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Gheisari M, Safari Giv T, Pourgholi E, Zaresharifi S. Rituximab-induced serum sickness in immunobullous disorders: A case series. Clin Case Rep 2024; 12:e9152. [PMID: 38979086 PMCID: PMC11228350 DOI: 10.1002/ccr3.9152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/11/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024] Open
Abstract
Key Clinical Message Rituximab-induced serum sickness (RISS) is a rare complication of Rituximab (RTX) in immunobullous disorders. Clinicians should be aware of the occurrence of serum sickness symptoms during RTX administration, and prompt initiation of corticosteroid therapy is crucial in these patients. Additionally, RISS may occur with subsequent RTX doses and patients should be counseled accordingly. Abstract Rituximab (RTX) is a chimeric monoclonal anti-CD20 antibody which has gained approval for the treatment of various autoimmune and lymphoproliferative disorders. While RTX-induced minor reactions, including immediate infusion-related reactions, are common, serum sickness is rare. Limited data exist regarding rituximab-induced serum sickness (RISS) in pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP). We report two cases of RISS following RTX administration in PV and MMP patients. Both patients presented with typical symptoms of serum sickness after RTX infusion, necessitating drug cessation and corticosteroid therapy for resolution. RISS represents a rare complication of RTX therapy. Clinicians should maintain awareness of serum sickness presentations during and post-RTX administration.
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Affiliation(s)
- Mehdi Gheisari
- Skin Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Dermatology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Toktam Safari Giv
- Skin Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Dermatology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Elnaz Pourgholi
- Skin Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Dermatology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Shirin Zaresharifi
- Skin Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Dermatology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
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Mostkowska A, Rousseau G, Raynal NJM. Repurposing of rituximab biosimilars to treat B cell mediated autoimmune diseases. FASEB J 2024; 38:e23536. [PMID: 38470360 DOI: 10.1096/fj.202302259rr] [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: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
Rituximab, the first monoclonal antibody approved for the treatment of lymphoma, eventually became one of the most popular and versatile drugs ever in terms of clinical application and revenue. Since its patent expiration, and consequently, the loss of exclusivity of the original biologic, its repurposing as an off-label drug has increased dramatically, propelled by the development and commercialization of its many biosimilars. Currently, rituximab is prescribed worldwide to treat a vast range of autoimmune diseases mediated by B cells. Here, we present a comprehensive overview of rituximab repurposing in 115 autoimmune diseases across 17 medical specialties, sourced from over 1530 publications. Our work highlights the extent of its off-label use and clinical benefits, underlining the success of rituximab repurposing for both common and orphan immune-related diseases. We discuss the scientific mechanism associated with its clinical efficacy and provide additional indications for which rituximab could be investigated. Our study presents rituximab as a flagship example of drug repurposing owing to its central role in targeting cluster of differentiate 20 positive (CD20) B cells in 115 autoimmune diseases.
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Affiliation(s)
- Agata Mostkowska
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Guy Rousseau
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Noël J-M Raynal
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Centre de recherche du CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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3
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Vesperinas-Castro A, Cortés-Vicente E. Rituximab treatment in myasthenia gravis. Front Neurol 2023; 14:1275533. [PMID: 37849836 PMCID: PMC10577386 DOI: 10.3389/fneur.2023.1275533] [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: 08/10/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease mediated by antibodies against post-synaptic proteins of the neuromuscular junction. Up to 10%-30% of patients are refractory to conventional treatments. For these patients, rituximab has been used off-label in the recent decades. Rituximab is a monoclonal antibody against the CD20 protein that leads to B cell depletion and to the synthesis of new antibody-secreting plasma cells. Although rituximab was created to treat B-cell lymphoma, its use has widely increased to treat autoimmune diseases. In MG, the benefit of rituximab treatment in MuSK-positive patients seems clear, but a high variability in the results of observational studies and even clinical trials has been reported for AChR-positive patients. Moreover, few evidence has been reported in seronegative MG and juvenile MG and some questions about regimen of administration or monitoring strategies, remains open. In this review, we intend to revise the available literature on this topic and resume the current evidence of effectiveness of Rituximab in MG, with special attention to results on every MG subtype, as well as the administration protocols, monitoring strategies and safety profile of the drug.
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Affiliation(s)
- Ana Vesperinas-Castro
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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Bartolini C, Roberto G, Girardi A, Moscatelli V, Spini A, Barchielli A, Bocchia M, Fabbri A, Donnini S, Ziche M, Monti MC, Gini R. Validity of Italian administrative healthcare data in describing the real-world utilization of infusive antineoplastic drugs: the study case of rituximab use in patients treated at the University Hospital of Siena for onco-haematological indications. Front Oncol 2023; 13:1059109. [PMID: 37324023 PMCID: PMC10264685 DOI: 10.3389/fonc.2023.1059109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Italian administrative healthcare databases are frequently used for studies on real-world drug utilization. However, there is currently a lack of evidence on the accuracy of administrative data in describing the use of infusive antineoplastics. In this study, we used rituximab as a case study to investigate the validity of the regional administrative healthcare database of Tuscany (RAD) in describing the utilization of infusive antineoplastics. Methods We identified patients aged 18 years or older who had received ≥1 rituximab administration between 2011 and 2014 in the onco-haematology ward of the University Hospital of Siena. We retrieved this information from the Hospital Pharmacy Database (HPD-UHS) and linked the person-level information to RAD. Patients who had received ≥1dispensing of rituximab, single administration episodes, and patients treated for non-Hodgkin Lymphoma (nHL) or Chronic Lymphocytic Leukemia (CLL) were identified in RAD and validated using HPD-UHS as the reference standard. We identified the indications of use using algorithms based on diagnostic codes (ICD9CM codes, nHL=200*, 202*; CLL=204.1). We tested 22 algorithms of different complexity for each indication of use and calculated sensitivity and positive predictive value (PPV), with 95% confidence intervals (95%CI), as measures of validity. Results According to HPD-UHS, 307 patients received rituximab for nHL (N=174), CLL (N=21), or other unspecified indications (N=112) in the onco-haematology ward of the University Hospital of Siena. We identified 295 rituximab users in RAD (sensitivity=96.1%), but PPV could not be assessed due to missing information in RAD on dispensing hospital wards. We identified individual rituximab administration episodes with sensitivity=78.6% [95%CI: 76.4-80.6] and PPV=87.6% [95%CI: 86.1-89.2]. Sensitivity of algorithms tested for identifying nHL and CLL ranged from 87.7% to 91.9% for nHL and from 52.4% to 82.7% for CLL. PPV ranged from 64.7% to 66.1% for nHL and from 32.4% to 37.5% for CLL. Discussion Our findings suggest that RAD is a very sensitive source of information for identifying patients who received rituximab for onco-haematological indications. Single administration episodes were identified with good-to-high accuracy. Patients receiving rituximab for nHL were identified with high sensitivity and acceptable PPV, while the validity for CLL was suboptimal.
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Affiliation(s)
- Claudia Bartolini
- Pharmaecoepidemiology Unit, Agenzia Regionale di Sanità della Toscana, Firenze, Italy
| | - Giuseppe Roberto
- Pharmaecoepidemiology Unit, Agenzia Regionale di Sanità della Toscana, Firenze, Italy
| | - Anna Girardi
- Pharmaecoepidemiology Unit, Agenzia Regionale di Sanità della Toscana, Firenze, Italy
| | | | - Andrea Spini
- Department of Life Sciences, Università Degli Studi di Siena, Siena, Italy
| | - Alessandro Barchielli
- Tuscany Cancer Registry, Istituto per lo Studio e la Prevenzione Oncologica, Firenze, Italy
| | - Monica Bocchia
- Onco-hematology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Alberto Fabbri
- Onco-hematology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Sandra Donnini
- Department of Life Sciences, Università Degli Studi di Siena, Siena, Italy
| | - Marina Ziche
- Department of Life Sciences, Università Degli Studi di Siena, Siena, Italy
| | - Maria Cristina Monti
- Università di Pavia, Dipartimento di Sanità Pubblica, Medicina Sperimentale e Forense, Pavia, Italy
| | - Rosa Gini
- Pharmaecoepidemiology Unit, Agenzia Regionale di Sanità della Toscana, Firenze, Italy
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Fraga-Olvera A, Saavedra-Salinas MÁ, Beltrán-Mendoza JQ, Mendieta-Flores E. [Prevalence of persistent hypogammaglobulinemia in patients with autoimmune rheumatic disease who received treatment with Rituximab in a national medical center in Mexico]. REVISTA ALERGIA MÉXICO 2023; 69:171-182. [PMID: 37218045 DOI: 10.29262/ram.v69i4.1142] [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: 06/29/2022] [Accepted: 01/31/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE To describe the prevalence of persistent hypogammaglobulinemia in patients receiving Rituximab as a treatment for autoimmune rheumatological diseases. METHODS A transversal, retrospective and unicentric study, carried out in patients with autoimmune rheumatic diseases who were admitted to the Rheumatology service of the Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Mexico City, to receive treatment with rituximab between January 2013 and January 2018. Descriptive and inferential statistics of serum levels of immunoglobulins, clinical-demographic characteristics, diagnosis, and treatment received were performed. RESULTS from 262 patients with autoimmune rheumatological disease who received treatment with Rituximab; We identified 8 patients with persistent hypogammaglobulinemia (6 women and 2 men), this is a prevalence of 3.1%. No associated factors with the development of hypogammaglobulinemia were identified. CONCLUSIONS Until now, no associated prognostic or predictive factors have been identified with persistent hypogammaglobulinemia. Additional prospective studies are required to understand more precisely the implications of persistent hypogammaglobulinemia in patients with autoimmune diseases.
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Quartuccio L, Bortoluzzi A, Scirè CA, Marangoni A, Del Frate G, Treppo E, Castelnovo L, Saccardo F, Zani R, Candela M, Fraticelli P, Mazzaro C, Renoldi P, Scaini P, Filippini DA, Visentini M, Scarpato S, Giuggioli D, Mascia MT, Sebastiani M, Zignego AL, Lauletta G, Fiorilli M, Casato M, Ferri C, Pietrogrande M, Pioltelli PE, De Vita S, Monti G, Galli M. Management of mixed cryoglobulinemia with rituximab: evidence and consensus-based recommendations from the Italian Study Group of Cryoglobulinemia (GISC). Clin Rheumatol 2023; 42:359-370. [PMID: 36169798 PMCID: PMC9873783 DOI: 10.1007/s10067-022-06391-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/06/2022] [Accepted: 09/21/2022] [Indexed: 01/28/2023]
Abstract
Cryoglobulinemic vasculitis (CV) or mixed cryoglobulinemic syndrome (MCS) is a systemic small-vessel vasculitis characterized by the proliferation of B-cell clones producing pathogenic immune complexes, called cryoglobulins. It is often secondary to hepatitis C virus (HCV), autoimmune diseases, and hematological malignancies. CV usually has a mild benign clinical course, but severe organ damage and life-threatening manifestations can occur. Recently, evidence in favor of rituximab (RTX), an anti-CD 20 monoclonal antibody, is emerging in CV: nevertheless, questions upon the safety of this therapeutic approach, especially in HCV patients, are still being issued and universally accepted recommendations that can help physicians in MCS treatment are lacking. A Consensus Committee provided a prioritized list of research questions to perform a systematic literature review (SLR). A search was made in Medline, Embase, and Cochrane library, updated to August 2021. Of 1227 article abstracts evaluated, 27 studies were included in the SLR, of which one SLR, 4 RCTs, and 22 observational studies. Seventeen recommendations for the management of mixed cryoglobulinemia with rituximab from the Italian Study Group of Cryoglobulinemia (GISC) were developed to give a valuable tool to the physician approaching RTX treatment in CV.
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Affiliation(s)
- Luca Quartuccio
- Unit of Rheumatology, Department of Medicine (DAME), University of Udine, ASUFC, Udine, Italy.
| | - Alessandra Bortoluzzi
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera, Universitaria Di Ferrara, Cona, FE, Italy
| | | | - Antonio Marangoni
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera, Universitaria Di Ferrara, Cona, FE, Italy
| | - Giulia Del Frate
- Unit of Rheumatology, Department of Medicine (DAME), University of Udine, ASUFC, Udine, Italy
| | - Elena Treppo
- Unit of Rheumatology, Department of Medicine (DAME), University of Udine, ASUFC, Udine, Italy
| | - Laura Castelnovo
- Department of Internal Medicine, Hospital of Legnano, Legnano, Italy
| | | | | | | | - Paolo Fraticelli
- Ematologia Ed Immunologia Clinica, Clinica Medica Generale, University of Ancona, Ancona, Italy
| | - Cesare Mazzaro
- Clinical Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081, Aviano, Italy
| | - Piero Renoldi
- UOS Di Immunologia Clinica, Ospedale S. Carlo Borromeo, Milan, Italy
| | | | | | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Dilia Giuggioli
- Department of Internal Medicine, Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Teresa Mascia
- Department of Internal Medicine, Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Sebastiani
- Department of Internal Medicine, Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Massimo Fiorilli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Clodoveo Ferri
- Department of Internal Medicine, Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Pietrogrande
- Department of Medicine, Surgery and Dentistry, Medicina Interna, Policlinico San Marco of Zingonia, University of Milan, Milan, Italy
| | | | - Salvatore De Vita
- Unit of Rheumatology, Department of Medicine (DAME), University of Udine, ASUFC, Udine, Italy
| | - Giuseppe Monti
- Medicina Interna, Ospedale Di Saronno, AO Busto Arsizio, Italy
| | - Massimo Galli
- Infectious Disease Unit, L. Sacco, Department of Clinical Sciences, University of Milan, Milan, Italy
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7
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Ottaviano G, Sgrulletti M, Moschese V. Secondary rituximab-associated versus primary immunodeficiencies: The enigmatic border. Eur J Immunol 2022; 52:1572-1580. [PMID: 35892275 DOI: 10.1002/eji.202149667] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/22/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
Rituximab (RTX), a chimeric monoclonal antibody targeting CD20-positive cells, is a valuable treatment option for malignant and benign immune-related disorders. The rationale of targeting the CD20 antigen relies on depletion of both healthy and autoreactive/malignant CD20-espressing cells, but normal B-cell reconstitution is expected within months after treatment. Nevertheless, a number of recent studies have documented prolonged B-cell deficiency associated with new-onset hypogammaglobulinemia in patients receiving RTX. Awareness of post-RTX hypogammaglobulinemia has become wider among clinicians, with a growing number of reports about the increased incidence, especially in children. Although these patients were previously regarded as affected by secondary/iatrogenic immunodeficiency, atypical clinical and immunological manifestations (e.g., severe or opportunistic infections; prolonged B-cell aplasia) raise concerns of delayed manifestations of genetic immunological disorders that have been unveiled by B-cell perturbation. As more patients with undiagnosed primary immune deficiency receiving RTX have been identified, it remains the challenge in discerning those that might display a higher risk of persistent RTX-associated hypogammaglobulinemia and need a tailored immunology follow-up. In this review, we summarize the principal evidence regarding post-RTX hypogammaglobulinemia and provide a guideline for identifying patients at higher risk of RTX-associated hypogammaglobulinemia that could harbor an inborn error of immunity.
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Affiliation(s)
- Giorgio Ottaviano
- Molecular and Cellular Immunology Unit, UCL Institute of Child Health, London, UK
| | - Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy.,PhD. Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
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8
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van Vugt LK, Schagen MR, de Weerd A, Reinders ME, de Winter BC, Hesselink DA. Investigational drugs for the treatment of kidney transplant rejection. Expert Opin Investig Drugs 2022; 31:1087-1100. [PMID: 36175360 DOI: 10.1080/13543784.2022.2130751] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Kidney transplant rejection remains an important clinical problem despite the development of effective immunosuppressive drug combination therapy. Two major types of rejection are recognized, namely T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), which have a different pathophysiology and are treated differently. Unfortunately, long-term outcomes of both TCMR and ABMR remain unsatisfactory despite current therapy. Hence, alternative therapeutic drugs are urgently needed. AREAS COVERED This review covers novel and investigational drugs for the pharmacological treatment of kidney transplant rejection. Potential therapeutic strategies and future directions are discussed. EXPERT OPINION The development of alternative pharmacologic treatment of rejection has focused mostly on ABMR, since this is the leading cause of kidney allograft loss and currently lacks an effective, evidence-based therapy. At present, there is insufficient high-quality evidence for any of the covered investigational drugs to support their use in ABMR. However, with the emergence of targeted therapies, this potential arises for individualized treatment strategies. In order to generate more high-quality evidence for such strategies and overcome the obstacles of classic, randomized, controlled trials, we advocate the implementation of adaptive trial designs and surrogate clinical endpoints. We believe such adaptive trial designs could help to understand the risks and benefits of promising drugs such as tocilizumab, clazakizumab, belimumab, and imlifidase.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maaike R Schagen
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annelies de Weerd
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies Ej Reinders
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda Cm de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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9
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Cunningham ET, Ng C, Suhler EB, Smit DP. Rituximab for Ocular Inflammatory Disease. Ocul Immunol Inflamm 2022; 30:1300-1302. [PMID: 36379016 DOI: 10.1080/09273948.2022.2141034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emmett T Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
- The Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
| | - Caleb Ng
- Retina Consultants of Orange County, Fullerton, CA, USA
| | - Eric B Suhler
- OHSU-PSU School of Public Health, and VA Portland Health Care System, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Derrick P Smit
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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10
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Manti S, Giallongo A, Papale M, Parisi GF, Leonardi S. Monoclonal Antibodies in Treating Chronic Spontaneous Urticaria: New Drugs for an Old Disease. J Clin Med 2022; 11:jcm11154453. [PMID: 35956071 PMCID: PMC9369449 DOI: 10.3390/jcm11154453] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Background: H1-antihistamines (H1AH) represent the current mainstay of treatment for chronic spontaneous urticaria (CSU). However, the response to H1AH is often unsatisfactory, even with increased doses. Therefore, guidelines recommend the use of omalizumab as an add-on treatment in refractory CSU. This paved the way for the investigation of targeted therapies, such as monoclonal antibodies (mAbs), in CSU. Methods: A literature review was conducted including papers published between 2009 and 2022 and ongoing trials about the efficacy and safety of mAbs as treatment for CSU. Results: Twenty-nine articles, a trial with preliminary results, and seventeen ongoing or completed clinical trials on the use of mAbs in CSU were included. Randomized controlled trials (RCTs), meta-analysis, and real-life studies have proven the effectiveness and safety of omalizumab as a third-line treatment in refractory CSU. However, a percentage of patients remain unresponsive to omalizumab. Therefore, other mAbs, targeting different pathways, have been used off-label in case series and others are under investigation in RCTs. Most of them have showed promising results. Conclusions: Omalizumab remains the best choice to treat refractory CSU. Although results from other mAbs seem to be encouraging to achieve symptom control in refractory CSU, thus improving patients’ QoL, RCTs are needed to confirm their effectiveness and safety.
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Affiliation(s)
- Sara Manti
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (M.P.); (G.F.P.); (S.L.)
- Pediatric Unit, Department of Human and Pediatric Pathology “Gaetano Barresi”, AOUP G. Martino, University of Messina, Via Consolare Valeria, 1, 98124 Messina, Italy
- Correspondence:
| | | | - Maria Papale
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (M.P.); (G.F.P.); (S.L.)
| | - Giuseppe Fabio Parisi
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (M.P.); (G.F.P.); (S.L.)
| | - Salvatore Leonardi
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (M.P.); (G.F.P.); (S.L.)
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11
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Griffin JM, Healy FM, Dahal LN, Floisand Y, Woolley JF. Worked to the bone: antibody-based conditioning as the future of transplant biology. J Hematol Oncol 2022; 15:65. [PMID: 35590415 PMCID: PMC9118867 DOI: 10.1186/s13045-022-01284-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Conditioning of the bone marrow prior to haematopoietic stem cell transplant is essential in eradicating the primary cause of disease, facilitating donor cell engraftment and avoiding transplant rejection via immunosuppression. Standard conditioning regimens, typically comprising chemotherapy and/or radiotherapy, have proven successful in bone marrow clearance but are also associated with severe toxicities and high incidence of treatment-related mortality. Antibody-based conditioning is a developing field which, thus far, has largely shown an improved toxicity profile in experimental models and improved transplant outcomes, compared to traditional conditioning. Most antibody-based conditioning therapies involve monoclonal/naked antibodies, such as alemtuzumab for graft-versus-host disease prophylaxis and rituximab for Epstein–Barr virus prophylaxis, which are both in Phase II trials for inclusion in conditioning regimens. Nevertheless, alternative immune-based therapies, including antibody–drug conjugates, radio-labelled antibodies and CAR-T cells, are showing promise in a conditioning setting. Here, we analyse the current status of antibody-based drugs in pre-transplant conditioning regimens and assess their potential in the future of transplant biology.
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Affiliation(s)
- James M Griffin
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Fiona M Healy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lekh N Dahal
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Yngvar Floisand
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.,The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - John F Woolley
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
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Krämer J, Wiendl H. What Have Failed, Interrupted, and Withdrawn Antibody Therapies in Multiple Sclerosis Taught Us? Neurotherapeutics 2022; 19:785-807. [PMID: 35794296 PMCID: PMC9294122 DOI: 10.1007/s13311-022-01246-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/13/2022] Open
Abstract
In the past two decades, monoclonal antibodies (mAbs) have revolutionized the treatment of multiple sclerosis (MS). However, a remarkable number of mAbs failed due to negative study results were withdrawn because of unexpected serious adverse events (SAEs) or due to studies being halted for other reasons. While trials with positive outcomes are usually published in prestigious journals, negative trials are merely published as abstracts or not at all. This review summarizes MS mAbs that have either failed in phase II-III trials, have been interrupted for various reasons, or withdrawn from the market since 2015. The main conclusions that can be drawn from these 'negative' experiences are as follows. mAbs that have been proven to be safe in other autoimmune conditions, will not have the same safety profile in MS due to immunopathogenetic differences in these diseases (e.g., daclizumab). Identification of SAEs in clinical trials is difficult highlighting the importance of phase IV studies. Memory B cells are central players in MS immunopathogenesis (e.g., tabalumab). The pathophysiological mechanisms of disease progression are independent of leukocyte 'outside-in' traffic which drives relapses in MS. Therefore, therapies for progressive MS must be able to sufficiently cross the blood-brain barrier. Sufficiently long trial duration and multicomponent outcome measures are important for clinical studies in progressive MS. The success of trials on remyelination-promoting therapies mainly depends on the sufficient high dose of mAb, the optimal readout for 'proof of concept', time of treatment initiation, and appropriate selection of patients. Failed strategies are highly important to better understand assumed immunopathophysiological mechanisms and optimizing future trial designs.
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Affiliation(s)
- Julia Krämer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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13
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Ciolfi C, Sernicola A, Alaibac M. Role of Rituximab in the Treatment of Pemphigus Vulgaris: Patient Selection and Acceptability. Patient Prefer Adherence 2022; 16:3035-3043. [PMID: 36387051 PMCID: PMC9651071 DOI: 10.2147/ppa.s350756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022] Open
Abstract
Anti-CD20 monoclonal antibody rituximab is an approved adjuvant treatment, in combination with oral corticosteroids, for patients with pemphigus vulgaris, a severe and potentially life-threatening autoimmune blistering skin disorder. Updated approaches to the management of pemphigus vulgaris support rituximab as a first-line adjuvant treatment to induce remission early in the course of disease; however, its feasibility in the clinical setting is often reduced by a series of limitations, including high cost of this biological drug, physician and patient concern for the risk of adverse reactions, and uncertainty regarding the optimum dosing and schedule of administration. The standard approved rituximab dosages, which are derived from lymphoma protocols, have been recognized to exceed the effective dose required for inducing B cell depletion, since the B cell burden in pemphigus vulgaris is much lower than in lymphoproliferative disorders. To overcome these limitations, recent research has investigated alternative regimens of rituximab, using lower doses of the drug. Moreover, differences in patient and disease characteristics that are highlighted in the literature strongly suggest that therapy should be tailored individually on a case-by-case basis: personalized treatment schedules may be necessary to optimize response to treatment and tolerability in different subjects, with the possibility of repeated infusions for severe forms and in case of relapse. Finally, low-dose regimens of rituximab were suggested to be favorable during the COVID-19 pandemic by providing a lesser degree of immune cell depletion while retaining a sufficient response. In conclusion, the current literature suggests that lower-dose regimens of rituximab are not only tolerable and cost-effective but may also be associated with a positive response in pemphigus vulgaris, comparable to that achieved with higher doses especially in early disease. Further evidence from rigorous clinical trials will be required to optimize lower-dose regimens of RTX and establish their position within the treatment scenario of pemphigus vulgaris.
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Affiliation(s)
- Christian Ciolfi
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Alvise Sernicola
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Correspondence: Alvise Sernicola, Dermatology Unit, Department of Medicine (DIMED), University of Padua, Via Vincenzo Gallucci, 4, Padua, 35121, Italy, Tel/Fax +39 049 821 2924, Email
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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14
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Abstract
BACKGROUND Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off-label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high-income countries where on-label disease-modifying treatments (DMTs) are available. OBJECTIVES: To assess beneficial and adverse effects of rituximab as 'first choice' and as 'switching' for adults with MS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registers for completed and ongoing studies on 31 January 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled non-randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We used the Cochrane Collaboration's tool for assessing risk of bias. We rated the certainty of evidence using GRADE for: disability worsening, relapse, serious adverse events (SAEs), health-related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching', relapsing or progressive MS, comparison versus placebo or another DMT, and RCTs or NRSIs. MAIN RESULTS We included 15 studies (5 RCTs, 10 NRSIs) with 16,429 participants of whom 13,143 were relapsing MS and 3286 progressive MS. The studies were one to two years long and compared rituximab as 'first choice' with placebo (1 RCT) or other DMTs (1 NRSI), rituximab as 'switching' against placebo (2 RCTs) or other DMTs (2 RCTs, 9 NRSIs). The studies were conducted worldwide; most originated from high-income countries, six from the Swedish MS register. Pharmaceutical companies funded two studies. We identified 14 ongoing studies. Rituximab as 'first choice' for relapsing MS Rituximab versus placebo: no studies met eligibility criteria for this comparison. Rituximab versus other DMTs: one NRSI compared rituximab with interferon beta or glatiramer acetate, dimethyl fumarate, natalizumab, or fingolimod in active relapsing MS at 24 months' follow-up. Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (hazard ratio (HR) 0.14, 95% confidence interval (CI) 0.05 to 0.39; 335 participants; moderate-certainty evidence). Rituximab may reduce relapses compared with dimethyl fumarate (HR 0.29, 95% CI 0.08 to 1.00; 206 participants; low-certainty evidence) and natalizumab (HR 0.24, 95% CI 0.06 to 1.00; 170 participants; low-certainty evidence). It may make little or no difference on relapse compared with fingolimod (HR 0.26, 95% CI 0.04 to 1.69; 137 participants; very low-certainty evidence). The study reported no deaths over 24 months. The study did not measure disability worsening, SAEs, HRQoL, and common infections. Rituximab as 'first choice' for progressive MS One RCT compared rituximab with placebo in primary progressive MS at 24 months' follow-up. Rituximab likely results in little to no difference in the number of participants who have disability worsening compared with placebo (odds ratio (OR) 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate-certainty evidence). Rituximab may result in little to no difference in recurrence of relapses (OR 0.60, 95% CI 0.18 to 1.99; 439 participants; low-certainty evidence), SAEs (OR 1.25, 95% CI 0.71 to 2.20; 439 participants; low-certainty evidence), common infections (OR 1.14, 95% CI 0.75 to 1.73; 439 participants; low-certainty evidence), cancer (OR 0.50, 95% CI 0.07 to 3.59; 439 participants; low-certainty evidence), and mortality (OR 0.25, 95% CI 0.02 to 2.77; 439 participants; low-certainty evidence). The study did not measure HRQoL. Rituximab versus other DMTs: no studies met eligibility criteria for this comparison. Rituximab as 'switching' for relapsing MS One RCT compared rituximab with placebo in relapsing MS at 12 months' follow-up. Rituximab may decrease recurrence of relapses compared with placebo (OR 0.38, 95% CI 0.16 to 0.93; 104 participants; low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to placebo on SAEs (OR 0.90, 95% CI 0.28 to 2.92; 104 participants; very low-certainty evidence), common infections (OR 0.91, 95% CI 0.37 to 2.24; 104 participants; very low-certainty evidence), cancer (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence), and mortality (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence). The study did not measure disability worsening and HRQoL. Five NRSIs compared rituximab with other DMTs in relapsing MS at 24 months' follow-up. The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to interferon beta or glatiramer acetate on disability worsening (HR 0.86, 95% CI 0.52 to 1.42; 1 NRSI, 853 participants; very low-certainty evidence). Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 NRSI, 1383 participants; moderate-certainty evidence); and fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 NRSI, 256 participants; moderate-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to natalizumab on relapses (HR 1.0, 95% CI 0.2 to 5.0; 1 NRSI, 153 participants; very low-certainty evidence). Rituximab likely increases slightly common infections compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 NRSI, 5477 participants; moderate-certainty evidence); and compared with natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 NRSIs, 5001 participants; moderate-certainty evidence). Rituximab may increase slightly common infections compared with fingolimod (OR 1.26, 95% CI 0.90 to 1.77; 3 NRSIs, 5187 participants; low-certainty evidence). It may make little or no difference compared with ocrelizumab (OR 0.02, 95% CI 0.00 to 0.40; 1 NRSI, 472 participants; very low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab on mortality compared with fingolimod (OR 5.59, 95% CI 0.22 to 139.89; 1 NRSI, 136 participants; very low-certainty evidence) and natalizumab (OR 6.66, 95% CI 0.27 to 166.58; 1 NRSI, 153 participants; very low-certainty evidence). The included studies did not measure SAEs, HRQoL, and cancer. AUTHORS' CONCLUSIONS For preventing relapses in relapsing MS, rituximab as 'first choice' and as 'switching' may compare favourably with a wide range of approved DMTs. A protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab for progressive MS. The evidence is uncertain about the effect of rituximab on SAEs. They are relatively rare in people with MS, thus difficult to study, and they were not well reported in studies. There is an increased risk of common infections with rituximab, but absolute risk is small. Rituximab is widely used as off-label treatment in people with MS; however, randomised evidence is weak. In the absence of randomised evidence, remaining uncertainties on beneficial and adverse effects of rituximab for MS might be clarified by making real-world data available.
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Affiliation(s)
- Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Jera Kruja
- Neurology, UHC Mother Theresa, University of Medicine, Tirana, Albania
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
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Klarquist J, Cross EW, Thompson SB, Willett B, Aldridge DL, Caffrey-Carr AK, Xu Z, Hunter CA, Getahun A, Kedl RM. B cells promote CD8 T cell primary and memory responses to subunit vaccines. Cell Rep 2021; 36:109591. [PMID: 34433030 PMCID: PMC8456706 DOI: 10.1016/j.celrep.2021.109591] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/22/2021] [Accepted: 08/02/2021] [Indexed: 01/14/2023] Open
Abstract
The relationship between B cells and CD4 T cells has been carefully studied, revealing a collaborative effort in which B cells promote the activation, differentiation, and expansion of CD4 T cells while the so-called “helper” cells provide signals to B cells, influencing their class switching and fate. Interactions between B cells and CD8 T cells are not as well studied, although CD8 T cells exhibit an accelerated contraction after certain infections in B-cell-deficient mice. Here, we find that B cells significantly enhance primary CD8 T cell responses after vaccination. Moreover, memory CD8 numbers and function are impaired in B-cell-deficient animals, leading to increased susceptibility to bacterial challenge. We also show that interleukin-27 production by B cells contributes to their impact on primary, but not memory, CD8 responses. Better understanding of the interactions between CD8 T cells and B cells may aid in the design of more effective future vaccine strategies. Generating cytotoxic CD8 T cell responses with vaccines can greatly improve their efficacy, but inducing adequate numbers of these cells can be challenging. Klarquist et al. reveal that the magnitude, persistence, and function of CD8 T cell vaccine responses depend on B cells.
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Affiliation(s)
- Jared Klarquist
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Eric W Cross
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Scott B Thompson
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Benjamin Willett
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Daniel L Aldridge
- University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA 19104, USA
| | - Alayna K Caffrey-Carr
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Zhenming Xu
- Department of Microbiology, Immunology and Molecular Genetics, The Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Christopher A Hunter
- University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA 19104, USA
| | - Andrew Getahun
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Ross M Kedl
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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