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A multicenter, open-label, comparative study of B-cell depletion therapy with Rituximab for systemic sclerosis-associated interstitial lung disease
Seminars in Arthritis and Rheumatism 46 (2017) 625–631
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A multicenter, open-label, comparative study of B-cell depletion therapy with Rituximab for systemic sclerosis-associated interstitial lung disease☆ Dimitrios Daoussis, MDa,n,1, Konstantinos Melissaropoulos, MDa,1, Georgios Sakellaropoulose, Ioannis Antonopoulos, MDa, Theodora E. Markatseli, MDb, Theodora Simopoulou, MDc, Panagiotis Georgiou, MDd, Andrew P. Andonopoulos, MDa, Alexandros A. Drosos, MDb, Lazaros Sakkas, MD, DM, PhD(UK), FRCP(UK)c, Stamatis-Nick Liossis, MDa a
Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece c Department of Rheumatology, Larissa University Hospital, University of Thessaly Medical School, Larissa, Greece d Department of Rheumatology, Agios Andreas District Hospital, Patras, Greece e Department of Medical Physics, University of Patras, Patras, Greece b
a r t i c l e in fo
Keywords: Scleroderma Systemic sclerosis Rituximab Interstitial lung disease Fibrosis B cells
a b s t r a c t Objectives: Rituximab (RTX) may favorably affect lung function and skin fibrosis in patients with systemic sclerosis (SSc). We aimed to assess long-term efficacy and safety of RTX in SSc compared to standard treatment. Methods: A total of 51 patients with SSc-associated interstitial lung disease were recruited and treated with RTX (n ¼ 33) or conventional treatment (n ¼ 18). Median follow-up was 4 years (range: 1–7). Conventional treatment consisted of azathioprine (n ¼ 2), methotrexate (n ¼ 6), and mycophenolate mofetil (n ¼ 10). Results: Patients in the RTX group showed an increase in FVC at 2 years (mean 7 SD of FVC: 80.60 7 21.21 vs 86.90 7 20.56 at baseline vs 2 years, respectively, p ¼ 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up. At the 7 year time point the remaining patients in the RTX group (n ¼ 5) had higher FVC compared to baseline (mean 7 SD of FVC: 91.60 7 14.81, p ¼ 0.158 compared to baseline) in contrast to patients in the control group (n ¼ 9) where FVC deteriorated (p o 0.01, compared to baseline). Direct comparison between the 2 groups showed a significant benefit for the RTX group in FVC (p ¼ 0.013). Improvement of skin thickening was found in both the RTX and the standard treatment group; however, direct comparison between groups strongly favored RTX at all-time points. Adverse events were comparable between groups. Conclusions: Our data indicate that RTX has a beneficial effect on lung function and skin fibrosis in patients with SSc. Randomized controlled studies are highly needed. & 2017 Elsevier Inc. All rights reserved.
Introduction Systemic sclerosis (SSc) is a prototype, multisystem fibrotic disease which carries the worst standardized mortality ratio among all systemic rheumatic diseases [1]. The pathogenesis of ☆ n
This study was partially funded by a “Karathodori” grant (D184). Corresponding author. E-mail address: [email protected].(D. Daoussis) 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.semarthrit.2016.10.003 0049-0172/& 2017 Elsevier Inc. All rights reserved.
SSc is not well understood, however, autoimmunity, endothelial dysfunction/vasculopathy, and eventually aberrant fibroblast activation are considered the cornerstones of the pathophysiologic process [2–6]. Nowadays, the leading cause of death in patients with SSc is interstitial lung disease (ILD). Treatment strategies for SSc-associated ILD have mainly relied on non-specific immunosuppression in the form of cyclophosphamide or mycophenolate [7–10]. However, during the last years other immune based therapies have emerged such as B-cell depletion therapy and hematopoietic stem cell transplantation, which have shown
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encouraging results [11–15]. A great amount of data derived from both animal models and humans indicates that B cells are key players in the fibrotic process thus supporting the concept of B-cell depletion therapy in SSc [16–26]. In our department we have conducted the first randomized controlled study assessing the efficacy of the B-cell depleting agent, Rituximab (RTX), in the treatment of SSc-associated ILD [27]. We have shown that treatment with RTX significantly improves pulmonary function as well as skin fibrosis in patients with SSc. The improvement in pulmonary function tests (PFTs) found in our study should be considered as strong evidence in favor of a disease modifying role of RTX in SSc since PFTs have a clear tendency to decline over time in SSc associated ILD [28]. The follow-up of patients enrolled in our study has shown that continuous treatment with RTX further enhances this beneficial effect [15]. During the last 5 years several research groups have also employed B-cell depletion therapy in patients with SSc and most have produced similar results [12–14,29–36]. These encouraging but preliminary results have been recently verified in large scale multicenter studies, including one from the European League against Rheumatism Scleroderma Trial and Research group, which reported improvement of pulmonary function following RTX administration [32,37]. Since the completion of our randomized controlled study in 2009 we have been using RTX as an off label treatment in SSc-associated ILD, alongside with other research groups in our country. In the present study we aimed to assess the long-term effect of RTX treatment on pulmonary function in patients with SSc-associated ILD compared to patients on conventional treatment. Moreover, we provide data on the long-term safety profile of RTX in these patients.
Patients and methods Patients Four major rheumatology centers (three academic units and one district hospital) covering a wide geographical area of Greece, participated in the study. All patients with SSc-associated ILD that were followed up in these centers were offered treatment with RTX either as monotherapy or in some cases as an add-on treatment to conventional therapy. Patients fulfilled the preliminary American College of Rheumatology criteria for the classification of the disease [38]. Retrospective analysis of our cohort revealed that all patients also fulfilled the newer 2013 ACR/EULAR classification criteria [39]. The presence of SSc-associated ILD was documented by findings in either high resolution computed tomography (HRCT) of the chest or PFTs or both. PFT measurements were considered abnormal if FVC and/or DLCO were o80% of the estimated values, while HRCT was considered indicative of ILD after assessment of the presence of ground glass, reticular, or honeycombing lesions by an experienced radiologist. Treatment with RTX was offered to 51 patients with SSc-associated ILD that had no changes in medications and/or dosage of treatment administered during the last 12 months. Thirty three patients (n ¼ 33) agreed to receive RTX and formed the RTX group whereas eighteen (n ¼ 18) patients declined; these patients formed the control group. Median follow-up for all (n ¼ 51) patients was 4 years. All patients in the RTX group received at least two cycles of RTX and were evaluated during a median follow-up period of 2 years (range: 1–7 years). The majority of patients (n ¼ 19) received at least four cycles of RTX and have completed a 2-year follow-up; following this time point continuation of RTX treatment was decided by the treating physician. In most cases RTX treatment was continued throughout the follow-up period; however, treatment was temporarily discontinued in six patients (in three patients at 2 years and in three patients at 3 years of treatment). Since patients who
Fig. 1. Timeline depicting the number of patients followed for each time point.
discontinued RTX treatment exhibited deterioration in pulmonary function they were rechallenged with RTX following 1–2 years of treatment cessation. From the fourth up to the seventh year of follow-up all patients were on continuous RTX treatment. Followup data were available from all patients in the RTX group (n ¼ 33) for the 1-year time point and for 19, 15, 10, 6, 5, and 5 for the 2, 3, 4, 5, 6, and 7-year time point, respectively (94 patient-years totally). For the control group follow-up data were available from all patients (n ¼ 18) for the 1-year time point and for 17, 16, 15, 13, 10, and 9 for the 2, 3, 4, 5, 6, and 7-year time point, respectively. These are diagrammatically depicted in Figure 1. All patients were subjected to routine blood tests every 3 months (full blood count and biochemistry profile) and a cardiac ultrasound annually. PFTs and clinical assessment of skin thickening (Modified Rodnan Skin Score-MRSS) were performed every 6 months for the first 2 years of follow-up and annually thereafter. The majority of the patients enrolled (30/33 in the RTX group and 14/18 in the control group) belonged to the diffuse subtype of the disease. A local Ethics Committee approved the study in each participating center and a written informed consent was obtained from all patients.
Treatment Rituximab group Patients were treated with two or more cycles of RTX. Each cycle consisted of four infusions of 375 mg of RTX per m2 of body surface area, once weekly. RTX cycles were repeated every 6 months. Thirteen patients in the RTX group received concurrent immune based therapies; methotrexate (n ¼ 2), hydroxychloroquine (n ¼ 1) and mycophenolate mofetil(n ¼ 10, dosage 2 g/day). Patients on mycophenolate (MMF) had been on that treatment for a median of 24 months prior to enrollment. Moreover, 18/33 patients were receiving small doses of corticosteroids po ( o10 mg prednisolone or equivalent). Seven patients in the RTX group had received cyclophosphamide (CYC) in the past; in all these patients CYC had been stopped at least 1 year before enrollment. Control group All patients in the control group received conventional treatment, which consisted of azathioprine (n ¼ 2), methotrexate (n ¼ 6), and mycophenolate (n ¼ 10, dosage 2 g/d). Moreover, most patients (17/18) patients were receiving small doses of corticosteroids po (o 10 mg prednisolone or equivalent). Three patients in the control group had received CYC in the past; in all these patients CYC had been stopped at least 1 year before enrollment. Lung and skin fibrosis assessment Standard PFTs were performed at baseline and then every 6 months for the first 2 years and annually thereafter in all patients, including assessments of forced vital capacity (FVC), total lung capacity and diffusing capacity of carbon monoxide (DLCO)
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corrected for hemoglobin concentration. PFT parameters are expressed as a percentage of normal predicted values based on age, sex, and height. The MRSS tool was used for clinical assessment of skin thickening at baseline, every 6 months for the first 2 years and annually thereafter, by an experienced assessor.
Statistical analysis Comparisons between the treated and control groups were performed after appropriate adjustment for disease duration using an analysis of covariance (ANCOVA) model. The comparison of ANCOVA-based adjusted values of MRSS, FVC, and DLCO at various time points with their respective baseline levels was performed using t-test. The corresponding comparisons of observed means to baseline were performed using either paired t-test or Wilcoxon test, according to the significance of an initial Kolmogorov–Smirnov test for normality. In order to provide further evidence for the effect of treatment, we took into consideration the repeated measures nature of our data to fit FVC, DLCO, and MRSS variables with a linear mixed model with random intercepts using “Treatment Group” as factor and “Disease Duration,” “baseline FVC/DLCO/MRSS” and treatment with MMF as covariates. In order to confine the number of parameters as much as possible, we chose the autoregressive covariance matrix for the repeated measures data and did not include any interactions. Kaplan–Meier analysis was used to assess potential differences in survival between groups. The level of statistical significance was set to 0.05. SPSS version 22 and GraphPad5 statistical software were used for statistical analysis.
Results Patients in the treatment and control group had similar epidemiologic and clinical characteristics apart from disease duration; patients in the control group had shorter disease duration. Mean disease duration (defined as duration from first non-Raynaud’s
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disease manifestation) at baseline was 5.73 years in the RTX group and 2.56 years in the control group. Baseline demographic and clinical characteristics of the patients, as well as their concurrent medication, are presented in Table. Continuous treatment with RTX for 2 years significantly improves pulmonary function in patients with SSc Patients in the RTX group showed a non-significant increase in FVC during the first year of treatment (mean 7 SD of FVC: 80.60 7 21.21 vs 83.02 7 19.05 at baseline vs 1-year, respectively, p ¼ 0.136); this beneficial effect was further augmented at 2 years (mean 7 SD of FVC: 86.90 7 20.56, p ¼ 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up (mean 7 SD of FVC: 77.72 7 18.29 vs 77.18 7 19.25 vs 77.59 7 19.45 at baseline, 1 and 2 years respectively, p ¼ ns for both comparison to baseline). Direct comparison between the RTX and the control group at the 2-year time point favored the RTX group as shown in Figure 2, however, the results tended but did not reach statistical significance (p ¼ 0.063). There was an upward trend in DLCO following 2 years of RTX treatment of borderline statistical significance (mean 7 SD of DLCO: 59.22 7 18.17 vs 61.51 7 17.58 at baseline vs 2-years, respectively, p ¼ 0.053). In the standard treatment group DLCO remained stable (mean 7 SD of DLCO: 64.24 7 25.56 vs 63.12 7 23.98 at baseline vs 2-years, respectively, p ¼ 0.384). Direct comparison between the two groups at the 1- and 2-year time point did not reveal any differences (p ¼ 0.398 and p ¼ 0.966 for the 1- and 2-year time point, respectively). These results are diagrammatically depicted in Figure 3. Long-term treatment with RTX improves lung function in patients with SSc-associated ILD At the 7-year time point five patients in the RTX group and nine patients in the control group were still followed. The patients in the RTX group had numerically higher FVC compared to baseline
Table Baseline demographic and clinical characteristics of the RTX cohort matched with the control cohort RTX cohort
Control cohort
p Value
Patients, n Age mean, years 7 SD Female sex (%) Disease duration mean in years (range)
33 54.3 7 14.33 25/33 (75.8) 5.73 (1–28)
18 52.11 7 16.10 16/18 (88.9) 2.56 (1–10)
0.62 0.46 0.012
Autoantibodies positive Scl70 (%) ACA (%) Other (%)
25/33 (75.8) 3/33 (9.1) 5/33 (15.1)
14/18 (77.8) 3/18 (16.7) 1/18 (5.5)
1.00 0.65 0.40
Disease subtype Diffuse (%) Limited (%)
30/33 (90.9) 3/33 (9.1)
14/18 (77.8) 4/18 (22.2)
0.22 0.22
Pulmonary hypertension (%)a MRSS, mean 7 SD FVC, mean 7 SD DLCO, mean 7 SD
6/33 14.72 80.60 59.22
(18.2) 7 10.52 7 21.21 7 18.17
5/18 17.78 77.72 64.24
(27.8) 7 9.48 7 18.29 7 25.56
0.48 0.31 0.63 0.42
Concurrent medication Prednisolone(or equivalent) (%) Methotrexate (%) Mycophenolate (%) Azathioprine (%) Hydroxychloroquine (%)
18/33 2/33 10/33 0/33 1/33
(54.5) (6.1) (30.3) (0.0) (3.0)
17/18 6/18 10/18 2/18 0/18
(94.4) (33.3) (55.5) (11.1) (0.0)
p Value refers to the comparison of the variables presented between the two cohorts. Level of statistical significance is set to 0.05. a
Based on ultrasound PASP values.
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Fig. 2. Time plot depicting FVC values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between two groups tended to favor RTX at the 2-year time point (p ¼ 0.063) whereas at the 7-year time point direct comparison between the two groups showed a significant benefit for the RTX group (p ¼ 0.013) (A). Time plot depicting % changes in FVC compared to baseline values for the RTX and the standard treatment group (B).
(mean 7 SD of FVC: 80.60 7 21.21 vs 91.60 7 14.81, at baseline vs 7 years, respectively, p ¼ 0.158) in contrast to patients in the control group where FVC showed a significant deterioration (mean 7 SD of FVC: 77.72 7 18.29 vs 61.11 7 15.73 at baseline vs 7 years respectively, p ¼ 0.001). Direct comparison between the two groups showed a significant benefit for the RTX group (p ¼ 0.013). DLCO remained stable in the RTX group (mean 7 SD of DLCO: 59.08 7 18.17 vs 60.66 7 24.71 at baseline vs 7 years respectively, p ¼ ns). On the other hand, DLCO significantly declined in the control group (mean 7 SD of DLCO: 64.50 7 25.562 vs 51.08 7 15.69 at baseline vs 7 years respectively, p ¼ 0.004). However, direct comparison between the two groups did not reveal any differences (p ¼ 0.495). In order to explore in more detail the effect of RTX on pulmonary function we used a linear mixed model analysis with the inclusion of disease duration, baseline FVC/DLCO/MRSS and treatment with MMF as covariates. According to the linear mixed models fitted, there was a significant effect of treatment on FVC and DLCO. Specifically, the RTX group presented a mean increase in both FVC (10.02 units, p ¼ 0.004) and DLCO (8.14 units, p ¼ 0.043) compared to the control group.
(mean 7 SD of MRSS: 14.72 7 10.52 vs 8.83 7 7.83 vs 5.93 7 5.15 vs 4.53 7 5.29 vs 5.37 7 8.34 at baseline, 1–4 years respectively, p o 0.01 for all comparisons to baseline). In the control group a decline in MRSS was also noted (mean 7 SD of MRSS: 17.78 7 9.48 vs 15.78 7 9.89 vs 13.72 7 9.67 vs 15.53 7 9.53 vs 13.64 7 8.56 at baseline, 1–4 years respectively, p ¼ 0.064 for 1 year vs baseline, 0.030 for 2 years vs baseline, 0.041 for 3-years vs baseline and 0.023 for 4-years vs baseline). Direct comparison between the 2 groups showed a clear benefit for the RTX group in most time points; p ¼ 0.002, 0.015, 0.002, 0.053, and 0.029 for the 1–5-year time point, respectively, indicating that RTX treatment leads to an enhanced resolution of skin fibrosis compared to patients on standard treatment. In order to explore in more detail the effect of RTX on skin thickening we used a linear mixed model analysis with the inclusion of disease duration, baseline FVC/DLCO/MRSS and treatment with MMF as covariates. According to the linear mixed models fitted MRSS was higher in the control group (3.89 units, p ¼ 0.007) compared to the RTX group. Adverse events Rituximab group Treatment with RTX was generally well tolerated, even in cases of advanced disease with presence of comorbidities. Five deaths were reported during the follow-up period. Three of them concerned patients with end stage lung fibrosis before the initiation of RTX, with the cause of death being respiratory insufficiency. Another patient was diagnosed with lung cancer, approximately 1 year after starting treatment with RTX and consequently died because of this. The last death was a case of sudden death during sleep; the exact cause of death is unknown since an autopsy was not performed. Three patients with severe lung involvement were hospitalized, two of them more than once, with a diagnosis of respiratory infection, requiring treatment with intravenous antibiotics. In one case cytomegalovirus was identified as the causal agent. Another patient was hospitalized with urinary infection. A known HBV carrier, receiving lamivudine, was diagnosed as having HBV reactivation during RTX treatment. Antiviral treatment scheme
Cessation of RTX treatment associates with a decline in pulmonary function In six patients in the RTX group treatment was temporarily discontinued following 2 (n ¼ 3) or 3 years (n ¼ 3) of continuous treatment. In all 6 patients a decline in FVC was evident following treatment cessation as shown in Figure 4. Taking into account this deterioration following RTX discontinuation, all these patients were rechallenged with RTX. Three patients (pts 1–3) showed an increase in FVC following retreatment. However, in the remaining 3 patients (pts 4–6) there was no evidence of efficacy. Patients 5 and 6 died due to respiratory insufficiency a few months following retreatment. Enhanced resolution of skin thickening in patients with SSc treated with RTX compared to patients receiving standard treatment In the RTX group there was a significant improvement in skin thickening as assessed by the MRSS tool as shown in Figure 5
Fig. 3. Time plot depicting DLCO values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between groups did not reveal any statistical significant changes (A). Time plot depicting % changes in DLCO compared to baseline values for the RTX and the standard treatment group. DLCO remained stable in the RTX group whereas a deterioration of DLCO can be seen in the standard treatment group (p ¼ 0.004 for the comparison of the 7-year time point vs baseline) (B).
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Fig. 4. Time plots of FVC values in 6 patients who discontinued RTX treatment. Black arrows indicate the time of RTX discontinuation whereas red arrows indicate the time of retreatment with RTX. A clear decline in FVC can be seen in all patients following treatment cessation. Upon rechallenge with RTX patients 1–3 exhibited an increase in FVC. However, in the remaining three patients there was no evidence of efficacy (pts 4–6). Patients 5 and 6 died due to respiratory insufficiency a few months following retreatment. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
was altered by the local infectious disease specialists, and RTX was continued few months later when HBV DNA levels were sufficiently low. A male patient was diagnosed with prostate cancer shortly after starting RTX. In this case, older age and pre-existing urinary symptoms could point to a pre-existing prostate disease. Lastly, two cases of mild infusion reactions were reported.
because of treatment with mycophenolate mofetil when conception was achieved. A similar percentage of patients died during follow-up in the two groups (15% vs 11%, for the RTX and the control group, respectively, p ¼ 0.68). Kaplan–Meier analysis did not detect differences in survival between groups (p ¼ 0.123, log-rank test).
Control group Discussion Two deaths were reported in this cohort during the follow-up period. Both of them were attributed to lung infection with coexistence of extensive lung disease in one case and pulmonary arterial hypertension in the other. Five patients with lung infection and four patients with urinary infection were hospitalized, requiring treatment with IV antibiotics. In four cases, infections were recurrent. One patient was hospitalized due to digital ulcers requiring IV antibiotics and iloprost while one female patient decided to stop pregnancy
Fig. 5. Time plot depicting MRSS values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between groups favored RTX in all time points (p ¼ 0.002, 0.015, 0.002, 0.053, 0.029 for the 1–5-year time point, respectively).
Interstitial lung disease alongside pulmonary arterial hypertension (PAH) are the most fearful complications of SSc and are nowadays the leading causes of death. During the last decade there has been a substantial progress in the treatment of the vascular complications of SSc, such as PAH. However, therapeutic approaches for fibrotic complications such as ILD remain limited and exhibit only modest efficacy. During the last 5 years there has been an increasing interest in B-cell depletion as a potential therapeutic strategy for SSc, mainly targeting lung and skin fibrosis. This was based on strong experimental evidence pointing to the direction that B cells are crucial regulators of the fibrotic process [40]. In animal models of scleroderma, B cells exhibit increased CD19 signaling [25] (a positive B-cell receptor response regulator); moreover, B-cell depletion leads to attenuation of skin fibrosis [21]. In vitro data suggest that B cells may directly interact with fibroblasts and enhance collagen production in a TGFβdependent manner [16]. In patients with SSc, B cells exhibit increased CD19 expression and are activated [40,41]. Furthermore, scleroderma skin is characterized by a B-cell signature [42] whereas lung biopsies from patients with SSc-associated ILD display prominent B-cell infiltration [43]. All these data coming from basic research points to the direction that B cells are a an
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attractive candidate for the treatment of fibrotic diseases such as SSc [44,45]. Indeed, clinical data related to B-cell depletion therapy in SSc are encouraging. Many research groups have reported that RTX treatment improved skin thickening and lung fibrosis in patients with SSc. Our current data further support the concept that RTX may have disease modifying properties in SSc. It is generally not easy to assess the potential clinical efficacy of a given treatment in patients with SSc because it is a slowly progressive disease affecting several internal organs that are not directly accessible through physical examination. Moreover, skin thickening tends to resolve in late stages of the disease and this makes the assessment even more complicated. This is why controlled data are necessary for evaluating the potential efficacy of a treatment in SSc. In this study we compared the group receiving RTX treatment with a similar cohort of patients on standard treatment; our controlled data further substantiate previous reports indicating that RTX favorably affects lung function and skin fibrosis in patients with SSc. There are only limited long-term data related to the use of RTX in SSc. This study is the first to report long-term data, extending to 7 years. A critical question in therapy of SSc-associated ILD is the length of treatment. So far, evidence indicates that continuous treatment is warranted. This was clearly shown in the case of CYC where cessation of treatment following 1 year led to a decline in PFTs throughout the second year of follow-up [8]. This fact underlines the necessity of developing a treatment that can be administered on a long-term basis, something that cannot be done with CYC due to its toxicity. RTX appears as an attractive candidate treatment for SSc-associated ILD; data derived from rheumatoid arthritis suggest that RTX can be safely administered over long periods carrying an acceptable safety profile. In this study we also had the chance to explore outcomes following RTX cessation after an initial favorable response. It is noteworthy that all patients deteriorated and this is why we propose that patients who received RTX and had a favorable response should remain on treatment on a long-term basis. Our data indicate that RTX is generally well tolerated in patients with SSc. A similar percentage of patients died during follow-up in the two groups. Moreover, all deaths in the RTX group were most likely not directly attributed to treatment. We did not find any differences in the rate and pattern of infections between the two groups apart from a case hepatitis B reactivation which occurred in the RTX group indicating that RTX carries a similar safety profile with classic immunosuppressive agents such as mycophenolate, methotrexate, and azathioprine, which were used in the conventional treatment group. Our study has potential limitations. Even though it was prospective and controlled, it was not randomized and this may lead to some bias. However, the two groups had similar demographic and clinical characteristics apart from disease duration. To overcome this, we used the proper statistical analysis in order to adjust all variable assessed for disease duration and only adjusted variables were used for comparisons between groups. Nevertheless, the number of patients assessed and the extended follow-up are strengths of the study. Definite answers can only derive from a large scale randomized controlled trial with statistical power to prove efficacy; such trials are currently underway (ISRCTN16474148 and NCT01748084). Up until then, our data indicate that RTX may be used in SSc-associated ILD when conventional treatment fails. References [1] Elhai M, Meune C, Avouac J, Kahan A, Allanore Y. Trends in mortality in patients with systemic sclerosis over 40 years: a systematic review and metaanalysis of cohort studies. Rheumatology (Oxford) 2012;51:1017–26.
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CD19-dependent B lymphocyte signaling thresholds influence skin fibrosis and autoimmunity in the tight-skin mouse. J Clin Invest 2002;109: 1453–1462. [26] Fraticelli P, De Vita S, Franzolini N, Svegliati S, Scott CA, Tonnini C, et al. Reduced type I collagen gene expression by skin fibroblasts of patients with systemic sclerosis after one treatment course with rituximab. Clin Exp Rheumatol 2015;33(4 Suppl. 91):S160–7. [27] Daoussis D, Liossis SN, Tsamandas AC, Kalogeropoulou C, Kazantzi A, Sirinian C, et al. Experience with rituximab in scleroderma: results from a 1-year, proof-ofprinciple study. Rheumatology (Oxford) 2010;49:271–80. [28] Steen VD, Conte C, Owens GR, Medsger TA Jr. Severe restrictive lung disease in systemic sclerosis. Arthritis Rheum 1994;37:1283–9. [29] Bosello SL, De Luca G, Rucco M, Berardi G, Falcione M, Danza FM, et al. Longterm efficacy of B cell depletion therapy on lung and skin involvement in diffuse systemic sclerosis. Semin Arthritis Rheum 2015;44:428–36.
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Seminars in Arthritis and Rheumatism journal homepage: www.elsevier.com/locate/semarthrit
A multicenter, open-label, comparative study of B-cell depletion therapy with Rituximab for systemic sclerosis-associated interstitial lung disease☆ Dimitrios Daoussis, MDa,n,1, Konstantinos Melissaropoulos, MDa,1, Georgios Sakellaropoulose, Ioannis Antonopoulos, MDa, Theodora E. Markatseli, MDb, Theodora Simopoulou, MDc, Panagiotis Georgiou, MDd, Andrew P. Andonopoulos, MDa, Alexandros A. Drosos, MDb, Lazaros Sakkas, MD, DM, PhD(UK), FRCP(UK)c, Stamatis-Nick Liossis, MDa a
Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece c Department of Rheumatology, Larissa University Hospital, University of Thessaly Medical School, Larissa, Greece d Department of Rheumatology, Agios Andreas District Hospital, Patras, Greece e Department of Medical Physics, University of Patras, Patras, Greece b
a r t i c l e in fo
Keywords: Scleroderma Systemic sclerosis Rituximab Interstitial lung disease Fibrosis B cells
a b s t r a c t Objectives: Rituximab (RTX) may favorably affect lung function and skin fibrosis in patients with systemic sclerosis (SSc). We aimed to assess long-term efficacy and safety of RTX in SSc compared to standard treatment. Methods: A total of 51 patients with SSc-associated interstitial lung disease were recruited and treated with RTX (n ¼ 33) or conventional treatment (n ¼ 18). Median follow-up was 4 years (range: 1–7). Conventional treatment consisted of azathioprine (n ¼ 2), methotrexate (n ¼ 6), and mycophenolate mofetil (n ¼ 10). Results: Patients in the RTX group showed an increase in FVC at 2 years (mean 7 SD of FVC: 80.60 7 21.21 vs 86.90 7 20.56 at baseline vs 2 years, respectively, p ¼ 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up. At the 7 year time point the remaining patients in the RTX group (n ¼ 5) had higher FVC compared to baseline (mean 7 SD of FVC: 91.60 7 14.81, p ¼ 0.158 compared to baseline) in contrast to patients in the control group (n ¼ 9) where FVC deteriorated (p o 0.01, compared to baseline). Direct comparison between the 2 groups showed a significant benefit for the RTX group in FVC (p ¼ 0.013). Improvement of skin thickening was found in both the RTX and the standard treatment group; however, direct comparison between groups strongly favored RTX at all-time points. Adverse events were comparable between groups. Conclusions: Our data indicate that RTX has a beneficial effect on lung function and skin fibrosis in patients with SSc. Randomized controlled studies are highly needed. & 2017 Elsevier Inc. All rights reserved.
Introduction Systemic sclerosis (SSc) is a prototype, multisystem fibrotic disease which carries the worst standardized mortality ratio among all systemic rheumatic diseases [1]. The pathogenesis of ☆ n
This study was partially funded by a “Karathodori” grant (D184). Corresponding author. E-mail address: [email protected].(D. Daoussis) 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.semarthrit.2016.10.003 0049-0172/& 2017 Elsevier Inc. All rights reserved.
SSc is not well understood, however, autoimmunity, endothelial dysfunction/vasculopathy, and eventually aberrant fibroblast activation are considered the cornerstones of the pathophysiologic process [2–6]. Nowadays, the leading cause of death in patients with SSc is interstitial lung disease (ILD). Treatment strategies for SSc-associated ILD have mainly relied on non-specific immunosuppression in the form of cyclophosphamide or mycophenolate [7–10]. However, during the last years other immune based therapies have emerged such as B-cell depletion therapy and hematopoietic stem cell transplantation, which have shown
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encouraging results [11–15]. A great amount of data derived from both animal models and humans indicates that B cells are key players in the fibrotic process thus supporting the concept of B-cell depletion therapy in SSc [16–26]. In our department we have conducted the first randomized controlled study assessing the efficacy of the B-cell depleting agent, Rituximab (RTX), in the treatment of SSc-associated ILD [27]. We have shown that treatment with RTX significantly improves pulmonary function as well as skin fibrosis in patients with SSc. The improvement in pulmonary function tests (PFTs) found in our study should be considered as strong evidence in favor of a disease modifying role of RTX in SSc since PFTs have a clear tendency to decline over time in SSc associated ILD [28]. The follow-up of patients enrolled in our study has shown that continuous treatment with RTX further enhances this beneficial effect [15]. During the last 5 years several research groups have also employed B-cell depletion therapy in patients with SSc and most have produced similar results [12–14,29–36]. These encouraging but preliminary results have been recently verified in large scale multicenter studies, including one from the European League against Rheumatism Scleroderma Trial and Research group, which reported improvement of pulmonary function following RTX administration [32,37]. Since the completion of our randomized controlled study in 2009 we have been using RTX as an off label treatment in SSc-associated ILD, alongside with other research groups in our country. In the present study we aimed to assess the long-term effect of RTX treatment on pulmonary function in patients with SSc-associated ILD compared to patients on conventional treatment. Moreover, we provide data on the long-term safety profile of RTX in these patients.
Patients and methods Patients Four major rheumatology centers (three academic units and one district hospital) covering a wide geographical area of Greece, participated in the study. All patients with SSc-associated ILD that were followed up in these centers were offered treatment with RTX either as monotherapy or in some cases as an add-on treatment to conventional therapy. Patients fulfilled the preliminary American College of Rheumatology criteria for the classification of the disease [38]. Retrospective analysis of our cohort revealed that all patients also fulfilled the newer 2013 ACR/EULAR classification criteria [39]. The presence of SSc-associated ILD was documented by findings in either high resolution computed tomography (HRCT) of the chest or PFTs or both. PFT measurements were considered abnormal if FVC and/or DLCO were o80% of the estimated values, while HRCT was considered indicative of ILD after assessment of the presence of ground glass, reticular, or honeycombing lesions by an experienced radiologist. Treatment with RTX was offered to 51 patients with SSc-associated ILD that had no changes in medications and/or dosage of treatment administered during the last 12 months. Thirty three patients (n ¼ 33) agreed to receive RTX and formed the RTX group whereas eighteen (n ¼ 18) patients declined; these patients formed the control group. Median follow-up for all (n ¼ 51) patients was 4 years. All patients in the RTX group received at least two cycles of RTX and were evaluated during a median follow-up period of 2 years (range: 1–7 years). The majority of patients (n ¼ 19) received at least four cycles of RTX and have completed a 2-year follow-up; following this time point continuation of RTX treatment was decided by the treating physician. In most cases RTX treatment was continued throughout the follow-up period; however, treatment was temporarily discontinued in six patients (in three patients at 2 years and in three patients at 3 years of treatment). Since patients who
Fig. 1. Timeline depicting the number of patients followed for each time point.
discontinued RTX treatment exhibited deterioration in pulmonary function they were rechallenged with RTX following 1–2 years of treatment cessation. From the fourth up to the seventh year of follow-up all patients were on continuous RTX treatment. Followup data were available from all patients in the RTX group (n ¼ 33) for the 1-year time point and for 19, 15, 10, 6, 5, and 5 for the 2, 3, 4, 5, 6, and 7-year time point, respectively (94 patient-years totally). For the control group follow-up data were available from all patients (n ¼ 18) for the 1-year time point and for 17, 16, 15, 13, 10, and 9 for the 2, 3, 4, 5, 6, and 7-year time point, respectively. These are diagrammatically depicted in Figure 1. All patients were subjected to routine blood tests every 3 months (full blood count and biochemistry profile) and a cardiac ultrasound annually. PFTs and clinical assessment of skin thickening (Modified Rodnan Skin Score-MRSS) were performed every 6 months for the first 2 years of follow-up and annually thereafter. The majority of the patients enrolled (30/33 in the RTX group and 14/18 in the control group) belonged to the diffuse subtype of the disease. A local Ethics Committee approved the study in each participating center and a written informed consent was obtained from all patients.
Treatment Rituximab group Patients were treated with two or more cycles of RTX. Each cycle consisted of four infusions of 375 mg of RTX per m2 of body surface area, once weekly. RTX cycles were repeated every 6 months. Thirteen patients in the RTX group received concurrent immune based therapies; methotrexate (n ¼ 2), hydroxychloroquine (n ¼ 1) and mycophenolate mofetil(n ¼ 10, dosage 2 g/day). Patients on mycophenolate (MMF) had been on that treatment for a median of 24 months prior to enrollment. Moreover, 18/33 patients were receiving small doses of corticosteroids po ( o10 mg prednisolone or equivalent). Seven patients in the RTX group had received cyclophosphamide (CYC) in the past; in all these patients CYC had been stopped at least 1 year before enrollment. Control group All patients in the control group received conventional treatment, which consisted of azathioprine (n ¼ 2), methotrexate (n ¼ 6), and mycophenolate (n ¼ 10, dosage 2 g/d). Moreover, most patients (17/18) patients were receiving small doses of corticosteroids po (o 10 mg prednisolone or equivalent). Three patients in the control group had received CYC in the past; in all these patients CYC had been stopped at least 1 year before enrollment. Lung and skin fibrosis assessment Standard PFTs were performed at baseline and then every 6 months for the first 2 years and annually thereafter in all patients, including assessments of forced vital capacity (FVC), total lung capacity and diffusing capacity of carbon monoxide (DLCO)
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corrected for hemoglobin concentration. PFT parameters are expressed as a percentage of normal predicted values based on age, sex, and height. The MRSS tool was used for clinical assessment of skin thickening at baseline, every 6 months for the first 2 years and annually thereafter, by an experienced assessor.
Statistical analysis Comparisons between the treated and control groups were performed after appropriate adjustment for disease duration using an analysis of covariance (ANCOVA) model. The comparison of ANCOVA-based adjusted values of MRSS, FVC, and DLCO at various time points with their respective baseline levels was performed using t-test. The corresponding comparisons of observed means to baseline were performed using either paired t-test or Wilcoxon test, according to the significance of an initial Kolmogorov–Smirnov test for normality. In order to provide further evidence for the effect of treatment, we took into consideration the repeated measures nature of our data to fit FVC, DLCO, and MRSS variables with a linear mixed model with random intercepts using “Treatment Group” as factor and “Disease Duration,” “baseline FVC/DLCO/MRSS” and treatment with MMF as covariates. In order to confine the number of parameters as much as possible, we chose the autoregressive covariance matrix for the repeated measures data and did not include any interactions. Kaplan–Meier analysis was used to assess potential differences in survival between groups. The level of statistical significance was set to 0.05. SPSS version 22 and GraphPad5 statistical software were used for statistical analysis.
Results Patients in the treatment and control group had similar epidemiologic and clinical characteristics apart from disease duration; patients in the control group had shorter disease duration. Mean disease duration (defined as duration from first non-Raynaud’s
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disease manifestation) at baseline was 5.73 years in the RTX group and 2.56 years in the control group. Baseline demographic and clinical characteristics of the patients, as well as their concurrent medication, are presented in Table. Continuous treatment with RTX for 2 years significantly improves pulmonary function in patients with SSc Patients in the RTX group showed a non-significant increase in FVC during the first year of treatment (mean 7 SD of FVC: 80.60 7 21.21 vs 83.02 7 19.05 at baseline vs 1-year, respectively, p ¼ 0.136); this beneficial effect was further augmented at 2 years (mean 7 SD of FVC: 86.90 7 20.56, p ¼ 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up (mean 7 SD of FVC: 77.72 7 18.29 vs 77.18 7 19.25 vs 77.59 7 19.45 at baseline, 1 and 2 years respectively, p ¼ ns for both comparison to baseline). Direct comparison between the RTX and the control group at the 2-year time point favored the RTX group as shown in Figure 2, however, the results tended but did not reach statistical significance (p ¼ 0.063). There was an upward trend in DLCO following 2 years of RTX treatment of borderline statistical significance (mean 7 SD of DLCO: 59.22 7 18.17 vs 61.51 7 17.58 at baseline vs 2-years, respectively, p ¼ 0.053). In the standard treatment group DLCO remained stable (mean 7 SD of DLCO: 64.24 7 25.56 vs 63.12 7 23.98 at baseline vs 2-years, respectively, p ¼ 0.384). Direct comparison between the two groups at the 1- and 2-year time point did not reveal any differences (p ¼ 0.398 and p ¼ 0.966 for the 1- and 2-year time point, respectively). These results are diagrammatically depicted in Figure 3. Long-term treatment with RTX improves lung function in patients with SSc-associated ILD At the 7-year time point five patients in the RTX group and nine patients in the control group were still followed. The patients in the RTX group had numerically higher FVC compared to baseline
Table Baseline demographic and clinical characteristics of the RTX cohort matched with the control cohort RTX cohort
Control cohort
p Value
Patients, n Age mean, years 7 SD Female sex (%) Disease duration mean in years (range)
33 54.3 7 14.33 25/33 (75.8) 5.73 (1–28)
18 52.11 7 16.10 16/18 (88.9) 2.56 (1–10)
0.62 0.46 0.012
Autoantibodies positive Scl70 (%) ACA (%) Other (%)
25/33 (75.8) 3/33 (9.1) 5/33 (15.1)
14/18 (77.8) 3/18 (16.7) 1/18 (5.5)
1.00 0.65 0.40
Disease subtype Diffuse (%) Limited (%)
30/33 (90.9) 3/33 (9.1)
14/18 (77.8) 4/18 (22.2)
0.22 0.22
Pulmonary hypertension (%)a MRSS, mean 7 SD FVC, mean 7 SD DLCO, mean 7 SD
6/33 14.72 80.60 59.22
(18.2) 7 10.52 7 21.21 7 18.17
5/18 17.78 77.72 64.24
(27.8) 7 9.48 7 18.29 7 25.56
0.48 0.31 0.63 0.42
Concurrent medication Prednisolone(or equivalent) (%) Methotrexate (%) Mycophenolate (%) Azathioprine (%) Hydroxychloroquine (%)
18/33 2/33 10/33 0/33 1/33
(54.5) (6.1) (30.3) (0.0) (3.0)
17/18 6/18 10/18 2/18 0/18
(94.4) (33.3) (55.5) (11.1) (0.0)
p Value refers to the comparison of the variables presented between the two cohorts. Level of statistical significance is set to 0.05. a
Based on ultrasound PASP values.
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Fig. 2. Time plot depicting FVC values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between two groups tended to favor RTX at the 2-year time point (p ¼ 0.063) whereas at the 7-year time point direct comparison between the two groups showed a significant benefit for the RTX group (p ¼ 0.013) (A). Time plot depicting % changes in FVC compared to baseline values for the RTX and the standard treatment group (B).
(mean 7 SD of FVC: 80.60 7 21.21 vs 91.60 7 14.81, at baseline vs 7 years, respectively, p ¼ 0.158) in contrast to patients in the control group where FVC showed a significant deterioration (mean 7 SD of FVC: 77.72 7 18.29 vs 61.11 7 15.73 at baseline vs 7 years respectively, p ¼ 0.001). Direct comparison between the two groups showed a significant benefit for the RTX group (p ¼ 0.013). DLCO remained stable in the RTX group (mean 7 SD of DLCO: 59.08 7 18.17 vs 60.66 7 24.71 at baseline vs 7 years respectively, p ¼ ns). On the other hand, DLCO significantly declined in the control group (mean 7 SD of DLCO: 64.50 7 25.562 vs 51.08 7 15.69 at baseline vs 7 years respectively, p ¼ 0.004). However, direct comparison between the two groups did not reveal any differences (p ¼ 0.495). In order to explore in more detail the effect of RTX on pulmonary function we used a linear mixed model analysis with the inclusion of disease duration, baseline FVC/DLCO/MRSS and treatment with MMF as covariates. According to the linear mixed models fitted, there was a significant effect of treatment on FVC and DLCO. Specifically, the RTX group presented a mean increase in both FVC (10.02 units, p ¼ 0.004) and DLCO (8.14 units, p ¼ 0.043) compared to the control group.
(mean 7 SD of MRSS: 14.72 7 10.52 vs 8.83 7 7.83 vs 5.93 7 5.15 vs 4.53 7 5.29 vs 5.37 7 8.34 at baseline, 1–4 years respectively, p o 0.01 for all comparisons to baseline). In the control group a decline in MRSS was also noted (mean 7 SD of MRSS: 17.78 7 9.48 vs 15.78 7 9.89 vs 13.72 7 9.67 vs 15.53 7 9.53 vs 13.64 7 8.56 at baseline, 1–4 years respectively, p ¼ 0.064 for 1 year vs baseline, 0.030 for 2 years vs baseline, 0.041 for 3-years vs baseline and 0.023 for 4-years vs baseline). Direct comparison between the 2 groups showed a clear benefit for the RTX group in most time points; p ¼ 0.002, 0.015, 0.002, 0.053, and 0.029 for the 1–5-year time point, respectively, indicating that RTX treatment leads to an enhanced resolution of skin fibrosis compared to patients on standard treatment. In order to explore in more detail the effect of RTX on skin thickening we used a linear mixed model analysis with the inclusion of disease duration, baseline FVC/DLCO/MRSS and treatment with MMF as covariates. According to the linear mixed models fitted MRSS was higher in the control group (3.89 units, p ¼ 0.007) compared to the RTX group. Adverse events Rituximab group Treatment with RTX was generally well tolerated, even in cases of advanced disease with presence of comorbidities. Five deaths were reported during the follow-up period. Three of them concerned patients with end stage lung fibrosis before the initiation of RTX, with the cause of death being respiratory insufficiency. Another patient was diagnosed with lung cancer, approximately 1 year after starting treatment with RTX and consequently died because of this. The last death was a case of sudden death during sleep; the exact cause of death is unknown since an autopsy was not performed. Three patients with severe lung involvement were hospitalized, two of them more than once, with a diagnosis of respiratory infection, requiring treatment with intravenous antibiotics. In one case cytomegalovirus was identified as the causal agent. Another patient was hospitalized with urinary infection. A known HBV carrier, receiving lamivudine, was diagnosed as having HBV reactivation during RTX treatment. Antiviral treatment scheme
Cessation of RTX treatment associates with a decline in pulmonary function In six patients in the RTX group treatment was temporarily discontinued following 2 (n ¼ 3) or 3 years (n ¼ 3) of continuous treatment. In all 6 patients a decline in FVC was evident following treatment cessation as shown in Figure 4. Taking into account this deterioration following RTX discontinuation, all these patients were rechallenged with RTX. Three patients (pts 1–3) showed an increase in FVC following retreatment. However, in the remaining 3 patients (pts 4–6) there was no evidence of efficacy. Patients 5 and 6 died due to respiratory insufficiency a few months following retreatment. Enhanced resolution of skin thickening in patients with SSc treated with RTX compared to patients receiving standard treatment In the RTX group there was a significant improvement in skin thickening as assessed by the MRSS tool as shown in Figure 5
Fig. 3. Time plot depicting DLCO values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between groups did not reveal any statistical significant changes (A). Time plot depicting % changes in DLCO compared to baseline values for the RTX and the standard treatment group. DLCO remained stable in the RTX group whereas a deterioration of DLCO can be seen in the standard treatment group (p ¼ 0.004 for the comparison of the 7-year time point vs baseline) (B).
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Fig. 4. Time plots of FVC values in 6 patients who discontinued RTX treatment. Black arrows indicate the time of RTX discontinuation whereas red arrows indicate the time of retreatment with RTX. A clear decline in FVC can be seen in all patients following treatment cessation. Upon rechallenge with RTX patients 1–3 exhibited an increase in FVC. However, in the remaining three patients there was no evidence of efficacy (pts 4–6). Patients 5 and 6 died due to respiratory insufficiency a few months following retreatment. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
was altered by the local infectious disease specialists, and RTX was continued few months later when HBV DNA levels were sufficiently low. A male patient was diagnosed with prostate cancer shortly after starting RTX. In this case, older age and pre-existing urinary symptoms could point to a pre-existing prostate disease. Lastly, two cases of mild infusion reactions were reported.
because of treatment with mycophenolate mofetil when conception was achieved. A similar percentage of patients died during follow-up in the two groups (15% vs 11%, for the RTX and the control group, respectively, p ¼ 0.68). Kaplan–Meier analysis did not detect differences in survival between groups (p ¼ 0.123, log-rank test).
Control group Discussion Two deaths were reported in this cohort during the follow-up period. Both of them were attributed to lung infection with coexistence of extensive lung disease in one case and pulmonary arterial hypertension in the other. Five patients with lung infection and four patients with urinary infection were hospitalized, requiring treatment with IV antibiotics. In four cases, infections were recurrent. One patient was hospitalized due to digital ulcers requiring IV antibiotics and iloprost while one female patient decided to stop pregnancy
Fig. 5. Time plot depicting MRSS values (adjusted for disease duration) for the RTX and the standard treatment group. Direct comparison between groups favored RTX in all time points (p ¼ 0.002, 0.015, 0.002, 0.053, 0.029 for the 1–5-year time point, respectively).
Interstitial lung disease alongside pulmonary arterial hypertension (PAH) are the most fearful complications of SSc and are nowadays the leading causes of death. During the last decade there has been a substantial progress in the treatment of the vascular complications of SSc, such as PAH. However, therapeutic approaches for fibrotic complications such as ILD remain limited and exhibit only modest efficacy. During the last 5 years there has been an increasing interest in B-cell depletion as a potential therapeutic strategy for SSc, mainly targeting lung and skin fibrosis. This was based on strong experimental evidence pointing to the direction that B cells are crucial regulators of the fibrotic process [40]. In animal models of scleroderma, B cells exhibit increased CD19 signaling [25] (a positive B-cell receptor response regulator); moreover, B-cell depletion leads to attenuation of skin fibrosis [21]. In vitro data suggest that B cells may directly interact with fibroblasts and enhance collagen production in a TGFβdependent manner [16]. In patients with SSc, B cells exhibit increased CD19 expression and are activated [40,41]. Furthermore, scleroderma skin is characterized by a B-cell signature [42] whereas lung biopsies from patients with SSc-associated ILD display prominent B-cell infiltration [43]. All these data coming from basic research points to the direction that B cells are a an
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attractive candidate for the treatment of fibrotic diseases such as SSc [44,45]. Indeed, clinical data related to B-cell depletion therapy in SSc are encouraging. Many research groups have reported that RTX treatment improved skin thickening and lung fibrosis in patients with SSc. Our current data further support the concept that RTX may have disease modifying properties in SSc. It is generally not easy to assess the potential clinical efficacy of a given treatment in patients with SSc because it is a slowly progressive disease affecting several internal organs that are not directly accessible through physical examination. Moreover, skin thickening tends to resolve in late stages of the disease and this makes the assessment even more complicated. This is why controlled data are necessary for evaluating the potential efficacy of a treatment in SSc. In this study we compared the group receiving RTX treatment with a similar cohort of patients on standard treatment; our controlled data further substantiate previous reports indicating that RTX favorably affects lung function and skin fibrosis in patients with SSc. There are only limited long-term data related to the use of RTX in SSc. This study is the first to report long-term data, extending to 7 years. A critical question in therapy of SSc-associated ILD is the length of treatment. So far, evidence indicates that continuous treatment is warranted. This was clearly shown in the case of CYC where cessation of treatment following 1 year led to a decline in PFTs throughout the second year of follow-up [8]. This fact underlines the necessity of developing a treatment that can be administered on a long-term basis, something that cannot be done with CYC due to its toxicity. RTX appears as an attractive candidate treatment for SSc-associated ILD; data derived from rheumatoid arthritis suggest that RTX can be safely administered over long periods carrying an acceptable safety profile. In this study we also had the chance to explore outcomes following RTX cessation after an initial favorable response. It is noteworthy that all patients deteriorated and this is why we propose that patients who received RTX and had a favorable response should remain on treatment on a long-term basis. Our data indicate that RTX is generally well tolerated in patients with SSc. A similar percentage of patients died during follow-up in the two groups. Moreover, all deaths in the RTX group were most likely not directly attributed to treatment. We did not find any differences in the rate and pattern of infections between the two groups apart from a case hepatitis B reactivation which occurred in the RTX group indicating that RTX carries a similar safety profile with classic immunosuppressive agents such as mycophenolate, methotrexate, and azathioprine, which were used in the conventional treatment group. Our study has potential limitations. Even though it was prospective and controlled, it was not randomized and this may lead to some bias. However, the two groups had similar demographic and clinical characteristics apart from disease duration. To overcome this, we used the proper statistical analysis in order to adjust all variable assessed for disease duration and only adjusted variables were used for comparisons between groups. Nevertheless, the number of patients assessed and the extended follow-up are strengths of the study. Definite answers can only derive from a large scale randomized controlled trial with statistical power to prove efficacy; such trials are currently underway (ISRCTN16474148 and NCT01748084). Up until then, our data indicate that RTX may be used in SSc-associated ILD when conventional treatment fails. References [1] Elhai M, Meune C, Avouac J, Kahan A, Allanore Y. Trends in mortality in patients with systemic sclerosis over 40 years: a systematic review and metaanalysis of cohort studies. Rheumatology (Oxford) 2012;51:1017–26.
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