurak M, Shanbhag S, Hurtt J, Sawyer K, Swinnen LJ, Wagner-Johnston N, Jones RJ, Ambinder RF, Gladstone DE. Pharmacokinetically-targeted dosed everolimus maintenance therapy in lymphoma patients. Cancer Chemother Pharmacol 2017; 81:347-354. [PMID: 29234922 DOI: 10.1007/s00280-017-3499-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/08/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Everolimus, an mTOR inhibitor, is active in refractory lymphomas. However, toxicity with flat dosing limits its usage. Speculatively, pharmacokinetically-targeted dosing could improve tolerability. Therefore, we studied serum-trough dosing with rituximab as maintenance after high-dose cyclophosphamide (HDC) consolidation in lymphoma patients. PATIENTS/METHODS After HDC, everolimus was dosed to serum trough levels (goal 3-15 ng/mL), with quarterly rituximab infusions for 1 year while maintaining < grade II non-hematologic and < grade III hematologic toxicities. Adult patients in first PR/CR with: mantle cell, transformed, double-hit, or high risk chronic lymphocytic leukemia or in second PR for any relapsed B cell lymphoma were eligible. Prophylaxis was given for encapsulated organisms, HSV and PCP. Serum IgG levels were maintained > 500 mg/dL. RESULTS 49 patients, median age: 59.0 years enrolled; MCL (26), CLL (10), transformed lymphoma (7), and other histologies (6). During the life of the study, the most frequent everolimus dosing has been 2.5 mg daily or 2.5 mg every other day; at these doses, serum levels are within the therapeutic range and non-hematologic toxicity is rare. At a median follow-up of 27.1 months, three patients remain on active therapy. Two patients withdrew secondary to potentially-attributable adverse events including a bacterial pneumonia and a viral pneumonia; this low rate of discontinuation compares well to other long-term everolimus trials. While a 58 and 76% EFS at 30 months for the entire cohort and MCL cohort, respectively, compares similarly to previously published HDC/rituximab data, longer follow-up is required. CONCLUSIONS Pharmacokinetically-targeted dosing appears to increase everolimus tolerability. This finding may be applicable to other patient populations.
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Affiliation(s)
- L K Schoch
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - A Asiama
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - M Zahurak
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - S Shanbhag
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - J Hurtt
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - K Sawyer
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - L J Swinnen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - N Wagner-Johnston
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - R J Jones
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - R F Ambinder
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA
| | - Douglas E Gladstone
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N. Broadway room 1363, Baltimore, MD, 21287, USA.
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14
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Singh AG, Hamarneh IS, Karwal MW, Lentz SR. Durable responses to rituximab in acquired factor VIII deficiency. Thromb Haemost 2017; 106:172-4. [DOI: 10.1160/th11-02-0097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 03/25/2011] [Indexed: 12/18/2022]
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15
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Verriere B, Gastaud L, Chamorey E, Peyrade F, Deletie E, Bouredji K, Quinsat D, Schiappa R, Thyss A, Re D. Description of late onset neutropenia in indolent lymphoma patients treated with bendamustine plus rituximab. Hematol Oncol 2017; 36:144-149. [PMID: 28685846 DOI: 10.1002/hon.2458] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/11/2022]
Abstract
Bendamustine (B) associated with rituximab (R) is widely described in literature for the management of patients with chronic lymphoid leukaemia (CLL) and indolent non-Hodgkin lymphoma. Safety data regarding late hematotoxicity such as late onset neutropenia (LON) are scarce. The aim of our study was to assess the incidence and to identify risk factors for LON in patients with indolent non-Hodgkin lymphoma and CLL treated with B and R (B-R). One hundred forty five patients were treated with B-R as first or second line. Patients with neutropenia prior induction treatment, treated beyond second line and relapsing within 3 months after the end of induction treatment, were excluded. Patients receiving at least 1 cycle of B-R and having LON during follow-up period were included and considered as eligible for toxicity assessment. A complete blood count was performed 4 weeks after the last cycle of induction treatment and thereafter every 3 months for 1 year. Thirty six patients were identified in our cohort (incidence of 25%), mostly affected by CLL (n = 11) and follicular lymphoma (FL) (n = 15). During follow-up, 84 events of LON were recorded, 61% and 39% were of grades 1/2 and 3/4, respectively. No episode of febrile neutropenia was documented. Amongst 13 of the 15 patients with FL undergoing R maintenance, 8 had treatment discontinuation because of LON. Median time for LON (grade > 2) and time to recovery (grade < 3) were of 11.2 and 17.3 weeks, respectively. One year after B-R induction, LON persisted in 4 patients. The risk of LON was increased both in patients with FL or CLL and performance status >1. The LON in B-R treated patients is clinically relevant. Close clinical and biological follow-up and treatment prophylaxis (eg, valaciclovir and cotrimoxazole) especially for FL patients undergoing maintenance with R monotherapy seems relevant.
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Affiliation(s)
- B Verriere
- Pharmacy department, Antibes Hospital, Antibes, France
| | - L Gastaud
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - E Chamorey
- Biostatistics and epidemiology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - F Peyrade
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - E Deletie
- Pharmacy department, Antibes Hospital, Antibes, France
| | - K Bouredji
- Oncology and hemato oncology department, Antibes Hospital, Antibes, France
| | - D Quinsat
- Internal Medicine department, Antibes Hospital, Antibes, France
| | - R Schiappa
- Biostatistics and epidemiology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - A Thyss
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France
| | - D Re
- Oncology department, Anticancer Center Antoine Lacassagne, Nice, France.,Oncology and hemato oncology department, Antibes Hospital, Antibes, France
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16
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How gene polymorphisms can influence clinical response and toxicity following R-CHOP therapy in patients with diffuse large B cell lymphoma. Blood Rev 2017; 31:235-249. [DOI: 10.1016/j.blre.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 12/07/2016] [Accepted: 02/03/2017] [Indexed: 12/20/2022]
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17
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Ha VH, Ghosh S, Leyshon C, Ryan N, Chambers CR, Stewart DA. Incidence of late onset neutropenia associated with rituximab use in B cell lymphoma patients undergoing autologous stem cell transplantation. J Oncol Pharm Pract 2017; 24:323-331. [DOI: 10.1177/1078155217702214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Reversible late onset neutropenia associated with rituximab has been reported with incidence rates varying from 15 to 70% in B cell lymphoma patients receiving autologous stem cell transplantation. We conducted a retrospective descriptive study at one tertiary care center in adult B cell lymphoma patients treated with rituximab and autologous stem cell transplantation between 1 January 2004 and 30 June 2014. Late onset neutropenia was defined as an absolute neutrophil count <1.0 × 109 cells/L after neutrophil engraftment and less than six months post autologous stem cell transplantation. The primary objective was to determine the incidence of late onset neutropenia. The secondary objectives were to examine whether the use of rituximab with re-induction therapy, mobilization or high dose chemotherapy regimens increased the risk for late onset neutropenia, and to evaluate infectious complications. Of 315 subjects, 92 (29.2%) developed late onset neutropenia. Mobilization regimens containing rituximab (OR 2.90 95% CI: 1.31–6.40), high dose chemotherapy containing rituximab (OR 1.87 95% CI: 1.14–3.05), and exposure to rituximab in either or both regimens (OR 3.05 95% CI: 1.36–6.88) significantly increased the risk of late onset neutropenia. While neutropenic, 17.4% experienced an infection, 7.6% experienced febrile neutropenia, and 5.4% were hospitalized. In conclusion, rituximab with mobilization or high dose chemotherapy may increase the risk of late onset neutropenia post autologous stem cell transplantation.
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Affiliation(s)
- Vincent H Ha
- Department of Pharmacy, Cross Cancer Institute, Edmonton, Canada
- Department of Pharmacy, Tom Baker Cancer Centre, Calgary, Canada
| | - Sunita Ghosh
- Department of Experimental Oncology, Cross Cancer Institute, Edmonton, Canada
| | | | - Nikki Ryan
- Department of Pharmacy, Tom Baker Cancer Centre, Calgary, Canada
| | | | - Douglas A Stewart
- Department of Oncology, University of Calgary and Tom Baker Cancer Centre, Calgary, Canada
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Ajeganova S, Tesfa D, Hägglund H, Fadeel B, Vedin I, Zignego AL, Palmblad J. Effect of FCGR polymorphism on the occurrence of late-onset neutropenia and flare-free survival in rheumatic patients treated with rituximab. Arthritis Res Ther 2017; 19:44. [PMID: 28270182 PMCID: PMC5341184 DOI: 10.1186/s13075-017-1241-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/20/2017] [Indexed: 12/23/2022] Open
Abstract
Background The causes and mechanisms of late-onset neutropenia (LON) following rituximab treatment in patients with rheumatic diseases are not known. In this study, we aimed to investigate the role of established Fcγ receptor gene (FCGR) polymorphisms and B-cell-activating factor (BAFF) gene promoter polymorphisms for the development of LON and for the efficacy of rituximab in patients with rheumatic diseases. Methods A single-center case-control retrospective study was nested in a cohort of 214 consecutive patients with rheumatic diseases treated with rituximab. Eleven patients presented with LON. Fifty non-LON control subjects were matched by diagnosis, age, sex, and treatments. Single-nucleotide polymorphisms of FCGR (FCGR2A 131H/R, FCGR2B 232I/T, FCGR3A 158V/F) and BAFF promoter polymorphism −871C/T were analyzed with polymerase chain reaction-based techniques, and serum immunoglobulin M (IgM) and BAFF levels were analyzed by enzyme-linked immunosorbent assay. Flare-free survival was related to LON occurrence and polymorphisms. Results The FCGR3A V allele, but not other FCGR polymorphisms, correlated with the occurrence of LON; each V allele conferred a fourfold increased OR for LON (p = 0.017). FCGR3A 158V/V and presentation with LON were associated with a longer flare-free survival (p = 0.023 and p = 0.031, respectively). FCGR3A 158V/V was related to lower IgM levels (p = 0.016). Serum BAFF levels showed no relationship with LON and BAFF −871C/T promoter polymorphism. There was a tendency toward longer flare-free survival in patients with the BAFF −871T/T allotype compared with the C/T or C/C allotypes (p = 0.096). Conclusions The results of the present study suggest that presentation with LON may be a result of the intrinsic efficacy of rituximab in patients with rheumatic diseases. LON could indicate a longer biological and therapeutic activity of rituximab modulated by a certain genotypic polymorphism: the high-affinity FCGR3A V allele. This genotype and the occurrence of LON are both related to longer flare-free survival, suggestive of common mechanisms for LON and duration of response to rituximab. The role of the BAFF −871C/T promoter polymorphism in LON occurrence is unclear.
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Affiliation(s)
- Sofia Ajeganova
- Department of Medicine Huddinge, Karolinska Institutet, 14186, Stockholm, Sweden.
| | - Daniel Tesfa
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, 14186, Stockholm, Sweden.,Medical Affairs, Roche AB, 10074, Stockholm, Sweden
| | - Hans Hägglund
- Department of Hematology, Uppsala University Hospital, 75185, Uppsala, Sweden
| | - Bengt Fadeel
- Unit of Molecular Toxicology, Institute of Environmental Medicine, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Inger Vedin
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, 14186, Stockholm, Sweden
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses, Department of Internal Medicine, University of Florence, 50134, Florence, Italy
| | - Jan Palmblad
- Center for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, 14186, Stockholm, Sweden
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19
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Grigg A, Dyer MJS, Díaz MG, Dreyling M, Rule S, Lei G, Knapp A, Wassner-Fritsch E, Marlton P. Safety and efficacy of obinutuzumab with CHOP or bendamustine in previously untreated follicular lymphoma. Haematologica 2016; 102:765-772. [PMID: 28011903 PMCID: PMC5395117 DOI: 10.3324/haematol.2016.152272] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/22/2016] [Indexed: 12/29/2022] Open
Abstract
The GAUDI study assessed safety and preliminary efficacy of induction therapy with obinutuzumab plus chemotherapy, followed by maintenance therapy with obinutuzumab alone, in previously untreated patients with follicular lymphoma. Assignment to chemotherapy was decided on a per-center basis before the patients’ enrollment. Patients (n=81) received four to six cycles of obinutuzumab plus bendamustine every 4 weeks or six to eight cycles of obinutuzumab plus CHOP every 3 weeks. Patients with an end-of-treatment response were eligible for obinutuzumab maintenance therapy every 3 months for 2 years or until disease progression. Induction treatment was completed by 90% of patients in the obinutuzumab plus bendamustine group and 95% in the obinutuzumab plus CHOP group, while maintenance was completed by 81% and 72% of patients, respectively. All patients experienced at least one adverse event during induction, most commonly infusion-related reactions (58%), the majority of which were grade 1/2. The most common hematologic adverse event was grade 3/4 neutropenia (36% during induction and 7% during maintenance). One treatment-related death occurred during the maintenance phase. At the end of induction, 94% of patients had achieved an overall response, with complete response based on computed tomography in 36%. The progression-free survival rate at 36 months was 90% in the obinutuzumab plus bendamustine group and 84% in the obinutuzumab plus CHOP group. These results demonstrate that induction therapy with obinutuzumab plus bendamustine or obinutuzumab plus CHOP, followed by obinutuzumab maintenance, is associated with tolerable safety and promising efficacy. This study is registered at ClinicalTrials.gov as NCT00825149.
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Affiliation(s)
- Andrew Grigg
- Department of Clinical Haematology, Austin Hospital, Heidelberg, Australia
| | - Martin J S Dyer
- Ernest and Helen Scott Haematological Research Institute, University of Leicester, UK
| | | | | | - Simon Rule
- Department of Haematology, Derriford Hospital, Plymouth, UK
| | | | | | | | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital and University of Queensland School of Medicine, Brisbane, Australia
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20
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Davies HD. Infectious Complications With the Use of Biologic Response Modifiers in Infants and Children. Pediatrics 2016; 138:peds.2016-1209. [PMID: 27432853 DOI: 10.1542/peds.2016-1209] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Biologic response modifiers (BRMs) are substances that interact with and modify the host immune system. BRMs that dampen the immune system are used to treat conditions such as juvenile idiopathic arthritis, psoriatic arthritis, or inflammatory bowel disease and often in combination with other immunosuppressive agents, such as methotrexate and corticosteroids. Cytokines that are targeted include tumor necrosis factor α; interleukins (ILs) 6, 12, and 23; and the receptors for IL-1α (IL-1A) and IL-1β (IL-1B) as well as other molecules. Although the risk varies with the class of BRM, patients receiving immune-dampening BRMs generally are at increased risk of infection or reactivation with mycobacterial infections (Mycobacterium tuberculosis and nontuberculous mycobacteria), some viral (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, hepatitis B) and fungal (histoplasmosis, coccidioidomycosis) infections, as well as other opportunistic infections. The use of BRMs warrants careful determination of infectious risk on the basis of history (including exposure, residence, and travel and immunization history) and selected baseline screening test results. Routine immunizations should be given at least 2 weeks (inactivated or subunit vaccines) or 4 weeks (live vaccines) before initiation of BRMs whenever feasible, and inactivated influenza vaccine should be given annually. Inactivated and subunit vaccines should be given when needed while taking BRMs, but live vaccines should be avoided unless under special circumstances in consultation with an infectious diseases specialist. If the patient develops a febrile or serious respiratory illness during BRM therapy, consideration should be given to stopping the BRM while actively searching for and treating possible infectious causes.
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21
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Rituximab associated late-onset neutropenia—a rheumatology case series and review of the literature. Clin Rheumatol 2016; 35:2457-62. [DOI: 10.1007/s10067-016-3313-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/21/2016] [Accepted: 05/15/2016] [Indexed: 01/10/2023]
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22
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Late-Onset Neutropenia After Rituximab-Containing Therapy for Non-Hodgkin Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:761-5. [DOI: 10.1016/j.clml.2015.07.635] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 12/28/2022]
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23
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Choi BH, Cho HK, Jung JH, Choi JY, Shin S, Kim YH, Han DJ. How to reduce lethal infectious complications in ABO-incompatible kidney transplantation. Transplant Proc 2015; 47:653-9. [PMID: 25891705 DOI: 10.1016/j.transproceed.2014.11.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND ABO-incompatible organ transplants are good options for expanding the living donor pool; however, the necessary pre-conditioning to remove ABO antibodies before surgery can evoke critical infectious complications after surgery. METHODS Between February 2009 and July 2013, we performed ABO-incompatible kidney transplantation on 182 patients. We analyzed the first 85 patients for post-operative infectious complications in a cross-sectional cohort of patients (group 1, n = 85) who had received an ABO-incompatible kidney transplant and, in light of the results, amended the pre-conditioning (lower dose of rituximab, selective use of calcineurin inhibitors, anti-metabolite reduction, and prophylactic strategy) given to a prospective cohort (group 2, n = 97). RESULTS The characteristics of the two groups did not differ significantly. Infectious complications decreased significantly in group 2, including cytomegalovirus (anti-genemia 64.7% vs 27.8%, P < .001) and BK viremia (35.2% vs 18.6%, P = .008). The acute rejection rate and death-censored graft survival were similar in both groups. Notably, with the modified protocol, there were no deaths (8.2% vs 0.0%, P = .03). CONCLUSIONS Pre-conditioning for ABO-incompatible kidney transplantation is a prerequisite for successful outcome; its drawbacks can be limited with the use of a modified immunosuppressive strategy. If immunosuppression is modified according to host conditions, ABO-incompatible kidney transplantation can be performed safely with a successful graft outcome.
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Affiliation(s)
- B-H Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - H K Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J H Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J Y Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - S Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Y H Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - D J Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Shi Y, Zhou P, Han X, He X, Zhou S, Liu P, Yang J, Zhang C, Gui L, Qin Y, Yang S, Zhao L, Yao J, Zhang S. Autologous peripheral blood stem cell mobilization following dose-adjusted cyclophosphamide, doxorubicin, vincristine, and prednisolone chemotherapy alone or in combination with rituximab in treating high-risk non-Hodgkin's lymphoma. CHINESE JOURNAL OF CANCER 2015; 34:522-30. [PMID: 26370464 PMCID: PMC4593367 DOI: 10.1186/s40880-015-0045-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 07/26/2015] [Indexed: 01/27/2023]
Abstract
Background The regimen of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) is an efficient treatment of non-Hodgkin’s lymphoma (NHL). This study aimed to assess the efficacy and toxicity of dose-adjusted CHOP alone or in combination with rituximab (R-CHOP) by examining the stem cell mobilization in NHL patients. Factors affecting the collection of CD34+ cells were also explored. Methods Our retrospective study included 39 patients eligible for autologous stem cell transplantation: 14 patients who expressed CD20 and were financially eligible received R-CHOP for autologous peripheral blood stem cell (APBSC) mobilization; the remaining 25 patients received CHOP. Results The median CD34+ cell yield was 7.01 × 106 cells/kg body weight (range 1.49–28.39 × 106 cells/kg body weight), with only two patients failing to meet the target CD34+ cell harvest of ≥2.0 × 106 cells/kg body weight. The median number of apheresis procedures per patient was 1 (range 1–3). The APBSC mobilization yield of the CHOP group appeared to be higher than that of the R-CHOP group (P = 0.005), whereas the success rate was similar between groups. R-CHOP elevated the complete response (CR) rate in B cell lymphoma patients as compared with CHOP (P = 0.01). No significant differences in toxicity or engraftment were observed between the two groups. Conclusion The present study demonstrated that dose-adjusted CHOP chemotherapy effectively mobilized APBSCs in NHL patients and that the addition of rituximab to dose-adjusted CHOP chemotherapy elevated the CR rate for patients with B-cell lymphoma.
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Affiliation(s)
- Yuankai Shi
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Ping Zhou
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Xiaohong Han
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Xiaohui He
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Shengyu Zhou
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Peng Liu
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Jianliang Yang
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Changgong Zhang
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Lin Gui
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Yan Qin
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Sheng Yang
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Liya Zhao
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Jiarui Yao
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
| | - Shuxiang Zhang
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, 100021, P. R. China.
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Reitblat T, Wechsler A, Reitblat O. Rituximab-related late-onset neutropenia in patients with rheumatic diseases: successful re-challenge of the treatment. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:211-4. [PMID: 25855510 PMCID: PMC4407679 DOI: 10.12659/ajcr.892541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We describe here 2 patients who developed late-onset neutropenia after Rituximab treatment. While this phenomenon is well described among patients suffering from hematological malignancies, such adverse effects are rare among patients with rheumatic diseases. CASE REPORT Two patients, the first with rheumatoid arthritis and the second with granulomatosis with polyangiitis, were treated by Rituximab after all previous treatments failed. The patients developed late-onset neutropenia after several courses of treatment. The first patient, with symptomatic neutropenia, recovered after a single dose of granulocyte macrophage stimulating factor, and the second patient's neutrophils increased spontaneously. Both patients were retreated by rituximab in their scheduled time without further complications. CONCLUSIONS Our case series is unique because the same phenomenon appeared in patients with different rheumatic diseases. This case series confirms the possibility of continuing the treatment without further adverse effects.
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Affiliation(s)
- Tatiana Reitblat
- Department of Rheumatology, Barsilai Medical Center, Ashkelon, Israel
| | | | - Olga Reitblat
- Department of Rheumatology, Barsilai Medical Center, Ashkelon, Israel
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Arai Y, Yamashita K, Mizugishi K, Nishikori M, Hishizawa M, Kondo T, Kitano T, Kawabata H, Kadowaki N, Takaori-Kondo A. Risk factors for late-onset neutropenia after rituximab treatment of B-cell lymphoma. Hematology 2014; 20:196-202. [DOI: 10.1179/1607845414y.0000000188] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Yasuyuki Arai
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiyomi Mizugishi
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Momoko Nishikori
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masakatsu Hishizawa
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshiyuki Kitano
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Kawabata
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norimitsu Kadowaki
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and OncologyGraduate School of Medicine, Kyoto University, Kyoto, Japan
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27
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Kamei K, Takahashi M, Fuyama M, Saida K, Machida H, Sato M, Ogura M, Ito S. Rituximab-associated agranulocytosis in children with refractory idiopathic nephrotic syndrome: case series and review of literature. Nephrol Dial Transplant 2014; 30:91-6. [PMID: 25085238 DOI: 10.1093/ndt/gfu258] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Agranulocytosis has been reported as a delayed-onset complication of rituximab treatment. However, the exact incidence and risk factors of this complication in patients with nephrotic syndrome remain unknown. METHODS Records of 213 rituximab treatments for 114 patients with refractory nephrotic syndrome between February 2006 and April 2013 were reviewed to identify episodes of agranulocytosis (defined as an absolute neutrophil count of <500 mm(3)). RESULTS Eleven episodes of agranulocytosis were detected in 11 patients. Median time of onset of agranulocytosis was 66 days (range, 54-161 days) after rituximab treatment. Nine patients experienced acute infections and received antibiotics. All but one patient received granulocyte colony-stimulating factor. Agranulocytosis resolved in all cases within a median of 3 days. The incidence of agranulocytosis was 9.6% in total patients and 5.2% in all treatments. Median age of the 11 patients who developed agranulocytosis was 6.4 years at the first rituximab treatment, significantly younger than the median age of the 103 patients who did not (median, 12.5 years; P = 0.0009). Five patients received re-treatment with rituximab. No recurrence of agranulocytosis was observed in any patient. CONCLUSIONS It is important to pay extra attention to this clinically serious delayed-onset complication as it may be accompanied by life-threatening infections such as sepsis. Further clinical studies are needed to clarify its pathogenesis.
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Affiliation(s)
- Koichi Kamei
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masaki Takahashi
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masaki Fuyama
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Ken Saida
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Machida
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
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Autrel-Moignet A, Lamy T. Autoimmune neutropenia. Presse Med 2014; 43:e105-18. [PMID: 24680423 DOI: 10.1016/j.lpm.2014.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 02/08/2023] Open
Abstract
Autoimmune neutropenia (AIN) is a rare entity caused by antibodies directed against neutrophil-specific antigens. It includes primary and secondary autoimmune neutropenia. Acute autoimmune neutropenia can be related to drug-induced mechanism or viral infections. Chronic autoimmune neutropenias occur in the context of autoimmune diseases, hematological malignancies, such as large granular lymphocyte leukemia, primary immune deficiency syndromes or solid tumors. The therapeutic management depends on the etiology. Granulocyte growth factor is the main therapeutic option, raising the question of their long-term utilization safety. Corticosteroids or immunosuppressive therapy are indicated in infection-related AIN or in case of symptomatic autoimmune disease or LGL leukemia.
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Affiliation(s)
| | - Thierry Lamy
- CHU de Rennes, service d'hématologie clinique, Rennes 35043, France; Université Rennes 1, Rennes 35043, France.
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A Case of an Acquired Factor VIII Inhibitor Complicated by Multiple Treatment-Related Opportunistic Infections and Review of the Literature. Case Rep Hematol 2013; 2013:703027. [PMID: 24455336 PMCID: PMC3878284 DOI: 10.1155/2013/703027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 11/26/2013] [Indexed: 11/17/2022] Open
Abstract
This case report describes a patient with an idiopathic acquired Factor VIII inhibitor and severe bleeding. She was treated with rituximab after failing first-line treatment with steroids and cyclophosphamide. Two months following rituximab treatment, our patient developed a succession of severe opportunistic infections requiring intensive care unit admission. Over a period of 12 weeks she required treatment for Pseudomonas aeruginosa septicaemia, herpes simplex gingivostomatitis and pharyngotonsillitis, clostridium difficile-related diarrhoea, systemic cytomegalovirus infection, pneumocystis jiroveci, and invasive pulmonary aspergillosis lung infections. After significant rehabilitation, the patient was finally discharged following a 5-month admission. This case highlights the complexity of balancing a life-threatening condition with the side effects of treatment. It also raises the issue of routine prophylaxis for immunosuppression in nonmalignant conditions, which will become a common dilemma with the expanding indications for rituximab use.
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Plate A, Havla J, Kümpfel T. Late-onset neutropenia during long-term rituximab therapy in neuromyelitis optica. Mult Scler Relat Disord 2013; 3:269-72. [PMID: 25878016 DOI: 10.1016/j.msard.2013.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/02/2013] [Accepted: 08/07/2013] [Indexed: 11/25/2022]
Abstract
Late-onset neutropenia (LON) has been described as a side effect of rituximab (RX) therapy in patients with rheumatological and/or haematooncological diseases but not neuromyelitis optica (NMO). We describe a 71-year old female patient, who had NMO for 22 years, had been treated with RX monotherapy five times (cumulative dosage: 11g; duration of treatment: 3 years) before she developed severe neutropenia (IV) 3 months after the last RX infusion.(1) After exclusion of other causes, the diagnosis of LON was made. No complications occurred and neutropenia resolved without therapy. RX therapy was continued with intensive monitoring without any further LON and/or complications. In conclusion LON is a possible side effect during RX therapy and may also occur in NMO patients.
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Affiliation(s)
- Annika Plate
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Munich, Germany.
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Munich, Germany.
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University, Munich, Germany.
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FcgRIIIa 158 V/F polymorphism predicts rituximab-induced late onset neutropenia in newly-diagnosed CD20-positive B-cell lymphoma but is not correlated with long-term survival: A prospective study at a single institution with long-term follow-up. Tzu Chi Med J 2013. [DOI: 10.1016/j.tcmj.2013.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Simon Z, Illés A, Miltényi Z, Magyari F, Váróczy L, Péter N, Gergely L. [Immunologic changes in diffuse large B-cell lymphomas after rituximab-CHOP treatment: own data and review of the literature]. Orv Hetil 2012; 153:1658-66. [PMID: 23063898 DOI: 10.1556/oh.2012.29471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Rituximab treatment may induce a long-term B-cell depletion, which can be accompanied with an increased infection risk. AIMS To examine the changes of the white blood cell, CD19+ B-cell and CD4+ T-cell counts and the levels of immunoglobulin G, A, M after rituximab containing chemotherapy and to explore the infectious complications in our patients and review of the literature. PATIENTS AND METHODS Thirty-five diffuse large B-cell lymphoma patients were examined, who were treated with rituximab-cyclophosphamide-vincristine-doxoribicine-prednisolone (R-CHOP). The B- and T-cell populations were analyzed with flow-cytometry while the immunoglobulin levels were measured by nephelometry. RESULTS CD19+ B-lymphocytes were undetectable after the treatment and their count only increased from the post-therapeutic 12th month. Infection did not occur in this group of patients. CONCLUSIONS Rituximab induced B-cell depletion was appreciable also in this group of patients, while serious or unexpected infection did not occur. Increased infectious risk primarily can be observed after long-term, maintenance rituximab treatment.
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Affiliation(s)
- Zsófia Simon
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Belgyógyászati Intézet, Hematológia Tanszék Debrecen Nagyerdei krt. 98. 4032.
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Keane C, Nourse JP, Crooks P, Nguyen-Van D, Mutsando H, Mollee P, Lea RA, Gandhi MK. HomozygousFCGR3A-158Valleles predispose to late onset neutropenia after CHOP-R for diffuse large B-cell lymphoma. Intern Med J 2012; 42:1113-9. [DOI: 10.1111/j.1445-5994.2011.02587.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - J. P. Nourse
- Clinical Immunohaematology Laboratory; Queensland Institute of Medical Research; Brisbane; Queensland; Australia
| | - P. Crooks
- Clinical Immunohaematology Laboratory; Queensland Institute of Medical Research; Brisbane; Queensland; Australia
| | - D. Nguyen-Van
- Clinical Immunohaematology Laboratory; Queensland Institute of Medical Research; Brisbane; Queensland; Australia
| | - H. Mutsando
- Haematology Department; Princess Alexandra Hospital; Brisbane; Queensland; Australia
| | - P. Mollee
- Haematology Department; Princess Alexandra Hospital; Brisbane; Queensland; Australia
| | - R. A. Lea
- Genomics Research Centre, Griffith Health Institute; Griffith University; Brisbane; Queensland; Australia
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Kasamon YL, Brodsky RA, Borowitz MJ, Ambinder RF, Crilley PA, Cho SY, Tsai HL, Smith BD, Gladstone DE, Carraway HE, Huff CA, Matsui WH, Bolaños-Meade J, Jones RJ, Swinnen LJ. Brief intensive therapy for older adults with newly diagnosed Burkitt or atypical Burkitt lymphoma/leukemia. Leuk Lymphoma 2012; 54:483-90. [PMID: 22835045 DOI: 10.3109/10428194.2012.715346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Older patients with Burkitt lymphoma/leukemia (BL) have inferior outcomes. Because cyclophosphamide is highly active in BL and can be dose-escalated without stem-cell rescue, we designed a short, cyclophosphamide-intensive regimen without anthracyclines for patients aged ≥ 30 with untreated, non-HIV-associated BL/atypical BL. Two cycles involving cyclophosphamide 1500 mg/m(2), vincristine, rituximab, prednisone, methotrexate 3 g/m(2), and intrathecal cytarabine were delivered 2 weeks apart, followed by intensification with high-dose cyclophosphamide (50 mg/kg/day for 4 days) and rituximab. Of 21 patients, median age 53 (range, 34-75), 71% had stage IV, 95% were high-risk and 29% had performance status 3-4. Response occurred in all evaluable patients post-cycle 2 and in 76% post-intensification. Five non-relapse deaths occurred (four before intensification). The estimated 1-year and 3-year event-free survival was 52%; 1-year and 3-year overall survival was 57%. Seventeen (81%) received intensification (median 30 days to intensification). Brief, anthracycline-sparing, intensive cyclophosphamide (BASIC) therapy yields durable remissions in poorer-risk BL/atypical BL.
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36
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Rozman S, Sonc M, Novakovic BJ. Late-onset neutropenia following primary treatment of diff use large B-cell lymphoma with rituximab-containing therapy. Leuk Lymphoma 2012; 53:1945-8. [DOI: 10.3109/10428194.2012.679266] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tesfa D, Palmblad J. Late-onset neutropenia following rituximab therapy: incidence, clinical features and possible mechanisms. Expert Rev Hematol 2012; 4:619-25. [PMID: 22077526 DOI: 10.1586/ehm.11.62] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Late-onset neutropenia (LON) is emerging as a common adverse effect to rituximab therapy owing to widespread use of this drug in the treatment of B-cell lymphomas and autoimmune diseases. However, the true incidence and mechanisms are not fully understood. LON has been reported in 5?27% of rituximab-treated lymphoma patients. Similar figures apply for autoimmune patients but they appear to have more infections during the neutropenic period. Recent reports imply that host factors may play an intriguing role for development of LON, for example, polymorphisms in FCGR3. Pronounced B-lymphocyte depletion and lower serum IgM, as reported in LON patients during the period of neutropenia compared with matched controls, may play a role for understanding the mechanisms and risk stratification for emergence of LON.
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Affiliation(s)
- Daniel Tesfa
- The Hematology Center, Karolinska Institutet at Karolinska University Hospital Huddinge, S-14186 Stockholm, Sweden.
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38
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Weissmann-Brenner A, Brenner B, Belyaeva I, Lahav M, Rabizadeh E. Rituximab associated neutropenia: description of three cases and an insight into the underlying pathogenesis. Med Sci Monit 2012; 17:CS133-137. [PMID: 22037749 PMCID: PMC3539507 DOI: 10.12659/msm.882034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND To describe Rituximab associated neutropenia (RAN), and to explore its underlying mechanism. CASE REPORT We describe three patients with RAN. The effect of patient's plasma on colony forming unit, Granulocyte-Monocyte (CFU-GM) was measured by the addition of plasma to the culture of a healthy bone-marrow. Repeated tests were performed after recovery of white count. In the leukopenic period the patient's plasma inhibited CFU growth completely. Control plasma did not have such an effect. Addition of patient's cell supernatant to bone marrow cells did not change the number of CFU. The same effect was demonstrated in normal control. After recovery the patient's plasma did not inhibit colony formation, similar to control. CONCLUSIONS RAN is a clinically significant side effect. It may take place during treatment or several months afterwards. Circulating antibodies in the plasma may be responsible for this unique BM toxicity.
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Roccatello D, Sciascia S, Rossi D, Alpa M, Naretto C, Baldovino S, Menegatti E, La Grotta R, Modena V. Intensive short-term treatment with rituximab, cyclophosphamide and methylprednisolone pulses induces remission in severe cases of SLE with nephritis and avoids further immunosuppressive maintenance therapy. Nephrol Dial Transplant 2011; 26:3987-3992. [DOI: 10.1093/ndt/gfr109] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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41
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Delarue R. Neutropénie et risque infectieux sous rituximab. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2068-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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42
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Buch MH, Smolen JS, Betteridge N, Breedveld FC, Burmester G, Dörner T, Ferraccioli G, Gottenberg JE, Isaacs J, Kvien TK, Mariette X, Martin-Mola E, Pavelka K, Tak PP, van der Heijde D, van Vollenhoven RF, Emery P. Updated consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis 2011; 70:909-20. [PMID: 21378402 PMCID: PMC3086093 DOI: 10.1136/ard.2010.144998] [Citation(s) in RCA: 299] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2011] [Indexed: 01/19/2023]
Abstract
BACKGROUND Since initial approval for the treatment of rheumatoid arthritis (RA), rituximab has been evaluated in clinical trials involving various populations with RA. Information has also been gathered from registries. This report therefore updates the 2007 consensus document on the use of rituximab in the treatment of RA. METHODS Preparation of this new document involved many international experts experienced in the treatment of RA. Following a meeting to agree upon the core agenda, a systematic literature review was undertaken to identify all relevant data. Data were then interrogated by a drafting committee, with subsequent review and discussion by a wider expert committee leading to the formulation of an updated consensus statement. These committees also included patients with RA. RESULTS The new statement covers wide-ranging issues including the use of rituximab in earlier RA and impact on structural progression, and aspects particularly pertinent to rituximab such as co-medication, optimal dosage regimens, repeat treatment cycles and how to manage non-response. Biological therapy following rituximab usage is also addressed, and safety concerns including appropriate screening for hepatitis, immunoglobulin levels and infection risk. This consensus statement will support clinicians and inform patients when using B-cell depletion in the management of RA, providing up-to-date information and highlighting areas for further research. CONCLUSION New therapeutic strategies and treatment options for RA, a chronic destructive and disabling disease, have expanded over recent years. These have been summarised in general strategic suggestions and specific management recommendations, emphasising the importance of expedient disease-modifying antirheumatic drug implementation and tight disease control. This consensus statement is in line with these fundamental principles of management.
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Affiliation(s)
- Maya H Buch
- Section of Musculoskeletal Diseases, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Josef S Smolen
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
- Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | | | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Humboldt University, Charite Hospital, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Humboldt University, Charite Hospital, Berlin, Germany
| | | | - Jacques-Eric Gottenberg
- Rheumatology Department, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - John Isaacs
- Institute of Cellular Medicine, Newcastle University Medical School, Newcastle upon Tyne, UK
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Institut Pour la Santé et la Recherche Médicale (INSERM) U 1012, Hôpital Bicêtre, Université Paris-Sud 11, Paris, France
| | | | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology Charles University, Prague, Czech Republic
| | - Paul P Tak
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | | | - Ronald F van Vollenhoven
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
| | - Paul Emery
- Section of Musculoskeletal Diseases, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Disseminated Cryptococcosis in a Non-Hodgkin’s Lymphoma Patient with Late-Onset Neutropenia Following Rituximab-CHOP Chemotherapy: A Case Report and Literature Review. Mycopathologia 2011; 172:227-32. [DOI: 10.1007/s11046-011-9423-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 03/24/2011] [Indexed: 12/19/2022]
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Hincks I, Woodcock BE, Thachil J. Is Rituximab-induced Late-onset Neutropenia a good prognostic indicator in lymphoproliferatve disorders? Br J Haematol 2011; 153:411-3. [DOI: 10.1111/j.1365-2141.2010.08563.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maruyama D, Watanabe T, Maeshima AM, Nomoto J, Taniguchi H, Azuma T, Mori M, Munakata W, Kim SW, Kobayashi Y, Matsuno Y, Tobinai K. Modified cyclophosphamide, vincristine, doxorubicin, and methotrexate (CODOX-M)/ifosfamide, etoposide, and cytarabine (IVAC) therapy with or without rituximab in Japanese adult patients with Burkitt lymphoma (BL) and B cell lymphoma, unclassifiable, with features intermediate between diffuse large B cell lymphoma and BL. Int J Hematol 2010; 92:732-43. [PMID: 21120644 DOI: 10.1007/s12185-010-0728-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 11/07/2010] [Accepted: 11/11/2010] [Indexed: 11/27/2022]
Abstract
The feasibility and efficacy of cyclophosphamide, vincristine, doxorubicin, and methotrexate (CODOX-M)/ifosfamide, etoposide, and cytarabine (IVAC) therapy in Japanese adult patients with Burkitt lymphoma (BL) and B cell lymphoma, unclassifiable, with features intermediate between diffuse large B cell lymphoma and BL (intermediate DLBCL/BL) have never been reported. The effects of adding rituximab to CODOX-M/IVAC have not been published either. Fifteen consecutive patients with a median age of 39 years were treated with modified CODOX-M/IVAC regimen (particularly, reducing the dose of methotrexate to 3 g/m(2)) with or without rituximab at our institution. Although all patients developed grade 4 neutropenia and grade 3/4 thrombocytopenia/anemia, 93% had febrile neutropenia, 60% showed transaminase elevation, and 40% had mucositis/stomatitis (all grade 3), there were no treatment-related deaths. Two of nine patients treated with rituximab developed biphasic late-onset neutropenia. Thirteen patients (87%) showed complete responses. The remaining two patients had refractory disease; one had presented with peritoneal dissemination and complex chromosomal abnormalities, while the other had double IGH-MYC and IGH-BCL2 translocations. The estimated 5-year overall and progression-free survival were 87% each, with a median follow-up of 74 months. In conclusion, our modified CODOX-M/IVAC regimen is well tolerated and highly effective in Japanese adult patients with BL and intermediate DLBCL/BL, warranting a larger study for confirmation.
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Affiliation(s)
- Dai Maruyama
- Hematology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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Kim M, Lee JK, Hong YJ, Hong SI, Kang HJ, Chang YH. Late-onset Neutropenia Following Rituximab Therapy as a Treatment of Diffuse Large B-cell Lymphoma: A Single Institution Study. Ann Lab Med 2010; 30:575-9. [DOI: 10.3343/kjlm.2010.30.6.575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Minki Kim
- Departments of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Kyung Lee
- Departments of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Young Jun Hong
- Departments of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Seok-Il Hong
- Departments of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Hye Jin Kang
- Departments of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Yoon Hwan Chang
- Departments of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
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48
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Ayoola A, Terrell M, Bahrain H, Ford P, Auerbach M. Experience with maintenance rituximab after chemotherapy in patients with low-grade lymphoma. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s1548-5315(11)70416-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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49
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Wolach O, Bairey O, Lahav M. Late-onset neutropenia after rituximab treatment: case series and comprehensive review of the literature. Medicine (Baltimore) 2010; 89:308-318. [PMID: 20827108 DOI: 10.1097/md.0b013e3181f2caef] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rituximab is a chimeric monoclonal antibody against CD20 that is used mainly for the treatment of CD20-positive lymphoma. Recently, its use has been expanded to include treatment of other nonmalignant diseases such as rheumatologic diseases and autoimmune cytopenia. Correlating with the increased use of rituximab has been an increased number of reports of its late adverse effects. One of these is late-onset neutropenia (LON). Most investigators define LON as grade III-IV neutropenia occurring 3-4 weeks after the last treatment with rituximab, in the absence of an alternative explanation for the neutropenia.We report 6 cases of LON identified in our institution. Four patients were treated for diffuse large B-cell lymphoma, and 2 patients for follicular lymphoma. Median patient age was 68 years (range, 33-83 yr); LON appeared after a median interval of 77 days (range, 42-153 d) and lasted for a median of 5 days (range, 1-45 d). Five of the 6 patients presented with infectious complications, and 4 patients experienced recurrent episodes of neutropenia. One patient presented with LON and concomitant subacute pulmonary disease that was attributed to rituximab therapy.In addition to our own case series we present a systematic review of the literature, which we performed to compile data to describe better the syndrome of LON. Systematic studies, case series, and case reports were extracted. Most studies dealing with LON are retrospective by design and are limited by the heterogeneous populations included in the analysis. The incidence of LON is generally reported to be in the range of 3%-27%. Data regarding populations at risk are not consistent, and in some instances are conflicting.Patients considered at increased risk of LON include patients after autologous stem cell transplantation, patients treated for acquired immunodeficiency syndrome (AIDS)-related lymphoma, and patients treated with purine analogues. Patients who received previous cytotoxic treatment as well as those treated with more intensive chemotherapy or with chemotherapy in combination with radiotherapy are also considered to be at risk of LON. In addition, advanced stages of disease and having received multiple doses of rituximab are risk factors for LON.The mechanism of LON is poorly understood. Direct toxicity is very unlikely. Some speculate that there may be an infectious etiology involved, as well as an antibody-mediated process, but these ideas have not been substantiated. The concept of a lymphocyte subpopulation imbalance leading to LON has been presented based on the demonstration of T-LGL in peripheral blood and bone marrow of patients with LON. Perturbations in stromal-derived factor-1 and in the BAFF cytokine have also been discussed as potential players in the pathogenesis of LON. A recent study correlated specific polymorphism in the immunoglobulin G Fc receptor FCγRIIIa 158 V/F with increased rates of LON.The clinical significance of LON is important because it may affect treatment strategies. Of note, infectious complications are not very frequent and not very severe. Pooling data from the major retrospective studies reveals an infection rate of 16.9%. Most infections were mild and resolved promptly. One death occurred from infection during neutropenia. Repeated episodes of LON are not uncommon, but it is so far impossible to identify those patients at risk of these relapsing episodes of LON. Re-treatment with rituximab after LON may result in recurrent episodes, but the implications and risks are uncertain at the present time. The role of growth factors once LON appears is ill defined, and the decision to use them should be made on a case-by-case basis.
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Affiliation(s)
- Ofir Wolach
- From Internal Medicine A (OW, ML), and Institute of Hematology (OB, ML), Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva; and Sackler School of Medicine (OW, OB, ML), Tel Aviv University, Tel Aviv, Israel
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Kato H, Yamamoto K, Matsuo K, Oki Y, Taji H, Kuwatsuka Y, Seto M, Kagami Y, Morishima Y. Clinical impact and predisposing factors of delayed-onset neutropenia after autologous hematopoietic stem-cell transplantation for B-cell non-Hodgkin lymphoma: association with an incremental risk of infectious events. Ann Oncol 2010; 21:1699-1705. [DOI: 10.1093/annonc/mdq008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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