Management of therapy-resistant systemic lupus erythematosus with rituximab: report of a case and review of the literature

Efficacy of cyclosporin-A in the long-term management of thrombocytopenia associated with systemic lupus erythematosus

Thrombocytopenia frequently complicates systemic lupus erythematosus (SLE), and its long-term management may be problematic. Intravenous immunoglobulins and high doses of steroids are often effective as induction therapy, but thrombocytopenia frequently relapses during steroid tapering. Several immunosuppressive agents have been evaluated as induction or maintenance therapy in small series or in case reports. We describe six consecutive unselected SLE patients where cyclosporin-A (CyA) was effective and safe in the long-term management of thrombocytopenia and allowed steroid tapering. One relapse occurred during CyA reduction and responded to CyA dose adjustment. Steroids could be stopped in three out of six patients, and were maintained at very low doses in the remaining patients. CyA was stopped in one patient after one year of treatment, without relapse at month 11+ from discontinuation. No severe side effects were documented. Overall, these data suggest that CyA may prove to be an effective and safe therapeutic option for SLE-related thrombocytopenia.

Anti B-cell therapy against refractory thrombocytopenia in SLE and MCTD patients: long-term follow-up and review of the literature

OBJECTIVE

The objective of this study was to retrospectively evaluate the clinical and immunological effects of anti-B cell treatment in patients with systemic lupus erythematosus (SLE) and mixed connective-tissue disease (MCTD) with autoimmune thrombocytopenia (AITP) refractory to conventional immunosuppressive treatment.

METHODS

Rituximab (RTX) was added to the ongoing treatment of 16 patients (median age 36 years, range 17-84, all female) with treatment-resistant AITP. Thirteen patients had SLE and three had MCTD. RTX was given intravenously on four occasions during four consecutive weeks at a dose of 375 mg/m(2). Clinical and laboratory disease activity variables recorded at every follow-up visit were analyzed.

RESULTS

The median disease duration before RTX treatment was nine years (range 0.2-27) and the median post-treatment follow-up time was 28 months (range 3 to 92). Ten patients (63%) were treated repeatedly with RTX during the follow-up period. Complete depletion of B cells was achieved in 94% of cases one month after RTX treatment. A significant increase (p = 0.0001) of platelet counts was seen already after one month (median 58 × 10(9)/ml vs 110 × 10(9)/ml) whereas within three months platelet counts normalized in 10 patients (median 223 × 10(9)/ml). Three patients did not respond to RTX treatment (median platelet count 69 × 10(9)/ml). High titers of anti-platelet antibodies were detected in seven patients before RTX treatment, and the autoantibody titers decreased significantly (p < 0.03) after RTX treatment in six of these patients who also achieved complete remission. A review of the literature revealed 24 articles including 18 case reports, one retrospective cohort study and five prospective studies documenting the outcomes of 65 RTX-treated patients with SLE- or MCTD-related thrombocytopenia with an overall treatment response rate of 80%. In conclusion, these findings indicate that RTX is an additional potent therapeutic treatment option for SLE patients with AITP refractory to conventional immunosuppressive treatment whereas best response may be expected in patients with high titers of anti-platelet antibodies at baseline.

Beyond the LUNAR trial. Efficacy of rituximab in refractory lupus nephritis

BACKGROUND

The treatment of lupus nephritis (LN) remains problematic because the current treatment regimen based on unspecific immunosuppressants such as steroids, cyclophosphamide and mycophenolate has significant side effects and is often inefficient. B-cell ablation with the chimeric anti-CD20 antibody rituximab (RTX) has been considered as an alternative treatment option but the randomized controlled LUNAR trial failed to show any additive effect of RTX beyond a steroid-mycophenolate mofetil (MMF) combination for LN type III/IV/V in incident patients. At present, no such trial is available for the use of RTX in refractory LN.

METHODS

We analysed existing evidence on this topic by performing a systematic analysis of reports that document outcomes of RTX treatment for refractory LN.

RESULTS

Out of 233 reports, we selected 26 for analysis, which described 300 patients with a mean follow-up of 60 weeks. The complete or partial response criteria were met by 87% of patients with LN class III, 76% with class IV and 67% with class V, respectively. Mixed classes responded in 76% of patients. RTX induced complete responses in 60% (type III), 45% (type IV), 40% (type V) and 24% (mixed types), respectively.

CONCLUSIONS

Our systematic review of existing evidence suggests that RTX effectively induces remission of LN in patients who have not achieved remission with standard therapies. Another randomized controlled trial should be conducted to test the efficacy of RTX in refractory LN.

Rituximab in systemic lupus erythematosusA systematic review of off-label use in 188 cases

The complexity of the therapeutic approach in systemic lupus erythematosus (SLE) is increased by the large number of patients who do not respond to the first-line therapies and by relapses after initial clinical remission. In these patients, second-line drugs are often prescribed according to individual clinical decisions. The emergence of biological therapies has increased the therapeutic armamentarium available in these complex situations, but their use is limited by the lack of licensing. Available data on the use of rituximab in SLE rely on a large number of case reports and some observational studies. We analyzed current evidence on the therapeutic use of rituximab in adult SLE patients by a systematic review of reports included in the PubMed database between 2002 and 2007. A total of 188 SLE patients treated with rituximab were identified; 171 (91%) patients showed a significant improvement in one or more of the systemic SLE manifestations. There were 103 patients with lupus nephritis, with an overall rate of therapeutic response of renal involvement of 91%. Adverse events were reported in 44 (23%) patients; the most frequent were infections (19%). Although it is not yet possible to make definite recommendations, the global analysis of all cases reported to date support the off-label use of rituximab in severe, refractory SLE cases, whereas its use as a first-line therapy or in patients with a predominantly mild form of the disease is not advised.

Modulatory effects of 1,25-dihydroxyvitamin D3 on human B cell differentiation

1,25-Dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) can modulate immune responses, but whether it directly affects B cell function is unknown. Patients with systemic lupus erythematosus, especially those with antinuclear Abs and increased disease activity, had decreased 1,25(OH)(2)D(3) levels, suggesting that vitamin D might play a role in regulating autoantibody production. To address this, we examined the effects of 1,25(OH)(2)D(3) on B cell responses and found that it inhibited the ongoing proliferation of activated B cells and induced their apoptosis, whereas initial cell division was unimpeded. The generation of plasma cells and postswitch memory B cells was significantly inhibited by 1,25(OH)(2)D(3), although the up-regulation of genetic programs involved in B cell differentiation was only modestly affected. B cells expressed mRNAs for proteins involved in vitamin D activity, including 1 alpha-hydroxylase, 24-hydroxylase, and the vitamin D receptor, each of which was regulated by 1,25(OH)(2)D(3) and/or activation. Importantly, 1,25(OH)(2)D(3) up-regulated the expression of p27, but not of p18 and p21, which may be important in regulating the proliferation of activated B cells and their subsequent differentiation. These results indicate that 1,25(OH)(2)D(3) may play an important role in the maintenance of B cell homeostasis and that the correction of vitamin D deficiency may be useful in the treatment of B cell-mediated autoimmune disorders.