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Merolle M, Striepen B, Hunter CA. Parasite and host immune factors that impact the development of a mucosal vaccine for Cryptosporidium. Mucosal Immunol 2025:S1933-0219(25)00049-2. [PMID: 40379259 DOI: 10.1016/j.mucimm.2025.05.002] [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: 12/23/2024] [Revised: 03/28/2025] [Accepted: 05/07/2025] [Indexed: 05/19/2025]
Abstract
The parasite Cryptosporidium is a leading cause of diarrhea and death in malnourished children and immunocompromised individuals and an important enteric pathogen of livestock. A mucosal vaccine to mitigate clinical disease and decrease transmission would address the public health impact of this organism, but current options are limited. The development of a rational strategy for vaccination requires an appreciation of the parasite life cycle, how Cryptosporidium interacts with its host cell (the enterocyte), and the immune mechanisms that act locally to control this organism. Here we review current knowledge of the adaptive immune mechanisms that mediate resistance to Cryptosporidium, their relevance to vaccine design, and how recent advances in parasite genetics inform vaccine development.
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Affiliation(s)
- Maria Merolle
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, PA 19104, United States
| | - Boris Striepen
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, PA 19104, United States
| | - Christopher A Hunter
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, PA 19104, United States.
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2
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Cancemi G, Campo C, Caserta S, Rizzotti I, Mannina D. Single-Agent and Associated Therapies with Monoclonal Antibodies: What About Follicular Lymphoma? Cancers (Basel) 2025; 17:1602. [PMID: 40427101 PMCID: PMC12109769 DOI: 10.3390/cancers17101602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2025] [Revised: 05/01/2025] [Accepted: 05/07/2025] [Indexed: 05/29/2025] Open
Abstract
Monoclonal antibodies (mAbs) have become a cornerstone in the treatment of follicular lymphoma (FL), offering highly specific therapeutic targeting that enhances efficacy while minimizing systemic toxicity. Their mechanisms of action include antibody-dependent cellular cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC), and direct apoptotic signaling, effectively mediating malignant B-cell depletion. Anti-CD20 mAbs, such as rituximab and obinutuzumab, have significantly improved progression-free survival (PFS) and overall survival (OS), establishing immunochemotherapy as the standard of care for FL. However, the emergence of treatment resistance, often characterized by CD20 antigen downregulation or immune escape, has prompted the development of next-generation mAbs with enhanced effector functions. Bispecific antibodies (BsAbs), which simultaneously engage CD20-expressing tumor cells and CD3-positive cytotoxic T cells, have emerged as a novel immunotherapeutic strategy, redirecting T-cell activity to eliminate malignant B cells independently of major histocompatibility complex (MHC) antigen presentation. Additionally, antibody-drug conjugates (ADCs) offer a targeted cytotoxic approach by delivering potent chemotherapeutic payloads directly to tumor cells while limiting off-target effects. The integration of mAbs with immune checkpoint inhibitors and immunomodulatory agents is further enhancing treatment outcomes by overcoming immunosuppressive mechanisms within the tumor microenvironment. Despite these advancements, challenges remain, including optimizing the treatment sequence, mitigating immune-related toxicities-particularly cytokine release syndrome (CRS)-and identifying predictive biomarkers to guide patient selection. As the role of monoclonal antibodies continues to expand, their integration into therapeutic regimens is transforming the management of FL, paving the way for chemotherapy-free treatment approaches and long-term disease control. This review provides an updated overview of mAbs therapies for FL, emphasizing the advances brought by BsAbs and ADCs toward more tailored and effective treatments.
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Affiliation(s)
- Gabriella Cancemi
- Hematology Unit, Oncology-Hematology Department, Azienda Ospedaliera Papardo, 98158 Messina, Italy; (G.C.); (C.C.); (I.R.)
| | - Chiara Campo
- Hematology Unit, Oncology-Hematology Department, Azienda Ospedaliera Papardo, 98158 Messina, Italy; (G.C.); (C.C.); (I.R.)
| | - Santino Caserta
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy;
| | - Iolanda Rizzotti
- Hematology Unit, Oncology-Hematology Department, Azienda Ospedaliera Papardo, 98158 Messina, Italy; (G.C.); (C.C.); (I.R.)
| | - Donato Mannina
- Hematology Unit, Oncology-Hematology Department, Azienda Ospedaliera Papardo, 98158 Messina, Italy; (G.C.); (C.C.); (I.R.)
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Alhasawi RH, Shaheen EA, Alshabanat NM, Brashi R, Ahmed WA, Alqahtani SH, Alharbi E, Aljabri M. The efficacy of apremilast in pemphigus: a systematic review of case reports. Dermatol Reports 2025. [PMID: 40341768 DOI: 10.4081/dr.2025.10245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 04/11/2025] [Indexed: 05/11/2025] Open
Abstract
Pemphigus is a severe autoimmune blistering disorder that significantly affects patients' quality of life. While corticosteroids and immunosuppressive agents are commonly used, they have substantial side effects, highlighting the need for safer alternatives. Apremilast, an oral phosphodiesterase 4 (PDE4) inhibitor, has shown efficacy in treating other autoimmune diseases and may offer promise for pemphigus. This systematic review evaluated the clinical outcomes, safety, and potential role of apremilast in pemphigus treatment by synthesizing available case reports and series. A literature search was conducted across multiple databases (PubMed, EMBASE, Cochrane, Web of Science, ScienceDirect, and Google Scholar) for case reports and series involving apremilast in pemphigus. Inclusion criteria were a confirmed pemphigus diagnosis and apremilast treatment. Five studies (four case reports and one case series) involving seven patients were included. Apremilast led to significant clinical improvement in four patients, with reductions in disease activity, lesion severity, and symptom scores (Pemphigus Disease Area Index, Autoimmune Bullous Skin Disorder Intensity Score, Visual Analog Scale, and Numerical Rating Score). Increases in regulatory T cells and decreases in anti-desmoglein antibodies were observed. No serious adverse events were reported, although one study noted treatment failure, possibly due to short follow-up or concurrent infections. Apremilast appears to be a promising treatment for therapy-resistant or corticosteroid-intolerant pemphigus patients. Although the evidence is limited, it supports apremilast's efficacy and favorable safety profile. Further research with larger sample sizes and randomized controlled trials is necessary to confirm these findings.
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Affiliation(s)
| | | | | | - Reem Brashi
- General practitioner, King Abdulaziz Hospital, Makkah.
| | | | | | | | - Mazin Aljabri
- Dermatology Department, Heraa General Hospital, Makkah.
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Yeo AL, Winthrop KL. Pulmonary Complications of Biological Therapies in Inflammatory and Autoimmune Diseases. Clin Chest Med 2025; 46:169-183. [PMID: 39890287 DOI: 10.1016/j.ccm.2024.10.013] [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: 02/03/2025]
Abstract
Infective and noninfective pulmonary complications occur with biologic agents and targeted small molecule inhibitors used to treat immune-mediated inflammatory conditions. The most common lower respiratory tract infection is bacterial pneumonia. Opportunistic infections including tuberculosis can also occur at increased rates depending on the immunosuppressive agent, specific disease, and epidemiologic background of the patient. The most common noninfectious sequela is drug-induced interstitial lung disease.
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Affiliation(s)
- Ai Li Yeo
- Department of Rheumatology and Infectious Diseases, Monash Health, School of Clinical Sciences, Monash University, 246 Clayton Road, Clayton Melbourne, Victoria 3168, Australia.
| | - Kevin L Winthrop
- Divisions of Infectious Diseases, Ophthalmology, and Public Health, Oregon Health and Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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Price CF, Wood JP, Ismail I, Smith S, Hanson J. The Incidence, Aetiology and Clinical Course of Serious Infections Complicating Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drug Therapy in Patients with Rheumatoid Arthritis in Tropical Australia. Pathogens 2024; 13:943. [PMID: 39599496 PMCID: PMC11597851 DOI: 10.3390/pathogens13110943] [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] [Received: 09/27/2024] [Revised: 10/24/2024] [Accepted: 10/28/2024] [Indexed: 11/29/2024] Open
Abstract
Introduction: Patients receiving biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for rheumatological conditions are at an increased risk of serious, potentially life-threatening, infection. However, the incidence, aetiology, and clinical course of serious infection in patients receiving b/tsDMARDs in tropical settings are incompletely defined. Methods: We retrospectively reviewed all patients with rheumatoid arthritis receiving b/tsDMARDs between October 2012 and October 2021, at Cairns Hospital in tropical Australia. The incidence, aetiology, and clinical course of serious infections (those requiring admission to hospital or parenteral antibiotics) were determined. Results: 310 patients had 1468 patient years of b/tsDMARD therapy during the study period; 74/310 (24%) had 147 serious infections translating to an overall risk of 10.0 episodes of serious infection per 100 patient years. The respiratory tract (50/147, 34%) and skin (37/147, 25%) were the most frequently affected sites. A pathogen was identified in 59/147 (40%) episodes and was most commonly Staphylococcus aureus (24/147, 16%). Only 2/147 (1%) were confirmed "tropical infections": 1 case of Burkholderia pseudomallei and 1 case of mixed B. pseudomallei and community-acquired Acinetobacter baumannii infection. Overall, 13/147 (9%) episodes of serious infection required Intensive Care Unit admission (0.9 per 100-patient years of b/tsDMARD therapy) and 4/147 (3%) died from their infection (0.3 per 100-patient years of b/tsDMARD therapy). The burden of comorbidity and co-administration of prednisone were the strongest predictors of death or a requirement for ICU admission. Conclusions: The risk of serious infection in patients taking b/tsDMARDs in tropical Australia is higher than in temperate settings, but this is not explained by an increased incidence of traditional tropical pathogens.
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Affiliation(s)
- Cody F. Price
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia; (C.F.P.); (J.P.W.); (I.I.); (S.S.)
| | - John P. Wood
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia; (C.F.P.); (J.P.W.); (I.I.); (S.S.)
- College of Medicine and Dentistry, James Cook University, Cairns, QLD 4878, Australia
| | - Ibrahim Ismail
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia; (C.F.P.); (J.P.W.); (I.I.); (S.S.)
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia; (C.F.P.); (J.P.W.); (I.I.); (S.S.)
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia; (C.F.P.); (J.P.W.); (I.I.); (S.S.)
- The Kirby Institute, University of New South Wales, Kensington, NSW 2052, Australia
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Björnsson GS, Sigurgrímsdóttir H, Maggadóttir SM, Einarsdóttir BÓ, Sveinsson ÓÁ, Hjaltason H, Sigurðardóttir SÞ, Lúðvíksson BR, Brynjólfsson SF. Long-term use of rituximab increases T cell count in MS patients. Front Immunol 2024; 15:1412668. [PMID: 39086478 PMCID: PMC11288840 DOI: 10.3389/fimmu.2024.1412668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Rituximab has been used to treat MS patients in Iceland for over a decade. However, long-term effect of rituximab on leukocyte populations has not yet been elucidated. By retrospective analysis of flow cytometric data from 349 patients visiting the neurological ward at The National University Hospital of Iceland from 2012 to 2023 for rituximab treatment, the long-term effect of rituximab and whether the effect was dose dependent (1000mg vs 500mg) was evaluated. No difference was detected in efficacy of B cell depletion in patients treated with 500mg as an initial dose of rituximab when compared to 1000mg. Long-term use of rituximab led to an increase in T cell count (p=0,0015) in patients receiving 3-8 doses of rituximab (1.5-8 years of treatment). The increase occurred in both CD4+ (p=0,0028) and CD8+ T cells (p=0,0015) and led to a decrease in the CD4/CD8 ratio (p=0,004). The most notable difference lies in reshaping the balance between näive and effector CD8+ T cells. The clinical implications of long-term treatment with rituximab and its effect on the T cell pool needs to be explored further. Since no difference in B cell depletion was detected between the two patient groups, 1000mg as an initial dose might be excessive, suggesting a personalized dosing regimen might have therapeutic and financial advantages.
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Affiliation(s)
| | - Hildur Sigurgrímsdóttir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Immunology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Sólrún Melkorka Maggadóttir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Immunology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Ólafur Árni Sveinsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Neurology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Haukur Hjaltason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Neurology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Björn Rúnar Lúðvíksson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Immunology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Siggeir Fannar Brynjólfsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Immunology, Landspítali – The National University Hospital of Iceland, Reykjavik, Iceland
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Veeken LD, Opdam MAA, Verhoef LM, Popa C, van Crevel R, den Broeder AA. Infection incidence, timing and dose dependency in rheumatoid arthritis patients treated with rituximab: a retrospective cohort study. Rheumatology (Oxford) 2024; 63:1246-1250. [PMID: 37410085 DOI: 10.1093/rheumatology/kead328] [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: 02/15/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES Rituximab (RTX) is a safe and effective treatment for RA. However, there are some concerns about infection risk and preliminary data suggest dose and time dependency. This study aims to determine the infection incidence in a large real-life population of RA patients using RTX, with special focus on (ultra-)low dosing and time since last infusion. METHODS RA patients treated with 1000, 500 or 200 mg RTX per cycle between 2012 and 2021 at the Sint Maartenskliniek were included in a retrospective cohort study. Patient-, disease-, treatment- and infection characteristics were retrieved from electronic health records. Infection incidence rates, dose and time relations with RTX infusion were analysed using mixed-effects Poisson regression. RESULTS Among 490 patients, we identified 819 infections in 1254 patient years. Most infections were mild and respiratory tract infections were most common. Infection incidence rates were 41, 54 and 71 per 100 patient years for doses of 200, 500 and 1000 mg. Incidence rate ratio (IRR) was significantly lower for 200 mg compared with 1000 mg (adjusted IRR 0.35, 95% CI 0.17, 0.72, P = 0.004). In patients receiving 1000 or 500 mg RTX, infections seemed to occur more frequently within the first two months after infusion compared with later on in the treatment cycle, suggesting an association with peak concentration. CONCLUSION Ultra-low dosing (200 mg) of RTX is associated with a lower risk of infections in RA. Future interventions focusing on ultra-low dosing and slow release of RTX (e.g. by subcutaneous administration) may lower infection risk.
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Affiliation(s)
- Lara D Veeken
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Merel A A Opdam
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Calin Popa
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Infectious Diseases, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
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Spałek MM, Jałowska M, Bowszyc-Dmochowska M, Dmochowski M. Rituximab in the Management of Autoimmune Bullous Diseases: A Treatment-Resistant Case Series from a Single Central European Referral Center. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:270. [PMID: 38399557 PMCID: PMC10890531 DOI: 10.3390/medicina60020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Rituximab (RTX) has been the predominant treatment for autoimmune bullous diseases (AIBDs). The objective of this research was to assess the advantages and safety characteristics of RTX treatment in individuals with AIBD. This assessment focused on clinical remission and a reduction in glucocorticosteroid usage, its effect on the titers of autoantibodies targeting desmoglein-1 (DSG-1) and desmoglein-3 (DSG-3), and adverse occurrences during a 12-month follow-up period in a dermatology department within a Central European university context. Materials and Methods: Our case series involved eleven patients, including eight patients with pemphigus vulgaris, two with pemphigus foliaceus, and one with epidermolysis bullosa acquisita. They received a 1 g dose of rituximab, repeated over a two-week interval. Results: The reduction in a prednisone-equivalent dosage after 2, 6, and 12 months following the second RTX infusion was 65.05%, 73.99%, and 76.93%, in that order. The titers of antibodies against DSG-1 exhibited reductions of 43.29%, 75.86%, and 54.02% at 2, 6, and 12 months, respectively. By contrast, the antibody concentrations targeting DSG-3 displayed a decrease of 27.88%, 14.48%, and 5.09% at the corresponding time points. Over the course of the 12-month monitoring period, 18.18% of patients experienced disease relapse, while the remaining individuals achieved either complete or partial remission with minimal or no therapy. Adverse effects were noted in 36.36% of the patient population; they were mild, and no serious adverse effects were reported. Conclusions: RTX represents an efficacious and well-tolerated therapeutic option for the management of AIBD and merits consideration in cases of refractory AIBD. However, further research is imperative to delineate the most optimal dosage, dosing frequency, and total quantity of maintenance infusions required. Additionally, there is a compelling need for studies that explore the impact of RTX on individuals with AIBD who do not exhibit a significant reduction in anti-desmoglein autoantibody levels.
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Affiliation(s)
- Maciej Marek Spałek
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
| | - Magdalena Jałowska
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (M.M.S.); (M.J.)
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Welte T, Westermann L, Kappes J, Schramm MA, Bemtgen X, Staudacher DL, Hug MJ, Venhoff N, Arnold F. Identification of Covariates Modulating B-Cell Repopulation Kinetics in Subjects Receiving Rituximab Treatment. Arthritis Rheumatol 2023; 75:2045-2053. [PMID: 37276446 DOI: 10.1002/art.42625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/15/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE B-cell depletion using the anti-CD20 monoclonal antibody rituximab is a cornerstone in the therapeutic concept of multiple autoimmune diseases. B-cell depletion is associated with a higher risk for severe infections, and the time span of B-cell repopulation differs greatly between individuals. Data on factors influencing B-cell repopulation kinetics are limited. This study aims to identify patient-specific and therapy-associated covariates that modulate B-cell repopulation. METHODS This single-center retrospective observational study presents data of 839 subjects receiving 2,017 courses of rituximab for autoimmune diseases. Assessed covariates are patient-specific factors (sex, age, kidney function, and underlying disease) and co-immunosuppression with common agents (azathioprine, cyclosporine A, cyclophosphamide, hydroxychloroquine, methotrexate, mycophenolate mofetil, tacrolimus, and corticosteroids). The primary end point is the time to B-cell repopulation (≥5/μl). The secondary end point is the time to B-cell reconstitution (≥50/μl). Multivariate time-to-event analysis and logistic regression models were applied to estimate the influence of covariates. RESULTS Age over 60 years (hazard ratio [HR] 0.71 for repopulation, P = 0.008), impaired kidney function (HR 0.72, P = 0.001), antineutrophil cytoplasmic antibody-associated vasculitis (HR 0.61, P < 0.001), solid organ transplantation (HR 0.4, P < 0.001), and co-immunosuppression with corticosteroids (HR 0.64, P < 0.001) or azathioprine (HR 0.49, P < 0.001) were associated with impaired B-cell repopulation and reconstitution. Effects of corticosteroids (P = 0.043) and azathioprine (P = 0.025) were dose dependent. CONCLUSION Prolonged rituximab dosing intervals may be effective to achieve B-cell depletion and reduce risk of infection in advanced age or patients with impaired kidney function. Co-medication with corticosteroids or azathioprine prolongs B-cell recovery, which may increase therapeutic effects but also the rate of adverse events.
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Affiliation(s)
- Thomas Welte
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Kappes
- Department of Pneumology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus A Schramm
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, and Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, and Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin J Hug
- Pharmacy, Medical Center, University of Freiburg, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frederic Arnold
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, and Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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10
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Alhamadh MS, Alhowaish TS, Mathkour A, Altamimi B, Alheijani S, Alrashid A. Infection Risk, Mortality, and Hypogammaglobulinemia Prevalence and Associated Factors in Adults Treated with Rituximab: A Tertiary Care Center Experience. Clin Pract 2023; 13:1286-1302. [PMID: 37987416 PMCID: PMC10660466 DOI: 10.3390/clinpract13060115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/09/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Rituximab is a human monoclonal antibody directed against the B-cell transmembrane protein CD20. Although well-tolerated, given its mechanism of action, rituximab can induce a state of severe immunosuppression, increasing the risk of opportunistic and fulminant infection and mortality. AIM To evaluate the risk of infection, mortality, and hypogammaglobulinemia and their associated factors among rituximab receivers. METHOD This was a single-center retrospective cohort study of adults treated with rituximab for various indications. Hypogammaglobulinemia was defined by a cut-off value below the normal limit (an IgG level of <7.51 g/L, an IgM level of <0.46 g/L, and/or an IgA level of <0.82 g/L). Patients who met the definition of hypogammaglobinemia solely based on IgA were excluded. Severe infection was defined as any infection that required intensive care unit admission. RESULTS A total of 137 adults with a mean age of 47.69 ± 18.86 years and an average BMI of 28.57 ± 6.55 kg/m2 were included. Hematological malignancies and connective tissue diseases were the most common primary diagnoses for which rituximab was used. More than half of the patients received the 375 mg/m2 dose. Rituximab's mean cumulative dose was 3216 ± 2282 mg, and the overall mortality rate was 22.6%. Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more prevalent among males and the 375 mg/m2 and 500 mg doses. Hematological malignancy was the only predictor for infection. Patients with blood type AB or B, hematological malignancies, and corticosteroids had a significantly higher mortality rate. Receiving the 1000 mg dose and having a low CD19 were associated with a significantly lower risk of infection and mortality, respectively. CONCLUSIONS Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more common among males and the 375 mg/m2 and 500 mg doses. Hematological malignancies were significantly associated with higher infection and mortality rates, while corticosteroids were significantly associated with a higher mortality. Since the culprit of mortality was infection, these findings highlight the critical need for more frequent immunological monitoring during rituximab treatment period to mitigate the burden of infection and identify candidates for immunoglobulin replacement.
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Affiliation(s)
- Moustafa S. Alhamadh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
| | - Thamer S. Alhowaish
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Neurology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
| | | | - Bayan Altamimi
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Medicine, Division of Rheumatology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
| | - Shahd Alheijani
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Abdulrahman Alrashid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Medicine, Division of Rheumatology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
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11
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Edan G, Le Page E. Escalation Versus Induction/High-Efficacy Treatment Strategies for Relapsing Multiple Sclerosis: Which is Best for Patients? Drugs 2023; 83:1351-1363. [PMID: 37725259 PMCID: PMC10582148 DOI: 10.1007/s40265-023-01942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
After more than 2 decades of recommending an escalating strategy for the treatment of most patients with multiple sclerosis, there has recently been considerable interest in the use of high-efficacy therapies in the early stage of the disease. Early intervention with induction/high-efficacy disease-modifying therapy may have the best risk-benefit profile for patients with relapsing-remitting multiple sclerosis who are young and have active disease, numerous focal T2 lesions on spinal and brain magnetic resonance imaging, and no irreversible disability. Although we have no curative treatment, at least seven classes of high-efficacy drugs are available, with two main strategies. The first strategy involves the use of high-efficacy drugs (e.g., natalizumab, sphingosine 1-phosphate receptor modulators, or anti-CD20 drugs) to achieve sustained immunosuppression. These can be used as a first-line therapy in many countries. The second strategy entails the use of one of the induction drugs (short-term use of mitoxantrone, alemtuzumab, cladribine, or autologous hematopoietic stem cell transplant) that are mainly recommended as a second-line or third-line treatment in patients with very active or aggressive multiple sclerosis disease. Early sustained immunosuppression exposes patients to heightened risks of infection and cancer proportionate to cumulative exposure, and induction drugs expose patients to similar risks during the initial post-treatment period, although these risks decrease over time. Their initial potential safety risks should now be revisited, taking account of long-term data and some major changes in their regimens: natalizumab with the long-term monitoring of John Cunningham virus; use of monthly courses of mitoxantrone with maximum cumulative doses of 36-72 mg/m2, followed by a safer disease-modifying drug; cladribine with only 2-weekly treatment courses required in years 1 and 2 and no systematic treatment for the following 2 years; alemtuzumab, whose safety and clinical impacts have now been documented for more than 6 years after the last infusion; and autologous haematopoietic stem cell transplant, which dramatically reduces transplantation-related mortality with a new regimen and guidelines. Escalation and induction/high-efficacy treatments need rigorous magnetic resonance imaging monitoring. Monitoring over the first few years, using the MAGNIMS score or American Academy of Neurology guidelines, considerably improves prediction accuracy and facilitates the selection of patients with relapsing-remitting multiple sclerosis requiring aggressive treatment.
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Affiliation(s)
- Gilles Edan
- Empenn IRISA Research Group, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France.
| | - Emmanuelle Le Page
- Neurology Department, INSERM Clinical Investigation Center, Pontchaillou University Hospital, Rennes, France
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12
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Evans LS, Lewis KE, DeMonte D, Bhandari JG, Garrett LB, Kuijper JL, Ardourel D, Wolfson MF, Debrot S, Mudri S, Kleist K, Griffin LL, Hebb L, Sanderson RJ, Wang N, Seaberg M, Chunyk AG, Yang J, Hong Y, Maria Z, Messenheimer DJ, Holland PM, Peng SL, Rixon MW, Dillon SR. Povetacicept, an Enhanced Dual APRIL/BAFF Antagonist That Modulates B Lymphocytes and Pathogenic Autoantibodies for the Treatment of Lupus and Other B Cell-Related Autoimmune Diseases. Arthritis Rheumatol 2023; 75:1187-1202. [PMID: 36705554 DOI: 10.1002/art.42462] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Dysregulated APRIL/BAFF signaling is implicated in the pathogenesis of multiple autoimmune diseases, including systemic lupus erythematosus and lupus nephritis. We undertook this study to develop and evaluate a high-affinity APRIL/BAFF antagonist to overcome the clinical limitations of existing B cell inhibitors. METHODS A variant of TACI-Fc generated by directed evolution showed enhanced binding for both APRIL and BAFF and was designated povetacicept (ALPN-303). Povetacicept was compared to wild-type (WT) TACI-Fc and related molecules in vitro and in vivo. RESULTS Povetacicept inhibited APRIL and BAFF more effectively than all evaluated forms of WT TACI-Fc and selective APRIL and BAFF inhibitors in cell-based reporter assays and primary human B cell assays, mediating potent suppression of B cell proliferation, differentiation, and immunoglobulin (Ig) secretion. In mouse immunization models, povetacicept significantly reduced serum immunoglobulin titers and antibody-secreting cells more effectively than anti-CD20 monoclonal antibodies, WT TACI-Fc, or APRIL and BAFF inhibitors. In the NZB × NZW mouse lupus nephritis model, povetacicept significantly enhanced survival and suppressed proteinuria, anti-double-stranded DNA antibody titers, blood urea nitrogen, glomerulonephritis, and renal immunoglobulin deposition. In the bm12 mouse lupus model, povetacicept significantly reduced splenic plasmablasts, follicular helper T cells, and germinal center B cells. In non-human primates, povetacicept was well tolerated, exhibited high serum exposure, and significantly decreased serum IgM, IgA, and IgG levels after a single dose. CONCLUSION Enhanced APRIL and BAFF inhibition by povetacicept led to greater inhibition of B cell populations critical for autoantibody production compared to WT TACI-Fc and CD20-, APRIL-, or BAFF-selective inhibitors. Potent, dual inhibition by povetacicept has the potential to significantly improve clinical outcomes in autoantibody-related autoimmune diseases.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Susan Debrot
- Alpine Immune Sciences, Inc., Seattle, Washington
| | - Sherri Mudri
- Alpine Immune Sciences, Inc., Seattle, Washington
| | - Kayla Kleist
- Alpine Immune Sciences, Inc., Seattle, Washington
| | | | - LuAnne Hebb
- Alpine Immune Sciences, Inc., Seattle, Washington
| | | | - NingXin Wang
- Alpine Immune Sciences, Inc., Seattle, Washington
| | | | | | - Jing Yang
- Alpine Immune Sciences, Inc., Seattle, Washington
| | - Youji Hong
- Alpine Immune Sciences, Inc., Seattle, Washington
| | - Zahra Maria
- Alpine Immune Sciences, Inc., Seattle, Washington
| | | | | | | | - Mark W Rixon
- Alpine Immune Sciences, Inc., Seattle, Washington
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13
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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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14
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Kianfar N, Dasdar S, Daneshpazhooh M, Aryanian Z, Goodarzi A. A systematic review on efficacy, safety and treatment durability of intravenous immunoglobulin in autoimmune bullous dermatoses: Special focus on indication and combination therapy. Exp Dermatol 2023. [PMID: 37150538 DOI: 10.1111/exd.14829] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 05/09/2023]
Abstract
Autoimmune bullous diseases (AIBDs) are a group of rare blistering dermatoses of the mucous membrane and/or skin. The efficacy, safety and treatment durability of intravenous immunoglobulin (IVIg) as an alternative treatment should be explored to systematically review the available literature regarding treatment outcomes with IVIg in AIBD patients. The predefined search strategy was incorporated into the following database, MEDLINE/PubMed, Embase, Scopus and Web of Science on 18 July 2022. Sixty studies were enrolled using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The use of IVIg alone or combined with rituximab was reported in 500 patients with pemphigus, 82 patients with bullous pemphigoid, 146 patients with mucous membranes pemphigoid and 19 patients with epidermolysis bullosa acquisita. Disease remission with IVIg therapy and RTX + IVIg combination therapy were recorded as 82.8% and 86.7% in pemphigus, 88.0% and 100% in bullous pemphigoid and 91.3% and 75.0% in mucous membrane pemphigoid, respectively. In epidermolysis bullosa acquisita, treatment with IVIg led to 78.6% disease remission; no data were available regarding the treatment with RTX + IVIg in this group of patients. Among all the included patients, 37.5% experienced at least one IVIg-related side effect; the most common ones were headaches, fever/chills and nausea/vomiting. The use of IVIg with or without rituximab had a favourable clinical response in patients with AIBDs. IVIg has no major influence on the normal immune system, which makes its utilization for patients with AIBDs reasonable.
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Affiliation(s)
- Nika Kianfar
- Department of Dermatology, Razi Dermatology Hospital, Autoimmune Bullous Diseases Research Center, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Shayan Dasdar
- Department of Dermatology, Razi Dermatology Hospital, Autoimmune Bullous Diseases Research Center, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Razi Dermatology Hospital, Autoimmune Bullous Diseases Research Center, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Aryanian
- Department of Dermatology, Razi Dermatology Hospital, Autoimmune Bullous Diseases Research Center, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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15
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Techa-Angkoon P, Siritho S, Tisavipat N, Suansanae T. Current evidence of rituximab in the treatment of multiple sclerosis. Mult Scler Relat Disord 2023; 75:104729. [PMID: 37148577 DOI: 10.1016/j.msard.2023.104729] [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: 11/22/2022] [Revised: 04/15/2023] [Accepted: 04/22/2023] [Indexed: 05/08/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system. The immunopathology of MS involves both T and B lymphocytes. Rituximab is one of the anti-CD20 monoclonal antibody therapies which deplete B-cells. Although some anti-CD20 therapies have been approved by the Food and Drug Administration for treatment of MS, rituximab is used off-label. Several studies have shown that rituximab has a good efficacy and safety in MS, including certain specific patient conditions such as treatment-naïve patients, treatment-switching patients, and the Asian population. However, there are still questions about the optimal dose and duration of rituximab in MS due to the different dosing regimens used in each study. Moreover, many biosimilars have become available at a lower cost with comparable physicochemical properties, pharmacokinetics, pharmacodynamics, efficacy, safety, and immunogenicity. Thus, rituximab may be considered as a potential therapeutic option for patients without access to standard treatment. This narrative review summarized the evidence of both original and biosimilars of rituximab in MS treatment including pharmacokinetics, pharmacodynamics, clinical efficacy, safety, and dosing regimen.
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Affiliation(s)
- Phanutgorn Techa-Angkoon
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Sasitorn Siritho
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Bumrungrad International Hospital, Bangkok, Thailand
| | | | - Thanarat Suansanae
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathewi, Bangkok 10400, Thailand.
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16
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Armağan B, Konak HE, Özdemir B, Apaydın H, Atalar E, Akyüz Dağlı P, Güven SC, Erden A, Küçükşahin O, Omma A, Erten Ş. COVID-19 disease frequency, risk factors, and re-infection rates in patients with autoimmune rheumatic disease receiving rituximab. Int J Rheum Dis 2023; 26:930-937. [PMID: 36942871 DOI: 10.1111/1756-185x.14676] [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: 11/19/2022] [Revised: 01/01/2023] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Rituximab, which is used in autoimmune rheumatic diseases (ARD), can cause both an increased risk of development of COVID-19 disease and re-infection due to its potent and long-acting immunosuppression. So, we aimed to evaluate the frequency, risk factors and re-infection rates of COVID-19 in ARD patients receiving rituximab. METHODS A single-center retrospective study was performed with patients receiving rituximab for ARD in 12 months before the onset of COVID-19 in Turkey. The data regarding severe acute respiratory syndrome-coronavirus 2 reverse transcription polymerized chain reaction (RT-PCR) test, clinical, laboratory, and mortality data of all patients were collected from medical records. Logistic regression analysis was used for predictors of COVID-19 disease. COVID-19 re-infection was defined as RT-PCR positivity and recurrence of acute COVID-19 symptoms after at least 1 negative RT-PCR in patients with clinical improvement. RESULTS Ninety-eight ARD patients with rituximab were evaluated and 23 (23%) of them had COVID-19. The presence of hypogammaglobulinemia increased the risk of COVID-19 disease 8-fold. COVID-19 pneumonia occurred in 13 (57%) and these patients' age was higher than those without pneumonia (59.6 ± 11.8 vs 44.9 ± 14.2 years, P = 0.013). Mortality due to COVID-19 was 13% and COVID-19 re-infection was seen in 20% of survivors. CONCLUSION Regardless of the underlying rheumatic disease and organ involvements, hypogammaglobulinemia in ARD could be a risk factor for COVID-19 development, and advanced age could be for COVID-19 severity. Moreover, COVID-19 re-infection rates are high.
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Affiliation(s)
- Berkan Armağan
- Rheumatology Clinic, Ankara City Hospital, Ankara, Turkey
| | | | - Bahar Özdemir
- Rheumatology Clinic, Ankara City Hospital, Ankara, Turkey
| | - Hakan Apaydın
- Rheumatology Clinic, Ankara City Hospital, Ankara, Turkey
| | - Ebru Atalar
- Rheumatology Clinic, Ankara City Hospital, Ankara, Turkey
| | | | | | - Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Orhan Küçükşahin
- Division of Rheumatology, Department of Internal Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Ahmet Omma
- Division of Rheumatology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Şükran Erten
- Division of Rheumatology, Department of Internal Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Capkin E, Yazıcı A, Karkucak M, Durmaz Y, Toprak M, Ataman Ş, Şahin N, Cüzdan N, Kasapoğlu Aksoy M, Önder ME, Serdaroglu Beyazal M, Mesci N, Baykul M, Alkan Melikoğlu M, Alkan H, Dulgeroglu D, Cengiz AK, Nas K, Balevi Batur E, Çalışkan Uçkun A, Deveci H, Erol K, Albayrak Gezer İ, Akgöl G, Duruöz MT, Küçükakkaş O, Sarıkaya S, Rezvani A, Atan T, Göğüş F, Çağlayan G, Keskin Y, Bulut Keskin AS, Öz N, Yılmaz G. Evaluation of hepatitis serology and frequency of viral reactivation in patients with inflammatory arthritis receiving biologic agents: a multicenter observational study. Rheumatol Int 2023; 43:523-531. [PMID: 36063169 DOI: 10.1007/s00296-022-05169-2] [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: 06/01/2022] [Accepted: 07/01/2022] [Indexed: 10/14/2022]
Abstract
To evaluate of hepatitis serology and reactivation frequency in patients with rheumatic disease receiving biologic agents. Our study included patients with inflammatory rheumatic diseases from 23 centers, who were followed up with biological therapy. Demographic and clinical characteristics of the patients, duration of drug use and hepatitis serology and the state of viral reactivation were analyzed. A total of 4060 patients, 2095 being males, were included in our study. Of the patients, 2463 had Ankylosing Spondylitis (AS), 1154 had Rheumatoid Arthritis (RA), 325 had Psoriatic Arthritis (PsA), and 118 had other inflammatory rheumatic diseases. When the viral serology of the patients was evaluated, 79 patients (2%) who were identified as HBs Ag positive, 486 (12%) patients who were HBs Ag negative and anti-HBc IgG positive and 20 patients (0.5%) who were anti-HCV positive. When evaluated on a disease-by-disease basis, the rate of HBsAg was found to be 2.5% in RA, 2% in AS and 0.9% in PsA. Viral reactivation was detected in 13 patients while receiving biologic agents. HBs Ag was positive in nine patients with reactivation and negative in four patients. Anti-HBc IgG, however, was positive. Six of these patients had AS, four had RA, and three had PsA. The development of hepatitis reactivation in 11.4% of HBs Ag positive patients and 0.82% of anti-HBc IgG positive patients due to the use of biologic agents is an important problem for this group of patients. Antiviral prophylaxis is recommended to be started especially in patients who are HBs Ag positive and who are using biologic agents due to viral reactivation. Therefore, it is important to carry out hepatitis screenings before biologic agent treatment and to carefully evaluate the vaccination and prophylaxis requirements.
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Affiliation(s)
- Erhan Capkin
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Karadeniz Technical University School of Medicine, Trabzon, 61080, Turkey.
| | - Ali Yazıcı
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Karadeniz Technical University School of Medicine, Trabzon, 61080, Turkey
| | - Murat Karkucak
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Karadeniz Technical University School of Medicine, Trabzon, 61080, Turkey
| | - Yunus Durmaz
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Karabuk Training and Research Hospital, Karabuk, Turkey
| | - Murat Toprak
- Department of Physical Medicine and Rehabilitation, Medical Faculty of Yüzüncü, Yıl University, Van, Turkey
| | - Şebnem Ataman
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Nilay Şahin
- Department of Physical Medicine and Rehabilitation, School of Medicine, Balıkesir University, Balıkesir, Turkey
| | - Nihan Cüzdan
- Balıkesir Atatürk City Hospital, Rheumatology Clinic, Balıkesir, Turkey
| | - Meliha Kasapoğlu Aksoy
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Bursa Yuksek İhtisas Training and Research Hospital, Bursa, Turkey
| | - Mustafa Erkut Önder
- Department of Rheumatology, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Münevver Serdaroglu Beyazal
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Nilgün Mesci
- Department of Physical Medicine and Rehabilitation, Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey
| | - Merve Baykul
- Division of Rheumatology and Immunology, Department of Physical Medicine and Rehabilitation, School of Medicine, Sakarya University, Sakarya, Turkey
| | - Meltem Alkan Melikoğlu
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Ataturk University School of Medicine, Erzurum, Turkey
| | - Hakan Alkan
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Deniz Dulgeroglu
- Department of Physical Medicine and Rehabilitation, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Ahmet Kıvanç Cengiz
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Faculty of Medicine, 19 Mayıs University, Samsun, Turkey
| | - Kemal Nas
- Division of Rheumatology and Immunology, Department of Physical Medicine and Rehabilitation, School of Medicine, Sakarya University, Sakarya, Turkey
| | - Elif Balevi Batur
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Aslı Çalışkan Uçkun
- Department of Physical Medicine and Rehabilitation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Hülya Deveci
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Gaziosmanpaşa University, Tokat, Turkey
| | - Kemal Erol
- Department of Rheumatology, Kayseri City Hospital, Kayseri, Turkey
| | - İlknur Albayrak Gezer
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Gürkan Akgöl
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Faculty of Medicine, Firat University, Elazig, Turkey
| | - Mehmet Tuncay Duruöz
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Okan Küçükakkaş
- Department of Physical Medicine and Rehabilitation, Bezmiâlem Foundation University, Istanbul, Turkey
| | - Selda Sarıkaya
- Department of Physical Medicine and Rehabilitation, Zonguldak Bülent Ecevit University, School of Medicine, Zonguldak, Turkey
| | - Aylin Rezvani
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Medipol University, Istanbul, Turkey
| | - Tuğba Atan
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Feride Göğüş
- Physical Medicine and Rehabilitation, Division of Rheumatology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Gökhan Çağlayan
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Yaşar Keskin
- Department of Physical Medicine and Rehabilitation, Bezmiâlem Foundation University, Istanbul, Turkey
| | - Ayşe Selcen Bulut Keskin
- Department of Physical Medicine and Rehabilitation Çanakkale, Faculty of Medicine, Onsekiz Mart University, Çanakkale, Turkey
| | - Nuran Öz
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Gürdal Yılmaz
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
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18
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Van Meerhaeghe T, Néel A, Brouard S, Degauque N. Regulation of CD8 T cell by B-cells: A narrative review. Front Immunol 2023; 14:1125605. [PMID: 36969196 PMCID: PMC10030846 DOI: 10.3389/fimmu.2023.1125605] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
Activation of CD4 T cells by B cells has been extensively studied, but B cell-regulated priming, proliferation, and survival of CD8 T cells remains controversial. B cells express high levels of MHC class I molecules and can potentially act as antigen-presenting cells (APCs) for CD8 T cells. Several in vivo studies in mice and humans demonstrate the role of B cells as modulators of CD8 T cell function in the context of viral infections, autoimmune diseases, cancer and allograft rejection. In addition, B-cell depletion therapies can lead to impaired CD8 T-cell responses. In this review, we attempt to answer 2 important questions: 1. the role of B cell antigen presentation and cytokine production in the regulation of CD8 T cell survival and cell fate determination, and 2. The role of B cells in the formation and maintenance of CD8 T cell memory.
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Affiliation(s)
- Tess Van Meerhaeghe
- Department of Nephrology, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Antoine Néel
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
- Internal Medicine Department, Nantes University Hospital, Nantes, France
| | - Sophie Brouard
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Nicolas Degauque
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
- *Correspondence: Nicolas Degauque,
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19
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Chow TG, Oppenheimer J, Joshi SR. A Review of Adverse Reactions to Biologics Used in Allergy-Immunology Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3075-3086. [PMID: 36162800 DOI: 10.1016/j.jaip.2022.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023]
Abstract
Biologic agents have become an integral therapeutic option for practicing allergists-immunologists for the management of asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and various immunologic conditions. As these agents vary considerably from traditional small-molecule drugs, various adverse reactions have been noted. A different approach must be used to classify these reactions beyond the classic Gell-Coombs classification system as it does not capture many of the adverse events seen with biologic therapy. This article addresses the available literature on proposed classification systems and diagnostic modalities for adverse events associated with biologics and reviews each approved agent used frequently in allergy-immunology practice.
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Affiliation(s)
- Timothy G Chow
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - John Oppenheimer
- Department of Internal Medicine, UMDMJ Rutgers University School of Medicine, Newark, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Shyam R Joshi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, Ore.
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Somerville E, Gebauer K, Mclean‐Tooke A. Treatment of pemphigus in Australia: Aligning current practises with global recommendations. Australas J Dermatol 2022; 63:190-196. [DOI: 10.1111/ajd.13804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Kurt Gebauer
- University of Western Australia Crawley WA Australia
| | - Andrew Mclean‐Tooke
- Department of Clinical Immunology Sir Charles Gairdner Hospital Perth WA Australia
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Pereira SL, Duro R, Sarmento A. Late Hepatitis B reactivation after treatment with rituximab. IDCases 2022; 27:e01393. [PMID: 35070716 PMCID: PMC8761666 DOI: 10.1016/j.idcr.2022.e01393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 01/15/2023] Open
Abstract
Patients with past hepatitis B virus (HBV) infections that undergo immunosuppression are in risk of HBV reactivation. Antiviral prophylaxis in patient with previous contact with HBV treated with rituximab is recommended by current guidelines. The duration of antiviral prophylaxis in patients with hematologic malignancies treated with rituximab remains controversial.
There is a large reservoir of individuals with past hepatitis B virus (HBV) infection that are in risk for HBV reactivation when immunosuppressed. On the setting of hematologic malignancy, the malignancy itself and currently used treatments, especially anti-CD20 agents, have risk of HBV reactivation. Antiviral prophylaxis is recommended by some international societies. We present a case of HBV reactivation more than 12 months after stopping rituximab containing treatment and 6 months of antiviral prophylaxis with entecavir, in a patient with HBV functional cure. The patient was restarted on antivirals and again obtain functional cure. The antiviral was stopped 1 year after seroconversion and the patient followed for another year without evidence of new reactivation. Most literature supports the use of antiviral prophylaxis in patients treated with rituximab. However, there are still conflicting indications and no consensus regarding the duration of prophylaxis. This clinical case and review of the literature supports a longer prophylaxis duration (more than 18 months after finishing rituximab treatments) instead of standard 12 months prophylaxis.
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Affiliation(s)
- Sara Lacerda Pereira
- Infectious Diseases Department of Centro Hospitalar e Universitário de São João, Portugal
- Faculdade de Medicina da Universidade do Porto, Portugal
- Correspondence to: Serviço de Doenças Infecciosas, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Raquel Duro
- Infectious Diseases Department of Centro Hospitalar e Universitário de São João, Portugal
- Faculdade de Medicina da Universidade do Porto, Portugal
| | - António Sarmento
- Infectious Diseases Department of Centro Hospitalar e Universitário de São João, Portugal
- Faculdade de Medicina da Universidade do Porto, Portugal
- Instituto de Inovação e Investigação em Saúde (I3S), Grupo I&D em Nefrologia e Doenças Infecciosas, Instituto Nacional de Engenharia Biomédica (INEB), Portugal
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