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except for rheumatoid factor &#40;RF&#41;&#44; anti-cyclic citrullinated peptide antibodies &#40;anti-CCP&#41; and AMA-M2&#46; Serum lipids&#44; glucose&#44; renal function tests&#44; parathyroid-thyroid hormones&#44; viral markers and protein electrophoresis pattern were normal&#46; Abdominal ultrasonography showed no pathology&#46; She had a medical history of smoking and receiving ursodeoxycholic acid &#40;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; methotrexate &#40;MTX&#44; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#41;&#44; hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and methylprednisolone &#40;4&#8211;8<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; Due to high disease activity &#40;DAS-28&#58; 6&#46;24&#41; rituximab &#40;1000<span class="elsevierStyleHsp" style=""></span>mg IV every 2 weeks&#41; was administered&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second case was a 68-year-old female with the diagnosis of RA and PBC&#46; She had medical history of using ursodeoxycholic acid &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; leflunomide &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and prednisone &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; She had a RF of 34&#46;2<span class="elsevierStyleHsp" style=""></span>U&#47;mL &#40;3&#8211;18<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#41; and anti-CCP of 8&#46;7<span class="elsevierStyleHsp" style=""></span>U&#47;mL &#40;0&#8211;4&#46;99<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41;&#46; AMA-M2 was positive and viral serology was negative&#46; Abdominal ultrasonography showed no pathology&#46; Due to exacerbation of arthritis and high disease activity&#44; rituximab &#40;1000<span class="elsevierStyleHsp" style=""></span>mg IV every 2 weeks&#41; was administered&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Changes in laboratory findings of 2 cases are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Hepatic involvement is rare&#44; and not common in RA&#46; Hepatic abnormalities are generally associated with hepatotoxic drugs&#44; viral hepatitis and alcoholic cirrhosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> AMA&#44; which have an important role in PBC pathogenesis&#44; are useful indicators for liver diseases &#40;PBC&#41; in RA&#46; B-cells&#44; T-cells&#44; and TNF-&#945; have been implicated in the pathogenesis of PBC&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a> B-cells may contribute to pathogenesis with immunoglobulin production&#44; bile ducts destruction and regulatory function&#46; It suggests that B-cells and immunoglobulins are important and B-cell depletion may be a promising therapy for PBC&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a> Lazrak et al&#46; reported combination therapy with MTX and rituximab in a 60-year-old RA and PBC patient&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> There was a good clinical response for RA&#44; but abnormal liver function tests were found on the 5th month of therapy&#46; Exacerbation and development of PBC with B cell depletion in mice was reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Tsuda et al&#46; reported 6 PBC patients treated with rituximab due to the suboptimal response to UDCA&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The study showed that rituximab reduced B cells&#44; AMA&#44; alkaline phosphatase&#44; IgG&#44; IgM&#44; and IgA&#46; It has been reported the improvement in liver laboratory parameters with rituximab&#44; but not the improvement in symptoms such as fatigue&#46; According to Myers et al&#46;&#44; the levels of ALP&#44; IgM&#44; and AMA were significantly decreased at 6 months of rituximab in patients with PBC and incomplete response to ursodeoxycholic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> At 12 months of treatment&#44; the fatigue was the same&#44; and 60&#37; of patients had a reduction in itching&#46; We described 2 cases with RA and PBC who had a good clinical response to rituximab&#46; The activity of both diseases and abnormal hepatic tests returned to normal levels after therapy&#46; However&#44; reduction in the progression of disease and cirrhosis is unclear&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinicians should be aware of hepatic diseases in patients with RA&#46; It should be kept in mind that AMA is useful for the diagnosis of PBC in RA patients with abnormal hepatic tests&#46; Rituximab was tolerable in RA patients with PBC&#46; However&#44; further studies in larger groups are needed to clarify its role and long-term efficacy in PBC&#46;</p></span>"
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Letter to the Editor
Rituximab therapy in rheumatoid arthritis and primary biliary cholangitis
Terapia con Rituximab en artritis reumatoide y colangitis biliar primaria
Gokhan Sargin
Corresponding author
gokhan_sargin@hotmail.com

Corresponding author.
, Taskin Senturk, Songul Cildag
Adnan Menderes University Medical Faculty, Department of Rheumatology, Aydin, Turkey
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except for rheumatoid factor &#40;RF&#41;&#44; anti-cyclic citrullinated peptide antibodies &#40;anti-CCP&#41; and AMA-M2&#46; Serum lipids&#44; glucose&#44; renal function tests&#44; parathyroid-thyroid hormones&#44; viral markers and protein electrophoresis pattern were normal&#46; Abdominal ultrasonography showed no pathology&#46; She had a medical history of smoking and receiving ursodeoxycholic acid &#40;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; methotrexate &#40;MTX&#44; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#41;&#44; hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and methylprednisolone &#40;4&#8211;8<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; Due to high disease activity &#40;DAS-28&#58; 6&#46;24&#41; rituximab &#40;1000<span class="elsevierStyleHsp" style=""></span>mg IV every 2 weeks&#41; was administered&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second case was a 68-year-old female with the diagnosis of RA and PBC&#46; She had medical history of using ursodeoxycholic acid &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; leflunomide &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and prednisone &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; She had a RF of 34&#46;2<span class="elsevierStyleHsp" style=""></span>U&#47;mL &#40;3&#8211;18<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#41; and anti-CCP of 8&#46;7<span class="elsevierStyleHsp" style=""></span>U&#47;mL &#40;0&#8211;4&#46;99<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41;&#46; AMA-M2 was positive and viral serology was negative&#46; Abdominal ultrasonography showed no pathology&#46; Due to exacerbation of arthritis and high disease activity&#44; rituximab &#40;1000<span class="elsevierStyleHsp" style=""></span>mg IV every 2 weeks&#41; was administered&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Changes in laboratory findings of 2 cases are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Hepatic involvement is rare&#44; and not common in RA&#46; Hepatic abnormalities are generally associated with hepatotoxic drugs&#44; viral hepatitis and alcoholic cirrhosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> AMA&#44; which have an important role in PBC pathogenesis&#44; are useful indicators for liver diseases &#40;PBC&#41; in RA&#46; B-cells&#44; T-cells&#44; and TNF-&#945; have been implicated in the pathogenesis of PBC&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a> B-cells may contribute to pathogenesis with immunoglobulin production&#44; bile ducts destruction and regulatory function&#46; It suggests that B-cells and immunoglobulins are important and B-cell depletion may be a promising therapy for PBC&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a> Lazrak et al&#46; reported combination therapy with MTX and rituximab in a 60-year-old RA and PBC patient&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> There was a good clinical response for RA&#44; but abnormal liver function tests were found on the 5th month of therapy&#46; Exacerbation and development of PBC with B cell depletion in mice was reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Tsuda et al&#46; reported 6 PBC patients treated with rituximab due to the suboptimal response to UDCA&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The study showed that rituximab reduced B cells&#44; AMA&#44; alkaline phosphatase&#44; IgG&#44; IgM&#44; and IgA&#46; It has been reported the improvement in liver laboratory parameters with rituximab&#44; but not the improvement in symptoms such as fatigue&#46; According to Myers et al&#46;&#44; the levels of ALP&#44; IgM&#44; and AMA were significantly decreased at 6 months of rituximab in patients with PBC and incomplete response to ursodeoxycholic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> At 12 months of treatment&#44; the fatigue was the same&#44; and 60&#37; of patients had a reduction in itching&#46; We described 2 cases with RA and PBC who had a good clinical response to rituximab&#46; The activity of both diseases and abnormal hepatic tests returned to normal levels after therapy&#46; However&#44; reduction in the progression of disease and cirrhosis is unclear&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinicians should be aware of hepatic diseases in patients with RA&#46; It should be kept in mind that AMA is useful for the diagnosis of PBC in RA patients with abnormal hepatic tests&#46; Rituximab was tolerable in RA patients with PBC&#46; However&#44; further studies in larger groups are needed to clarify its role and long-term efficacy in PBC&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DAS-28&#44; disease activity score-28&#59; AST&#44; aspartate aminotransferase&#59; ALT&#44; alanine aminotransferase&#59; ALP&#44; alkaline phosphatase&#59; GGT&#44; gammaglutamyltransferase&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before rituximab&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">On the 6th month&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">On the 6th month&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">DAS-28</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#46;24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;79&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20<span class="elsevierStyleHsp" style=""></span>U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75<span class="elsevierStyleHsp" style=""></span>mm&#47;h&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">27<span class="elsevierStyleHsp" style=""></span>mm&#47;h&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ESR</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">81<span class="elsevierStyleHsp" style=""></span>mm&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">23<span class="elsevierStyleHsp" style=""></span>mm&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#46;31<span class="elsevierStyleHsp" style=""></span>mg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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Idiomas
Reumatología Clínica (English Edition)
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