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Yadav S, Balakrishnan C, Mangat G, Kothari J. Rituximab as add-on therapy in patients with resistant lupus nephritis who have failed induction or maintenance therapy with other agents: A real-world experience from a single center in Mumbai. Lupus 2024; 33:88-95. [PMID: 38048588 DOI: 10.1177/09612033231219354] [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] [Indexed: 12/06/2023]
Abstract
BACKGROUND Lupus nephritis (LN) is associated with poor outcomes and a significant risk of progression to end-stage renal disease (ESRD). Some patients with resistant LN do not respond adequately to current treatment options and need alternative strategies or therapies. OBJECTIVE The objective is to evaluate the efficacy and safety of rituximab as a re-induction therapy (Re-RTX) followed by maintenance therapy for patients with resistant LN. METHODS Twenty-four patients with resistant LN (failed initial induction therapy or severe relapse after remission) were analyzed. Re-RTX was co-administered with other immunosuppressants. The primary KDIGO criteria outcomes included renal response (complete and partial), disease progression, relapses, and infections. RESULTS The median age was 28 years (IQR 24.5-42), and the female-to-male ratio was 11:1. All patients had active LN, and 91.3% had proliferative LN. Baseline creatinine was 1.075 mg% (IQR 0.7-1.38), and mean urine protein-to-creatinine ratio (UPCR) was 4.9 (IQR 2.8-6.65). Of the patients receiving RTX as re-induction therapy, 66.6% (16/24) had failed initial induction therapy with other immunosuppressants, whereas 33.3% (8/24) had severe relapse during maintenance therapy.Re-RTX had a favorable renal response at 6 months, with 91.7% of the patients responding (20.8% complete response and 70.8% partial response). At 12 months, 58.3% of the patients maintained a renal response (25% complete response and 33.3% partial response). Approximately one-third of patients relapsed within a year.Fourteen patients (58.3%) continued RTX maintenance therapy with two different treatment regimens. At 6 months, Regimen-1 (500 mg every 6 months) resulted in a partial response in 43% (3/7) and relapse in 57% (4/7) of patients. Regimen 2 (1 g dose per year) achieved a complete response in 28.5% (2/7) and a partial response in 71.5% (5/7) with no relapses at 6 months.At a median follow-up of 29 months, adverse renal outcomes were observed in 29.16% of the patients with progression to advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD). The overall use of Re-RTX was considered safe, with a reported infection prevalence of 16%, which is comparable to the existing data. CONCLUSION Re-RTX demonstrated efficacy and safety as an induction therapy for resistant LN. However, the response waned after 1 year, underscoring the need for optimized maintenance therapy.
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Affiliation(s)
- Sandeep Yadav
- Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - C Balakrishnan
- Head of Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Gurmeet Mangat
- Department of Rheumatology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Jatin Kothari
- Renal Transplant Medicine, Nanavati Max Super Speciality Hospital, Mumbai and Consultant Nephrologist & Section Coordinator-Nephrology Hinduja Healthcare, Mumbai
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Yan Q, Zhang M, Du F, Kang Y, Ye P, Li Q, Liu B, Dai M, Bao C. Efficacy and safety of Iguratimod as an add-on therapy for refractory lupus nephritis: A preliminary investigational study. Front Immunol 2023; 14:1062919. [PMID: 36969217 PMCID: PMC10030952 DOI: 10.3389/fimmu.2023.1062919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
ObjectivesIGU (IGU), a novel immunomodulatory agent for rheumatoid arthritis, has been shown to be effective and safe as monotherapy in a small population with refractory lupus nephritis (LN). The aim of this prospective study was to evaluate the efficacy and safety of IGU as an add-on therapy in patients with refractory LN in the context of clinical practice.MethodsThis is a single-arm observational study. We have enrolled LN patients since 2019 at Renji Hospital. All participants should have recurrent or refractory LN with at least one immunosuppressant (IS) and have a baseline urine protein/creatinine ratio (UPCR) >1.0. After enrollment, we added IGU (25 mg twice daily) to one of their previous immunosuppressants (IS) without increasing the dose of steroids. The primary outcome was the complete renal response (CRR) in the 6th month. UPCR decrease of over 50% was defined as partial response (PR). Extended follow-up was performed after the initial 6 months.ResultsWe enrolled 26 eligible participants. 11/26 patients had chronic kidney disease (CKD) stage 2/3 at the baseline. The IS combined with IGU included mycophenolate mofetil, tacrolimus, and cyclosporin A. No IS change was allowed. 80.7% of patients had baseline steroids less than 0.5mg/kg daily and there was no steroids escalation during the IGU treatment. The CRR rate was 42.3% (11/26) at month 6. With a median follow-up of 52 weeks (range: 23-116 weeks), the CRR rate at the last visit was 50% (13/26) and 73.1% (19/26) of patients had UPCR decrease of over 50%. Six patients withdrew, three for no response and three for renal flare after initial CRR. One patient had an estimated glomerular filtration rate worsening of over 20% and was classified as renal flare. Three mild to moderate adverse events were recorded.ConclusionsOur investigation merits further investigation in IGU as a potentially tolerable component of combination therapy for refractory LN.
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Affiliation(s)
- Qingran Yan
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Chunde Bao, ; Min Dai, ; Qingran Yan,
| | - Mei Zhang
- Department of Nephrology and Rheumatology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Nephrology and Rheumatology, Anhui Public Health Clinical Center, Hefei, China
| | - Fang Du
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuening Kang
- The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Ping Ye
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qianqian Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bei Liu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Dai
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Chunde Bao, ; Min Dai, ; Qingran Yan,
| | - Chunde Bao
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Chunde Bao, ; Min Dai, ; Qingran Yan,
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Choi SJ, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Initial Preserved Renal Function as a Predictor of Favorable Renal Response to Rituximab in Refractory or Relapsing Lupus Nephritis: A Single-center Cohort Study in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:22-32. [PMID: 37476702 PMCID: PMC10324915 DOI: 10.4078/jrd.2022.29.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Previous studies investigating the beneficial effect of rituximab on lupus nephritis (LN) reported controversial results There have been few reports of renal response to rituximab according to renal function We investigated the efficacy of rituximab in refractory/relapsing LN and the role of renal function as a predictor of renal response. METHODS From 2016 to 2019, we retrospectively reviewed 22 patients with refractory/relapsing LN receiving rituximab Renal responses (complete and partial) at 6 and 12 months were compared between normal (glomerular filtration rate [GFR]≥90 mL/min/173 m2, n=11) and decreased (GFR<90 mL/min/173 m2, n=11) GFR groups Multivariate Cox regression analysis was used to assess predictors of renal response. RESULTS At baseline, the decreased GFR group had a higher urine proteinuria to creatinine ratio (p=0008) and proportion of refractory LN (p=0010) and previous cyclophosphamide therapy (p=0035) than the normal GFR group The overall renal response rate was 455% (10 patients) at 6 months and 545% (12 patients) at 12 months Renal response rates were higher in the normal GFR group (818% and 909% at 6 and 12 months, respectively) than in the decreased GFR group (91% and 182% at 6 and 12 months, respectively; p<0001) Normal GFR and anti-La were associated with renal response to rituximab, with hazard ratios of 9256 (p=0008) and 5478 (p=0041), respectively. CONCLUSION Rituximab is an effective therapy for refractory/relapsing LN, particularly in patients with preserved renal function.
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Affiliation(s)
- Su Jin Choi
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Rheumatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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The Economic Burden of Lupus Nephritis: A Systematic Literature Review. Rheumatol Ther 2021; 9:25-47. [PMID: 34731412 PMCID: PMC8814085 DOI: 10.1007/s40744-021-00368-y] [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: 05/07/2021] [Accepted: 08/27/2021] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Few studies have evaluated the economic burden of lupus nephritis (LN). The aim of this systematic literature review (SLR) was to assess the economic burden (direct and indirect costs, and healthcare resource utilization [HCRU]) associated with LN, with particular focus on the burden of renal flares and end-stage kidney disease (ESKD). METHODS This SLR (GSK study 213531) was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of the MEDLINE and Embase databases were conducted for English language publications reporting cost or HCRU data in patients with LN (regardless of age or LN histological class) until December 10, 2019. Handsearching of conference proceedings and keyword-based searches in PubMed, Google, and Google Scholar were also conducted. RESULTS Twenty-two studies were identified from 28 publications reporting the cost (n = 19) and HCRU (n = 13) associated with LN. Most studies were from North America (n = 13) and many used administrative claims data (n = 9). LN was associated with substantially higher direct costs (e.g., total annual, hospitalization, and ESKD-related direct costs), total indirect costs, and HCRU (e.g., hospitalization, outpatient services, and medication use) compared with patients without systemic lupus erythematosus (SLE) or non-renal SLE controls. ESKD and dialysis were significant contributors to economic burden. No studies described the cost of renal flares. CONCLUSIONS The consensus across the 22 studies was that the economic burden of LN is substantial, particularly in active or severe disease, or if there is progression to ESKD. Total direct cost may be underestimated in claims data given the challenges of identifying patients with LN. Further studies are vital to ascertain the cost of renal flares; a renal flare is likely to result in a period of increased HCRU, which could be mitigated by treatments that extend renal remission.
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Yan Q, Du F, Kang Y, Ye P, Wang X, Xu J, Tang J, Wang N, Jiang G, Li Z, Wang X, Xue Q, Huang X, Zhang X, Zhou Y, Dai M, Bao C. Comparison of iguratimod and conventional cyclophosphamide with sequential azathioprine as treatment of active lupus nephritis: study protocol for a multi-center, randomized, controlled clinical trial (iGeLU study). Trials 2021; 22:530. [PMID: 34380536 PMCID: PMC8356213 DOI: 10.1186/s13063-021-05475-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 07/21/2021] [Indexed: 12/02/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) is an autoimmune disease that can involve multiple organs or systems. Lupus nephritis (LN) is associated with high mortality and morbidity. However, plenty of patients do not respond to present treatment or relapse. Iguratimod (IGU) is a new small molecular, anti-rheumatic drug and has shown the potential for drug repurposing from rheumatoid arthritis (RA) to LN treatment. It has been approved for treating RA in northeast Asia. Beyond expectation in a recent observational study, over 90% of thirteen refractory LN patients responded to iguratimod monotherapy in 24 weeks, with no steroids dose increasing or any other medication add-on during the entire follow-up. Methods/design This study is a multi-center, randomized, 52-week parallel positive drug-controlled study. The study was designed as a head-to-head comparison between the iguratimod and present first-line therapy on LN patients. A total of 120 patients (60 patients each group) is in the enrolling plan. All enrolled patients are assigned randomly into trial and control groups. The patients will be selected from six study sites in China and will all have biopsy-proven active lupus nephritis. In the first 24 weeks of the trial, IGU is compared with cyclophosphamide as an induction therapy, and in the second 24 weeks, IGU is compared with azathioprine as a maintenance therapy. The primary outcome is renal remission rate including both complete remission and partial remission at week 52, which will be analyzed using a non-inferiority hypothesis test. Discussion Most patients diagnosed with SLE will develop LN within 5 years and LN remains a major cause of morbidity and death for SLE patients. Although some medications are proven effective for the treatment of this condition, at least 20–35% LN patients have to suffer from relapse or ineffective treatment and medication intolerance is also frequent. This trial is designed to demonstrate whether iguratimod can be used as an alternative induction or maintenance therapy in subjects who have lupus nephritis. Data from this study will provide an evidence on whether or not iguratimod should be recommended to active LN patients. Trial registration ClinicalTrials.govNCT 02936375. Registered on October 18, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05475-3.
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Affiliation(s)
- Qingran Yan
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China.
| | - Fang Du
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Yuening Kang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Ping Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Xiaodong Wang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Jianhua Xu
- Department of Rheumatology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Jianping Tang
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Niansong Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gengru Jiang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Zhijun Li
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Xuan Wang
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Qin Xue
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xinfang Huang
- Department of Rheumatology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Xiaoyan Zhang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Ying Zhou
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Min Dai
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China.
| | - Chunde Bao
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200001, China.
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Tanaka Y, O'Neill S, Li M, Tsai IC, Yang YW. Systemic Lupus Erythematosus: Targeted literature review of the epidemiology, current treatment and disease burden in the Asia Pacific region. Arthritis Care Res (Hoboken) 2020; 74:187-198. [PMID: 32841537 DOI: 10.1002/acr.24431] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 07/09/2020] [Accepted: 08/18/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To understand the epidemiology, current treatment and disease burden of systemic lupus erythematosus (SLE) in the Asia Pacific region (APAC). METHODS A targeted literature review of published evidence on SLE in APAC was conducted, using the MEDLINE® database (2008-2018), conference proceedings and other supplementary sources. RESULTS The review identified 70 studies conducted in China (n=15), Japan (n=13), Taiwan (n=12), Korea (n=9), Australia (n=7), Hong Kong (n=6), Singapore (n=4), and multiple places within the APAC region (n=4). Incidence rates (per 100,000 per year) ranged from 0.9-8.4, while prevalence rates ranged from 3.7-127 (per 100,000); however, recent data was limited. Asian SLE patients were reported to have higher disease severity, activity (higher SLE disease activity index scores) and organ damage accrual; along with increased morbidity, mortality, and susceptibility to renal involvement compared with other ethnicities in APAC. The risk of developing SLE is higher in the Asian population. Routinely used SLE therapies included belimumab, hydroxychloroquine, cyclophosphamide, tacrolimus, azathioprine, mycophenolate mofetil, and corticosteroids; however, prescribing patterns varied across the region. Increased disease activity was associated with high economic burden and poor quality of life for SLE patients in APAC. CONCLUSION SLE remains a disease with a significant unmet medical need for an innovative therapy that is well-tolerated and effective for patients in APAC. Further evidence is required to better characterize the disease and fully capture the burden and impact of SLE in APAC. This review has highlighted where there is a paucity of data from patients across the APAC region.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Sean O'Neill
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - I-Ching Tsai
- Janssen: Pharmaceutical Companies of Johnson & Johnson, 11F, No.2, Sec.3, Minsheng East Rd, Taipei City, Taiwan
| | - Ya-Wen Yang
- Janssen Global Services, LLC, Horsham, PA, USA
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Stolyar L, Lahita RG, Panush RS. Rituximab use as induction therapy for lupus nephritis: a systematic review. Lupus 2020; 29:892-912. [PMID: 32486934 DOI: 10.1177/0961203320928412] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Rituximab (RTX) has important usage in rheumatoid arthritis and vasculitis. There remains a need for more, better, and safer treatments for patients with lupus nephritis (LN). RTX has been trialed in such patients without definitive conclusions about its effectiveness. As a role for RTX has not been clearly established for LN, we carried out a systematic review and analysis. METHODS We identified 31 studies of RTX for class I-VI LN, and assessed complete renal response (CRR) and partial renal response (PRR) using criteria including serum creatinine, proteinuria, and urinary sediment. Due to differences in the pediatric presentation of the disease, studies focusing on pediatric patients were excluded. RESULTS One randomized controlled trial (RCT) showed superiority of RTX+cyclophosphamide (CYC) versus CYC alone (64% vs. 21% CRR and 19% vs. 36% PRR). Six prospective and retrospective studies utilizing RTX monotherapy found 66% CRR or PRR in all patients. Eleven studies that investigated RTX in combination with CYC or mycophenolate mofetil (MMF) also found 66% CRR or PRR in all patients. In total, the CRR for Caucasian, East Asian, and Hispanic patients were 77%, 38%, and 28%, respectively. CONCLUSIONS RTX appeared to benefit certain LN patients, but most studies were not randomized or properly controlled, were heterogeneous in design, subjects, and LN types, and were not comparable, and must therefore be interpreted cautiously. RTX alone may not deplete B cells sufficiently for the perturbations of LN. In addition, RTX may induce responses differently among patients of different ethnic and racial backgrounds. Furthermore, there were wide variations in the baseline characteristics of the patients, namely LN class, time course of disease, age, and prior immunosuppressive use. We suggest a prospective RCT in patients aged 18-65 years with class IV LN. Ideally, the patients would not have received prior immunosuppression and would better represent different ethnicities. The treatment groups would be RTX, RTX+belimumab, CYC, and MMF groups, with pulse-dose steroids during induction followed by maintenance steroids and MMF. The CRR and PRR would be assessed at 12 and 24 months. This or a similar study might clarify RTX's role in the treatment of LN.
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Affiliation(s)
- Liya Stolyar
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Robert G Lahita
- Department of Medicine, St. Joseph's Regional Medical Centre, Paterson, USA
| | - Richard S Panush
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Kang Y, Yan Q, Fu Q, Wang R, Dai M, Du F, Dai Q, Ye P, Wu C, Lu L, Bao C. Iguratimod as an alternative induction therapy for refractory lupus nephritis: a preliminary investigational study. Arthritis Res Ther 2020; 22:65. [PMID: 32228698 PMCID: PMC7106733 DOI: 10.1186/s13075-020-02154-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 03/13/2020] [Indexed: 12/18/2022] Open
Abstract
Objectives Iguratimod, a novel immunomodulatory agent for rheumatoid arthritis, has been shown to be effective against murine lupus. The aim of this study was to make a preliminary evaluation of the efficacy and safety of iguratimod as salvage therapy in patients with refractory lupus nephritis (LN). Methods We enrolled eligible patients with refractory LN, which we defined as having failed or relapsed on at least two immunosuppressant agents. After enrollment, we substituted iguratimod (25 mg twice daily) for their previous immunosuppressant agents without increasing the dose of steroids. The primary outcome was complete/partial remission (PR/CR) at week 24. Patients who achieved remission continued iguratimod as maintenance therapy over an extended follow-up. Results The study cohort comprised 14 patients with refractory LN, 10 of whom had recent treatment failure and 4 repeated relapses with inadequate initial responses. At enrollment, none of the patients had detectable evidence of extra-renal involvement. The median prednisone dosage was 10 mg/d (IQR 0–10 mg/day). Thirteen patients were eligible for response evaluation, with one patient missed. The renal response rate was 92.3% (12/13) at week 24, with 38.5% (5/13) achieving CR and 53.8% (7/13) achieving PR. We then continued to follow up the responding patients for up to 144 weeks. Twenty-five percent of the patients (3/12) had renal relapse after initial PR. The estimated glomerular filtration rate of all patients maintained stable during follow-up. One patient had a severe adverse reaction (anemia) but recovered fully after stopping iguratimod. Conclusions Our study supports the potential of iguratimod for treatment of refractory LN. Iguratimod could be a promising candidate drug for this condition.
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Affiliation(s)
- Yuening Kang
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Qingran Yan
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China.
| | - Qiong Fu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Ran Wang
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Min Dai
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Fang Du
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Qing Dai
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Ping Ye
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Chunmei Wu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China.
| | - Chunde Bao
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, 145 Shandong RD, Shanghai, 200001, China.
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Nasonov EL, Beketova TV, Ananyeva LP, Vasilyev VI, Solovyev SK, Avdeeva AS. PROSPECTS FOR ANTI-B-CELL THERAPY IN IMMUNO-INFLAMMATORY RHEUMATIC DISEASES. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-3-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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Kronbichler A, Brezina B, Gauckler P, Quintana LF, Jayne DRW. Refractory lupus nephritis: When, why and how to treat. Autoimmun Rev 2019; 18:510-518. [PMID: 30844548 DOI: 10.1016/j.autrev.2019.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Refractory lupus nephritis indicates an inadequate response to lupus nephritis therapy. It implies persisting or worsening disease activity despite therapy, but the definition is complicated by the parameters of response, proteinuria and renal function, that do not discriminate clearly between activity and irreversible damage. Understanding the causes of refractory disease and developing treatment strategies is important because these patients are more likely to develop poor outcomes, especially end stage renal disease. This review explores current concepts and definitions of refractory disease and summarises treatment approaches that have been used in observational cohort studies and case series. We highlight the importance of optimising adherence to the prescribed immunosuppressive and supportive measures and avoidance of diagnostic delay. Treatment options include higher dose glucocorticoid, switching between cyclophosphamide and mycophenolate acid derivates, or addition of rituximab, the latter potentially in combination with belimumab. Less evidence supports extracorporeal treatment (plasma exchange or immunoadsorption), calcineurin inhibitors (cyclosporine A or tacrolimus), intravenous immunoglobulin and stem cell transplantation. Improvements in understanding what refractory disease is and how definitions can be integrated into treatment pathways has the potential to enhance lupus nephritis outcomes.
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Affiliation(s)
- Andreas Kronbichler
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Biljana Brezina
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Luis F Quintana
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Department of Medicine, University of Cambridge, CB2 0QQ Cambridge, United Kingdom.
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Alshaiki F, Obaid E, Almuallim A, Taha R, El-Haddad H, Almoallim H. Outcomes of rituximab therapy in refractory lupus: A meta-analysis. Eur J Rheumatol 2018; 5:118-126. [PMID: 30185361 DOI: 10.5152/eurjrheum.2018.17096] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/14/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Conventional treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) is associated with damage accrual, hence increased morbidity rate. Off-label use of rituximab (RTX) has shown significant promise in this patient group; however, data are still controversial. We aimed to analyze the outcomes of RTX therapy in refractory lupus using a meta-analysis approach. METHODS Electronic search of the medical literature was conducted using a combination of relevant keywords to retrieve studies on the safety and efficacy of RTX in SLE and LN patients. Results were screened against our inclusion and exclusion criteria and two reviewers independently extracted the data for analysis. Comprehensive meta-analysis software was used to pool the data from individual studies and provide summary effect estimates. RESULTS Thirty-one studies that enrolled 1112 patients were finally eligible for the meta-analysis. The overall global, complete, and partial response rates to RTX therapy were 72%, 46%, and 32%, respectively. RTX significantly decreased Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and British Isles Lupus Activity Group (BILAG) scores (p<0.001). Prednisone dose was significantly reduced after RTX treatment in both SLE and LN groups (p<0.001), and proteinuria was lowered in SLE (p<0.001) than in LN patients (p=0.07). Infection and infusion-related reactions were the most common side effects. CONCLUSION RTX therapy in refractory SLE and LN patients proved clinical efficacy and favorable safety outcomes. Larger well-designed randomized clinical trials are warranted.
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Affiliation(s)
- Fatma Alshaiki
- Department of Medicine, East Jeddah Hospital, Jeddah, Saudi Arabia
| | - Elaf Obaid
- Department of Medicine, Umm Al-Qura University School of Medicine, Makkah, Saudi Arabia
| | - Abdulqader Almuallim
- Department of Medicine, Umm Al-Qura University School of Medicine, Makkah, Saudi Arabia
| | - Rabab Taha
- Department of Medicine, Dr. Sloiman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Hadeel El-Haddad
- Department of Medicine, Dr. Sloiman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Hani Almoallim
- Department of Medicine, Umm Al-Qura University School of Medicine, Makkah, Saudi Arabia.,Department of Medicine, Dr. Sloiman Fakeeh Hospital, Jeddah, Saudi Arabia.,Alzaidi Chair of Research in Rheumatic Diseases, Umm Al-Qura University, Makkah, Saudi Arabia
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12
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Galanopoulos N, Christoforidou A, Bezirgiannidou Z. Lupus thrombocytopenia: pathogenesis and therapeutic implications. Mediterr J Rheumatol 2017; 28:20-26. [PMID: 32185250 PMCID: PMC7045921 DOI: 10.31138/mjr.28.1.20] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/12/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) is frequently complicated by cytopenias. Thrombocytopenia is usually non severe and its frequency ranges from 20% to 40%. It is mostly an autoimmune process caused by autoantibodies against platelet surface glycoproteins and it is associated with worse prognosis in SLE. It can also be a result of SLE treatment with azathioprine, methotrexate and rarely hydroxychloroquine or thrombotic microangiopathy or macrophage activation syndrome. If thrombocytopenia is mild (>50×109/L) and there is no other evidence of disease there is no need of therapy. Severe thrombocytopenia is less frequent and needs therapeutic management. Corticosteroids are the cornerstone of therapy. Continuous high dose oral prednisolone or pulse high dose methylprednisolone (MP) with or without intravenous immune globulin are used in the acute phase. Second line agents (hydroxychloroquine, danazol, azathioprine, cyclosporine, mycophenolate mofetil, cyclophosphamide, rituximab) are usually needed. Splenectomy is indicated for recurrent or resistant cases. There are no evidence-based guidelines to facilitate selection of one drug over another but certainly the co-existence of other systemic SLE manifestations must be taken into account. Newer therapies are emerging although there is no consensus on the treatment of refractory lupus thrombocytopenia due to the absence of controlled randomized trials.
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Affiliation(s)
- Nikolaos Galanopoulos
- Outpatient Department of Rheumatology, University General Hospital of Evros (Alexandroupolis), Thrace, Greece
| | - Anna Christoforidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
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13
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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14
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Analysis of the effectiveness and safety of rituximab in patients with refractory lupus nephritis: a chart review. Clin Rheumatol 2016; 35:517-22. [DOI: 10.1007/s10067-015-3166-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 12/30/2015] [Accepted: 12/30/2015] [Indexed: 01/05/2023]
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Fayyaz A, Igoe A, Kurien BT, Danda D, James JA, Stafford HA, Scofield RH. Haematological manifestations of lupus. Lupus Sci Med 2015; 2:e000078. [PMID: 25861458 PMCID: PMC4378375 DOI: 10.1136/lupus-2014-000078] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/12/2015] [Accepted: 01/18/2015] [Indexed: 12/14/2022]
Abstract
Our purpose was to compile information on the haematological manifestations of systemic lupus erythematosus (SLE), namely leucopenia, lymphopenia, thrombocytopenia, autoimmune haemolytic anaemia (AIHA), thrombotic thrombocytopenic purpura (TTP) and myelofibrosis. During our search of the English-language MEDLINE sources, we did not place a date-of-publication constraint. Hence, we have reviewed previous as well as most recent studies with the subject heading SLE in combination with each manifestation. Neutropenia can lead to morbidity and mortality from increased susceptibility to infection. Severe neutropenia can be successfully treated with granulocyte colony-stimulating factor. While related to disease activity, there is no specific therapy for lymphopenia. Severe lymphopenia may require the use of prophylactic therapy to prevent select opportunistic infections. Isolated idiopathic thrombocytopenic purpura maybe the first manifestation of SLE by months or even years. Some manifestations of lupus occur more frequently in association with low platelet count in these patients, for example, neuropsychiatric manifestation, haemolytic anaemia, the antiphospholipid syndrome and renal disease. Thrombocytopenia can be regarded as an important prognostic indicator of survival in patients with SLE. Medical, surgical and biological treatment modalities are reviewed for this manifestation. First-line therapy remains glucocorticoids. Through our review, we conclude glucocorticoids do produce a response in majority of patients initially, but sustained response to therapy is unlikely. Glucocorticoids are used as first-line therapy in patients with SLE with AIHA, but there is no conclusive evidence to guide second-line therapy. Rituximab is promising in refractory and non-responding AIHA. TTP is not recognised as a criteria for classification of SLE, but there is a considerable overlap between the presenting features of TTP and SLE, and a few patients with SLE have concurrent TTP. Myelofibrosis is an uncommon yet well-documented manifestation of SLE. We have compiled the cases that were reported in MEDLINE sources.
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Affiliation(s)
- Anum Fayyaz
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Ann Igoe
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Departments of Medicine and Pediatrics , Metro Health System , Cleveland, Ohio , USA
| | - Biji T Kurien
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Debashish Danda
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Rheumatology , Christian Medical Center , Vellore , India
| | - Judith A James
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Haraldine A Stafford
- Depertment of Medicine , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City, Iowa , USA
| | - R Hal Scofield
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
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Fattah Z, Isenberg DA. Recent developments in the treatment of patients with systemic lupus erythematosus: focusing on biologic therapies. Expert Opin Biol Ther 2014; 14:311-26. [PMID: 24387632 DOI: 10.1517/14712598.2014.871256] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Major trials hoping to obtain optimal disease control in systemic lupus erythematosus (SLE) are ongoing. Given its complex aetiology and pathogenesis, it is not surprising that multiple therapeutic targets have emerged and that none are uniformly successful. AREAS COVERED In this review, we highlight the recent, more significant studies focusing on the use of biologic therapies. There has been great emphasis on the role of B cells in SLE and many uncontrolled studies have encouraged the use of rituximab (an anti-CD20 monoclonal). Disappointingly, two major trials, EXPLORER and LUNAR did not confirm its utility, although doubts have been expressed on their trial design, and other trials using this drug are commencing. In contrast, belimumab, which blocks a B-cell activating factor, did meet its end points in two major randomised controlled clinical trials and has been approved for use in SLE by both the FDA and the European Medicines Agency. Encouraging, albeit preliminary, results with epratuzumab (which blocks CD22) have also been reported. EXPERT OPINION In addition to targeting B cells, other approaches including biologics, which modulate T-cell function and block interleukin-6 and interferon-α, have been explored. Finally, we review the recent developments in the use of conventional drugs, such as cyclophosphamide and mycophenolate.
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Affiliation(s)
- Zozik Fattah
- University College Hospital, Department of Rheumatology , 3rd floor central, 250 Euston Road, London, NW1 2PG , UK
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17
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Ruiz-Irastorza G, Danza A, Khamashta M. Tratamiento del lupus eritematoso sistémico: mitos, certezas y dudas. Med Clin (Barc) 2013; 141:533-42. [DOI: 10.1016/j.medcli.2013.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/14/2013] [Indexed: 02/08/2023]
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Jovancevic B, Lindholm C, Pullerits R. Anti B-cell therapy against refractory thrombocytopenia in SLE and MCTD patients: long-term follow-up and review of the literature. Lupus 2013; 22:664-74. [PMID: 23612795 DOI: 10.1177/0961203313485489] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to retrospectively evaluate the clinical and immunological effects of anti-B cell treatment in patients with systemic lupus erythematosus (SLE) and mixed connective-tissue disease (MCTD) with autoimmune thrombocytopenia (AITP) refractory to conventional immunosuppressive treatment. METHODS Rituximab (RTX) was added to the ongoing treatment of 16 patients (median age 36 years, range 17-84, all female) with treatment-resistant AITP. Thirteen patients had SLE and three had MCTD. RTX was given intravenously on four occasions during four consecutive weeks at a dose of 375 mg/m(2). Clinical and laboratory disease activity variables recorded at every follow-up visit were analyzed. RESULTS The median disease duration before RTX treatment was nine years (range 0.2-27) and the median post-treatment follow-up time was 28 months (range 3 to 92). Ten patients (63%) were treated repeatedly with RTX during the follow-up period. Complete depletion of B cells was achieved in 94% of cases one month after RTX treatment. A significant increase (p = 0.0001) of platelet counts was seen already after one month (median 58 × 10(9)/ml vs 110 × 10(9)/ml) whereas within three months platelet counts normalized in 10 patients (median 223 × 10(9)/ml). Three patients did not respond to RTX treatment (median platelet count 69 × 10(9)/ml). High titers of anti-platelet antibodies were detected in seven patients before RTX treatment, and the autoantibody titers decreased significantly (p < 0.03) after RTX treatment in six of these patients who also achieved complete remission. A review of the literature revealed 24 articles including 18 case reports, one retrospective cohort study and five prospective studies documenting the outcomes of 65 RTX-treated patients with SLE- or MCTD-related thrombocytopenia with an overall treatment response rate of 80%. In conclusion, these findings indicate that RTX is an additional potent therapeutic treatment option for SLE patients with AITP refractory to conventional immunosuppressive treatment whereas best response may be expected in patients with high titers of anti-platelet antibodies at baseline.
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Affiliation(s)
- B Jovancevic
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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19
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Lan L, Han F, Chen JH. Efficacy and safety of rituximab therapy for systemic lupus erythematosus: a systematic review and meta-analysis. J Zhejiang Univ Sci B 2013; 13:731-44. [PMID: 22949364 DOI: 10.1631/jzus.b1200057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To review the efficacy and safety of rituximab therapy for systemic lupus erythematosus (SLE). METHODS We searched for randomized controlled trails and observational studies that evaluated the effect of rituximab based on the systemic lupus erythematosus disease activity index (SLEDAI), British Isles lupus assessment group index (BILAG), urine protein levels, and the prednisolone dose, and had adequate data to calculate the mean, standard deviation (SD), and 95% confidence intervals, and to systematically review and meta-analyze observational studies with fixed effects model or random effects model. RESULTS We included 2 randomized controlled studies and 19 observational clinical studies. We summarized the data from the 19 observational studies, analyzed the heterogeneity of the literature, and then used fixed effect model or random effect model for statistical analysis. The SLEDAI, BILAG, and urine protein levels and the prednisolone dosage were decreased after rituximab treatment, and the decreases in the BILAG, urine protein levels, and the prednisolone dose were found to be significant (P<0.05), when compared with baseline level. Rituximab's adverse effects generally could be controlled with an effective dosing regimen. CONCLUSIONS Although there are still controversies about rituximab's treatment on SLE, but our study had showed that rituximab had favorable effects on refractory lupus. The long-term efficacy and safety of rituximab require further study.
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Affiliation(s)
- Lan Lan
- Department of Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
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20
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Multicenter retrospective analysis of the effectiveness and safety of rituximab in korean patients with refractory systemic lupus erythematosus. Autoimmune Dis 2012; 2012:565039. [PMID: 23304457 PMCID: PMC3523406 DOI: 10.1155/2012/565039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 11/04/2012] [Indexed: 01/09/2023] Open
Abstract
Objective. Although two recent randomized placebo-controlled trials of rituximab (RTX) failed to demonstrate efficacy in systemic lupus erythematosus (SLE), clinicians continue to use off-label RTX for cases refractory to current treatments. We evaluated the effectiveness and safety of rituximab for patients with refractory SLE in Korea. Methods. We retrospectively analyzed multicenter patients treated with RTX in Korea. Results. 39 SLE patients treated with RTX were included in the following manner: lupus nephritis 43.6%, hematologic 33.3%, arthritis 7.8%, myositis 7.8%, and others 7.7%. All patients had responded poorly to at least one conventional immunosuppressive agent (mean 2.5 ± 1.1, cyclophosphamide 43.6%, mycophenolate mofetil 48.7%, and other drugs) before RTX. Clinical improvements (complete or partial remission) occurred in patients with renal disease, hematologic disease, arthritis, myositis, and other manifestations at 6 months after RTX. The SLEDAI score was significantly decreased from 10.8 ± 7.1 at baseline to 6.7 ± 4.0 at 6 months, 6.2 ± 4.1 at 12 months, and 5.5 ± 3.6 at 24 months after RTX (P < 0.05). Among 28 clinical responders, 4 patients experienced a relapse of disease at 25 ± 4 months. Infections were noted in 3 patients (7.7%). Conclusion. RTX could be an effective and relatively safe therapeutic option in patients with severe refractory SLE until novel B-cell depletion therapy is available.
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Wiesik-Szewczyk E, Olesinska M. B-cell targeted therapy in systemic lupus erythematosus: potential of rituximab. Biologics 2012; 6:347-54. [PMID: 23055692 PMCID: PMC3460634 DOI: 10.2147/btt.s25407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Indexed: 11/23/2022]
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease of unknown etiology, and the limited available therapeutic options for this disease, are frustrating to both clinicians and patients. However, recent advances in the understanding of disease mechanisms have given rise to numerous studies on specific approaches to SLE treatment. Rituximab, the first chimeric, mouse-human monoclonal antibody which is directed against CD20, seems to be a new therapeutic option. The purpose of this review is to explain the current clinical evidence on the therapeutic use of rituximab in adult SLE patients. Two randomized clinical trials with rituximab (the EXPLORER and LUNAR studies) failed to prove efficacy of this drug on SLE. Ongoing data analysis continues to explain the reasons behind why this treatment fails to work. However data from open source and observational studies contrast with clinical trials results. The global analysis of this data supports the off-label use of rituximab in subsets of SLE that are refractory to standard treatment.
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Affiliation(s)
- E Wiesik-Szewczyk
- Institute of Rheumatology, Department of Connective Tissue Diseases, Warsaw, Poland
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22
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Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that is clinically heterogeneous and affects multiple organs. Lupus nephritis is the most frequent severe manifestation of SLE. Conventional immunosuppressive therapy has increased the life expectancy of patients diagnosed with lupus nephritis, but only 70-80% of patients respond to this treatment and its adverse effects are considerable. B cells are central to the pathogenesis of SLE and are, therefore, an attractive therapeutic target. B-cell depletion has been used successfully to treat other autoimmune diseases, such as rheumatoid arthritis and antineutrophil cytoplasmic antibody-associated vasculitis, and many case reports and small nonrandomized trials of B-cell-depleting agents in patients with lupus nephritis have reported positive results. By contrast, two large placebo-controlled trials designed to investigate the efficacy of the B-cell-depleting agents rituximab and ocrelizumab as a treatment for lupus nephritis, failed to meet their primary efficacy end points (LUNAR and BELONG, respectively). This Review discusses the current evidence on the use of B-cell depletion in the treatment of lupus nephritis, which is derived from case studies and clinical trials including a total of over 800 patients.
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Affiliation(s)
- Jon W Gregersen
- Department of Nephrology, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark
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Fernández-Nebro A, de la Fuente JLM, Carreño L, Izquierdo MG, Tomero E, Rúa-Figueroa I, Hernández-Cruz BE, Narváez J, Ucar E, Olivé A, Zea A, Fernández-Castro M, Raya-Álvarez E, Pego-Reigosa JM, Freire M, Martínez-Taboada VM, Pérez-Venegas J, Sánchez-Atrio AI, Villa-Blanco I, Manrique-Arija S, López-Longo FJ, Carreira PE, Martínez-Pérez R, García-Vicuña R. Multicenter longitudinal study of B-lymphocyte depletion in refractory systemic lupus erythematosus: the LESIMAB study. Lupus 2012; 21:1063-76. [PMID: 22786985 DOI: 10.1177/0961203312446627] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to investigate the effectiveness and safety of single and repeated courses of rituximab in patients with refractory lupus. METHODS LESIMAB is a multicenter, retrospective, longitudinal study of lupus patients who have not responded to standard therapy and have been treated with rituximab. Response rates at six months and at follow-up were defined as efficacy outcomes. Complete response was defined as a SELENA-SLEDAI score ≤ two and a SELENA-SLEDAI Flare Index of zero. Partial response was defined as a reduction in the SELENA-SLEDAI score of ≥four points with no new or worsening of symptoms. Adverse events were collected. RESULTS Seventy-three (62.9%) of 116 patients achieved a response at six months (complete in 22 and partial in 51). Ninety-seven (77.6%) of 128 patients achieved a response after a mean follow-up of 20.0 ± 15.2 months (complete in 50 and partial in 47). High baseline SLEDAI score, previous treatment with ≥100 mg/day prednisone, and no history of severe hematologic flare were associated with response after the first treatment course. The median time to response was 6.5 months (95% CI, 5.0-8.0). Thirty-seven patients (38.1%) relapsed after the first infusion. The flare was severe in seven cases and mild to moderate in 29 cases. Serious infection rate was 12.6/100 patient-years. A schedule of four weekly doses was associated with more serious infections. Six patients died: two of infection and four of lupus complications. CONCLUSION Rituximab can be an effective treatment option for patients who have refractory lupus with severe or life-threatening disease with an acceptable tolerance profile.
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Affiliation(s)
- A Fernández-Nebro
- Rheumatology Service, Hospital Regional Universitario Carlos Haya, Spain.
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Weidenbusch M, Römmele C, Schröttle A, Anders HJ. Beyond the LUNAR trial. Efficacy of rituximab in refractory lupus nephritis. Nephrol Dial Transplant 2012; 28:106-11. [PMID: 22764193 DOI: 10.1093/ndt/gfs285] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The treatment of lupus nephritis (LN) remains problematic because the current treatment regimen based on unspecific immunosuppressants such as steroids, cyclophosphamide and mycophenolate has significant side effects and is often inefficient. B-cell ablation with the chimeric anti-CD20 antibody rituximab (RTX) has been considered as an alternative treatment option but the randomized controlled LUNAR trial failed to show any additive effect of RTX beyond a steroid-mycophenolate mofetil (MMF) combination for LN type III/IV/V in incident patients. At present, no such trial is available for the use of RTX in refractory LN. METHODS We analysed existing evidence on this topic by performing a systematic analysis of reports that document outcomes of RTX treatment for refractory LN. RESULTS Out of 233 reports, we selected 26 for analysis, which described 300 patients with a mean follow-up of 60 weeks. The complete or partial response criteria were met by 87% of patients with LN class III, 76% with class IV and 67% with class V, respectively. Mixed classes responded in 76% of patients. RTX induced complete responses in 60% (type III), 45% (type IV), 40% (type V) and 24% (mixed types), respectively. CONCLUSIONS Our systematic review of existing evidence suggests that RTX effectively induces remission of LN in patients who have not achieved remission with standard therapies. Another randomized controlled trial should be conducted to test the efficacy of RTX in refractory LN.
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Affiliation(s)
- Marc Weidenbusch
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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Rovin BH, Furie R, Latinis K, Looney RJ, Fervenza FC, Sanchez-Guerrero J, Maciuca R, Zhang D, Garg JP, Brunetta P, Appel G. Efficacy and safety of rituximab in patients with active proliferative lupus nephritis: the Lupus Nephritis Assessment with Rituximab study. ACTA ACUST UNITED AC 2012; 64:1215-26. [PMID: 22231479 DOI: 10.1002/art.34359] [Citation(s) in RCA: 900] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of rituximab in a randomized, double-blind, placebo-controlled phase III trial in patients with lupus nephritis treated concomitantly with mycophenolate mofetil (MMF) and corticosteroids. METHODS Patients (n = 144) with class III or class IV lupus nephritis were randomized 1:1 to receive rituximab (1,000 mg) or placebo on days 1, 15, 168, and 182. The primary end point was renal response status at week 52. RESULTS Rituximab depleted peripheral CD19+ B cells in 71 of 72 patients. The overall (complete and partial) renal response rates were 45.8% among the 72 patients receiving placebo and 56.9% among the 72 patients receiving rituximab (P = 0.18); partial responses accounted for most of the difference. The primary end point (superior response rate with rituximab) was not achieved. Eight placebo-treated patients and no rituximab-treated patients required cyclophosphamide rescue therapy through week 52. Statistically significant improvements in serum complement C3, C4, and anti-double-stranded DNA (anti-dsDNA) levels were observed among patients treated with rituximab. In both treatment groups, a reduction in anti-dsDNA levels greater than the median reduction was associated with reduced proteinuria. The rates of serious adverse events, including infections, were similar in both groups. Neutropenia, leukopenia, and hypotension occurred more frequently in the rituximab group. CONCLUSION Although rituximab therapy led to more responders and greater reductions in anti-dsDNA and C3/C4 levels, it did not improve clinical outcomes after 1 year of treatment. The combination of rituximab with MMF and corticosteroids did not result in any new or unexpected safety signals.
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Hadjinicolaou AV, Nisar MK, Parfrey H, Chilvers ER, Ostor AJK. Non-infectious pulmonary toxicity of rituximab: a systematic review. Rheumatology (Oxford) 2011; 51:653-62. [DOI: 10.1093/rheumatology/ker290] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Conti F, Ceccarelli F, Perricone C, Alessandri C, Conti V, Massaro L, Truglia S, Spinelli FR, Spadaro A, Valesini G. Rituximab infusion-related adverse event rates are lower in patients with systemic lupus erythematosus than in those with rheumatoid arthritis. Rheumatology (Oxford) 2011; 50:1148-52. [PMID: 21278072 DOI: 10.1093/rheumatology/keq436] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Rituximab (RTX) is a therapeutic option for patients with SLE or RA. We conducted a prospective, longitudinal, observational study to compare rates of RTX-related adverse events (AEs) in these two patient groups. METHODS RTX was used in 23 patients with SLE that was refractory to conventional therapy and in 31 patients with RA that had been unsuccessfully treated with TNF-α inhibitors. Infusion-related and infectious AE rates were calculated for each group. RESULTS Seven (22.5%) RA patients experienced an infusion-related reaction. These AEs involved 7/91 (7.7%) infusions administered in the RA group. None of the 102 infusions administered to SLE patients was associated with infusion-related AEs (P = 0.038 vs RA group). The mean daily glucocorticoid dose administered during the week preceding RTX treatment in the SLE group was higher than that for the RA group [0.25 (0.2) vs 0.18 (0.14) mg/kg, P = not significant] and significantly higher than that received by the subgroup of the seven RA patients who experienced infusion-related AEs [0.10 (0.02) mg/kg; P = 0.0017]. Infectious AE rates were also lower (but not significantly so) in the SLE group (8.7 vs 12.9% in RA). CONCLUSIONS Repeated cycles of RTX in combination with different immunosuppressants is a safe therapeutic option for SLE and RA patients. The lower incidence of infusion-related AEs in the SLE patients might reflect the higher dosage glucocorticoid therapy they received during the week before RTX infusion.
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Affiliation(s)
- Fabrizio Conti
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Rome, Italy
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Toong C, Adelstein S, Phan TG. Clearing the complexity: immune complexes and their treatment in lupus nephritis. Int J Nephrol Renovasc Dis 2011; 4:17-28. [PMID: 21694945 PMCID: PMC3108794 DOI: 10.2147/ijnrd.s10233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Indexed: 12/25/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a classic antibody-mediated systemic autoimmune disease characterised by the development of autoantibodies to ubiquitous self-antigens (such as antinuclear antibodies and antidouble-stranded DNA antibodies) and widespread deposition of immune complexes in affected tissues. Deposition of immune complexes in the kidney results in glomerular damage and occurs in all forms of lupus nephritis. The development of nephritis carries a poor prognosis and high risk of developing end-stage renal failure despite recent therapeutic advances. Here we review the role of DNA-anti-DNA immune complexes in the pathogenesis of lupus nephritis and possible new treatment strategies aimed at their control.
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Affiliation(s)
- Catherine Toong
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
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[Use of rituximab in the treatment of lupus patients. The LESIMAB database]. ACTA ACUST UNITED AC 2010; 6 Suppl 2:28-33. [PMID: 21794762 DOI: 10.1016/j.reuma.2010.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Accepted: 06/01/2010] [Indexed: 12/27/2022]
Abstract
Systemic lupus erythematosus is an autoimmune disease that may involve the function of organs and reduce the survival of patients. Advances in the diagnosis and treatment have improved the short-term prognosis.However, most therapeutic improvements come from progress in other areas of medicine and only in recent years is this trend changing. Unfortunately, the development of new drugs for lupus is facing specific difficulties and the development of rituximab in lupus has been stopped despite good results in the observational studies. This review examines some of the aspects that influence these difficulties from the perspective of the LESIMAB database.
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Conti F, Perricone C, Ceccarelli F, Valesini G. Rituximab treatment of systemic lupus erythematosus in controlled trials and in clinical practice: Two sides of the same coin. Autoimmun Rev 2010; 9:716-20. [PMID: 20667484 DOI: 10.1016/j.autrev.2010.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 07/17/2010] [Indexed: 12/12/2022]
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