Rituximab y penfigo

Journal Scan / Research · July 22, 2020

Long-Term Outcomes of Rituximab Therapy in Pemphigus

Journal of the European Academy of Dermatology and Venereology: JEADV

TAKE-HOME MESSAGE

• In this retrospective chart review, 59 pemphigus patients, 43 of whom achieved complete remission after their first rituximab infusion, were followed over 36 months after initial administration. Of the 43 with complete remission after first infusion, 27 (63%) relapsed after a median of 25 months. Of these 27 patients, 24 received a second infusion of rituximab and 22/24 (92%) achieved a second complete remission. Among the 22 patients who achieved second complete remission, 9 relapsed again, 7/9 received a third rituximab infusion, and all 7 again achieved complete remission. Overall, in 35 relapses after a complete remission, 33 retreatments (94%) resulted in complete remission. The median length of time to relapse was the same with subsequent infusions as the with the first. Baseline desmoglein autoantibody titers ≤250 U/mL were significantly associated with complete remission after the first rituximab cycle (P = .0006).

• Rituximab, an anti-CD20 antibody which depletes B cells, has been used for pemphigus with good effect. This study demonstrates that, even when patients relapse, complete remission can be subsequently achieved. Furthermore, desmoglein autoantibody titers could be used to select patients most likely to achieve a complete remission with rituximab.

– Margaret Hammond, MD

Written by

 

 

Anthony P. FernandezMD, PhD

The introduction of rituximab has significantly improved our ability to treat patients with pemphigus subtypes, and most dermatologists who commonly treat patients with pemphigus strongly believe rituximab should be used as first-line therapy. Most literature, however, does not address long-term response of pemphigus to rituximab therapy. Here, Shimanovich et al retrospectively assessed outcomes of 59 patients with pemphigus followed for a median 104 months after receiving at least one rituximab course.

This study reveals several important findings pertinent to clinical practice. First, rituximab treatment leads to a positive response in most patients, with a significant percentage achieving complete remission (CR). Second, in patients who relapse after achieving CR, repeat rituximab courses again lead to CR in the majority. Third, even patients who achieve only a partial response (PR) may attain CR after repeat rituximab courses. Fourth, patients who do not initially respond to rituximab most commonly will not respond to additional rituximab courses.

Although limited by its retrospective nature and lack of a control arm, this study's take-home message is likely one that many dermatologists who commonly treat patients with pemphigus adhere to in their practices already—retreatment with rituximab appears to be the treatment of choice for pemphigus relapses occurring after rituximab therapy in patients who initially achieve either PR or CR. Further research is needed to determine the rituximab treatment protocol over time that leads to optimal long-term responses in patients with pemphigus subtypes.

Abstract

BACKGROUND

Rituximab induces a rapid remission in most patients with pemphigus.

OBJECTIVE

Our aim was to assess the long-term efficacy of rituximab in this disease.

METHOD

We conducted a retrospective study of 59 patients with pemphigus treated with rituximab and observed over a median period of 104 months.

RESULTS

The rate of complete remission off therapy (CRoff) after the first rituximab cycle was 39%, increasing to 61% with additional rituximab courses. Long-term CRoff was achieved in 27% of patients. The recurrence rate after the first rituximab cycle was 63%, decreasing to approximately 40% with subsequent rituximab cycles. Median time to relapse after the first and subsequent rituximab cycles was 25 months. Renewed rituximab therapy reinduced complete remission in 94% of cases. Baseline anti-desmoglein antibody levels of ≤250 U/mL were significantly associated with the outcome of CRoff. In paired serum samples obtained before the first and six months after the last rituximab therapy, significant reductions of desmoglein-specific autoantibodies were observed. Patients relapsing after a complete remission induced by the first rituximab cycle were more likely to achieve CRoff than patients relapsing after a less favourable outcome and non-responders. There was no significant difference in age, sex, pemphigus subtype, rituximab dosing and disease duration between patients achieving CRoff and those not meeting this end point.

CONCLUSIONS

Lower desmoglein-specific antibody levels at baseline were predictive of CRoff. In patients receiving multiple rituximab cycles, complete remission after the first cycle was associated with a favourable long-term outcome. Repeated rituximab courses were highly effective for relapsed disease and improved the overall outcome.

Journal of the European Academy of Dermatology and Venereology: JEADV

Long-Term Outcomes of Rituximab Therapy in Pemphigus

J Eur Acad Dermatol Venereol 2020 May 04;[EPub Ahead of Print], I Shimanovich, T Baumann, E Schmidt, D Zillikens, CM Hammers 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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