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Vol. 11. Issue 3.
Pages 165-169 (May - June 2015)
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Vol. 11. Issue 3.
Pages 165-169 (May - June 2015)
Review Article
DOI: 10.1016/j.reumae.2015.01.004
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Rituximab in the Treatment of Eosinophilic Granulomatosis With Polyangiitis
Rituximab en el tratamiento de la granulomatosis eosinofílica con poliangitis
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Sebastián Andrés Muñoza,
Corresponding author
, Ignacio Javier Gandinoa, Alberto Omar Ordenb, Alberto Allievic
a Servicio de Clínica Médica División «A», Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
b Servicio de Reumatología, Hospital Aeronáutico Central, Ciudad Autónoma de Buenos Aires, Argentina
c Exjefe del Servicio de Clínica Médica División «A», Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
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Tables (3)
Table 1. General Characteristics of the 27 EGPA Patients Treated With RTX Until February 2014.
Table 2. Details of the Presence of ANCA, Eosinophils and Lymphocytes CD20+ Before and After Treatment With RTX.
Table 3. Details of Response to Treatment With RTX in EGPA Cases Analyzed and 2 Recent Series Reported in Abstracts.
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Abstract
Background

The general consensus is that for patients with EGPA with poor prognosis, intensive therapy with both GC and CF is indicated. The maintenance of remission is made with GC and AZA. A considerable number of patients with EGPA are refractory to first line therapy, experience dose-limiting side effects or relapse. In clinical trials, RTX was effective for the treatment of ANCA-associated vasculitis. However, patients with a diagnosis of EGPA were not included.

Objective

To review and analyze the published literature regarding the use of RTX in the treatment of EGPA.

Methods

The literature search was performed in MEDLINE and LILACS from 1965 and 1986 respectively until February 2014.

Results

27 patients were included. RTX treatment was due to refractory disease (n=20), relapse (n=5) and with new diagnosis (n=2). The affected organs were the lungs, peripheral nervous system, kidney and the eyes. Sixteen patients had clinical remission and 8 patients had clinical response.

Conclusions

RTX was effective and well tolerated for the treatment of EGPA.

Keywords:
Rituximab
Eosinophilic granulomatosis with polyangiitis
Antineutrophil cytoplasmic antibodies associated vasculitis
Resumen
Antecedentes

Algunos pacientes con granulomatosis eosinofílica con poliangitis (EGPA) y factores de mal pronóstico son refractarios o presentan efectos adversos al tratamiento de inducción (glucocorticoides [GC] y ciclofosfamida [CF]), o recaen durante el mantenimiento (GC y azatioprina), haciendo necesaria la búsqueda de alternativas terapéuticas. En ensayos clínicos, el RTX demostró ser eficaz para el tratamiento de las vasculitis asociadas al ANCA; sin embargo, los pacientes con EGPA no fueron incluidos.

Objetivo

Revisar y analizar la bibliografía sobre la uso de RTX para el tratamiento de la EGPA.

Métodos

La búsqueda se realizó en MEDLINE y LILACS (1965 y 1986, respectivamente, hasta febrero del 2014).

Resultados

Se incluyó a 27 pacientes. La indicación de RTX fue por enfermedad refractaria (n=20), recaída (n=5) y nuevo diagnóstico (n=2). Los órganos afectados fueron los pulmones, el sistema nervioso periférico, el riñón y los ojos. Se observó remisión en 16 y respuesta en 8 pacientes.

Conclusiones

El RTX fue eficaz y bien tolerado para el tratamiento de la EGPA.

Palabras clave:
Rituximab
Granulomatosis eosinofílica con poliangitis
Vasculitis asociadas a anticuerpos anticitoplasma de neutrófilo
Full Text
Introduction

EGPA is a necrotizing vasculitis that primarily affects small and medium caliber blood vessels, and is defined as a granulomatous inflammatory and necrotizing disease rich in eosinophils that often affects the airway and is characterized by the presence of asthma and eosinophilia. Along with granulomatosis with polyangiitis (Wegener's granulomatosis [GPA]) and microscopic polyangiitis (MPA), they are part of the antineutrophil cytoplasm antibodies (ANCA) associated vasculitis (AAV).1

The general consensus is to treat severe forms of EGPA, defined as those with a score on the 5 factor score (FFS) equal to or greater than 1, with glucocorticoids (GC) and cyclophosphamide (CYP) to achieve clinical remission. Maintaining remission is achieved using GC and AZA. Mild forms (FFA of 0) are treated with GC alone. However, the high rate of adverse events, lack of response to induction treatment or frequent relapses with first line treatments require the study of therapeutic alternatives.2–4

Rituximab (RTX) is a chimeric monoclonal antibody that specifically binds the CD20 antigen, a non-glycosilated transmembrane phosphoprotein expressed on pre-B and B lymphocytes. The reasonable use of this drug in EGPA is mainly based on its good results in case reports and small series of patients who have been refractory to first line treatment and, in addition is supported by its proven efficacy in clinical trials for AAV patients (GPA and MPA).5–8 As patients with EGPA were not included in these trials, RTX approval was not extended to EGPA.

The purpose of this study is to review and analyze the studies published in the literature on the use of RTX in the treatment of EGPA.

Materials and Methods

Literature search strategy: we consulted the databases of the Medical Literature Analysis and Retrieval System on Line (MEDLINE)/National Library of Medicine (NLM)-Library of Medicine of the United States and the Latin American and Caribbean Literature in Health Sciences (LILACS) library, since 1965 and 1986 respectively, until February 2014. Search terms in English and Spanish were Churg-Strauss (síndrome de Churg-Strauss) syndrome, eosinophilic granulomatosis with polyangiitis (granulomatosis eosinofílica conpoliangitis), allergic granulomatous angiitis (angeí-tis granulomatosa alérgica), RXT and monoclonal anti-CD20 (anti-CD20 monoclonal antibody).

The following data were analyzed: age, sex, affected organs/systems when RTX was indicated, clinical disease state (defined as relapse, treatment resistant or new diagnosis), ANCA determination, eosinophil and B lymphocyte counts in peripheral blood, number of immunosuppressive used before and after treatment with RTX, clinical patient progression and adverse events.

We excluded all those publications that did not have detailed data from the final analysis.

Statistical analysis: Qualitative variables were presented as percentages, and quantitative variables as means±standard deviations or median with minimal and maximum values.

Results

Table 1 shows the general characteristics of 27 patients with a diagnosis of EGPA included for analysis. Fifteen (55.5%) were male and 12 (44.5%) were female. Median follow-up was 15 months (3–60 months). The indication for RTX treatment was refractory disease in 20 (74.1%), relapse in 5 (18.5%) and a new diagnosis in 2 (7.4%) patients.

Table 1.

General Characteristics of the 27 EGPA Patients Treated With RTX Until February 2014.

Patient/reference  Age/gender  Status  Organs affected  Previous and concomitant treatments  Time of follow up(Months)  No. of cyclesof RTX and indication  Result  Adverse events 
19  49/F  Rf  Skin, lung  PS, CF, AZA  RM  Pneumonia, herpes zoster 
210  37/F  Rl  Lung, PNS, VAS  PS, CF, Ig, MFM, Alemtuzumab  18  3 (relapse)  RM  NR 
310  35/F  Rf  Lung, VAS, PNS, articular  PS, CF, AZA, MFM, INF Alemtuzumab  15  RM  Respiratory infection 
411  40/M  Rf  Skin, kidney, eye  MP, PS, CF, PF    RM  NR 
511  66/M  Rf  PNS, heart  MP, PS, Ig, CF  RM  NR 
612  60/M  Rf  PNS, joints, skin  MP, PS, CF, Ig  12  RM  NR 
713  44/F  Rf  PNS, lung  PS, AZA, MTX, CF  –  –  NA  Bronchospasm 
813  33/F  Rl  Joint  PS, CF, MFM, AZA  –  –  NA  Bronchospasm 
914  46/M  Rf  CNS  PS, CF, MFM  RM  NR 
1015  50/M  Rf  Lung, ear  PS, AZA, MTX, CSP, infliximab, anakinra  19  5 (prophylaxis)  RM  NR 
1115  35/F  Rl  Lung VAS  PS, AZA  2 (prophylaxis)  RM  NR 
1216  35/M  Rf  Lung, joint  PS  36  2 (relapse)  RM  NR 
1317  54/M  Rl  PNS, kidney  PS, CF  12  2 (relapse)  RM  NR 
1417  54/F  ND  PNS, kidney, lung  PS  12  RM  NR 
1517  64/F  ND  PNS, kidney, muscle  PS  12  RM  NR 
1618  59/F  Rf  PNS, kidney  PS, CF, AZA  16  RM  NR 
1719  44/F  Rf  PNS, febrile syndrome  MP, PS, Ig, CF  RM  NR 
1820  70/M  Rf  Lung, kidney  MP, CF, PF  60  RM  NR 
1921  Rf  Lung, eye, ear, heart  PS, CF, AZA  19  RP  NR 
2021  Rf  Lung, eye, ear, heart, PNS  PS, AZA  RP  NR 
2121  Rf  Lung, eye, ear, PNS, SNC  PS, MTX, AZA  RP  NR 
2221  Rf  Lung, eye, ear, heart, CNS, skin  PS, CF, AZA  32  2 (prophylaxis)  RP  NR 
2321  Rf  Lung, eye, ear, heart  PS, CF, AZA AZA  34  4 (prophylaxis)  RP  Seminoma 
2421  Rf  Lung, eye, ear, PNS, skin, kidney  PS, CF, MFM, MTX, LF  36  6 (prophylaxis)  RP  NR 
2521  Rf  Lung, eye, ear, heart, skin, PNS, CNS, kidney  PS, AZA, CF, MTX  13  RP  NR 
2621  Rf  Lung, PNS, kidney  PS, CF, AZA  RP  NR 
2721  Rc  Lung, eye, ear, PNS  PS, MTX  RM  NR 

AZA: azathioprine; CF: cyclophosphamide; CSP: cyclosporin; ND: new diagnosis; F: female; Ig: immunoglobulin; M: male; MFM: mycohenolate mofetil; MP: methylprednisolone; MTX: methotrexate, NA: not applicable; NR: not reported; PF: plasmapheresis; PS: prednisone; Rl: relapse; Rf: refractory; RP: response; RM: remission; CNS: central nervous system; PNS: peripheral nervous system; RTX: rituximab; UA: upper airway.

The affected organs that prompted the use of RTX were the lungs (n=18, 66.6%) (asthma, pulmonary infiltrates or alveolar hemorrhage), the peripheral nervous system (n=16, 59.3%) (mono- or polyneuropathy), kidneys (n=9, 33.3%), eyes (n=9, 33.3%) and heart (n=6, 22.2%) (Table 1).

ANCA were reported in 14 patients (51.8%), 11 (78.6%) with a perinuclear pattern (P-ANCA) and 3 (21.4%) with a cytoplasmic pattern (C-ANCA). In 10 (33.1%) patients, ANCA were negative and in 3 (11.1%) the ANCA status was not reported. The number of eosinophils, before the start of treatment with RTX, was elevated in all patients (Table 2).

Table 2.

Details of the Presence of ANCA, Eosinophils and Lymphocytes CD20+ Before and After Treatment With RTX.

  Patients studied/total prior rituximab  Patients studied/total after rituximab 
ANCA/specificity  24/27C (+): 12%P (+): 46%C and P (−): 42%  10/27C (+): 0%P (+): 10%C and P (−): 90% 
Eosinophil  22/27High: 100%  22/27Descent: 55%Normal: 45% 
CD20+lymphocytes  16/27Normal: 100%  19/27Undetectable: 100% 

The median of immunosuppressive drugs (including GC) used before the start of treatment with RTX was 3 (range 1–6).

The treatment strategies with RTX employed were: 375mg/m2 of total body surface every 7 days, a total of 4 infusions (n=8; 2) 1000mg every 15 days, a total of 2 infusions (n=13) and variants of these (n=4).

In 2 patients the RTX infusion was suspended due to adverse reactions, making it unable to finish the therapy.

Excluding the use of GC, 14 patients used another immunosuppressive drug concomitantly with RTX (CYP, AZA, methotrexate and mycophenolate mofetil).

Response to Treatment

Clinical disease remission was seen in 16 (59.2%) patients and response in 8 (29.6%) patients (Tables 1 and 3).

Table 3.

Details of Response to Treatment With RTX in EGPA Cases Analyzed and 2 Recent Series Reported in Abstracts.

  No. patients (M/F)  Age(years)  Meanfollow up(months)  Indicationdisease(No.)  Responsen (%) 
Cases analyzed9–21  27 (15/12)  48.6  14.7  Refractory (20)Relapse (5)New diag. (2)  Remission: 16 (59)Responded: 8 (29) 
Dubrau et al.22  11 (NR)  NR  Refractory (5)Relapse (3)New diag. (3)  Remission: 1 (9)Responded: 7 (64)No response 1 (9)Lost: 2 (18) 
Hot et al.23  30 (16/14)  NR  40  Refractory or relapsed  Remission: 26 (88)Responded: 2 (6)No response: 2 (6) 

NR: not reported.

In 3 (12%) patients a relapse was observed and in 2 of them this coincided with the reappearance of CD20+B lymphocytes in peripheral blood. All 3 patients were retreated with RTX, with a clinical response.

Table 2 shows the evolution of ANCA, eosinophil counts and the determination of CD20+B lymphocytes in patients before and after the administration of RTX.

Adverse events reported are detailed in Table 1. In 2 patients the first infusion of RTX had to be suspended due to serious bronchospasm; the remaining adverse events were respiratory infections and an episode of herpes zoster. One patient was diagnosed with a seminoma 12 months after receiving RTX. There were no deaths.

Discussion

EGPA belongs to the group of AAV along with GPA and MPA; however, it differs from them in several ways. The current treatment of EGPA is similar to that of the remaining AAV, but differs in that RTX has no defined indication as in GPA and MPA, as the randomized clinical trials such as the RAVE and RITUXVAS5,6 did not include patients with EGPA. So far, there are only anecdotal reports of EGPA patients treated with RTX, which makes it difficult to assess the effectiveness of this drug in this disease.

An analysis of the literature shows that most EGPA patients treated with RTX were refractory to first line treatment or relapsed during maintenance immunosuppressive therapy. Only 5 patients received RTX as first line induction treatment (Table 3).

In all patients there was a rapid response observed after treatment with RTX; 2 patients did not complete the infusion of the drug due to a severe adverse reaction.12 Clinical disease remission was seen in most patients. Three patients had one or more relapses, but responded to a new cycle of RTX. Table 3 shows the response to treatment with RTX of cases analyzed along with 2 sets of cases recently reported as abstracts.22,23

A major problem in patients with EGPA is the persistence of symptoms of asthma, despite treatment and the morbidity dependent on long-term GC treatment. While the studies did not analyze the therapeutic response of asthma to RTX, a recent communication presented at the 16th International Vasculitis & ANCA Workshop (Paris, France) by Hot et al. found that 39% of patients treated with RTX for EGPA continued with GC requirements due to persistent asthma.23

Decreased values of peripheral blood eosinophil were reduced or normal after treatment with RTX regardless of the dosage regimen used, in most patients. This finding puts the close relationship that the different cells of the immune system, and especially the strong Th2 lymphocyte interaction through the secretion of cytokines (IL-4, IL-5 and IL-13), with the B cell and the subsequent production and secretion of eotaxin-1, IgG4, IgE and ANCA in perspective.2,24 IgE is elevated in the serum of patients with EGPA. This immunoglobulin, which is produced by plasma cells, is bound to receptors (Fc??R1) on the surface of eosinophils, which, by binding to antigen, induces their involvement in the inflammatory response. Furthermore, eotaxin-1 participates in the recruitment of eosinophils to the site of inflamation.2 These mechanisms could explain in part the decline of eosinophils after treatment with RTX.

Circulating CD20+lymphocytes after RTX use were undetectable and thus persisted for variable time. The period until the repopulation of CD20+B cells was not uniform and in some patients was not correlated with the clinical evolution of the disease. In the RAVE6 study, a high percentage of patients had undetectable CD20+B cell counts after the infusion of RTX (as occurred in the group using CYP) and the time to repopulation thereof was variable. Of greater importance was the finding regarding the repopulation of CD20+B lymphocytes as an isolated variable that did not predict the relapse risk in the individual patient. However, patients who after the use of RTX persisted with undetectable CD20+B lymphocyte levels and negative ANCA were unlikely to relapse.

ANCA are not the only pathogenic mechanism involved in the genesis of this vasculitis; EGPA patients have a strong IgG4 response regardless of the status of ANCA; evidence of a dialog between the B lymphocytes and eosinophils, and the ability of the B cell to secrete eotaxin-1, which is involved in the recruitment of eosinophils at sites of inflammation24–26 could be another pathogenic mechanism involved in the response mediated by RTX; therefore the fact that a patient is ANCA negative does not predict a failure to respond to treatment with RTX.

RTX was well tolerated; only 2 patients experienced adverse reactions during infusion. Adverse events were minor, usually respiratory infections in outpatient care. No deaths directly attributed to RTX were reported. This is consistent with the adverse effects reported in large series and extensive clinical studies demonstrating the safety of RTX in the treatment of AAV.5–8

The most commonly used treatment strategies were: RTX 1000mg every 15 days (total 2 infusions) and 375mg/m2 of RTX per week (total of 4 infusions). Although both strategies were not formally compared, they appear to be equally effective for the induction of remission in the AAV; the expert recommendation on the use of RTX in AAV is to use both strategies interchangeably.27

This study has limitations: the number of patients is small, follow-up time is limited, definitions of activity and damage were not uniform – only in some studies was the Birmingham Vasculitis Activity Score used, and in different versions, immunosuppressive drugs and use of RTX differed between patients. In addition, we did not find publications regarding EGPA patients who did not respond to RTX.

However, there is a widespread tendency to reconsider the standards of treatment for AAV, including EGPA, both in the induction as well as in the maintenance.28,29

Finally, RTX appears to be effective and safe for the treatment of refractory EGPA, relapses or newly diagnosed, independent ANCA status. Randomized clinical trials are necessary to confirm this observation.

Ethical ResponsibilitiesProtection of people and animals

The authors declare that this research did not perform experiments on humans or animals.

Data privacy

The authors state that no patient data appear in this article.

Right to privacy and informed consent

The authors state that no patient data appear in this article.

Conflict of Interest

None.

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Please cite this article as: Muñoz SA, Gandino IJ, Orden AO, Allievi A. Rituximab en el tratamiento de la granulomatosis eosinofílica con poliangitis. Reumatol Clin. 2015;11:165–169.

Copyright © 2014. Elsevier España, S.L.U.. All rights reserved
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