1
|
Yamagami J. B-cell targeted therapy of pemphigus. J Dermatol 2023; 50:124-131. [PMID: 36478455 PMCID: PMC10107866 DOI: 10.1111/1346-8138.16653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 12/12/2022]
Abstract
Pemphigus is an autoimmune disease that causes blistering and erosion of the skin and mucous membranes because of autoantibodies against desmoglein, which plays an important role in adhesion between epidermal keratinocytes. Treatment of pemphigus has long been centered on corticosteroids, and the guidelines for management of pemphigus have recommended high-dose systemic corticosteroids as the first-line treatment. While guideline-based treatment has been shown to be beneficial in patients with pemphigus, it has also become clear that this treatment is accompanied by significant burden and risk. The challenge for future pemphigus treatment is to maximize efficacy while minimizing risk during the course of the disease. In this regard, treatment targeting B cells is expected to become increasingly important as autoreactive B cells in pemphigus patients are thought to play a major role in the production of autoantibodies, which form the basis of the pathogenesis. The recent expansion of insurance coverage to rituximab, a monoclonal antibody against CD20, for refractory pemphigus in the USA, Europe, and Japan has opened up a new era of pemphigus treatment by enabling treatment strategies with drugs targeting B cells in patients. Here, we discuss the current status and future prospects of pemphigus treatment, focusing on rituximab and Bruton's tyrosine kinase inhibitors, which are expected to become essential drugs for pemphigus treatment in the future.
Collapse
Affiliation(s)
- Jun Yamagami
- Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
2
|
Miše J, Jukić IL, Marinović B. Rituximab - Progress but Still Not a Final Resolution for Pemphigus Patients: Clinical Report From a Single Center Study. Front Immunol 2022; 13:884931. [PMID: 35592312 PMCID: PMC9110665 DOI: 10.3389/fimmu.2022.884931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022] Open
Abstract
Pemphigus is a rare autoimmune disease characterized by the production of pathogenic autoantibodies against desmosomal adhesion proteins, desmoglein 1 and 3. The pathophysiological process leads to the development of blisters and erosions on mucosal and/or skin surfaces as the main clinical manifestation of the disease. Rituximab emerged as the first-line therapeutic option for pemphigus due to its ability to induce remission by depleting peripheral B lymphocytes. Our aim was to assess the efficacy of rituximab in the treatment of patients in Croatia. A single-center, retrospective study was conducted on 19 patients treated with rituximab following a rheumatoid arthritis dosing protocol between October 2015 and March 2021, with a mean follow-up of 24.1 months. After the first rituximab cycle, two patients achieved complete remission off therapy (10.5%), and six patients achieved complete remission on minimal therapy (31.6%). Partial remission was observed among ten patients (52.6%). Eight patients (44.4%) relapsed after the first rituximab cycle. The mean relapse time was 21 months. Seven patients received two rituximab cycles, and three patients received three cycles. Overall, 13 out of 19 patients experienced complete remission at some point during the study, while there were no non-responders after the rituximab treatment. No statistically significant associations were observed between age, sex, type of disease involvement and clinical remission, either on or off therapy. A steady decrease in anti-desmoglein 1 and anti-desmoglein 3 levels was measured among all patients following rituximab treatment. One patient experienced a treatment-related adverse event of infectious etiology (cellulitis). One patient died following the first rituximab cycle, with the cause of death likely not to be associated with the treatment. Rituximab is an effective disease-modifying agent in the treatment of pemphigus with the main benefit of reducing corticosteroid exposure and steroid-related side effects among pemphigus patients. However, a feature of rituximab therapy is high relapse rates and the need for repeated treatment cycles to achieve complete remission. Developing an optimal protocol for rituximab treatment and finding suitable markers for predicting relapse will improve the management of pemphigus patients.
Collapse
Affiliation(s)
- Joško Miše
- Department of Dermatology and Venereology, European Reference Network (ERN) – Skin Reference Center, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ines Lakoš Jukić
- Department of Dermatology and Venereology, European Reference Network (ERN) – Skin Reference Center, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Branka Marinović
- Department of Dermatology and Venereology, European Reference Network (ERN) – Skin Reference Center, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| |
Collapse
|
3
|
Perifani V, Dalamaga M, Theodoropoulos K, Theotokoglou S, Syrmali A, Loumou P, Papadavid E. Real world evidence: Patients with refractory pemphigus treated with Rituximab. Metabol Open 2021; 12:100142. [PMID: 34746731 PMCID: PMC8551647 DOI: 10.1016/j.metop.2021.100142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Pemphigus is a group of autoimmune blistering diseases, potentially life-threatening. Rituximab received FDA approval in June 2018 for the treatment of moderate to severe pemphigus vulgaris. OBJECTIVES To evaluate the efficacy and safety of rituximab in patients with pemphigus, resistant to previous therapies or unable to receive classic immunosuppressive treatment due to serious adverse events or comorbidities. MATERIALS AND METHODS Twenty-five patients (9 men, 16 women), mean age 49.4 ± 15.9 years (range 21-74 years), mean disease duration 4 ± 2.7 years (range 0.25-10 years) were included in the study: 19 patients with pemphigus vulgaris and 6 with pemphigus foliaceous. The efficacy of rituximab was evaluated according to the control of disease, retention of remission, disease severity, previous treatments and adverse reactions. During COVID-19 pandemic patients are monitored closely through tele-dermatology. RESULTS Twenty-three out of 25 patients had great improvement, 2 out of 25 ceased therapy due to adverse events (arthralgias and dyspnea). Sixteen out of 23 received additional course after 8 months (range 5-60 months). More aged patients presented more frequently adverse events and underwent additional courses (p = 0.002). Rituximab was found superior to classic immunosuppressive treatment in terms of efficacy and safety, with larger periods of remission and lower doses of corticosteroids and immunosuppressants. No major adverse events were noticed. CONCLUSIONS Rituximab is a very effective treatment of pemphigus and, remarkably, superior to classic immunosuppressive treatment.
Collapse
Affiliation(s)
- Vagiani Perifani
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Maria Dalamaga
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, 115 27, Athens, Greece
| | - Konstantinos Theodoropoulos
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Sofia Theotokoglou
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Anna Syrmali
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Panagiota Loumou
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Evangelia Papadavid
- 2nd Department of Dermatology and Venereology, Unit of Autoimmune Skin Disorders, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari 124 62, Athens, Greece
| |
Collapse
|
4
|
Markmann C, Bhoj VG. On the road to eliminating long-lived plasma cells-"are we there yet?". Immunol Rev 2021; 303:154-167. [PMID: 34351644 DOI: 10.1111/imr.13015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/19/2023]
Abstract
Central to protective humoral immunity is the activation of B cells and their terminal differentiation into antibody-secreting plasma cells. Long-lived plasma cells (LLPC) may survive for years to decades. Such long-lived plasma cells are also responsible for producing pathogenic antibodies that cause a variety of challenges such as autoimmunity, allograft rejection, and drug neutralization. Up to now, various therapeutic strategies aimed at durably eliminating pathogenic antibodies have failed, in large part due to their inability to efficiently target LLPCs. Several antibody-based therapies have recently gained regulatory approval or are in clinical phases of development for the treatment of multiple myeloma, a malignancy of plasma cells. We discuss the exciting potential of using these emerging cancer immunotherapies to solve the antibody problem.
Collapse
Affiliation(s)
- Caroline Markmann
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Vijay G Bhoj
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
5
|
McClatchy J, Yap T, Koo K, Kern JS, Scardamaglia L. De-escalation of anti-CD20 monoclonal antibody (Rituximab) protocols in Pemphigus Vulgaris - a systematic review. Expert Opin Biol Ther 2021; 21:1591-1601. [PMID: 34092162 DOI: 10.1080/14712598.2021.1937118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: This review assesses current evidence supporting dose de-escalated rituximab therapy in pemphigus vulgaris, compared to standard protocols. Primary outcome measures were remission and relapse rates. Adverse effects, cumulative steroid dosages, and serological markers of disease activity were also reported.Areas covered: A literature search was performed to look for reports describing the use of de-escalated rituximab therapy in pemphigus vulgaris. Results from heterogenous studies showed a large variation in remission and relapse rates. Complete remission rates from de-escalated treatment ranged from 41.7 to 100.0%, while rates in the control groups ranged from 60.0 to 90.9%. Relapse rates varied from 8.0 to 81.3% in the de-escalated group and from 0.0 to 72.4% in the control group. Of the 165 patients included in this report, only two major adverse effects were reported.Expert Opinion: Overall, dose de-escalated rituximab protocols reported to date appear effective and safe. However, it is unclear if treatment effect parallels that of standard regimens in regard to disease control in the long term. A lower limit of effective dosing for rituximab in pemphigus vulgaris has not yet been reached or defined. The role for and timing of repeated cycles of low-dose rituximab therapy require further exploration.
Collapse
Affiliation(s)
- Jessica McClatchy
- Dermatology Department, The Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Tami Yap
- Dermatology Department, The Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Melbourne Dental School, The University of Melbourne, Melbourne, Australia
| | - Kendrick Koo
- Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Melbourne Dental School, The University of Melbourne, Melbourne, Australia
| | - Johannes S Kern
- Dermatology Department, The Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Laura Scardamaglia
- Dermatology Department, The Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
6
|
Bozca BC, Bilgiç A, Uzun S. Long-term experience with rituximab therapy for treatment-resistant moderate-to-severe pemphigus. J DERMATOL TREAT 2021; 33:2102-2109. [PMID: 34027788 DOI: 10.1080/09546634.2021.1919288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rituximab appears to be effective for treating pemphigus, although there are limited long-term data. METHODS This retrospective single-center study evaluated patients with conventional treatment-resistant pemphigus who received rituximab during September 2010-December 2019. The first rituximab cycle was based on the rheumatoid arthritis protocol in all patients except one patient, and additional single doses (500 mg or 1000 mg) were administered after clinical and/or serological relapse. The consensus definitions were used for complete remission off therapy, complete remission on minimal therapy, and clinical relapse. Serological relapse was defined as a progressive ≥2-fold increase in anti-desmoglein titers (vs. previous the measurement). RESULTS The study included 52 patients with pemphigus vulgaris and 1 patient with pemphigus foliaceus. The mean number of infusions was 5 and the average follow-up after the first infusion was 56 months. The average time to clinical and/or serological relapse was 12 months. Complete remission was achieved in 84.9% of patients, including after the first rituximab cycle in 25 patients (47.1%). Two patients died during the follow-up period. CONCLUSION Additional rituximab cycles may help achieve and prolong remission in patients with moderate-to-severe pemphigus resistant to conventional therapies. However, prospective trials are needed to identify the optimal dosing protocol.
Collapse
Affiliation(s)
- Burçin Cansu Bozca
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Aslı Bilgiç
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Soner Uzun
- Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey
| |
Collapse
|
7
|
Kanokrungsee S, Anuntrangsee T, Tankunakorn J, Srisuwanwattana P, Suchonwanit P, Chanprapaph K. Rituximab Therapy for Treatment of Pemphigus in Southeast Asians. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:1677-1690. [PMID: 33911853 PMCID: PMC8075311 DOI: 10.2147/dddt.s306046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/01/2021] [Indexed: 01/12/2023]
Abstract
Background Rituximab provides more effective and less adverse effects than the standard dose of corticosteroids, but evidence on its efficacy and safety in the Thai population is lacking. Objective To evaluate the efficacy and safety of rituximab in the treatment of pemphigus and also to determine prognostic factors linked to the treatment outcomes. Methods Pemphigus patients who received rituximab from November 2017 to December 2020 were retrospectively reviewed. The outcome was evaluated by using early (end of consolidation phase [ECP]) and late endpoints (complete remission [CR] on/off therapy, immunological remission [IR], and relapse). Adverse events were noted. Prognostic factors associated with remission and relapse were analyzed. Results Of 53 pemphigus patients, all attained ECP within 1.61 months. Almost 80% achieved CR on therapy within a median time of 6.36 months, while 33.9% reached CR off therapy in 19.74 months. Nearly half had IR within a median time of 6.88 months. Relapse occurred in 33.3% with a median time of 14 months. In multivariate analysis, receiving rituximab within 12 months of disease duration was more likely to achieve CR off therapy and IR (hazard ratio [HR] 3.79; 95% confidence interval [CI] 1.38, 10.42; P = 0.01 and HR 2.74; 95% CI 1.12, 6.69; P = 0.027, respectively), whereas older patients and positive anti-desmoglein 1 levels at the time of CR were predictive indicators for relapse (HR 1.07; 95% CI 1.01, 1.13; P = 0.036 and HR 4.38; 95% CI 1.24, 15.46; P = 0.022, respectively). The treatment-related adverse effects occurred in 33.9%. Conclusion Rituximab is effective and safe in Thai pemphigus patients. Early administration of rituximab was a predictor of clinical and immunological remission. Older age and persistently positive anti-Dsg1 were correlated with disease relapse.
Collapse
Affiliation(s)
- Silada Kanokrungsee
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Graduate School of Srinakharinwirot University, Bangkok, Thailand
| | - Tanaporn Anuntrangsee
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jutamas Tankunakorn
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ploychompoo Srisuwanwattana
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Chakri Naruebodindra Hospital, Mahidol University, Samut Prakan, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
8
|
Bohelay G, Caux F, Musette P. Clinical and biological activity of rituximab in the treatment of pemphigus. Immunotherapy 2021; 13:35-53. [PMID: 33045883 DOI: 10.2217/imt-2020-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
B-cells are major effector cells in autoimmunity since they differentiate into plasmocytes that produce pathogenic auto-antibody such as anti-desmoglein antibodies in pemphigus patients. Major advances were obtained using whole B-cell depleting therapies including anti-CD20 antibodies in refractory pemphigus patients that lead to rituximab approval in pemphigus patients in EU and USA. This review summarizes the data supporting the efficacy of rituximab in pemphigus and provides an overview of the reported immunological changes underlying its therapeutic action. Short and long-term remission in pemphigus is explained by the removal of autoreactive B-cells involved in the production of pathogenic IgG auto-antibodies and by enhancement of the appearance of regulatory B-cells that could maintain long term immune tolerance.
Collapse
Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Philippe Musette
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| |
Collapse
|
9
|
Shimanovich I, Baumann T, Schmidt E, Zillikens D, Hammers CM. Long-term outcomes of rituximab therapy in pemphigus. J Eur Acad Dermatol Venereol 2020; 34:2884-2889. [PMID: 32367562 DOI: 10.1111/jdv.16561] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/15/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rituximab induces a rapid remission in most patients with pemphigus. OBJECTIVE Our aim was to assess the long-term efficacy of rituximab in this disease. METHOD We conducted a retrospective study of 59 patients with pemphigus treated with rituximab and observed over a median period of 104 months. RESULTS The rate of complete remission off therapy (CRoff) after the first rituximab cycle was 39%, increasing to 61% with additional rituximab courses. Long-term CRoff was achieved in 27% of patients. The recurrence rate after the first rituximab cycle was 63%, decreasing to approximately 40% with subsequent rituximab cycles. Median time to relapse after the first and subsequent rituximab cycles was 25 months. Renewed rituximab therapy reinduced complete remission in 94% of cases. Baseline anti-desmoglein antibody levels of ≤250 U/mL were significantly associated with the outcome of CRoff. In paired serum samples obtained before the first and six months after the last rituximab therapy, significant reductions of desmoglein-specific autoantibodies were observed. Patients relapsing after a complete remission induced by the first rituximab cycle were more likely to achieve CRoff than patients relapsing after a less favourable outcome and non-responders. There was no significant difference in age, sex, pemphigus subtype, rituximab dosing and disease duration between patients achieving CRoff and those not meeting this end point. CONCLUSIONS Lower desmoglein-specific antibody levels at baseline were predictive of CRoff. In patients receiving multiple rituximab cycles, complete remission after the first cycle was associated with a favourable long-term outcome. Repeated rituximab courses were highly effective for relapsed disease and improved the overall outcome.
Collapse
Affiliation(s)
- I Shimanovich
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - T Baumann
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - C M Hammers
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| |
Collapse
|
10
|
Sharma VK, Gupta V, Bhari N, Singh V. Rituximab as an adjuvant therapy for pemphigus: experience in 61 patients from a single center with long-term follow-up. Int J Dermatol 2020; 59:76-81. [PMID: 31257579 DOI: 10.1111/ijd.14546] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Rituximab is increasingly being used as an adjuvant treatment for recalcitrant or relapsed pemphigus, but information on its use as a first-line agent is limited. We describe the long-term effectiveness and safety of rituximab in the treatment of pemphigus and compare the treatment outcomes when rituximab is used as first-line treatment vis-à-vis after treatment failure or relapse. METHODS This was a retrospective review of 61 patients with pemphigus treated with rituximab at our center from March 2012 to October 2018. RESULTS Of the 61 patients, 51 achieved complete remission (on or off treatment) and 10 had partial remission. Forty-nine (80.33%) patients achieved complete remission off prednisolone over a mean period of 8.08 ± 4.45 (range 3-20) months. Seventeen (27.9%) patients relapsed after a mean period of 23.94 ± 13.15 months after first rituximab cycle and 15.97 + 13.7 months after stopping prednisolone. Treatment-related serious adverse effects were noted in six (9.8%) patients. Eighteen (29.5%) patients were administered rituximab as the first-line adjuvant, while 43 (70.5%) patients received it after treatment failure or relapse. In both groups, remission rates on prednisolone (88.9%, 81.4%) and off prednisolone (88.9%, 76.7%) were comparable (P > 0.05). Relapse rates in the group which received rituximab as first-line treatment were about half of those who received rituximab after relapse or treatment failure (16.7% vs. 32.6%, P = 0.348). No statistically significant difference was seen in the times to different treatment endpoints (disease control, complete remission on and off prednisolone, and relapse) between the two groups. CONCLUSIONS Rituximab is a safe and effective adjuvant in the treatment of pemphigus. Treatment outcomes were better for patients who received rituximab as first-line treatment, but the difference was not statistically significant.
Collapse
Affiliation(s)
- Vinod K Sharma
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishal Gupta
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Bhari
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
11
|
Cho YT, Huang YM, Wang LF, Chu CY. Maintenance therapy with azathioprine prolonged duration of remission for pemphigus patients who received rituximab as first-line or add-on therapy. J Formos Med Assoc 2020; 119:230-237. [DOI: 10.1016/j.jfma.2019.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/25/2019] [Accepted: 04/29/2019] [Indexed: 11/29/2022] Open
|
12
|
Kridin K, Kowalski EH, Kneiber D, Laufer-Britva R, Amber KT. From bench to bedside: evolving therapeutic targets in autoimmune blistering disease. J Eur Acad Dermatol Venereol 2019; 33:2239-2252. [PMID: 31314932 DOI: 10.1111/jdv.15816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
Autoimmune blistering diseases comprise a group of heterogenous conditions characterized by the loss of tolerance and subsequent development of autoantibodies targeting epidermal and subepidermal adhesion proteins. Blisters and erosions form on the skin and mucous membranes leading to significant morbidity and mortality. Traditional therapies rely on systemic immunosuppression. Advancements in our understanding of the pathophysiology of pemphigus and pemphigoid have led to the development of molecules which target specific pathways involved in induction and perpetuation of disease. In this review, we outline the novel therapeutic strategies including B-cell depletion, T-regulatory cell repletion, cell signalling inhibitors and small molecular inhibitors, inhibitory monoclonal antibodies, as well as complement inhibition. We additionally review their current level of clinical evidence. We lastly review therapeutics targets gleaned from the experimental epidermolysis bullosa acquisita mouse model. These emerging treatments offer an exciting progression from basic science discoveries that have the potential to transform the treatment paradigm in autoimmune blistering diseases.
Collapse
Affiliation(s)
- K Kridin
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - E H Kowalski
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - D Kneiber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - R Laufer-Britva
- Department of Dermatology, Rambam Healthcare Campus, Haifa, Israel
| | - K T Amber
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
13
|
Kraft M, Worm M. Pemphigus Foliaceus-Repeated Treatment With Rituximab 7 Years After Initial Response: A Case Report. Front Med (Lausanne) 2018; 5:315. [PMID: 30474029 PMCID: PMC6237918 DOI: 10.3389/fmed.2018.00315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/23/2018] [Indexed: 11/13/2022] Open
Abstract
Pemphigus foliaceus is an autoimmune skin disease mediated by autoantibodies directed against desmoglein-1 located in the upper epidermal layer. Rituximab, a monoclonal anit-CD20 antibody depleting b-cells, offers an effective treatment possibility for therapy-resistant pemphigus foliaceus. Here, we present the case of 55-year-old man who did not respond sufficiently to conventional treatment with prednisolone, azathioprine, and cyclophosphamide, but underwent almost complete remission after rituximab treatment. The patient relapsed 7 years later, and a repeated course of rituximab infusions led to a partial remission.
Collapse
Affiliation(s)
- Magdalena Kraft
- Department of Dermatology, Venerology and Allergology, Allergy-Center-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Allergy-Center-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
14
|
Kim J, Kim TG, Lee SH, Lee MK, Kim JH, Lee SE, Kim DY, Roh MR, Park CO, Lee JH, Lee MG, Bang D, Oh SH, Chung KY. Centennial History of Yonsei University Dermatology in Korea: 1917 to 2017. Ann Dermatol 2018; 30:513-521. [PMID: 33911472 PMCID: PMC7992467 DOI: 10.5021/ad.2018.30.5.513] [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: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 11/18/2022] Open
Abstract
Yonsei Dermatology celebrated its centennial in 2017, marking 100 years since Kung Sun Oh established the first Department of Dermatology and Urology in Korea in 1917. Following the footsteps of Kung Sun Oh, a pioneer of Korean dermatology, its members united and worked to provide the best medical service and achieve academic milestones in dermatology. Over the past hundred years, Yonsei Dermatology has played a pivotal role in the advancement of medical science and academia in Korea. The main activities of the department include medical care, education, and dermatologic research. Its research activities have encompassed a wide spectrum of dermatologic manifestations from skin immunology and pathology to introduction of newly developed treatment technologies. As Kung Sun Oh was the first Korean professor of dermatology at Severance Medical School and a passionate educator, we continue to serve his will by nurturing medical students and dermatology specialists to serve as global medical leaders. The Kung Sun Oh Memorial Lecture, first hosted in 1977, was the beginning of mutual international academic exchange in the field of dermatology in Korea. The memorial lecture has played a major role in advancing the academic status of Korean dermatological science by inviting distinguished dermatologists from around the world as guest lecturers. Yonsei Dermatology has played a key role in the history of modern medicine and dermatology in Korea over the last 100 years and continues to make an impact.
Collapse
Affiliation(s)
- Jihee Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Gyun Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Si Hyung Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Min Kyung Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Ryung Roh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Ook Park
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ju Hee Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Geol Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dongsik Bang
- Department of Dermatology, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| | - Sang Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kee Yang Chung
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
15
|
Keeley JM, Bevans SL, Jaleel T, Sami N. Rituximab and low dose oral immune modulating treatment to maintain a sustained response in severe pemphigus patients. J DERMATOL TREAT 2018; 30:340-345. [DOI: 10.1080/09546634.2018.1510173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jordan M. Keeley
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephanie L. Bevans
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tarannum Jaleel
- Department of Dermatology, Duke University Medical Center, Durham, NC, USA
| | - Naveed Sami
- Department of Medicine, University of Central Florida, Orlando, FL, USA
| |
Collapse
|
16
|
Grando SA. Retrospective analysis of a single‐center clinical experience toward development of curative treatment of 123 pemphigus patients with a long‐term follow‐up: efficacy and safety of the multidrug protocol combining intravenous immunoglobulin with the cytotoxic immunosuppressor and mitochondrion‐protecting drugs. Int J Dermatol 2018; 58:114-125. [DOI: 10.1111/ijd.14143] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 06/16/2018] [Accepted: 06/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Sergei A. Grando
- Departments of Dermatology and Biological Chemistry and Institute for Immunology University of California Irvine CA USA
| |
Collapse
|
17
|
Tavakolpour S, Mahmoudi H, Balighi K, Abedini R, Daneshpazhooh M. Sixteen-year history of rituximab therapy for 1085 pemphigus vulgaris patients: A systematic review. Int Immunopharmacol 2018; 54:131-138. [DOI: 10.1016/j.intimp.2017.11.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/12/2017] [Accepted: 11/05/2017] [Indexed: 12/16/2022]
|