Variability in clinical and biological response to rituximab in autoimmune diseases: an opportunity for personalized therapy?

Cardiomyopathy following COVID-19 vaccination in a patient with systemic lupus erythematosus

There are an increasing number of reports of myocarditis associated with mRNA-based COVID-19 vaccination. We describe the case of a female patient with underlying systemic lupus erythematosus, who developed heart failure symptoms following a second dose of the BNT162b2 vaccine. Despite her history of refractory systemic lupus erythematosus, the disease remained stable after she began rituximab treatment. She underwent serial transthoracic echocardiogram and cardiac magnetic resonance imaging for the evaluation of cardiomyopathy. She showed improvement in cardiac function after treatment with glucocorticoids and intravenous immunoglobulin therapy.

Low-dose rituximab protocol in rheumatoid arthritis-outcome and economic impact

OBJECTIVES

A significant proportion of RA patients, particularly those associated with poor prognostic factors, fail on conventional DMARDs (cDMARDs). Although rituximab (RTX) has been effective in these patients, the cost of therapy makes it unaffordable, particularly in poor and developing countries. Numerous, albeit small, studies using lower doses have shown contradictory results. We aimed to analyse the effectiveness of a low-dose RTX protocol based on clinical outcomes in RA patients.

METHODS

Seropositive RA patients with moderate to high disease activity (DAS28-ESR > 3.2) despite combination cDMARDs, treated with RTX, were included in retrospective analysis. All patients were treated according to a predefined protocol, using 500 mg RTX with ongoing cDMARDs at baseline and repeat dosing at 6 weeks or beyond, on lack of moderate to good EULAR response. The B cell count was assessed at baseline, 2 and 24 weeks.

RESULTS

At 12 weeks, 93% of 166 patients [mean (s.d.) age, 51.5 (11.96) years, 25 men and 141 women, with a disease duration of 10.4 (6.29) years] achieved moderate to good EULAR response. At 24 weeks, 90.8% of patients achieved moderate to good EULAR response, 19.8% achieved low disease activity and 29.5% achieved remission, with a mean change in DAS28-ESR from baseline of 2.9 (1.3). RTX failure and relapse were seen in 5.4% and 3.6%, respectively. The response was maintained for 12.3 (7.2) months with a mean RTX dose 521.1 (100.8) mg. Adverse events were seen in 9.6%. When compared with the standard dosing regimen with the originator molecule, a cost reduction of 90% was achieved.

CONCLUSION

A low-dose RTX regimen achieved reasonably good clinical outcomes at the end of 6 months, with a significantly lower cost.

THE EFFICACY AND SAFETY OF RITUXIMAB BIOSIMILAR (ACELLBIA®) IN RHEUMATOID ARTHRITIS AS THE FIRST BIOLOGICAL AGENT: RESULTS OF PHASE III (ALTERRA) CLINICAL TRIAL

The Russian biotechnological company «BIOCAD» has designed a chimeric monoclonal antibody against CD20 (BCD-020, Acellbia®) that is a biosimilar of rituximab (RTM; MabThera®, F. Hoffmann-La Roche Ltd., Switzerland). In recent years, there has been evidence that RTM can be used at lower doses than those given in the standard recommendations and instructions for the use of this drug. This serves as the basis for the BCD-020-4/ALTERRA (ALTErnative Rituximab regimen in Rheumatoid Arthritis) trial, the objective of which was to investigate the efficiency and safety of using Acellbia® (at a dose of 600 mg twice at a 2-week interval) as the first biological agent (BA) for methotrexate (MTX)-resistant active rheumatoid arthritis (RA). The investigation enrolled 159 patients aged 18 to 80 years with active RA. After 24 weeks 65.7 and 29.4% of patients achieved 20% improvement by the American College of Rheumatology (ACR) criteria in the Acellbia® + MTX and placebo (PL) + MTX groups, respectively (p<0.0001). The differences in the ACR20 response rate in the two groups were 36.3% (95% CI, 19.27–53.28%). There were significant differences between the groups in the ACR50 response rates: 28.4% and 5.9% (p=0.001) and in the ACR70 ones: 12.8% and only 2.0%, respectively (p=0.036). Analysis of all recorded adverse events (AE) frequency showed no significant differences between the patients in the study and control groups and demonstrates its equivalence with that of RTM (MabThera®); all the AE were expectable. It is noted that antibodies to RTM with binding and neutralizing activities had no impact on the efficiency and safety of therapy.

Effect of Rituximab on Serum Levels of Anti-C1q and Antineutrophil Cytoplasmic Autoantibodies in Refractory Severe Lupus Nephritis

The objective of this study was to analyze and compare the effects of rituximab (RTX) and cyclophosphamide (CTX) on the serum levels of anti-C1q antibodies and antineutrophil cytoplasmic autoantibodies (ANCA) in assessing the prognosis of severe and refractory lupus nephritis (LN). Eighty-four cases of severe and refractory LN were randomly divided into two groups of 42 cases each: CTX group and RTX group (CTX+RTX) during February 2010 to February 2014 in our hospital. Changes in serum levels of anti-C1q antibodies and ANCA in the two groups were examined, and efficacies of the drugs were compared. The total efficacy of RTX group was found to be 83.3 %, which was significantly higher than that of the CTX group, 57.1 % (p < 0.05). The serum anti-C1q antibodies and ANCA were decreased to 11.9 and 26.2 % in the RTX-treated group, which was significantly lower than those observed in the CTX-treated patients (21.4 and 69.0 % respectively) (p < 0.05). The clinical indices of LN were significantly improved in the two groups after the treatment. However, the urinary protein, albumin, complement C3, the percentage of CD19(+)B cells, and SLEDAI scores in the RTX group were significantly lower than those in the CTX group (p < 0.05). RTX plus with CTX showed a better therapeutic efficacy compared to CTX, and it significantly improved the prognosis of refractory and severe LN. The improvement in disease prognosis was directly related to the reduced serum levels of anti-C1q and ANCA measured during the course of treatment suggesting that they can serve to be valuable biomarkers of LN prognosis. Moreover, the measurement can assist in the judgment of RTX efficacy guiding the adjustment of the drug dose to improve the quality of life.

Improving B-cell depletion in systemic lupus erythematosus and rheumatoid arthritis

INTRODUCTION

Rituximab-based B-cell depletion (BCD) therapy is effective in refractory rheumatoid arthritis (RA) and although used to treat patients with refractory systemic lupus erythematosus (SLE) in routine clinical practice, rituximab failed to meet the primary endpoints in two large randomised controlled trials (RCTs) of non-renal (EXPLORER) and renal (LUNAR) SLE. Areas covered: We review how BCD could be improved to achieve better clinical responses in RA and SLE. Insights into the variability in clinical response to BCD in RA and SLE may help develop new therapeutic strategies. To this end, a literature search was performed using the following terms: rheumatoid arthritis, systemic erythematosus lupus, rituximab and B-cell depletion. Expert commentary: Poor trial design may have, at least partly, contributed to the apparent lack of response to BCD in the two RCTs of patients with SLE. Enhanced B-cell depletion and/or sequential therapy with belimumab may improve clinical response at least in some patients with SLE.