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Carver CA, Kalesinskas M, Ahmed AR. Current biologics in treatment of pemphigus foliaceus: a systematic review. Front Immunol 2023; 14:1267668. [PMID: 37901249 PMCID: PMC10600482 DOI: 10.3389/fimmu.2023.1267668] [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: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Background Pemphigus foliaceus (PF) differs from pemphigus vulgaris (PV) in that it affects only the skin and mucous membranes are not involved. Pemphigus is commonly treated with systemic corticosteroids and immunosuppressive agents (ISAs). More recently, biologics have been used. The current literature on biologic therapy often combines treatment of PF with PV, hence it is often difficult for clinicians to isolate the treatment of PF from PV. The purpose of this review was to provide information regarding the use of current biological therapy, specifically in PF. Materials and methods A search of PubMed, Embase, and other databases was conducted using keywords pemphigus foliaceus (PF), rituximab (RTX), intravenous immunoglobulin (IVIg), and biologics. Forty-one studies were included in this review, which produced 105 patients with PF, treated with RTX, IVIg, or a combination of both. Eighty-five patients were treated with RTX, eight patients with IVIg, and 12 received both RTX and IVIg. Results Most patients in this review had PF that was nonresponsive to conventional immunosuppressive therapies (CIST), and had significant side effects from their use. RTX treatment resulted in complete remission (CR) in 63.2%, a relapse rate of 39.5%, an infection rate of 19.7%, and a mortality rate of 3.9%. Relapse was greater in the lymphoma (LP) protocol than the rheumatoid arthritis (RA) protocol (p<0.0001). IVIg led to CR in 62.5% of patients, with no relapses or infections. Patients receiving both biologics experienced better outcomes when RTX was first administered, then followed by IVIg. Follow-up durations for patients receiving RTX, IVIg, and both were 22.1, 24.8, and 35.7 months, respectively. Discussion In pemphigus foliaceus patients nonresponsive to conventional immunosuppressive therapy or in those with significant side effects from CIST, RTX and IVIg appear to be useful agents. Profile of clinical response, as well as relapse, infection, and mortality rates in PF patients treated with RTX were similar to those observed in PV patients. The data suggests that protocols specific for PF may produce better outcomes, less adverse effects, and improved quality of life.
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Affiliation(s)
- Caden A. Carver
- Midwestern University, Arizona College of Osteopathic Medicine, Glendale, AZ, United States
| | - Mikole Kalesinskas
- Department of Dermatology, Center for Blistering Disease, Tufts University School of Medicine, Boston, MA, United States
| | - A. Razzaque Ahmed
- Department of Dermatology, Center for Blistering Disease, Tufts University School of Medicine, Boston, MA, United States
- Department of Dermatology, Tufts University School of Medicine, Boston, MA, United States
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2
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Yamagami J. B-cell targeted therapy of pemphigus. J Dermatol 2023; 50:124-131. [PMID: 36478455 PMCID: PMC10107866 DOI: 10.1111/1346-8138.16653] [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: 10/03/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 12/12/2022]
Abstract
Pemphigus is an autoimmune disease that causes blistering and erosion of the skin and mucous membranes because of autoantibodies against desmoglein, which plays an important role in adhesion between epidermal keratinocytes. Treatment of pemphigus has long been centered on corticosteroids, and the guidelines for management of pemphigus have recommended high-dose systemic corticosteroids as the first-line treatment. While guideline-based treatment has been shown to be beneficial in patients with pemphigus, it has also become clear that this treatment is accompanied by significant burden and risk. The challenge for future pemphigus treatment is to maximize efficacy while minimizing risk during the course of the disease. In this regard, treatment targeting B cells is expected to become increasingly important as autoreactive B cells in pemphigus patients are thought to play a major role in the production of autoantibodies, which form the basis of the pathogenesis. The recent expansion of insurance coverage to rituximab, a monoclonal antibody against CD20, for refractory pemphigus in the USA, Europe, and Japan has opened up a new era of pemphigus treatment by enabling treatment strategies with drugs targeting B cells in patients. Here, we discuss the current status and future prospects of pemphigus treatment, focusing on rituximab and Bruton's tyrosine kinase inhibitors, which are expected to become essential drugs for pemphigus treatment in the future.
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Affiliation(s)
- Jun Yamagami
- Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
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3
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Yamagami J, Kurihara Y, Funakoshi T, Saito Y, Tanaka R, Takahashi H, Ujiie H, Iwata H, Hirai Y, Iwatsuki K, Ishii N, Sakurai J, Abe T, Takemura R, Mashino N, Abe M, Amagai M. Rituximab therapy for intractable pemphigus: A multicenter, open-label, single-arm, prospective study of 20 Japanese patients. J Dermatol 2023; 50:175-182. [PMID: 36196051 PMCID: PMC10091989 DOI: 10.1111/1346-8138.16597] [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: 07/17/2022] [Revised: 09/14/2022] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
This was a multicenter clinical trial of rituximab, a chimeric monoclonal IgG antibody directed against CD20, for the treatment of refractory pemphigus vulgaris and pemphigus foliaceus. In total, 20 patients were treated with two doses of rituximab (1000 mg; 2 weeks apart) on days 0 and 14. The primary end point was the proportion of patients who achieved complete or partial remission on day 168 following the first rituximab dose. Of the 20 enrolled patients, 11 (55%) and four (20%) achieved complete and partial remission, respectively; therefore, remission was achieved in a total of 15 patients (75.0% [95% confidence interval, 50.9%-91.3%]). It was demonstrated that the remission rate was greater than the prespecified threshold (5%). In addition, a significant improvement in clinical score (Pemphigus Disease Area Index) and decrease in serum anti-desmoglein antibody level were observed over time. Four serious adverse events (heart failure, pneumonia, radial fracture, and osteonecrosis) were recorded in two patients, of which only pneumonia was considered causally related with rituximab. The level of peripheral blood CD19-positive B lymphocytes was decreased on day 28 after rituximab treatment and remained low throughout the study period until day 168. Our results confirm the efficacy and safety of rituximab therapy for refractory pemphigus in Japanese patients.
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Affiliation(s)
- Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.,Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuichi Kurihara
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takeru Funakoshi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuko Saito
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Tanaka
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yoji Hirai
- Department of Dermatology, Okayama University School of Medicine, Okayama, Japan
| | - Keiji Iwatsuki
- Department of Dermatology, Okayama University School of Medicine, Okayama, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Jun Sakurai
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| | - Takayuki Abe
- Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan.,Yokohama City University School of Data Science, Yokohama, Japan
| | - Ryo Takemura
- Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
| | - Naomi Mashino
- Prescription Products Development Department, Zenyaku Kogyo Co., Ltd., Tokyo, Japan
| | - Masahiro Abe
- Prescription Products Development Department, Zenyaku Kogyo Co., Ltd., Tokyo, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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4
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Miyachi H, Konishi T, Hashimoto Y, Matsui H, Fushimi K, Inozume T, Yasunaga H. Clinical course and outcomes of pemphigus vulgaris and foliaceus: A retrospective study using a nationwide database in Japan. J Dermatol 2023; 50:212-221. [PMID: 36424909 DOI: 10.1111/1346-8138.16641] [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: 08/18/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
Pemphigus is a life-threatening autoimmune blistering disease. Patient characteristics, treatment courses, and outcomes remain unclear owing to its rarity. To describe the background, treatment, and outcomes of pemphigus, we identified 2598 patients with pemphigus vulgaris and 1186 patients with pemphigus foliaceus from a nationwide inpatient database in Japan. Patients with pemphigus vulgaris were younger (62 vs 72 years, P < 0.001), had fewer comorbidities, and were more likely to be admitted to high-volume hospitals (38% vs 30%, P < 0.001) than those with pemphigus foliaceus. Patients with pemphigus vulgaris had undergone more aggressive treatment, including steroid pulse therapy, intravenous immunoglobulin, or plasmapheresis, compared with those with pemphigus foliaceus (48% vs 42%, P = 0.001); specifically, in patients aged <70 years, the pemphigus vulgaris group was more likely to undergo aggressive treatment than the pemphigus foliaceus group (52% vs 45%), whereas there was no significant difference in patients aged ≥70 years (40% vs 40%). Immunosuppressive agents (30% vs 26%, P = 0.015) and analgesics, including opioids (45% vs 36%, P < 0.001), were used more frequently, whereas topical corticosteroids were used less frequently (32% vs 48%, P < 0.001) in patients with pemphigus vulgaris compared with those with pemphigus foliaceus. In-hospital mortality was lower in patients with pemphigus vulgaris than in those with pemphigus foliaceus (2.2% vs 4.0%, P = 0.002); in the comparison stratified by age, the mortality was equivalent among the two groups (0.6% in patients aged <70 years and 6.1% in those aged ≥70 years). Overall, patients with pemphigus vulgaris had a 10-day longer hospitalization period and higher hospitalization costs than those with pemphigus foliaceus. Our findings provide useful information for understanding the current trends in the management of pemphigus in Japan.
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Affiliation(s)
- Hideaki Miyachi
- Department of Dermatology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Inozume
- Department of Dermatology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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5
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Zeng FA, Wilson A, Sheriff T, Murrell DF. Side effects of steroid-sparing agents in patients with bullous pemphigoid and pemphigus: A systematic review. JAAD Int 2022; 9:33-43. [PMID: 36089938 PMCID: PMC9450124 DOI: 10.1016/j.jdin.2022.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 10/26/2022] Open
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6
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Ujiie H, Yamagami J, Takahashi H, Izumi K, Iwata H, Wang G, Sawamura D, Amagai M, Zillikens D. The pathogeneses of pemphigus and pemphigoid diseases. J Dermatol Sci 2021; 104:154-163. [PMID: 34916040 DOI: 10.1016/j.jdermsci.2021.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/22/2021] [Accepted: 11/06/2021] [Indexed: 12/21/2022]
Abstract
Autoimmune bullous diseases (AIBDs) are skin disorders which are mainly induced by autoantibodies against desmosomal or hemidesmosomal structural proteins. Previous studies using patients' samples and animal disease models identified target antigens and elucidated the mechanisms of blister formation. Pemphigus has been the subject of more active clinical and basic research than any other AIBD. These efforts have revealed the pathogenesis of pemphigus, which in turn has led to optimal diagnostic methods and novel therapies, such as rituximab. In bullous pemphigoid (BP), studies with passive-transfer mouse models using rabbit anti-mouse BP180 antibodies and studies with passive-transfer or active mouse models using autoantigen-humanized mice elucidated the immune reactions to BP180 in vivo. Recently, dipeptidyl peptidase-4 inhibitors have attracted attention as a trigger for BP. For epidermolysis bullosa acquisita (EBA), investigations using mouse models are actively under way and several molecules have been identified as targets for novel therapies. In this review, we give an overview and discussion of the recent progress in our understanding of the pathogenesis of pemphigus, BP, and EBA. Further studies on the breakdown of self-tolerance and on the identification of key molecules that are relevant to blister formation may expand our understanding of the etiology of AIBDs and lead to the development of novel therapeutic strategies.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Jun Yamagami
- Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Detlef Zillikens
- Center for Research on Inflammation of the Skin (CRIS), University of Lübeck, Lübeck, Germany; Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany, University of Lübeck, Lübeck, Germany
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7
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Shahrigharahkoshan S, Dadkhahfar S, Mozafari N, Shahidi-Dadras M. A review of reported infectious events following rituximab therapy in pemphigus patients. Dermatol Ther 2021; 35:e15264. [PMID: 34907628 DOI: 10.1111/dth.15264] [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: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022]
Abstract
Pemphigus is a rare autoimmune blistering condition that used to be fatal before the introduction of corticosteroid (CS) and immunosuppressive agents. Rituximab is a monoclonal anti-CD-20 antibody that induces the pathologic B-cells apoptosis with significant efficacy in the treatment of pemphigus. The application of rituximab can lead to infectious events. We aim to review the reported infectious events in pemphigus patients who previously received rituximab and classify them based on the causative agents. A thorough search of PubMed was conducted using the keywords "rituximab," "pemphigus," "infection," "viral disease," "viral infection," "complication," "efficacy" and their combinations also applying their equivalent Mesh terms and including the references cited in each study. All studies that mentioned at least one infectious event were included. A total of 77 infectious events in 68 patients were reported in the literature out of which the most reported causative agent was viral but the most fatal one found to be bacterial. Although rituximab therapy has shown promising results in controlling pemphigus patients mainly the refractory cases, given possible fatal outcomes, we believe the medical profile of the patients before initiating the therapy warrants careful examination to search for any risk factors or predisposing conditions.
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Affiliation(s)
| | - Sahar Dadkhahfar
- Skin research center, Shahid Beheshti University of medical sciences, Tehran, Iran
| | - Nikoo Mozafari
- Skin research center, Shahid Beheshti University of medical sciences, Tehran, Iran
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8
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Faraji H, Daneshpazhooh M, Ehsani AH, Mahmoudi H, Tavakolpour S, Aryanian Z, Aslani S, Khodaveisi H, Balighi K. Evaluating the risk-to-benefit ratio of using cotrimoxazole as a pneumocystis pneumonia preventative intervention among pemphigus patients treated with rituximab: A retrospective study with 494 patients. Dermatol Ther 2021; 35:e15257. [PMID: 34890103 DOI: 10.1111/dth.15257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/27/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Abstract
Rituximab is widely used as the first-line treatment for pemphigus patients. Since it depletes the B cells, it increases the risk of infections. Here, we evaluated the prophylactic efficacy of cotrimoxazole in decreasing the risk of pneumocystis pneumonia (PCP) infection in the pemphigus patients treated with rituximab. The medical records of confirmed pemphigus patients receiving rituximab were evaluated in two groups; those who received cotrimoxazole as a prophylactic after rituximab and patients who only received rituximab without any prophylaxis. The occurrence of PCP infection was determined in each group and compared. Medical records of 494 patients, including 301 women and 193 men, with the mean age of 46.74 years were analyzed. The phenotypes of the disease were mucocutaneous (n = 364), mucosal (n = 88), and cutaneous (n = 42). Among them, 235 cases had received cotrimoxazole as a prophylaxis and 259 patients did not. The incidence of PCP in total patients was 2 (0.4%), one in each group. Accordingly, no significant difference was observed in the incidence of PCP between two groups (p = 0.84). Also, no cotrimoxazole-related side effect was observed in the treated group. It seems that due to the low incidence of PCP in pemphigus patients treated with rituximab, prophylactic cotrimoxazole therapy is not necessary and it only increases the overall therapy cost and might cause cotrimoxazole-related adverse effects in some patients. However, regarding its probable beneficial effect in patients with long-term history of immunosuppressive therapy, more studies are required.
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Affiliation(s)
- Hannaneh Faraji
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hooshang Ehsani
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Zeinab Aryanian
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Saeed Aslani
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Khodaveisi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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9
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Mohammed Niamat Alla W, Mohamed Ali Ahmed B, Adam Essa ME, Abdalla Babker AE, Mohammed Elagib E. Vesiculobullous disease with Cutaneous Systemic Lupus Erythematosus Treated by Rituximab: A case report. Clin Case Rep 2021; 9:e04967. [PMID: 34691464 PMCID: PMC8517575 DOI: 10.1002/ccr3.4967] [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: 09/23/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/09/2022] Open
Abstract
Vesiculobullous lesions in systemic lupus erythematosus (SLE) are a rare cutaneous manifestation of cutaneous and/or systemic LE with variable presentation. The diagnosis of SLE-associated vesiculobullous diseases remains challenging, due to the poorly defined similarities and nosology in immunohistopathological and clinical and features.
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Affiliation(s)
| | | | - Mohammed Elmujtba Adam Essa
- Department of Clinical MedicineMedical and Cancer Research InstituteKhartoumSudan
- Faculty of MedicineAlfashir UniversityAlfashirSudan
| | | | - Elnour Mohammed Elagib
- Department of RheumatologySudan Medical Specialization BoardKhartoumSudan
- Department of Internal Medicine and RheumatologyOmdurman Military hospitalKhartoumSudan
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10
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Yamagami J, Ujiie H, Aoyama Y, Ishii N, Tateishi C, Ishiko A, Ichijima T, Hagihara S, Hashimoto K, Amagai M. A multicenter, open-label, uncontrolled, single-arm phase 2 study of tirabrutinib, an oral Bruton's tyrosine kinase inhibitor, in pemphigus. J Dermatol Sci 2021; 103:135-142. [PMID: 34376340 DOI: 10.1016/j.jdermsci.2021.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/02/2021] [Accepted: 07/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The treatment of pemphigus is based on systemic corticosteroid use and adjuvant therapies, but some patients are resistant to conventional therapy. Tirabrutinib is a highly selective oral Bruton's tyrosine kinase inhibitor that may be clinically effective in treating pemphigus by suppressing B-cell signaling. OBJECTIVE We investigated the efficacy and safety of tirabrutinib in patients with refractory pemphigus. METHODS This was a multicenter, open-label, single-arm phase 2 study of Japanese patients with refractory pemphigus receiving appropriate treatment with an oral corticosteroid and adjuvant therapies. Patients received postprandial oral tirabrutinib 80 mg once daily for 52 weeks. After 16 weeks of tirabrutinib treatment, the corticosteroid dose was tapered to ≤10 mg/day of prednisolone equivalent. RESULTS In total, 16 patients were evaluated (mean age, 52.5 years; 50 % male). The complete remission rate after 24 weeks of treatment (primary endpoint) was 18.8 % (3/16; 95 % confidence interval, 6.6 %-43.0 %). By Week 52, eight patients (50.0 %) achieved complete remission and 10 patients (62.5 %) achieved remission. Over 52 weeks of treatment, the mean prednisolone dose decreased from 17.03 to 7.65 mg/day. Incidences of adverse events (AEs) and adverse drug reactions were 87.5 % and 43.8 %, respectively. A relationship with tirabrutinib was ruled out for all serious AEs and Grade ≥3 AEs. CONCLUSION Treatment with tirabrutinib enabled remission and reduced oral corticosteroid exposure over time and did not result in any major safety concerns in patients with refractory pemphigus. Thus, oral tirabrutinib may be a new treatment option for patients with refractory pemphigus.
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Affiliation(s)
- Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yumi Aoyama
- Department of Dermatology, Kawasaki Medical School, Okayama, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, Kurume, Japan
| | - Chiharu Tateishi
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akira Ishiko
- Department of Dermatology, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Tomoki Ichijima
- Clinical Development Planning, Ono Pharmaceutical Co., Ltd., Osaka, Japan
| | - Shunsuke Hagihara
- Department of Statistical Analysis, Ono Pharmaceutical Co., Ltd., Osaka, Japan
| | - Koji Hashimoto
- Ehime University Graduate School of Medicine, Ehime, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.
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11
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Kanokrungsee S, Anuntrangsee T, Tankunakorn J, Srisuwanwattana P, Suchonwanit P, Chanprapaph K. Rituximab Therapy for Treatment of Pemphigus in Southeast Asians. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:1677-1690. [PMID: 33911853 PMCID: PMC8075311 DOI: 10.2147/dddt.s306046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/01/2021] [Indexed: 01/12/2023]
Abstract
Background Rituximab provides more effective and less adverse effects than the standard dose of corticosteroids, but evidence on its efficacy and safety in the Thai population is lacking. Objective To evaluate the efficacy and safety of rituximab in the treatment of pemphigus and also to determine prognostic factors linked to the treatment outcomes. Methods Pemphigus patients who received rituximab from November 2017 to December 2020 were retrospectively reviewed. The outcome was evaluated by using early (end of consolidation phase [ECP]) and late endpoints (complete remission [CR] on/off therapy, immunological remission [IR], and relapse). Adverse events were noted. Prognostic factors associated with remission and relapse were analyzed. Results Of 53 pemphigus patients, all attained ECP within 1.61 months. Almost 80% achieved CR on therapy within a median time of 6.36 months, while 33.9% reached CR off therapy in 19.74 months. Nearly half had IR within a median time of 6.88 months. Relapse occurred in 33.3% with a median time of 14 months. In multivariate analysis, receiving rituximab within 12 months of disease duration was more likely to achieve CR off therapy and IR (hazard ratio [HR] 3.79; 95% confidence interval [CI] 1.38, 10.42; P = 0.01 and HR 2.74; 95% CI 1.12, 6.69; P = 0.027, respectively), whereas older patients and positive anti-desmoglein 1 levels at the time of CR were predictive indicators for relapse (HR 1.07; 95% CI 1.01, 1.13; P = 0.036 and HR 4.38; 95% CI 1.24, 15.46; P = 0.022, respectively). The treatment-related adverse effects occurred in 33.9%. Conclusion Rituximab is effective and safe in Thai pemphigus patients. Early administration of rituximab was a predictor of clinical and immunological remission. Older age and persistently positive anti-Dsg1 were correlated with disease relapse.
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Affiliation(s)
- Silada Kanokrungsee
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Graduate School of Srinakharinwirot University, Bangkok, Thailand
| | - Tanaporn Anuntrangsee
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jutamas Tankunakorn
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ploychompoo Srisuwanwattana
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Chakri Naruebodindra Hospital, Mahidol University, Samut Prakan, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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12
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Cao M, Koneczny I, Vincent A. Myasthenia Gravis With Antibodies Against Muscle Specific Kinase: An Update on Clinical Features, Pathophysiology and Treatment. Front Mol Neurosci 2020; 13:159. [PMID: 32982689 PMCID: PMC7492727 DOI: 10.3389/fnmol.2020.00159] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022] Open
Abstract
Muscle Specific Kinase myasthenia gravis (MuSK-MG) is an autoimmune disease that impairs neuromuscular transmission leading to generalized muscle weakness. Compared to the more common myasthenia gravis with antibodies against the acetylcholine receptor (AChR), MuSK-MG affects mainly the bulbar and respiratory muscles, with more frequent and severe myasthenic crises. Treatments are usually less effective with the need for prolonged, high doses of steroids and other immunosuppressants to control symptoms. Under physiological condition, MuSK regulates a phosphorylation cascade which is fundamental for the development and maintenance of postsynaptic AChR clusters at the neuromuscular junction (NMJ). Agrin, secreted by the motor nerve terminal into the synaptic cleft, binds to low density lipoprotein receptor-related protein 4 (LRP4) which activates MuSK. In MuSK-MG, monovalent MuSK-IgG4 autoantibodies block MuSK-LRP4 interaction preventing MuSK activation and leading to the dispersal of AChR clusters. Lower levels of divalent MuSK IgG1, 2, and 3 antibody subclasses are also present but their contribution to the pathogenesis of the disease remains controversial. This review aims to provide a detailed update on the epidemiological and clinical features of MuSK-MG, focusing on the pathophysiological mechanisms and the latest indications regarding the efficacy and safety of different treatment options.
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Affiliation(s)
- Michelangelo Cao
- Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
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13
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Yamagami J, Kakuta R, Amagai M. A milestone in reaching the goal of complete remission off‐therapy in pemphigus. J Eur Acad Dermatol Venereol 2020; 34:e405. [DOI: 10.1111/jdv.16323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J. Yamagami
- Department of Dermatology Keio University School of Medicine Tokyo Japan
| | - R. Kakuta
- Department of Dermatology Keio University School of Medicine Tokyo Japan
| | - M. Amagai
- Department of Dermatology Keio University School of Medicine Tokyo Japan
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14
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Kaibuchi-Ando K, Sugiura K, Muro Y, Takahashi Y, Kojima S, Ishii N, Hashimoto T, Akiyama M. Successful treatment with i.v. immunoglobulin and rituximab for bronchiolitis obliterans associated with paraneoplastic pemphigus. J Dermatol 2020; 47:e368-e370. [PMID: 32656784 DOI: 10.1111/1346-8138.15496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kaori Kaibuchi-Ando
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazumitsu Sugiura
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Dermatology, Fujita Health University Hospital, Toyoake, Japan
| | - Yoshinao Muro
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatritics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Kojima
- Department of Pediatritics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Japan
| | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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