Background Rituximab (RTX) is an effective and relatively safe treatment for rheumatoid arthritis (RA). Following treatment initiation there is still controversy on how best to optimise further retreatment while limiting risks of cumulative immunosuppression and cost. There is evidence that retreatment at 6 months in patients with initial response but still have active disease can lead to further improvement1,2.
Objectives Evaluate how often is retreatment with RTX at 6 months associated with further improvement in disease activity in patients with RA that responded to 1 cycle of RTX.
Methods Retrospective study of patients in the UCLH/UCL cohort:RA patients retreated with RTX (2x1000mg) at 6 months for improvement of initial response were selected and divided into 2 groups:patients that improved further (group A), and patients that did not (group B). Clinical and laboratorial data were assessed.
Results Out of 40 selected patients, 32 (80%) improved further while 8 (20%) did not. Median age was 54 years with median disease duration (MDD) of 13 years in group A, and 51 years with 19 years MDD in group B. In both groups:75% were female, more than 87% were seropositive and more than 75% anti-cyclic citrullinated peptide antibody positive. In group A:10 received RTX alone, 11 with Methotrexate (MTX), 4 MTX and prednisolone, and 7 other immunosuppressants/immunomodulators. In group B:3 received RTX alone, 4 with MTX, and 1 with Etanercept. At baseline, group A presented a mean swollen joint count (mSJC) of 7.81, mean tender joint count (mTJC) 15.56, mean erythrocyte sedimentation rate (mESR) 41.5 and mean C-reactive protein (mCRP) 25.5, giving a median baseline DAS28 of 6.13 (IQ 5.23–7.21). Group B recorded:mSJC of 8.5, mTJC 16.9, mESR 44.25, mCRP 42.25, giving a median DAS28 of 6.49 (IQ 5.32–7.6). After the 1st RTX cycle group A recorded a median DAS28 decrease of 1.83 (IQ 1.11–2.5):4 (12%) achieving low disease activity, 22 (69%) moderate activity and 6 (19%) still high activity scores. While group B also presented improvement, the decrease in DAS28 was only a median of 1.07 (IQ 0.76–1.94): 1 patient (13%) achieving remission,2 (25%) moderate activity and 5 (62%) remaining with high disease activity. After the 2nd RTX cycle,in group A median DAS28 decreased a further 0.6 (IQ-0.12–1.3): 11 (35%) achieving remission or low disease activity, 19 (59%) moderate activity and 2 (6%) remaining with high disease scores. In group B DAS28 recorded a median decrease of 0.04 (IQ 0.72–0.67): 6 (75%) presenting high disease scores, 2 (25%) moderate and none remission or low disease activity.
Conclusions Not all patients treated with RTX will achieve remission or low disease activity, but the majority that improve after 1 RTX cycle will improve even further after a 2nd cycle1,2. In our group 80% of patients improved further after a 2nd RTX cycle, with more than a third achieving remission or low disease activity and more than half moderate activity. There was a suggestion that patients who responded less well to their 1st cycle were less likely to improve further
P Emery et al: Efficacy and safety of different doses and retreatment of RTX:SERENE trial, Ann Rheum Dis 2010;69
P Emery et al: Retreatment with RTX based on a TT approach provides better disease control than PRN in patients with RA: a retrospective analysis, Rheumatology 2011;50
Disclosure of Interest None declared