In the JournalsPerspective

Study: Anti-CD-20 agent treatment can be guided by B-cell monitoring for lupus

Among patients with lupus, B-cell monitoring can guide treatment with anti-CD-20 agents, according to a recently published study.

“[Treatment] with anti-CD20 agents can be guided by B-cell monitoring with the aim of achieving complete depletion,” Edward M. Vital, MD, from the University of Leeds in the United Kingdom, and colleagues wrote. “About one in eight patients with [systemic lupus erythematosus] SLE lose depletion on repeat cycles of rituximab, regardless of prior response, and secondary non-depletion is associated with anti-rituximab antibodies.”

Researchers assessed 117 patients with SLE who were treated with rituximab for 12 years. Patients with a secondary non-depletion non-response (2NDNR) were treated with either ocrelizumab or ofatumumab.

After the first cycle, 82% of patients achieved a British Isle lupus assessment group response, as 32% achieved a partial response and 50% achieved a major response. Investigators found an increased chance for major response among patients who were younger (odds ratio [OR] = 0.97) and patients who had B-cell depletion after 6 weeks (OR = 3.22).

Of the 77 patients treated on clinical relapse, 85% responded in the second cycle. Of the second cycle non-responders, nine met criteria for 2NDNR and also tested positive for anti-rituximab antibodies. Five of these patients switched to ocrelizumab or ofatumumab and all depleted or responded.

“If 2NDNR occurs, switching to humanized anti-CD20 mAbs restores depletion and response,” the researchers wrote. “Therefore, alternative anti-CD20 antibodies may be more consistently effective in SLE treatment and several ongoing trials are addressing these issues.” – by Will A. Offit

Disclosures: Vital reports he is a National Institute for Health Research (NIHR) Clinical Scientist and has received honoraria and research grant support from Roche, GSK and AstraZeneca.

Among patients with lupus, B-cell monitoring can guide treatment with anti-CD-20 agents, according to a recently published study.

“[Treatment] with anti-CD20 agents can be guided by B-cell monitoring with the aim of achieving complete depletion,” Edward M. Vital, MD, from the University of Leeds in the United Kingdom, and colleagues wrote. “About one in eight patients with [systemic lupus erythematosus] SLE lose depletion on repeat cycles of rituximab, regardless of prior response, and secondary non-depletion is associated with anti-rituximab antibodies.”

Researchers assessed 117 patients with SLE who were treated with rituximab for 12 years. Patients with a secondary non-depletion non-response (2NDNR) were treated with either ocrelizumab or ofatumumab.

After the first cycle, 82% of patients achieved a British Isle lupus assessment group response, as 32% achieved a partial response and 50% achieved a major response. Investigators found an increased chance for major response among patients who were younger (odds ratio [OR] = 0.97) and patients who had B-cell depletion after 6 weeks (OR = 3.22).

Of the 77 patients treated on clinical relapse, 85% responded in the second cycle. Of the second cycle non-responders, nine met criteria for 2NDNR and also tested positive for anti-rituximab antibodies. Five of these patients switched to ocrelizumab or ofatumumab and all depleted or responded.

“If 2NDNR occurs, switching to humanized anti-CD20 mAbs restores depletion and response,” the researchers wrote. “Therefore, alternative anti-CD20 antibodies may be more consistently effective in SLE treatment and several ongoing trials are addressing these issues.” – by Will A. Offit

Disclosures: Vital reports he is a National Institute for Health Research (NIHR) Clinical Scientist and has received honoraria and research grant support from Roche, GSK and AstraZeneca.

    Perspective

    I found this observational study interesting for a couple of reasons. First, it observed a large number of patients with RA, including patients naive to treatment and patients with established disease. Second, it looked particularly at two subsets: patients who are on Medicaid and, further, patients who are African American.

    The observations about who received biologics based on prior DMARD use and prior steroid use were not especially surprising and reflects what I believe to be the habits of most rheumatologists. The initial biologics chosen is reflective the length of time a given biologic has been available during the observational period.

    While also not surprising to me, the fact that for Medicaid beneficiaries, African-American race was associated with less likelihood of initiation of biologics. This raises important red flags for me.

    We have known that there are discrepancies in access to care and differential care based on race. For instance, the American College of Rheumatology Lupus Initiative seeks to ameliorate discrepancies in the diagnosis and treatment of people of color who have lupus. This study offers a basis for further exploration of questions about access to life altering medication based on race. Numerous questions arise about the severity of disease based on race, or more likely the economic and racial barriers to effective, yet expensive, care.

    I hope these discrepancies are relayed to health care policymakers and members of Congress as they contemplate changes to the American health care system. I wonder if the same discrepancies are seen in countries with more open access to care.

    • Joseph Flood, MD
    • Columbus Arthritis Center Clinical professor of internal medicine The Ohio State University College of Medicine Columbus, Ohio

    Disclosures: Flood reports no relevant financial disclosures.