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Rheumatologic diseases and antiphospholipid syndrome
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Thomas J. Santoro, Michiyo Tomita, Alfonse T. Masi
Rituximab is a monoclonal antibody, which is directed against a receptor expressed on a broad lineage of B cells that is FDA approved for the treatment of RA. Anecdotal reports indicated that rituximab can suppress neonatal B cell development and the manufacturer recommends the drug be discontinued 12 months before pregnancy (44).
Antibody-Based Therapies
Published in David E. Thurston, Ilona Pysz, Chemistry and Pharmacology of Anticancer Drugs, 2021
Serious ADRs include infusion reactions, tumor lysis syndrome (that can lead to acute renal failure), cardiac arrest, Hepatitis B re-activation, viral infections, progressive multifocal leukencephalopathy (PML), and pulmonary toxicity. Toxicity to the immune system can also be problematic, as significant depletion of B cells will occur in 70–80% of lymphoma patients. A small number of immune-compromised patients with systemic lupus erythematosus have died due to re-activation of latent JC virus (a common virus that can cause PML) in the brain. Rituximab should be used with caution in patients receiving cardiotoxic chemotherapy or with a history of cardiovascular disease, as exacerbation of angina, arrhythmia, and heart failure have been reported. Transient hypotension occurs frequently during infusion, and so antihypertensives may need to be withheld for 12 hours prior to infusion. Rituximab should be avoided in pregnancy unless potential benefits to the mother outweigh the risk of B-lymphocyte depletion in the fetus. Also, effective contraception is required during and for 12 months after treatment. Finally, in some patients, rituximab treatment can paradoxically increase the number of circulating CD20+ B cells to a clinically significant level, although the reason for this is uncertain.
AIDS-Related Malignancy
Published in Pat Price, Karol Sikora, Treatment of Cancer, 2020
Mark Bower, Elena Gervasi, Alessia Dalla Pria
Whilst surgery is often curative in localized Castleman’s disease, it has a limited role in MCD. In recent years, rituximab has emerged as the gold standard treatment for KSHV-associated MCD based on two phase II trials. One study of 21 patients with newly diagnosed HIV MCD reported a radiological response rate of 67%, and the overall and disease-free survival rates at 2 years were 95% and 79% respectively.41 The second prospective study enrolled 24 patients with HIV MCD who were classified as chemotherapy-dependent. Rituximab induced a sustained remission of 1 year duration in 17/24 (71%) patients and the 1-year overall survival was 92%.42 A stratified approach to the management of MCD is advocated with patients with poor performance status and end-organ involvement receiving a combination of rituximab and etoposide whilst those with less severe disease are treated with rituximab alone. This algorithm of care was applied to 84 patients yielding 5-year overall survival of 92%.43 High plasma cell-free levels of KSHV DNA viral load appear to reflect disease activity in Castleman’s disease and may be useful in diagnosing and monitoring the disease.44
Combination strategies for lupus nephritis: facts and controversies
Published in Expert Review of Clinical Immunology, 2023
There are insufficient data of the safety of novel therapeutic agents during pregnancy. The CNIs such as cyclosporin A and tacrolimus have established safety in LN [112–114]. However, the use of voclosporin in pregnancy is not recommended because there is still a lack of safety data [115]. Although there was so far no increase in the rate of congenital malformations documented with the use of rituximab during pregnancy, risk of B cell depletion and cytopenia in the neonates exists [114]. The EULAR recommends replacement of rituximab with other pregnancy-compatible drugs before pregnancy unless there are no alternatives to control disease activity [114]. Product information of rituximab suggests discontinuation of rituximab for at least 12 months from the last dose before conception because of its long half-life. Likewise, current data are insufficient to establish the safety of belimumab during pregnancy. Cases of congenital malformations and birth defects have been reported with belimumab, but interpretation was confounded by incomplete information, effects of concomitant medications and small number of patients [116]. Belimumab should be replaced by other drugs during pregnancy [114] and discontinuation for at least 4 months is recommended according to the product information. Thus, the conception plan of individual LN patients should be taken into account when choosing newer agents for combination therapies.
Belimumab for the treatment of pediatric patients with lupus nephritis
Published in Expert Opinion on Biological Therapy, 2023
Although not FDA-approved for pediatric LN (or pediatric SLE), rituximab has been used in children for severe and/or refractory disease. Thus, the physician may need to choose between an FDA-approved drug (belimumab), despite the limited evidence supporting its efficacy in pediatric SLE or pediatric LN, and an FDA-non-approved drug (rituximab). In a retrospective study of 50 SLE patients from an academic pediatric rheumatology practice, 22 of whom with biopsy-proven LN, treatment with rituximab led to a significant reduction in corticosteroid dosage and ESR level, significant increases in C3 and C4 levels, and significant improvement in physician global assessment after at least 12 months of follow-up [107]. However, neither the urinary protein:creatinine ratio nor serum creatinine level significantly improved during this time period, making one wonder how effective a rituximab-based approach will be on long-term renal function.
Treatment considerations in myasthenia gravis for the pregnant patient
Published in Expert Review of Neurotherapeutics, 2023
Rituximab is a monoclonal IgG antibody against the CD20 antigen on B lymphocytes. The drug is widely used in the treatment of MG [2,44–46]. One half of MG patients respond. The manufacturer does not recommend use during pregnancy nor during 12 months before pregnancy. Consensus-based treatment guidelines and recommendations reduce this period to 3 months before pregnancy or state that the drug can be continued through conception [37,47]. Rituximab has an elimination half-life of about 3 weeks. Drugs are considered to have fully cleared after five half-lives, that is, 4 months for rituximab [47] IgG antibodies pass placenta. However, until week 13 of the pregnancy the IgG concentrations in the fetus are very low, and even at week 17–22 it is only 5–10% of the maternal level [48]. Rituximab treatment during pregnancy can lead to transient B-cell depletion in the newborn baby and is therefore not recommended. However, in some patients with severe and difficult-to-treat MG, the risks of the disease and alternative treatments may outweigh the very low risks of continued rituximab treatment in pregnancy.