ABSTRACT
Serum levels of B cell-activating factor (BAFF) rise following rituximab (RTX) therapy in patients with rheumatoid arthritis (RA). Initiation of naive B cell return to the periphery and autoreactive B cell expansion leading to relapse after RTX may therefore be linked to interactions between BAFF and BAFF-binding receptors (BBR). Relationships between serum BAFF and BBR expression [(BAFFR, calcium signal modulating cyclophilic ligand interactor (TACI) and B cell maturation antigen (BCMA)] were determined on B cell subsets, defined using immunoglobulin (Ig)D/CD38. Twenty pre-RTX and 18 RA patients relapsing after B cell depletion were included. Results were analysed with respect to timing of relapse up to 7 months after peripheral B cell return (≥ 5 B cells/µl) and to serum BAFF levels. After B cell return, B cell populations from relapsing patients had significantly lower BAFFR+ expression compared to HC and pre-RTX patients. The percentage of BAFFR+ B cells increased with time after B cell return and was correlated inversely with serum BAFF levels. BAFFR expression remained reduced. The percentage of TACI+ memory B cells were lower in RA patients after RTX compared with healthy controls (HC). BCMA expression (% and expression) did not differ between patients and HC. Relapse following B cell return appeared largely independent of the percentage of BAFFR+ or percentage of BCMA+ B cells or serum BAFF levels. The lower percentage of TACI+ memory B cells may reduce inhibitory signalling for B cell differentiation. In patients relapsing at longer periods after B cell return, recovery of the B cell pool was more complete, suggesting that selection or expansion of autoreactive B cells may be needed to precipitate relapse.
Subject(s)
Arthritis, Rheumatoid , B-Cell Activation Factor Receptor , B-Lymphocyte Subsets , Gene Expression Regulation , Immunologic Memory , Rituximab/administration & dosage , Arthritis, Rheumatoid/blood , Arthritis, Rheumatoid/drug therapy , Arthritis, Rheumatoid/immunology , Arthritis, Rheumatoid/pathology , B-Cell Activating Factor/blood , B-Cell Activating Factor/immunology , B-Cell Activation Factor Receptor/blood , B-Cell Activation Factor Receptor/immunology , B-Cell Maturation Antigen/blood , B-Cell Maturation Antigen/immunology , B-Lymphocyte Subsets/immunology , B-Lymphocyte Subsets/metabolism , B-Lymphocyte Subsets/pathology , Gene Expression Regulation/drug effects , Gene Expression Regulation/immunology , Immunologic Memory/drug effects , Immunologic Memory/immunology , Transmembrane Activator and CAML Interactor Protein/blood , Transmembrane Activator and CAML Interactor Protein/immunologyABSTRACT
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a heterogeneous condition of unknown aetiology characterized by multiple symptoms including fatigue, post-exertional malaise and cognitive impairment, lasting for at least 6 months. Recently, two clinical trials of B cell depletion therapy with rituximab (anti-CD20) reported convincing improvement in symptoms. A possible but undefined role for B cells has therefore been proposed. Studies of the relative percentages of B cell subsets in patients with ME/CFS have not revealed any reproducible differences from healthy controls (HC). In order to explore whether more subtle alterations in B cell subsets related to B cell differentiation exist in ME/CFS patients we used flow cytometry to immunophenotype CD19⺠B cells. The panel utilized immunoglobulin (Ig)D, CD27 and CD38 (classical B cell subsets) together with additional markers. A total of 38 patients fulfilling Canadian, Centre for Disease Control and Fukuda ME/CFS criteria and 32 age- and sex-matched HC were included. We found no difference in percentages of classical subsets between ME/CFS patients and HC. However, we observed an increase in frequency (P < 0·01) and expression (MFI; P = 0·03) of CD24 on total B cells, confined to IgD⺠subsets. Within memory subsets, a higher frequency of CD21⺠CD38â» B cells (> 20%) was associated with the presence of ME/CFS [odds ratio: 3·47 (1·15-10·46); P = 0·03] compared with HC, and there was a negative correlation with disease duration. In conclusion, we identified possible changes in B cell phenotype in patients with ME/CFS. These may reflect altered B cell function and, if confirmed in other patient cohorts, could provide a platform for studies based on clinical course or responsiveness to rituximab therapy.
Subject(s)
ADP-ribosyl Cyclase 1/metabolism , B-Lymphocyte Subsets/immunology , Fatigue Syndrome, Chronic/immunology , Membrane Glycoproteins/metabolism , Tumor Necrosis Factor Receptor Superfamily, Member 7/metabolism , Adolescent , Adult , Aged , Antigens, CD19/metabolism , Antigens, CD20/immunology , Biomarkers , CD24 Antigen/immunology , Cross-Sectional Studies , Female , Flow Cytometry , Humans , Immunoglobulin D/immunology , Immunologic Factors/therapeutic use , Male , Middle Aged , Receptors, Complement 3d/immunology , Rituximab/therapeutic use , Young AdultABSTRACT
Autoantibodies inhibiting the activity of the metalloproteinase, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13), underlie the pathogenesis of thrombotic thrombocytopenic purpura (TTP). Rituximab (RTX) combined with plasma-exchange (PEX) is an effective treatment in TTP. Patients can remain in remission for extended periods following PEX/RTX, and this is associated with continuing reduction in antibodies to ADAMTS13. Factors controlling B cell differentiation to autoantibody production, including stimulation through the B cell receptor and interactions with the B cell-activating factor (BAFF), may thus impact length of remission. In this cross-sectional study, we measured naive and memory B cell phenotypes [using CD19/immunoglobulin (Ig)D/CD27] following PEX/RTX treatment in TTP patients at B cell return (n=6) and in 12 patients in remission 10-68 months post-RTX. We also investigated relationships among serum BAFF, soluble CD23 (sCD23(-) a surrogate measure of acquiring B memory (CD27(+) ) phenotype) and BAFF receptor (BAFF-R) expression. At B cell return after PEX/RTX, naive B cells predominated and BAFF-R expression was reduced compared to healthy controls (P<0.001). In the remission group, despite numbers of CD19(+) B cells within normal limits in most patients, the percentage and absolute numbers of pre-switch and memory B cells remained low, with sCD23 levels at the lower end of the normal range. BAFF levels were correlated inversely with BAFF-R expression and time after therapy. In conclusion, the long-term effects of RTX therapy in patients with TTP included slow regeneration of memory B cell subsets and persistently reduced BAFF-R expression across all B cell subpopulations. This may reflect the delay in selection and differentiation of potentially autoreactive (ADAMTS13-specific) B cells, resulting in relatively long periods of low disease activity after therapy.
Subject(s)
Antibodies, Monoclonal, Murine-Derived/therapeutic use , B-Lymphocyte Subsets/drug effects , B-Lymphocytes/drug effects , Purpura, Thrombotic Thrombocytopenic/therapy , ADAM Proteins/immunology , ADAMTS13 Protein , Adolescent , Adult , Aged , Aged, 80 and over , Antigens, CD/metabolism , Autoantibodies/metabolism , B-Cell Activating Factor/blood , B-Cell Activation Factor Receptor/genetics , B-Cell Activation Factor Receptor/metabolism , B-Lymphocyte Subsets/immunology , B-Lymphocytes/immunology , Biomarkers/metabolism , Cell Differentiation/drug effects , Cells, Cultured , Cross-Sectional Studies , Disease Progression , Female , Follow-Up Studies , Gene Expression Regulation/drug effects , Humans , Immunologic Memory , Immunophenotyping , Lymphocyte Activation/drug effects , Male , Middle Aged , Plasma Exchange , Purpura, Thrombotic Thrombocytopenic/immunology , Rituximab , Treatment Outcome , Young AdultABSTRACT
B-cell depletion therapy (BCDT) based on rituximab (RTX) induces clinical remission in a majority of seropositive patients with Rheumatoid arthritis (RA). However, all patients eventually relapse. The aim of this study was to determine whether dynamic changes in combinations of serological measures of B-cell activation were associated over up to three cycles of BCDT. We included only RA patients who gave an adequate clinical response, as measured by DAS28. Twenty three patients were studied over 1 cycle, 21 over 2, and 15 over 3 cycles of BCDT. Serum analytes including isotypes of Rheumatoid factors (RhF) and anti-citrullinated protein/peptide antibodies (ACPA), B-cell activating factor (BAFF), serum free light chains (SFLC), soluble CD23 (sCD23), antibodies to tetanus toxoid (TT) and to pneumococcal capsular polysaccharide (PCP) were measured by ELISA at 4 key points in each cycle, namely: Baseline (pre-RTX in each cycle); when B-cell depleted (CD19+B-cells < 5/µl); at B-cell return (CD19+B-cells ≥ 5/µl); and at clinical relapse (ΔDAS28 > 1.2). SFLC were used as a measure of plasmablast activity. As sCD23 is cleaved from naïve B-cells coincident with attaining CD27 expression, levels were used as a novel measure of maturation of B-cells to CD27+. The most consistent changes between baseline and B-cell depletion within all 3 cycles were in SFLC, sCD23 and IgM-RhF which fell and in BAFF levels which rose. After 3 complete cycles of BCDT, both IgM autoantibodies and IgG-CCP had decreased, BAFF levels were higher (all p < 0.05); other analytes remained unchanged compared with baseline. Dynamic changes in λSFLC, sCD23, IgM-RhF and BAFF were also consistently associated with relapse in patients with longer clinical responses after B-cell return. Incremental rises in sCD23 levels in cycles 2 and 3 were correlated with time to relapse. Repopulation of the periphery after BCDT is initiated by naïve B-cells and precedes relapse. Our study showed that differentiation into plasmablasts, attended by sCD23 and SFLC production and IgM-RhF specificity may be required to precipitate relapse in patients experiencing longer responses after RTX. These studies also provide novel information related to the resumption of autoimmune responses and their association with B-cell kinetics following BCDT.
Subject(s)
Arthritis, Rheumatoid/therapy , B-Lymphocyte Subsets/immunology , Lymphocyte Depletion , Plasma Cells/immunology , Adult , Aged , Aged, 80 and over , Antibodies, Monoclonal, Murine-Derived/therapeutic use , Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/genetics , Arthritis, Rheumatoid/immunology , Arthritis, Rheumatoid/pathology , Autoantibodies/blood , B-Cell Activating Factor/genetics , B-Cell Activating Factor/immunology , B-Lymphocyte Subsets/drug effects , B-Lymphocyte Subsets/pathology , Biomarkers/metabolism , Cell Differentiation , Gene Expression , Humans , Immunoglobulin M/genetics , Immunoglobulin M/immunology , Lymphocyte Activation , Middle Aged , Plasma Cells/drug effects , Plasma Cells/pathology , Receptors, IgE/genetics , Receptors, IgE/immunology , Recurrence , Remission Induction , Rituximab , Tumor Necrosis Factor Receptor Superfamily, Member 7/genetics , Tumor Necrosis Factor Receptor Superfamily, Member 7/immunologyABSTRACT
Cutaneous manifestations occur frequently in systemic lupus erythematosus (SLE) and are pathognomonic in subacute-cutaneous lupus erythematosus (SCLE) and chronic cutaneous lupus erythematosus (CCLE). Although B-cell depletion therapy (BCDT) has demonstrated efficacy in SLE with visceral involvement, its usefulness for patients with predominant skin manifestations has not been fully established. In this single-centre, retrospective study 14 consecutive SLE, one CCLE and two SCLE patients with recalcitrant skin involvement were treated with 2 × rituximab 1 g, and 1 × cyclophosphamide 750 mg. Six months after BCDT, nine of 17 (53%) patients were in complete (CR) or partial remission (PR). Relapses occurred in 12 patients (71%) at a mean time of 10 ± 1.8 months after BCDT. A second cycle of BCDT achieved a more sustained remission in seven of nine patients (78%) lasting for a mean time of 18.4 ± 2.7 months. Minor adverse events were experienced by three patients. Mean follow-up was 30 months. Our own results and the literature review demonstrate that BCDT based on rituximab is well tolerated and may be effective for cutaneous lesions of lupus erythematosus. Randomized controlled trials are necessary to further evaluate the value of BCDT for this group of patients.
Subject(s)
Antibodies, Monoclonal, Murine-Derived/therapeutic use , B-Lymphocytes/immunology , Lupus Erythematosus, Cutaneous/drug therapy , Lupus Erythematosus, Systemic/drug therapy , Adult , Antibodies, Monoclonal, Murine-Derived/adverse effects , Cohort Studies , Female , Follow-Up Studies , Humans , Immunologic Factors/adverse effects , Immunologic Factors/therapeutic use , Lupus Erythematosus, Cutaneous/immunology , Lupus Erythematosus, Systemic/immunology , Male , Middle Aged , Recurrence , Retrospective Studies , RituximabABSTRACT
AIM: To review available data regarding the safety of biological therapies during pregnancy, focusing on agents used in rheumatology. METHODS: A systematic literature search was carried out to identify all studies with human data on fetal and/or child outcomes following exposure to biologic agents during pregnancy. RESULTS: A total of 65 publications out of 745 identified references were included in the review. CONCLUSIONS: Experience with pregnancy exposure to anti-TNF agents has been slowly accumulating. Although the numbers are small and with few controlled studies the reviewed data suggest that the overall risk of TNF antagonists is relatively low and benefits may outweigh the risks of drug exposure to the fetus. Information on other biologic agents is still very limited. Large controlled studies with longer follow-up periods will be necessary before firm conclusions about the safety of biologics du-ring conception and pregnancy can be drawn.
Subject(s)
Pregnancy Complications/drug therapy , Rheumatic Diseases/drug therapy , Tumor Necrosis Factor Inhibitors , Biological Therapy , Female , Humans , PregnancyABSTRACT
B cell depletion therapy with rituximab (BCDT) is a licensed treatment for rheumatoid arthritis and has shown promising results in the treatment of severe, refractory patients with other autoantibody-associated autoimmune diseases (AAID). The exact role that B cells play in the pathogenesis of AAID and consequently the mechanisms by which BCDT is effective are not known. The two more widely discussed hypotheses are that BCDT is effective because it removes the precursors of plasma cells producing pathogenic autoantibody species, or because it depletes a critical mass of autoreactive B cell clones that present antigen to pathogenic autoreactive T cells. This review will focus on the effects of BCDT and whether the response of patients with AAID to BCDT could be due ultimately to its effects on autoantibodies. A better knowledge of the main role that B cells play in the pathogenesis of the different diseases and a better understanding of the most likely mechanism of relapse following an earlier response to BCDT would help to guide further developments of B cell targeting therapies and potentially increase the chance of designing a protocol that could induce a long-term remission.
Subject(s)
Autoantibodies/immunology , Autoimmune Diseases/immunology , B-Lymphocytes/physiology , Animals , Antigen Presentation , Autoimmune Diseases/therapy , Humans , Immunotherapy/methods , Lymphocyte DepletionABSTRACT
OBJECTIVE: To assess the relationships between serum B lymphocyte stimulator (BLyS) levels, autoantibody profile and clinical response in patients with systemic lupus erythematosus (SLE) following rituximab-based B cell depletion therapy (BCDT). METHODS: A total of 25 patients with active refractory SLE were followed for >or=1 year following BCDT. Disease activity was assessed using the British Isles Lupus Assessment Group (BILAG) system, and serum levels of BLyS and autoantibodies to dsDNA and extractable nuclear antigens (ENA) measured by ELISA. Serum immunoglobulins and anti-dsDNA antibodies were assessed for expression of the 9G4 idiotope (indicating VH4-34 germline gene origin). RESULTS: Following BCDT, all patients depleted in the peripheral blood and improved clinically for >or=3 months. Pre-BCDT BLyS levels were quantifiable (median 1.9 ng/ml) in 18/25 patients and rose in most patients at 3 months post-BCDT (median 4.15 ng/ml). Nine patients, all with quantifiable pre-BCDT serum BLyS, experienced a disease flare within 1 year. This group of patients was more likely to harbour anti-Ro/SSA antibodies (odds ratio 1.76; p = 0.06) with higher serum levels (p = 0.0027; Mann-Whitney U test). Serum levels of anti-ribonucleoprotein (RNP)/Sm were also higher in this group (p<0.05). Expression of VH4-34 by serum immunoglobulins and anti-dsDNA antibodies had no predictive value for the length of clinical response. CONCLUSIONS: Patients with SLE with an expanded autoantibody profile and raised BLyS levels at baseline had shorter clinical responses to BCDT. This may reflect a greater propensity to, and degree of, epitope spreading in such patients and suggests that treatment regimens beyond BCDT may be necessary to induce long-lasting clinical remissions in these individuals.
Subject(s)
Autoantibodies/blood , B-Cell Activating Factor/blood , B-Lymphocytes/immunology , Lupus Erythematosus, Systemic/drug therapy , Lymphocyte Depletion/methods , Antibodies, Antinuclear/blood , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Antirheumatic Agents/therapeutic use , Follow-Up Studies , Genes, Immunoglobulin Heavy Chain/immunology , Humans , Immunoglobulin G/blood , Immunoglobulin M/blood , Lupus Erythematosus, Systemic/immunology , Lymphocyte Count , Recurrence , Rituximab , Severity of Illness Index , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: B cell depletion therapy (BCDT) has recently been used with success to treat patients with rheumatoid arthritis and systemic lupus erythematosus (SLE). As antiphospholipid antibodies have been implicated in the pathogenesis of the antiphospholipid syndrome (APS), we asked the question whether BCDT affects levels of IgG anticardiolipin antibodies (aCL) in our cohort of 32 SLE patients given this treatment. METHODS: We identified seven SLE patients who had undergone BCDT and had had at least two moderate positive aCL titres at least 12 weeks apart. Of these only one patient had APS. IgG aCL were measured at time 0 and 6-9 months post BCDT. RESULTS: At time 0, the mean IgG aCL level was 20.6 standardized IgG antiphospholipid units (GPLU) (range (SD) 10-32, (10.1), normal level <5). At 6-9 months post depletion the IgG aCL levels in six of the seven patients was undetectable and in the other patient the level reduced from 25 GPLU to 15 GPLU (p<0.005, two-tailed paired t test). At baseline, only one patient had a mildly positive anti-beta(2)-glycoprotein I (beta(2)GPI) antibody level at 30% (compared to an in-house standard), which fell to 5% post-BCDT. CONCLUSIONS: This small observational study in patients with SLE is the first to demonstrate that BCDT results in a significant reduction in levels of IgG aCL.
Subject(s)
Antibodies, Anticardiolipin/blood , B-Lymphocytes/immunology , Lupus Erythematosus, Systemic/therapy , Lymphocyte Depletion , Follow-Up Studies , Humans , Immunoglobulin G/blood , Lupus Erythematosus, Systemic/immunology , Severity of Illness Index , Treatment OutcomeABSTRACT
OBJECTIVE: To assess safety and efficacy of repeated B-cell depletion with rituximab in patients with rheumatoid arthritis (RA). METHODS: Thirty-seven patients with refractory RA entered into a programme of repeated B-lymphocyte depletion (up to 5 cycles, 89 cycles in total) with protocols based on the anti-CD20 monoclonal antibody, rituximab, have been observed over periods of >5 yrs (n = 22) or 3-5 yrs (n = 14). RESULTS: Twenty two subjects have been followed up for >5 yrs. Average duration of benefit per cycle was 15 months (maximum 43 months), and time to re-treatment 20 months. Nineteen patients remain on the programme. Patients were withdrawn for lack of efficacy (n = 5), hypersensitivity infusion reaction (n = 1), brevity of response (n = 8), or occurrence of adverse respiratory events (n = 1). Sixteen major lower respiratory events occurred during the 180 patient-yrs of follow-up. Of these only one had low IgG. In patients receiving rituximab +/- cyclophosphamide (cy) carcinomata have developed as follows: breast (3, +cy), ovary (1, +cy), transitional cell (1, +cy), and renal cell (1, -cy). Falls in total immunoglobulin levels to below the normal range occurred in 12 patients for IgM (undetectable levels in three after repeated cycles), seven for IgG and one for IgA, not taking into account patients who started off with low immunoglobulin levels before the first cycle. CONCLUSION: Repeated B-lymphocyte depletion over a 5-yr period appears to be an acceptable and relatively well-tolerated therapy in RA with a relatively high rate of continuation. Long-term effects on immunoglobulin levels require surveillance.
Subject(s)
Antibodies, Monoclonal/administration & dosage , Antirheumatic Agents/administration & dosage , Arthritis, Rheumatoid/drug therapy , B-Lymphocytes/drug effects , Lymphocyte Depletion/methods , Adult , Aged , Aged, 80 and over , Antibodies, Monoclonal/adverse effects , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Antirheumatic Agents/adverse effects , Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/blood , Arthritis, Rheumatoid/immunology , B-Lymphocytes/immunology , C-Reactive Protein/metabolism , Drug Administration Schedule , Drug Evaluation , Female , Follow-Up Studies , Humans , Immunoglobulins/blood , Male , Middle Aged , Rituximab , Treatment OutcomeABSTRACT
OBJECTIVE: To assess the presence and phenotype of B-lineage cells in the bone marrow (BM) of rheumatoid arthritis (RA) patients after rituximab therapy. METHODS: Six patients were studied. BM aspirates were collected 3 months after the treatment and analysed using the four-colour flow cytometry. RESULTS: CD19+ (B-lineage) cells in BM samples varied from 0.1 to 3.25% in the lymphoid gate. CD34+ cells varied from 1.23 to 4.86%. The proportion of CD34+ cells committed to the B-lineage varied between 0 and 42.19%. Pro-B-cells were undetectable in one case. The majority of B-cell precursors were pro-B-cells in Patients 5 and 6 (50 and 62% of CD19+ cells, respectively), pre-B-cells in Patients 3 and 4 (64 and 70%) and immature B-cells in Patient 1 (44%). Detectable CD20 expression on CD19+ cells was either low or absent. Plasma cells varied from 0.01 to 0.36% of the total nucleated cells. There was a trend towards longer duration of clinical response in patients with evidence of more complete depletion in BM. CONCLUSION: In this small cohort of RA patients treated with rituximab, differences in proportion and phenotype of CD19+ BM cells were detected. These differences suggest variation in the degree of depletion achieved and correlate with time to relapse. Although pro-B-cells are not targeted directly by rituximab as they do not express CD20, the levels were unexpectedly low.
Subject(s)
Antibodies, Monoclonal/pharmacology , Arthritis, Rheumatoid/immunology , B-Lymphocyte Subsets/drug effects , Bone Marrow Cells/drug effects , Lymphocyte Depletion/methods , Adult , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Antigens, CD20/metabolism , Antirheumatic Agents/pharmacology , Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/drug therapy , Bone Marrow Cells/immunology , Female , Flow Cytometry/methods , Follow-Up Studies , Humans , Immunophenotyping , Lymphocyte Count , Male , Middle Aged , Plasma Cells/drug effects , RituximabABSTRACT
OBJECTIVE: Autoantibody production in patients with systemic lupus erythematosus (SLE) is associated with abnormalities of B cell function and phenotype. Clinical responses to B cell depletion therapy (BCDT), based on rituximab, are encouraging. Therefore, we undertook this study to investigate the effect of BCDT on antibody profiles. METHODS: Serial sera from 16 patients with active, refractory SLE were assayed for antinucleosome antibodies, anti-double-stranded DNA (anti-dsDNA), anti-extractable nuclear antigen, anti-tetanus toxoid, and antibodies to pneumococcal capsular polysaccharide for at least 1 year following BCDT. Anti-dsDNA antibodies derived from the V(H)4.34 immunoglobulin germ line gene (9G4+) were also measured. RESULTS: All patients achieved peripheral B cell depletion and improved clinically for at least 3 months. Antinucleosome and anti-dsDNA antibodies decreased to a mean +/- SD of 64 +/- 37% and 38 +/- 33% of baseline values, respectively, by 6-8 months post-BCDT. Levels of other autoantibodies and antimicrobial antibodies were generally unchanged. In the 9 of 16 patients who were still well at 1 year, anti-dsDNA antibodies fell to 42 +/- 36% of baseline values at 6-8 months and to 37 +/- 33% at 10-14 months. In patients who had disease flares within 1 year of BCDT, levels of these antibodies decreased to 60 +/- 40% and 83 +/- 93% of baseline values at 6-8 months and at 10-14 months, respectively. Circulating anti-dsDNA antibodies were positive for 9G4 expression in 4 of 6 patients tested, and flares in 2 of these patients were accompanied by rises in 9G4+ anti-dsDNA antibodies. CONCLUSION: These observations suggest that B cell clones committed to producing antinucleosome and anti-dsDNA antibodies, including the V(H)4.34 subpopulation of anti-dsDNA antibodies, have a relatively rapid turnover compared with B cell clones producing other antibodies. There was also a trend toward a greater and more sustained decrease in anti-dsDNA antibodies in patients with clinical benefit lasting >1 year.
Subject(s)
Autoantibodies/blood , B-Lymphocytes/cytology , Leukocyte Reduction Procedures , Lupus Erythematosus, Systemic/immunology , Lupus Erythematosus, Systemic/therapy , Adolescent , Adult , Antibodies, Bacterial/blood , B-Lymphocytes/immunology , DNA/immunology , Female , Humans , Male , Nucleosomes/immunologyABSTRACT
B cell depletion therapy was introduced for auto-antibody associated rheumatic disease in 1998. Encouraging pilot studies in rheumatoid arthritis were followed by randomised controlled trials confirming major benefit. Licensing for use in patients unable to benefit from tumour necrosis factor alpha (TNFalpha) neutralising agents is envisaged shortly. Open studies in other disorders, in particular systemic lupus erythematosus (SLE), have also suggested benefit and its use in life-threatening situations is becoming widespread. Toxicity appears to compare favourably with other agents, but respiratory problems may be more common. Repeated therapy is effective, but may lead to hypogammaglobulinemia. Rituximab is currently the main agent used but other agents are in development. Optimal protocols are not well characterised and will probably be different for different conditions.
Subject(s)
B-Lymphocytes/immunology , Lymphocyte Depletion , Rheumatic Diseases/therapy , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Antirheumatic Agents/therapeutic use , B-Lymphocytes/physiology , Humans , Lupus Erythematosus, Systemic/drug therapy , Lupus Erythematosus, Systemic/immunology , Rheumatic Diseases/drug therapy , Rheumatic Diseases/immunology , Rheumatic Diseases/physiopathology , Rituximab , Scleroderma, Systemic/drug therapy , Scleroderma, Systemic/immunology , Sjogren's Syndrome/drug therapy , Sjogren's Syndrome/immunologyABSTRACT
OBJECTIVES: To report the clinical outcome and safety profile of repeated B cell depletion in seven patients with refractory systemic lupus erythematosus (SLE). METHODS: Since June 2000, seven patients with refractory SLE had repeated cycles of B cell depletion (18 cycles in total, up to three cycles per patient) because of disease relapse. The clinical response (assessed by the British Isles Lupus Activity Guide (BILAG) activity index), duration of B cell depletion, and adverse events in these patients was reviewed. RESULTS: Four patients (Nos 1, 2, 3, 6) had three cycles of treatment and three (Nos 4, 5, 7) had two cycles. Four of the seven patients (Nos 1, 3, 5, 6) improved. The mean global BILAG scores dropped from 15 to 6 at 5-7 months. The median duration of clinical response and B cell depletion was 13 months and 6 months, respectively. After the third cycle, 2/4 patients (Nos 1 and 2) improved. The median duration of clinical benefit was 12 months. Most patients tolerate re-treatment very well. CONCLUSION: Re-treatment with B cell depletion of patients with severe SLE is safe and may be effective for 6-12 months on average.
Subject(s)
Antibodies, Monoclonal/therapeutic use , B-Lymphocytes/immunology , Cyclophosphamide/therapeutic use , Immunosuppressive Agents/therapeutic use , Lupus Erythematosus, Systemic/immunology , Lymphocyte Depletion , Adult , Autoantibodies/blood , Complement C3/analysis , Follow-Up Studies , Humans , Immunoglobulins/blood , Infliximab , Lupus Erythematosus, Systemic/drug therapy , Male , Middle Aged , RecurrenceABSTRACT
OBJECTIVES: To assess the clinical and basic serological consequences of B-cell depletion with rituximab in the treatment of patients with systemic lupus erythematosus (SLE) who have failed conventional immunosuppression. METHODS: An open study of 24 patients with severe SLE followed for a minimum of 3 months is reported. In the majority of patients (19 out of 24), 6 months follow-up data are described. Disease activity in these patients was assessed every 1-2 months using the British Isles Lupus Assessment Group (BILAG) system and estimates of anti-double-stranded DNA antibodies and serum C3 levels. During the follow-up period, significant side-effects were sought and the reduction in oral prednisolone was recorded. It was our general practice to stop concomitant immunosuppression (e.g. azathioprine, mycophenolate) when B-cell depletion was given (in most cases in the form of two 1 g intravenous infusions of rituximab 2 weeks apart accompanied by two 750 mg intravenous cyclophosphamide infusions and two methylprednisolone infusions of 250 mg each). RESULTS: Twenty-two patients were female and two male. At the time of B-cell depletion, the mean age was 28.9 yr (range 17-49) and the mean disease duration was 7.9 yr (range 1-18). The global BILAG score (P < 0.00001), serum C3 (P < 0.0005) and double-stranded DNA binding (P < 0.002) all improved from the time of B-cell depletion to 6 months after this treatment. Only one patient failed to achieve B-lymphocyte depletion in the peripheral blood. The period of B-lymphocyte depletion ranged from 3 to 8 months except for one patient who remains depleted at more than 4 yr. Analysis of the regular BILAG assessments showed that improvements occurred in each of the eight organs or systems. The mean daily prednisolone dose fell from 13.8 mg (s.d. 11.3) to 10 mg (s.d. 3.1). CONCLUSION: In this open study of patients who had failed conventional immunosuppressive therapy, considerable utility in the use of B-cell depletion has been demonstrated. Our data provide strong support for the performance of a full double-blind control trial.
Subject(s)
Antibodies, Monoclonal/therapeutic use , B-Lymphocyte Subsets/immunology , Immunosuppressive Agents/therapeutic use , Lupus Erythematosus, Systemic/therapy , Lymphocyte Depletion/methods , Adolescent , Adult , Antibodies, Antinuclear/blood , Antibodies, Monoclonal, Murine-Derived , Antigens, CD20/immunology , Complement C3/analysis , Female , Follow-Up Studies , Humans , Lupus Erythematosus, Systemic/immunology , Male , Rituximab , Severity of Illness Index , Treatment OutcomeABSTRACT
B lymphocyte depletion therapy in rheumatoid arthritis can provide major clinical benefits. Widespread use in the future will depend on continued evidence of safety, particularly in the context of long term use. Rituximab is a highly effective agent, but it may be best used in combination with other agents. Substantial improvement following a single course of therapy has been found to last up to 42 months, and it is reasonable to hope that further development of strategies targeting B cells will extend this toward the original aim of truly long-term remission.
Subject(s)
Antibodies, Monoclonal/therapeutic use , Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/therapy , B-Lymphocytes/immunology , Lymphocyte Depletion/methods , Antibodies, Monoclonal/immunology , Antibodies, Monoclonal, Murine-Derived , Antirheumatic Agents/immunology , Arthritis, Rheumatoid/immunology , Humans , Rituximab , Treatment OutcomeABSTRACT
OBJECTIVES: To obtain evidence for dose response and to extend evidence of safety and efficacy for B lymphocyte depletion in rheumatoid arthritis. METHODS: Twenty two patients with rheumatoid arthritis received a total of 29 treatments with five different combinations of rituximab (RTX), cyclophosphamide (CP), and/or high dose prednisolone (PR) on an open basis as follows; cohort I: RTX 1400 mg/m(2), CP 750x2+PR; cohort II: RTX 300-700 mg/m(2), -CP+/-PR); cohort III: RTX 600-700 mg/m(2), CP 750x2+PR; cohort IV: RTX 1200 mg/m(2), CP 750x2-PR; cohort V: RTX 500 mg/m(2), CP 750x2+PR. American College of Rheumatology (ACR) criteria of improvement at six months were chosen as the primary outcome measure. Disease activity scores and total duration of improvement and of B cytopenia were also recorded. RESULTS: No major adverse events attributable to treatment were seen. ACR grades of improvement at six months were as follows: cohort I: ACR70x3, ACR50x2; cohort II: ACR20x1, ACR0x3; cohort III: ACR70x6, ACR50x2, ACR20x2; cohort IV: ACR70x2, ACR50x2, ACR20x1, ACR0x1; cohort V: ACR0x4. CONCLUSIONS: B lymphocyte depletion in rheumatoid arthritis has so far proved to be safe and associated with major improvement with protocols including RTX 600 mg/m(2) or more and CP, but not with more limited protocols. These observations provide an initial basis for the design of formal trials of B cell depletion and other B cell directed treatments, including a phase II controlled trial now in progress.
Subject(s)
Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/therapy , B-Lymphocytes/drug effects , Lymphocyte Depletion/methods , Adult , Aged , Aged, 80 and over , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Arthritis, Rheumatoid/drug therapy , Combined Modality Therapy , Cyclophosphamide/therapeutic use , Drug Administration Schedule , Drug Therapy, Combination , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prednisolone/therapeutic use , Rituximab , Severity of Illness Index , Treatment OutcomeABSTRACT
B-lymphocyte depletion therapy is being explored in a wide range of autoimmune disorders. In many, there is early evidence for efficacy, and immunosuppression has not been a major problem. The mechanism of action is unclear, but appears to be consistent with the lowering of autoantibody levels, where relevant antibodies are quantifiable. An interesting finding is the persistence of clinical improvement for periods of 1 year or more after B-lymphocyte return, which supports the concept that stochastic generation of rare pathogenic B-lymphocyte subsets may be a rate-limiting step in pathogenesis.