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Brazel D, Grant C, Cabal A, Chen WP, Pinter-Brown L. Baseline immunoglobulin G and immune function in non-Hodgkin lymphoma: a retrospective analysis. Front Immunol 2024; 15:1334899. [PMID: 38745669 PMCID: PMC11091275 DOI: 10.3389/fimmu.2024.1334899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Non-Hodgkin's lymphoma (NHL) encompasses a diverse group of lymphoma subtypes with a wide range in disease course. Previous studies show that hypogammaglobulinemia in treatment-naïve patients is associated with poorer survival in high grade B-cell non-Hodgkin's lymphomas, though it is not known how this applies across all B-cell lymphoid malignancies. Methods We conducted a retrospective study of immunoglobulin levels and clinical outcomes including survival, hospitalization, and infection rates in patients diagnosed with B-cell non-Hodgkin lymphomas of all grades at our institution. Results Two-hundred twenty-three adults (aged = 18 years) with available pre-treatment IgG levels were selected, with hypogammaglobulinemia defined as IgG< 500 mg/mL. For this analysis, we grouped DLBCL (n=90), Primary CNS (n=5), and Burkitt lymphoma (n=1) together as high-grade, while CLL (n=52), mantle cell (n=20), marginal zone (n=25), follicular (n=21), and Waldenstrom macroglobulinemia (n=5) were low-grade. The incidence of hypogammaglobulinemia in our cohort of both high and low-grade lymphoma patients was 13.5% (n=30). Across all NHL subtypes, individuals with baseline IgG< 500 mg/dL showed an increased rate of hospitalization (4.453, CI: 1.955-10.54, p= 0.0005) and higher mortality (3.325, CI: 1.258, 8.491, p= 0.013), yet no association in number of infections when compared with those with IgG=500 mg/dL. There was a higher hospitalization rate (3.237, CI: 1.77-6.051, p=0.0017) in those with high-grade lymphoma with hypogammaglobulinemia when compared with low-grade. There was no statistically significant difference in individuals who were alive after three years in those with baseline IgG<500 mg/dL. Discussion Our study is the first to analyze incidence of hypogammaglobulinemia at the time of diagnosis of NHL as a potential biomarker of interest for future outcomes including hospitalization and infection.
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Affiliation(s)
- Danielle Brazel
- Department of Hematology/Oncology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, United States
| | - Christopher Grant
- Department of Medicine, University of California Irvine Medical Center, Orange, CA, United States
| | - Angelo Cabal
- Department of Biostatistics, University of California Irvine Medical School, Irvine, CA, United States
| | - Wen-Pin Chen
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, United States
| | - Lauren Pinter-Brown
- Department of Medicine, University of California Irvine Medical Center, Orange, CA, United States
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, United States
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Rempe T, Elfasi A, Rodriguez E, Vasquez M, Graves J, Kinkel R. Ocrelizumab B-cell repopulation-guided extended interval dosing versus standard dosing - similar clinical efficacy with decreased immunoglobulin M deficiency rates. Mult Scler Relat Disord 2023; 79:105028. [PMID: 37813071 DOI: 10.1016/j.msard.2023.105028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/07/2023] [Accepted: 09/23/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Ocrelizumab (OCR) is a humanized anti-CD20 monoclonal antibody used in treatment of multiple sclerosis. The standard dosing (SD) regimen consists of OCR maintenance infusions every 6 months. In B-cell repopulation-guided extended interval dosing (EID), repeat infusions are delayed until there is evidence for B-cell repopulation. OBJECTIVES To compare frequencies of 'no evidence of disease activity' (NEDA-3) and immunoglobulin G (hypo-IgG; <600 mg/dL) and M (hypo-IgM; <40 mg/dL) deficiencies in persons with multiple sclerosis (PwMS) treated with OCR B-cell repopulation-guided EID versus SD. METHODS Two-center retrospective study comparing frequencies of NEDA-3 and hypo-IgG and hypo-IgM in PwMS treated with OCR B-cell repopulation-guided EID versus SD using a multivariate generalized linear model adjusted for age, sex, and treatment duration. RESULTS A total of 112 OCR-treated PwMS were included (B-cell repopulation-guided EID n = 52; SD n = 60) with average infusion intervals of 319 (246-485) days (EID) and 184 (170-218) days (SD). There was no significant difference in NEDA-3 (EID: 47/52 [90.4 %]; SD: 50/60 [83.3 %]; p = 0.161) or hypo-IgG (EID: 1/52 [1.9 %]; SD: 4/60 [6.7 %]; p = 0.298) rates. Hypo-IgM was significantly less common in EID (EID: 9/52 [17.3 %] vs. SD: 34/60 [55 %]; p<0.001) upon assessment 1099 (475-1436) days (EID) and 980 (409-1846) days (SD) post-initiation of OCR. Hypo-IgM was associated with average infusion interval length (p = 0.005) and total number of OCR cycles (p = 0.003). CONCLUSIONS OCR B-cell repopulation-guided EID may be a safe alternative to traditional SD with similar efficacy and significantly less hypo-IgM rates.
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Affiliation(s)
- Torge Rempe
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA; Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Aisha Elfasi
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Elsa Rodriguez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Matthew Vasquez
- Department of Neurology, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Jennifer Graves
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Revere Kinkel
- Department of Neurosciences, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
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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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4
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Fischer T, Ni A, Bantilan KS, Soumerai JD, Alperovich A, Batlevi C, Younes A, Zelenetz AD. The impact of anti-CD20-based therapy on hypogammaglobulinemia in patients with follicular lymphoma. Leuk Lymphoma 2022; 63:573-582. [PMID: 35109746 PMCID: PMC10754062 DOI: 10.1080/10428194.2021.2010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
Although treatment with anti-CD20 monoclonal antibodies (mAb) has improved outcomes in B-cell malignancies, it's associated with increased risk of hypogammaglobulinemia (HG). Our study aimed to determine the effects of anti-CD20 mAb on serum immunoglobulins (Ig) in follicular lymphoma (FL). Ig concentrations, infectious complications, and need for intravenous Ig were evaluated by level of exposure to anti-CD20 mAb in 380 patients. Prevalence of HG significantly differed by level of treatment exposure (p < 0.001). Single course anti-CD20 mAb was associated with rising IgG (+10.3 mg/dL/year), whereas the addition of maintenance therapy (-7.4 mg/dL/year) or multiple courses of treatment (-10.3 mg/dL/year) was associated with declining IgG. Among patients treated with anti-CD20 mAb, 45.2% developed IgG-HG and 10.3% developed symptomatic IgG-HG. Pretreatment IgG levels gradually declined in all patients, suggesting tumor burden may contribute to HG. Baseline and periodic monitoring of serum Ig is appropriate in patients with FL, including those managed with active surveillance.
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Affiliation(s)
- Thaís Fischer
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- A.C.Camargo Cancer Center, São Paulo, Brazil
| | - Andy Ni
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- The Ohio State University, College of Public Health, Columbus, OH, USA
| | | | - Jacob D. Soumerai
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | | | - Connie Batlevi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Anas Younes
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Andrew D. Zelenetz
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
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Engel ER, Walter JE. Rituximab and eculizumab when treating nonmalignant hematologic disorders: infection risk, immunization recommendations, and antimicrobial prophylaxis needs. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:312-318. [PMID: 33275746 PMCID: PMC7727502 DOI: 10.1182/hematology.2020000171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Rituximab and eculizumab, monoclonal antibodies that deplete most B cells and activate the terminal complement, respectively, are used to treat nonmalignant hematologic disorders (NMHDs), sometimes with unfavorable effects on the immune system. Hypogammaglobulinemia and neutropenia have been reported with variable prevalence in patients treated with rituximab. Neutropenia is mild and transient, and serious infectious complications are uncommon, so treatment is not indicated. Hypogammaglobulinemia is of greater concern. There is a lack of agreement on a standardized definition, and pre- and posttreatment immunoglobulin (Ig) levels are not routinely obtained. The association among low Ig levels, infectious risk, and mortality and morbidity in this population is unclear. There are also no formal guidelines on indication, risk factors, and threshold level of IgG to prompt Ig replacement therapy (IgRT). Among patients with NMHD, preexisting or persistent hypogammaglobulinemia (PH) after treatment with rituximab has been linked to underlying primary immunodeficiency disorders; therefore, a high index of suspicion should be maintained, and immunologic and genetic evaluation should be considered. Overall, important strategies in managing patients who are receiving rituximab include routine monitoring of pre- and posttreatment IgG levels, immune reconstitution (eg, B-cell subsets), assessment of vaccination status and optimization before treatment, and individualized consideration for IgRT. Accordingly, we discuss immunizations. Eculizumab, most commonly used in the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome, poses increased risk of meningococcal infections. To decrease the risk of infection, a meningococcal vaccination series is recommended before initiating therapy, and prophylactic antibiotics are preferred during the course of treatment.
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Affiliation(s)
- Elissa R. Engel
- Department of Pediatrics, University of South Florida, Tampa, FL
| | - Jolan E. Walter
- Department of Pediatrics, University of South Florida, Tampa, FL
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children’s Hospital, St. Petersburg, FL; and
- Massachusetts General Hospital for Children, Boston, MA
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6
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Wang H, Yan S, Liu H, Li L, Song J, Wang G, Wang H, Wu Y, Shao Z, Fu R. Infection risk in autoimmune hematological disorders with low-dose rituximab treatment. J Clin Lab Anal 2020; 34:e23455. [PMID: 32794271 PMCID: PMC7595891 DOI: 10.1002/jcla.23455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background Rituximab has been widely used in many autoimmune diseases. Aim To evaluate the infection risk of rituximab in autoimmune hematological disorders. Methods Retrospectively studied and compared the clinical data of 89 patients in our hospital who used low‐dose rituximab (group R) or pulse cyclophosphamide (group C) for their refractory/relapsed autoimmune hematological diseases from January 2011 to January 2017. The kinds of their diseases included autoimmune hemolytic disease (AIHA), Evans syndrome, and idiopathic thrombocytopenic purpura (ITP). All patients chose either rituximab treatment or cyclophosphamide treatment on their own considerations. Findings The median follow‐up time was six months in group R and four months in group C. After treatments, the patients in group R showed higher white blood cell (WBC) count and neutrophil count than group C (P = .020, P = .037). CD20‐positive B cells in group R remained at a very low level after rituximab treatment and need about 15 months to return to normal level, which was longer than group C (six months). The incidence of infection in these two groups has no significant difference, which was 34.7% (17/30) in group R and 32.5% (13/28) in group C (P = .976). Tuberculosis infections after rituximab treatment were found in three patients for the first time. Conclusion The G‐CSF, nadir WBC count, and IgA level were protective factors of infection during rituximab treatment. Low‐dose rituximab therapy in autoimmune hematological diseases does not increase infection risk compared with cyclophosphamide.
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Affiliation(s)
- Honglei Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Siyang Yan
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lijuan Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jia Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Guojin Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuhong Wu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
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7
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Post-rituximab immunoglobulin M (IgM) hypogammaglobulinemia. Autoimmun Rev 2020; 19:102466. [PMID: 31917267 DOI: 10.1016/j.autrev.2020.102466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody that targets the B cell-specific cell surface antigen CD20 and is currently used to treat several autoimmune diseases. The elimination of mature CD20-positive B lymphocytes committed to differentiate into autoantibody-producing plasma cells is considered to be the major effect of rituximab, that makes it a beneficial biological agent in treating autoimmune diseases. Hypogammaglobulinemia has been reported after rituximab therapy in patients with lymphoma and rheumatoid arthritis. Similar data are scarce for other autoimmune diseases. Low immunoglobulin G (IgG) or hypogammaglobulinemia has attracted the most attention because of its significant role in protective immunity. However, the incidence and clinical implications of low immunoglobulin M (IgM) or hypogammaglobulinemia have not been studied in detail. This review will focus on the frequency and the clinical concerns of low IgM levels that result as a consequence of the administration of rituximab. The etiopathogenic mechanisms underlying post-rituximab IgM hypogammaglobulinemia and its implications are presented. The long-term consequences, if any, are not known or documented. Multiple factors may be involved in whether IgG or IgM decreases secondary to rituximab therapy. It is possible that the autoimmune disease itself may be one of the important factors. The dose, frequency and number of infusions appear to be important variables. Post-rituximab therapy immunoglobulin levels return to normal. During this process. IgM levels take a longer time to return to normal levels when compared to IgG or other immunoglobulins. IgM deficiency persists after B cell repopulation to normal levels has occurred. Laboratory animals and humans deficient in IgM can have multiple infections. Specific pharmacologic agents or biologic therapy that address and resolve IgM deficiency are currently unavailable. If the clinical situation so warrants, then prophylactic antibiotics may be indicated and perhaps helpful. Research in this iatrogenic phenomenon will provide a better understanding of not only the biology of IgM, but also the factor(s) that control its production and regulation, besides its influence if any, on rituximab therapy.
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Kaplan B, Bonagura VR. Secondary Hypogammaglobulinemia: An Increasingly Recognized Complication of Treatment with Immunomodulators and After Solid Organ Transplantation. Immunol Allergy Clin North Am 2019; 39:31-47. [PMID: 30466771 DOI: 10.1016/j.iac.2018.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Secondary hypogammaglobulinemia is a common development in patients treated with immunomodulatory agents for autoimmune, connective tissue, and malignant diseases. It has been observed in the medical management of patients undergoing hematopoietic stem cell and solid organ transplantation. Some patients have preexisting immunodeficiency associated with these illnesses; immunosuppressive treatment magnifies their immune defect. This article reviews immunosuppressive medications, including biological treatments that cause secondary hypogammaglobulinemia. It summarizes risk factors for rituximab-induced hypogammaglobulinemia, such as preexisting low immunoglobulin G levels, CD19 levels, host factors, and additive effect of all immunomodulatory drugs used. The evaluation and management of secondary hypogammaglobulinemia are discussed.
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Affiliation(s)
- Blanka Kaplan
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA.
| | - Vincent R Bonagura
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA
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Christou EAA, Giardino G, Worth A, Ladomenou F. Risk factors predisposing to the development of hypogammaglobulinemia and infections post-Rituximab. Int Rev Immunol 2017; 36:352-359. [PMID: 28800262 DOI: 10.1080/08830185.2017.1346092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.
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Affiliation(s)
- Evangelos A A Christou
- a Division of Internal Medicine, Medical School , University of Ioannina , Ioannina , Greece
| | - Giuliana Giardino
- b Department of Translational Medical Sciences , Federico II University , Naples , Italy
| | - Austen Worth
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Fani Ladomenou
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
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10
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Vacunación en el paciente con linfoma no hodgkiniano en tratamiento con rituximab u otros fármacos inmunodepresores. Med Clin (Barc) 2016; 146:43-4. [DOI: 10.1016/j.medcli.2015.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/26/2015] [Indexed: 11/18/2022]
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11
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Immunoglobulin G replacement for the treatment of infective complications of rituximab-associated hypogammaglobulinemia in autoimmune disease: A case series. J Autoimmun 2015; 57:24-9. [DOI: 10.1016/j.jaut.2014.11.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/26/2014] [Indexed: 01/18/2023]
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12
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Roberts DM, Jones RB, Smith RM, Alberici F, Kumaratne DS, Burns S, Jayne DRW. Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun 2014; 57:60-5. [PMID: 25556904 DOI: 10.1016/j.jaut.2014.11.009] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 11/16/2014] [Accepted: 11/28/2014] [Indexed: 12/25/2022]
Abstract
Rituximab is a B cell depleting monoclonal antibody used to treat lymphoma and autoimmune disease. Hypogammaglobulinemia has occurred after rituximab for lymphoma and rheumatoid arthritis but data are scarce for other autoimmune indications. This study describes the incidence and severity of hypogammaglobulinemia in patients receiving rituximab for small vessel vasculitis and other multi-system autoimmune diseases. Predictors for and clinical outcomes of hypogammaglobulinemia were explored. We conducted a retrospective study in a tertiary referral specialist clinic. The severity of hypogammaglobulinemia was categorized by the nadir serum IgG concentration measured during clinical care. We identified 288 patients who received rituximab; 243 were eligible for inclusion with median follow up of 42 months. 26% were IgG hypogammaglobulinemic at the time that rituximab was initiated and 56% had IgG hypogammaglobulinemia during follow-up (5-6.9 g/L in 30%, 3-4.9 g/L in 22% and <3 g/L in 4%); IgM ≤0.3 g/L in 58%. The nadir IgG was non-sustained in 50% of cases with moderate/severe hypogammaglobulinemia. A weak association was noted between prior cyclophosphamide exposure and nadir IgG concentration, but not cumulative rituximab dose. IgG concentrations prior to and at the time of rituximab correlated with the nadir IgG post rituximab. IgG replacement was initiated because of recurrent infection in 12 (4.2%) patients and a lower IgG increased the odds ratio of receiving IgG replacement. Rituximab is associated with an increased risk of hypogammaglobulinemia but recovery of IgG level can occur. IgG monitoring may be useful for patients receiving rituximab.
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Affiliation(s)
- Darren M Roberts
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK; School of Medicine, University of Queensland, Butterfield Street, Herston, Queensland, 4006, Australia.
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Rona M Smith
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Federico Alberici
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK; Department of Clinical Medicine, University of Parma, Via Gramsci 14, Parma 43126, Italy; Department of Nephrology, University of Parma, Via Gramsci 14, Parma 43126, Italy
| | - Dinakantha S Kumaratne
- Department of Clinical Immunology, Box 109, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - Stella Burns
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Box 57, Addenbrooke's Hospital, Hills Rd, Cambridge, CB20QQ, UK
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Compagno N, Malipiero G, Cinetto F, Agostini C. Immunoglobulin replacement therapy in secondary hypogammaglobulinemia. Front Immunol 2014; 5:626. [PMID: 25538710 PMCID: PMC4259107 DOI: 10.3389/fimmu.2014.00626] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 12/02/2022] Open
Abstract
Immunoglobulin (Ig) replacement therapy dramatically changed the clinical course of primary hypogammaglobulinemias, significantly reducing the incidence of infectious events. Over the last two decades its use has been extended to secondary antibody deficiencies, particularly those related to hematological disorders as lymphoproliferative diseases (LPDs) and multiple myeloma. In these malignancies, hypogammaglobulinemia can be an intrinsic aspect of the disease or follow chemo-immunotherapy regimens, including anti-CD20 treatment. Other than in LPDs the broadening use of immunotherapy (e.g., rituximab) and immune-suppressive therapy (steroids, sulfasalazine, and mycophenolate mofetil) has extended the occurrence of iatrogenic hypogammaglobulinemia. In particular, in both autoimmune diseases and solid organ transplantation Ig replacement therapy has been shown to reduce the rate of infectious events. Here, we review the existing literature about Ig replacement therapy in secondary hypogammaglobulinemia, with special regard for subcutaneous administration route, a safe, effective, and well-tolerated treatment approach, currently well established in primary immunodeficiencies and secondary hypogammaglobulinemias.
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Affiliation(s)
- Nicolò Compagno
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Giacomo Malipiero
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Francesco Cinetto
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Carlo Agostini
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
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Kelesidis T, Daikos G, Boumpas D, Tsiodras S. Does rituximab increase the incidence of infectious complications? A narrative review. Int J Infect Dis 2010; 15:e2-16. [PMID: 21074471 DOI: 10.1016/j.ijid.2010.03.025] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rituximab has increasingly been used for the treatment of hematological malignancies and autoimmune diseases, and its efficacy and safety are well established. Although clinical trials have shown conflicting results regarding the association of rituximab with infections, an increased incidence of infections has recently been reported in patients with lymphomas being treated with rituximab. However, clinical experience regarding the association of rituximab with different types of infection is lacking and this association has not been established in patients with rheumatoid arthritis. METHODS All previous studies included in our literature review were found using a PubMed, EMBASE, and Cochrane database search of the English-language medical literature applying the terms 'rituximab', 'monoclonal antibodies', 'infections', 'infectious complications', and combinations of these terms. In addition, the references cited in these articles were examined to identify additional reports. RESULTS We performed separate analyses of data regarding the association of rituximab with infection in (1) patients with hematological malignancies, (2) patients with autoimmune disorders, and (3) transplant patients. Recent data show that rituximab maintenance therapy significantly increases the risk of both infection and neutropenia in patients with lymphoma or other hematological malignancies. On the other hand, data available to date do not indicate an increased risk of infections when using rituximab compared with concurrent control treatments in patients with rheumatoid arthritis. However, there is a lack of sufficient long-term data to allow such a statement to be definitively made, and caution regarding infections should continue to be exercised, especially in patients who have received repeated courses of rituximab, are receiving other immunosuppressants concurrently, and in those whose immunoglobulin levels have fallen below the normal range. Few data are available concerning the risk of organ transplant recipients developing infections following rituximab therapy. Data from case reports, case series, and retrospective studies correlate rituximab use with the development of a variety of infections in transplant patients. CONCLUSIONS Further studies are needed to clarify the association of rituximab with infection. Physicians and patients should be educated about the association of rituximab with infectious complications. Monitoring of absolute neutrophil count and immunoglobulin levels and the identification of high-risk groups for the development of infectious complications, with timely vaccination of these groups, are clearly needed.
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Affiliation(s)
- Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 37-121, Los Angeles, CA 90095, USA.
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Maródi L, Casanova JL. Primary immunodeficiencies may reveal potential infectious diseases associated with immune-targeting mAb treatments. J Allergy Clin Immunol 2010; 126:910-7. [DOI: 10.1016/j.jaci.2010.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/16/2010] [Accepted: 08/06/2010] [Indexed: 01/13/2023]
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Can primary immunodeficiencies help to provide insights into infectious risks of therapeutic antibodies? Nat Rev Immunol 2010; 10:299-300. [PMID: 20422788 DOI: 10.1038/nri2764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ram R, Ben-Bassat I, Shpilberg O, Polliack A, Raanani P. The late adverse events of rituximab therapy--rare but there! Leuk Lymphoma 2009; 50:1083-95. [PMID: 19399690 DOI: 10.1080/10428190902934944] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rituximab, an anti CD20 monoclonal antibody, has now become a cornerstone in the treatment of many CD20 positive hematological malignancies and a variety of autoimmune disorders. In contrast to the acute allergic and cytokine associated reactions, late adverse events of rituximab are indeed uncommon but at the same time probably under-reported. In this review, we detail late adverse events reported since its use in hemato-oncological neoplasias and other disorders. These adverse events include the development of late-onset neutropenia, defects of immune reconstitution with associated immune compromise, infections, progressive multifocal leukoencephalopathy, reactivation of hepatitis, intestinal perforation and interstitial pneumonitis. Possible mechanisms involved in rituximab-associated complications and the pathogenesis of these adverse effects are reviewed and discussed. Evidence based graded recommendations for the management of these adverse effects are proposed.
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Affiliation(s)
- Ron Ram
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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