1
|
Boumaza X, Lafaurie M, Treiner E, Walter O, Pugnet G, Martin-Blondel G, Biotti D, Ciron J, Constantin A, Tauber M, Puisset F, Moulis G, Alric L, Renaudineau Y, Chauveau D, Sailler L. Infectious risk when prescribing rituximab in patients with hypogammaglobulinemia acquired in the setting of autoimmune diseases. Int Immunopharmacol 2023; 120:110342. [PMID: 37276827 DOI: 10.1016/j.intimp.2023.110342] [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: 02/03/2023] [Revised: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 06/07/2023]
Abstract
We conducted a single-centre retrospective cohort study in a French University Hospital between 2010 and 2018 to describe the risk of severe infectious event (SIE) within 2 years after the date of first rituximab infusion (T0) prescribed after the evidence of acquired hypogammaglobulinemia (gamma globulins [GG] ≤ 6 g/L) in the setting of autoimmune diseases (AID) other than rheumatoid arthritis. SIE occurred in 26 out of 121 included patients. Two years cumulative incidence rates were 12.7 % (95 % CI 5.1-23.9) in the multiple sclerosis/neuromyelitis optica spectrum disorder group (n = 48), 27.6 % (95 % CI 15.7-40.9) in the ANCA-associated vasculitis group (n = 48) and 30.6 % (95 % CI 13.1-50.3) in the 'other AID' group (n = 25). Median GG level at T0 was 5.3 g/l (IQR 4.1-5.6) in the 'SIE' group and 5.6 g/l (IQR 4.7-5.8) in the 'no SIE' group (p = 0.04). In regression analysis, risk of SIE increased with Charlson comorbidity index ≥ 3 (OR 2.77; 95 % CI 1.01-7.57), lung disease (OR 3.20; 95 % CI 1.27-7.99), GG < 4 g/L (OR 3.39; 95 % CI 1.02-11.19), concomitant corticosteroid therapy (OR 4.13; 95 % CI 1.63-10.44), previous cyclophosphamide exposure (OR 2.69; 95 % CI 1.10-6.61), a lymphocyte count < 1000 cells/µL (OR 2.86; 95 % CI 1.12-7.21) and absence of pneumococcal vaccination (OR 3.50; 95 % CI 1.41-8.70). These results may help to inform clinical decision when considering a treatment by rituximab in immunosuppressed AID patients with hypogammaglobulinemia.
Collapse
Affiliation(s)
- Xavier Boumaza
- Service de Médecine Interne Purpan, Centre Hospitalier Universitaire de Toulouse, France; Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Toulouse, France.
| | - Margaux Lafaurie
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire de Toulouse, France; Centre d'Investigation Clinique 1436, Equipe PEPSS, Centre Hospitalier Universitaire de Toulouse, INSERM, Toulouse, France
| | - Emmanuel Treiner
- Laboratoire d'Immunologie, Institut Fédératif de Biologie, Centre Hospitalier Universitaire de Toulouse, France; Centre de Physiopathologie de Toulouse-Purpan, Centre Hospitalier Universitaire de Toulouse, France
| | - Ondine Walter
- Service de Médecine Interne Purpan, Centre Hospitalier Universitaire de Toulouse, France; Centre d'Investigation Clinique 1436, Equipe PEPSS, Centre Hospitalier Universitaire de Toulouse, INSERM, Toulouse, France
| | - Gregory Pugnet
- Service de Médecine Interne et immunologie clinique Rangueil, Centre Hospitalier Universitaire de, Toulouse, France
| | - Guillaume Martin-Blondel
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, France
| | - Damien Biotti
- Service de Neurologie, Centre Hospitalier Universitaire de Toulouse, France
| | - Jonathan Ciron
- Service de Neurologie, Centre Hospitalier Universitaire de Toulouse, France
| | - Arnaud Constantin
- Service de Rhumatologie, Centre Hospitalier Universitaire de Toulouse, France
| | - Marie Tauber
- Service de Dermatologie, Centre Hospitalier Universitaire de Toulouse, France
| | - Florent Puisset
- Service de Pharmacologie, Institut Universitaire du Cancer Oncopole, France
| | - Guillaume Moulis
- Service de Médecine Interne Purpan, Centre Hospitalier Universitaire de Toulouse, France; Centre d'Investigation Clinique 1436, Equipe PEPSS, Centre Hospitalier Universitaire de Toulouse, INSERM, Toulouse, France
| | - Laurent Alric
- Service de Médecine Interne et immunologie clinique Rangueil, Centre Hospitalier Universitaire de, Toulouse, France
| | - Yves Renaudineau
- Laboratoire d'Immunologie, Institut Fédératif de Biologie, Centre Hospitalier Universitaire de Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, France
| | - Dominique Chauveau
- Service de Néphrologie et Transplantation d'Organes, Centre de Référence Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, France
| | - Laurent Sailler
- Service de Médecine Interne Purpan, Centre Hospitalier Universitaire de Toulouse, France; Centre d'Investigation Clinique 1436, Equipe PEPSS, Centre Hospitalier Universitaire de Toulouse, INSERM, Toulouse, France
| |
Collapse
|
2
|
Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
Collapse
Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
| |
Collapse
|