Factores asociados con remisión del penfigo...

Published in Dermatology

Journal Scan / Research · November 05, 2019

Factors Associated With Complete Remission After Rituximab Therapy for Pemphigus

JAMA Dermatology

TAKE-HOME MESSAGE

• This retrospective study included 112 patients with either pemphigus vulgaris (n=96) or pemphigus foliaceous (n=16) treated with rituximab therapy. These patients received rituximab dosing using either a lymphoma regimen (375 mg/m2 weekly for 4 weeks) or rheumatoid arthritis regimen (1000-mg doses 2 weeks apart). Overall, 93 patients (83.0%) achieved complete remission on no or minimal systemic therapy, and, of these, 69 (61.6%) achieved complete remission after one cycle of rituximab and 18 (16.1%) after two cycles; 6 patients required three or more cycles.

• Patients who received the lymphoma regimen of rituximab were 2.70 times more likely to achieve complete remission than those who were dosed with the rheumatoid arthritis regimen. Older age, especially 65 years or older, and lower BMI were also associated with better response to rituximab therapy. Serious adverse infectious events occurred in 5 patients (4.5%).

– Caitlyn Reed, M

Abstract

IMPORTANCE  

Rituximab has emerged as a front-line therapy for pemphigus, but prognostic factors for achieving complete remission off therapy (CROT) with oral systemic agents remain unknown.

OBJECTIVES  

To describe rates of CROT and relapse and identify prognostic factors for achieving CROT after rituximab therapy for pemphigus.

DESIGN, SETTING, AND PARTICIPANTS  

A single-center, retrospective, cohort study was conducted at the University of Pennsylvania including 112 patients with pemphigus treated with rituximab with at least 12 months' clinical follow-up after the start of rituximab therapy. Multivariate regression analysis of factors predictive of CROT and Kaplan-Meier analysis of disease relapse were conducted. The study included patients treated with rituximab from March 15, 2005, until December 19, 2016. Data analysis was performed from December 2017 to June 2018.

MAIN OUTCOMES AND MEASURES  

The primary study outcome was CROT after 1 cycle. Secondary study outcomes included rate of CROT or the composite end point of CROT or complete remission on minimal therapy after 1 or more cycle, and median time to relapse. Multivariate regression analysis for prognostic variables for CROT, including age, sex, pemphigus subtype, body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), disease duration, and dosing regimen, was performed.

RESULTS

 A total of 112 patients with pemphigus with median 37.8 months (range, 12.1-130.7) follow-up after rituximab therapy were identified. Of these, 65 were women (58.0%). At the time of first rituximab infusion, median age was 52.3 years (range, 20.0-89.3). Including patients who received multiple cycles of rituximab, 79 patients (70.5%) achieved CROT after a median time of 10.5 months (range, 2.0-49.8), and 36 of 72 patients (50.0%) subsequently experienced relapse after a median of 23.3 months (interquartile range, 10.8-50.4 months). Considering only the first cycle of rituximab, 54 patients (48.2%) achieved CROT. Controlling for age, sex, pemphigus subtype, BMI, and disease duration, patients who received lymphoma vs rheumatoid arthritis dosing were 2.70-fold more likely to achieve CROT (odds ratio [OR], 2.70; 95% CI, 1.03-7.12; P = .04). Increasing age was associated with significant increases in achieving CROT (Wald test for trend, P = .01), whereas BMI greater than or equal to 35 was associated with a 0.14 OR (95% CI, 0.03-0.63; P = .01) for achieving CROT, regardless of the dosing regimen. In multivariate analysis, there was no significant difference in CROT rates with sex (OR, 1.01; 95% CI, 0.42-2.50; P = .97), pemphigus subtype (OR, 0.37; 95% CI, 0.09-1.51; P = .17), or disease duration (OR, 0.99; 95% CI, 0.98-1.00; P = .09).

CONCLUSIONS AND RELEVANCE  

Lymphoma dosing and older age may be associated with CROT and BMI greater than or equal to 35 may be a negative prognostic factor for CROT after rituximab therapy for pemphigus. These findings help inform clinical expectations and merit evaluation in future prospective clinical trials.

Copyright © 2019 Elsevier Inc. All rights reserved.

Additional Info

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• Article Citation

JAMA Dermatology

Factors Associated With Complete Remission After Rituximab Therapy for Pemphigus

JAMA Dermatol 2019 Oct 23;[EPub Ahead of Print], CJ Kushner, S Wang, N Tovanabutra, DE Tsai, VP Werth, AS Payne