Rituximab for remission induction and maintenance in refractory granulomatosis with polyangiitis (Wegener's): Ten-year experience at a single center

Authors

  • Rodrigo Cartin-Ceba,

    1. Mayo Clinic, Rochester, Minnesota
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  • Jason M. Golbin,

    1. Mayo Clinic, Rochester, Minnesota, and Long Island Lung Center, Bay Shore, New York
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  • Karina A. Keogh,

    1. Mayo Clinic, Rochester, Minnesota
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    • Drs. Keogh, Peikert, Ytterberg, and Fervenza were site coinvestigators on the Rituximab in ANCA-Associated Vasculitis (RAVE) trial, for which only Drs. Ytterberg and Fervenza received support.

  • Tobias Peikert,

    1. Mayo Clinic, Rochester, Minnesota
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    • Drs. Keogh, Peikert, Ytterberg, and Fervenza were site coinvestigators on the Rituximab in ANCA-Associated Vasculitis (RAVE) trial, for which only Drs. Ytterberg and Fervenza received support.

  • Marta Sánchez-Menéndez,

    1. Mayo Clinic, Rochester, Minnesota
    2. Centro Médico de Asturias, Oviedo, Spain
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  • Steven R. Ytterberg,

    1. Mayo Clinic, Rochester, Minnesota
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    • Drs. Keogh, Peikert, Ytterberg, and Fervenza were site coinvestigators on the Rituximab in ANCA-Associated Vasculitis (RAVE) trial, for which only Drs. Ytterberg and Fervenza received support.

  • Fernando C. Fervenza,

    1. Mayo Clinic, Rochester, Minnesota
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    • Drs. Keogh, Peikert, Ytterberg, and Fervenza were site coinvestigators on the Rituximab in ANCA-Associated Vasculitis (RAVE) trial, for which only Drs. Ytterberg and Fervenza received support.

    • Dr. Fervenza has received unrestricted research grants from Genentech and Biogen Idec.

  • Ulrich Specks

    Corresponding author
    1. Mayo Clinic, Rochester, Minnesota
    • Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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    • Dr. Specks was coprincipal investigator for the RAVE trial, for which he received support. The RAVE trial was sponsored by the National Institute of Allergy and Infectious Diseases and was partially funded by Genentech and Biogen Idec. Participants in the RAVE trial were excluded from the present study.


Abstract

Objective

This study was conducted to evaluate the efficacy and safety of repeated and prolonged B cell depletion with rituximab (RTX) for the maintenance of long-term remission in patients with chronic relapsing granulomatosis with polyangiitis (Wegener's) (GPA).

Methods

We conducted a single-center observational study of all patients with chronic relapsing GPA treated with at least 2 courses of RTX between January 1, 2000 and May 31, 2010. Participants in the Rituximab in ANCA-Associated Vasculitis (RAVE) trial were excluded from this analysis. Data were abstracted from electronic medical records.

Results

Fifty-three patients with refractory GPA (median age 46 years [interquartile range (IQR) 30–61 years]; 53% women) received at least 2 courses of RTX to treat GPA relapses or to maintain remission. All but 1 patient had antineutrophil cytoplasmic antibodies (ANCA) against proteinase 3 (PR3). These patients received a median of 4 courses of RTX (IQR 3–5); all had depletion of B cells, and the median time to return of B cells was 8.5 months (IQR 6–11 months). All observed relapses occurred after reconstitution of B cells and were accompanied or preceded by an increase in ANCA levels, except for the 1 ANCA-negative patient. Infusion-related adverse events occurred in 16 patients. During the period of B cell depletion, 30 infections requiring antimicrobial therapy were recorded.

Conclusion

RTX appeared to be effective and safe for the induction and maintenance of remission in patients with chronic relapsing GPA. Repeated depletion of B lymphocytes seems to be associated with a low risk of infections. Preemptive re-treatment decisions can be individualized based on serial B lymphocyte and PR3 ANCA monitoring. The use of RTX for the maintenance of long-term remission merits further formal investigation.

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