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Obinutuzumab in connective tissue diseases after former rituximab-non-response: a case series
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  • Published on: 8 April 2022
    Calcinosis and obinutuzumab
    • Wolfgang Merkt, senior physician Department of Internal Medicine V Hematology Oncology Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
    • Other Contributors:
      • Peter Kvacskay, assistant physician
      • Hanns-Martin Lorenz, head physician

    We thank the author for this comment and his interest in our report. We agree that obinutuzumab has shown efficacy in a phase 2 trial in rituximab-naïve SLE patients. In our report, three of four patients did not respond to rituximab prior to receiving obinutuzumab. In our CREST syndrome patient (case 4), the combined obinutuzumab/chemotherapy led to a remission of her chronic lymphatic leukemia; leukocyte counts dropped from >200/nl to normal values. During this therapy, cutaneous calcinosis located on the distal upper extremities gradually regressed until its disappearance in clinical examination. We thank the author for pointing out that due to multiple comedications the disappearance of calcinosis cannot be solely traced back to obinutuzumab. However, we are not aware of cases in which calcinosis resolved due to chemotherapy so that we think obinutuzumab might have been at least partially responsible for this improvement. Further studies are needed to corroborate the effect of obinutuzumab on cutaneous manifestations in systemic sclerosis.

    Conflict of Interest:
    None declared.
  • Published on: 8 April 2022
    Calcinosis and Obinutuzumab
    • Kunal Chandwar, Senior Resident, Department of Clinical Immunology and Rheumatology King George's Medical University

    Dear Editor,
    I want to congratulate Kvacskay et al. on an ingenious case series. While we have had evidence of the efficacy of obninutuzumab in lupus nephritis (2) in phase 2 trials and the RIM trial did show the efficacy of rituximab in anti-Jo1 positive myositis hence the expected responses with obinutuzumab, owing to its greater and more effective B cell depletion. The most interesting of the cases was case 4, where, according to the authors, obinutuzumab led to clearance of calcinosis in the patient. In a case series by Narváez et al.(4) only 50% of the patients with calcinosis in systemic sclerosis responded to rituximab (none of them had a complete response) in the systematic review, only one patient had a complete response to the treatment; overall among 19 patients, only 1 had complete response, so complete response with obinutuzumab is quite exciting as nothing sort of works for calcinosis.
    When the authors mean complete response, do they mean complete radiological response and clinical response?
    Also, the patient was given chlorambucil and bendamustine for her CLL, so the authors' attributing the response was solely due to obinutuzumab is doubtful.

    1. Kvacskay P, Merkt W, Günther J, et al. Obinutuzumab in connective tissue diseases after former rituximab-non-response: a case series. Annals of the Rheumatic Diseases. Published Online First: 13 January 2022. doi: 10.1136/annrheumdis-2021-221756
    2.Furie RA, Aroca G, Cascino MD, e...

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    Conflict of Interest:
    None declared.