Updated consensus statement on the use of rituximab in patients with rheumatoid arthritis

Abstract

BackgroundSince initial approval for the treatment of rheumatoid arthritis (RA), rituximab has been evaluated in clinical trials involving various populations with RA. Information has also been gathered from registries. This report therefore updates the 2007 consensus document on the use of rituximab in the treatment of RA.MethodsPreparation of this new document involved many international experts experienced in the treatment of RA. Following a meeting to agree upon the core agenda, a systematic literature review was undertaken to identify all relevant data. Data were then interrogated by a drafting committee, with subsequent review and discussion by a wider expert committee leading to the formulation of an updated consensus statement. These committees also included patients with RA.ResultsThe new statement covers wide-ranging issues including the use of rituximab in earlier RA and impact on structural progression, and aspects particularly pertinent to rituximab such as co-medication, optimal dosage regimens, repeat treatment cycles and how to manage non-response. Biological therapy following rituximab usage is also addressed, and safety concerns including appropriate screening for hepatitis, immunoglobulin levels and infection risk. This consensus statement will support clinicians and inform patients when using B-cell depletion in the management of RA, providing up-to-date information and highlighting areas for further research.ConclusionNew therapeutic strategies and treatment options for RA, a chronic destructive and disabling disease, have expanded over recent years. These have been summarised in general strategic suggestions and specific management recommendations, emphasising the importance of expedient disease-modifying antirheumatic drug implementation and tight disease control. This consensus statement is in line with these fundamental principles of management.

Is Newer Safer? Adverse Events Associated with First-Line Therapies for ANCA-Associated Vasculitis and Lupus Nephritis

“…It is unclear whether the development of serum sickness is related to the development of human antichimeric antibodies to rituximab. Rare cases of JC virusassociated progressive multifocal leukoencephalopathy have been reported in rituximab-treated patients (reported incidence ,1:20,000 with extensive use in rheumatoid arthritis [26]), but it is not clear whether there is a true association between rituximab and development of progressive multifocal leukoencephalopathy. Noninfectious pulmonary toxicity has also been reported in rituximabtreated patients (three cases reported in patients with rheumatoid arthritis) (48,49).…”

“…The reason for the latter observation is unclear. Although rituximab has been associated with increased long-term risk of solid malignancies in patients with lymphoma (32), this association has not been shown in the rheumatoid arthritis population (26,33). Patients should be educated about these risks when choosing between treatment regimens.…”

“…The reactivation of hepatitis B virus with rituximab use for rheumatoid arthritis and AAV has been published in case reports, but the large clinical trials with rituximab in rheumatoid arthritis required hepatitis B screening before treatment (26). Extrapolating from this experience, hepatitis B screening should be conducted prior to rituximab therapy.…”

Tocilizumab for Severe Chronic Anterior Uveitis Associated with Juvenile Idiopathic Arthritis in a Pediatric Patient

“…The onset of action of rituximab is variable and a delay of up to 4 months has been described in various autoimmune diseases. 9 Our patient's initial improvement following the rituximab infusions was likely due to serial periocular steroid injections that were necessary to control a significant uveitis flare-up.…”

Prevention of Infection in Lupus Patients

“…In patients in whom rituximab treatment is planned, Ig levels should be tested before administration. If low baseline levels are detected, they should be monitored periodically, particularly in those at high risk, such as elderly patients or those undergoing concomitant glucocorticoid treatments [37].…”