Background Palindromic rheumatism (PR) although often considered as a benign disease can be severe and resistant to DMARDs in some patients. In these patients it can result in almost daily attacks, migrating from joint to joint resulting in poor quality of life. Rituximab has been proven to be effective in treatment of seropositive RA.
Objectives To determine the efficacy and safety of Rituximab in patients with seropositive PR who had an inadequate response to CsDMARDs
Methods PR was diagnosed based on criteria proposed by Hannonen P et al. Seropositive (ACPA±RF positivity) PR patients who had active disease despite being treated with two Cs DMARDs for >3 months, were treated with Rituximab. Active disease was defined as >4 attacks per month requiring intake of NSAIDS. All the patients were started on 500mg of rituximab after baseline work up. If complete control of palindromic attacks was not achieved and B cells were detectable in the peripheral blood by flow cytometry another 500 mg infusion was given after 2 weeks. Patients were continued on maximum tolerable dose of DMARDS. Patients were given repeat infusion of Rituximab once the patient developed clinical relapses as evidenced by recurrence of palindromic attacks.
Results Twenty three patients with a mean age of 44.60±13.51 yrs and mean disease duration of 5.47±3.25 yrs were included. All patients were positive for ACPA while 17 patients were positive for RF. These patients were on a background of minimum of 2 DMARDs. Despite the maximum tolerable dose of DMARDs they had mean attack rate of 5.30±2.38 attacks per month. During a mean follow up of 14.17±8.62 months seven patients required two infusions and three patients required three infusions. Of the 33 infusions 500 mg was effective in controlling the attacks majority (88%) of the times. Seven patients required another 500 mg infusion after 2 weeks as initial 500 mg dose failed to achieve complete control of disease and B cell were not depleted in the peripheral blood. At one month follow up all patients achieved complete control of disease. Remission lasted for 10.33±5.75 months. When symptoms recurred patients were treated with rituximab again and all regained complete control of the symptoms. None of the patients evolved into RA during the study period. No serious adverse events were observed. Five patients experienced minor allergic reactions during infusion which were managed according to the standard protocol.
Conclusions This case series indicates in patients of PR resistant to Cs DMARDs rituximab not only achieves disease control but also prevents progression to RA. To best of our knowledge this is the first report regarding efficacy of rituximab in PR. Although it needs to be proved in a larger blinded RCT this early data indicates that Rituximab may be a therapeutic option to prevent development of RA in seropositive patients.
Hannonen P, Möttönen T, Oka M. Palindromic rheumatism. A clinical surveyof sixty patients. Scand J Rheumatol. 1987;16(6):413–420.
Sanmarti R, Cañete JD, Salvador G. Palindromic rheumatism and other relapsing arthritis. Best Pract Res ClinRheumatol. 2004;18(5):647–661.
Disclosure of Interest None declared