Background Since the description of the efficacy of rituximab (RTX) in treating patients with rheumatoid arthritis (RA), the use of this drug has been extended. Nevertheless, there are not clearly established guidelines to follow after administration of the first cycle.
Objectives To systematically review the published evidence to date regarding on the difference in efficacy in the treatment of RA with RTX when it is used with a fixed, every 6 months, or an on-demand pattern.
Methods A sensitive search of all published studies on the difference in the efficacy of RTX in RA patients used in a fixed pattern or on-demand was performed in Medline, Embase and Cochrane Central databases since its inception until July 2013. We selected all studies involving adult patients with RA treated with RTX in which intervention was described as treatment with RTX in a fixed pattern, every 6 months, and comparator as the administration of RTX in an on-demand pattern. Any standardized measure of efficacy in RA was considered as outcome measure. Although meta analysis, systematic reviews, clinical trials and cohorts well designed were preferably selected, finally we also included open studies and all studies that showed a methodologically correct subanalysis related to the question even if it had not been its main objective. After removing duplicates, an initial selection by reading titles, a second selection after reading abstracts and, finally, full reading of selected studies, assessing the methodological quality by levels of the Oxford Centre for Evidence Based Medicine Evidence (2001 update) where applicable, was carried out. A manual search of the references of included studies was also performed.
Results A total of 1118 citations about the treatment of RA patients with RTX used in a fixed pattern, every 6 months, or in an on-demand one were identified, which were reduced to 52 after removing duplicates and selection by reading titles and abstracts. Of the 52 articles selected, finally only two were included in the review both from the same study. Despite not being able to be included in the review for methodological reasons, four additional studies that had included analysis of several cycles of retreatment with RTX were specially revised.
Conclusions The effectiveness of the administration of successive cycles of RTX is equal when is done according to a fixed schedule every 6 months or as decided by the doctor following the patient (level of evidence 2b, grade of recommendation B). However, careful reading of some of the articles not included in the review permits us to conclude that, after a first cycle with RTX, a more efficiency is obtained when close monitoring and treatment by objective is done since 4-6 months of previous cycle.
Acknowledgements This work has been funded by the Spanish Society of Rheumatology.
Disclosure of Interest A. M. Ortiz Grant/research support: Spanish Society of Rheumatology, M. Rosario Lozano: None declared, C. Martínez Fernández: None declared, I. González-Άlvaro Grant/research support: Spanish Society of Rheumatology