Just as the FDA called for a "black box" warning on the TNF-blocker etanercept due to increased risk of tuberculosis (TB) and other serious infections, a new case report suggests that rituximab is both safe and effective in rheumatoid arthritis (RA) patients with a history of anti-TNF-associated TB. The new report appears in Rheumatology.1
"We report the first use of B-cell depleting therapy in an RA patient who had developed TB while under treatment with anti-TNF," write the researchers led by Marian L. Burr, MD, of Addenbrooke's Hospital in Cambridge, UK. "This case demonstrates the safety and efficacy of rituximab in this setting."
Rituximab improves RA, keeps TB at bay
In the new case report a 54-year-old white female with a history of severe erosive RA was treated with infliximab, concomitant methotrexate (MTX), and steroids. She had previously failed multiple conventional disease-modifying antirheumatic drugs.The patient responded well to infliximab for 42 months. In April 2006, however, she was diagnosed with TB and infliximab therapy was stopped.
The patient’s TB responded to treatment, but her RA flared 14 weeks after her last dose of infliximab. She started etanercept, failed to respond, and was subsequently treated with two doses of rituximab 1000 mg plus methylprednisolone 100 mg as premedication. The patient continued taking MTX 12.5 mg weekly and prednisolone 10 mg. Her RA improved within 12 weeks and this improvement was maintained for 9 months. She was then treated with a second course of rituximab and her response was "even more impressive," than the initial dosing, the authors write.
"The mechanism of active of rituximab does not raise the same theoretical concerns as TNF inhibition with regard to TB reactivation," they write.
Translating research into practice
"The clinical response of this patient to rituximab after the TNF agent etanercept failed following discontinuation of infliximab due to the patient developing TB is encouraging," said Eric Matteson, MD, professor of medicine at the Mayo Clinic in Rochester, Minnesota. "It is certainly possible that rituximab is less likely to be associated with a reactivation of TB, but…this has not been formally studied," he told MSKreport.com. "Still, it is true that cases are less frequent in patients treated with rituximab, arguing that it might be preferred in patients with a history of TB."
The bottom line is that "at present, and in consideration of the relatively small amount of knowledge we have, [rituximab] can be preferred over anti-TNF agents in patients needing such therapies who have had a history of TB."
References
1. Burr ML, Malaviya AP, Gaston JH, et al. Rituximab in rheumatoid arthritis following anti-TNF-associated tuberculosis. Rheumatology. 2008;47:739-740.
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