Rituximab B-Cell Depletion Stops JIA

KFAR-SABA and TEL AVIV, Israel—B-lymphocyte depletion with a dose or two of rituximab (Rituxan^®, Genentech Biogen), induced a durable remission in a patient with otherwise untreatable systemic onset juvenile idiopathic arthritis (SOJIA) and might represent a new option for JIA patients. The case was reported early online in Rheumatology.¹

The 18-year old patient had a 12-year history of severe, refractory arthritis involving multiple joints. She had numerous joint deformities and was no longer able to stand or walk due to severe pain, despite ongoing treatment with weekly high-dose infusions of methylprednisolone (300-500 mg), which had continued for more than a year. The patient also had major steroid-induced adverse effects, including osteoporosis, several vertebral fractures, and significant cushingoid features.

Lead author Michal Kasher-Meron, MD, and colleagues reported that 2 infusions of rituximab (1 g, days 1 and 15) produced a sustained remission with “marked functional improvement with a significant decrease of the intensity of her joint pain.” This enabled the patient to resume physical therapy with weight-bearing exercises. Cushingoid features also resolved, and the steroid dose was reduced to 30 mg/dL/week.

“Since B-cell depletion therapy is considered relatively safe, it may present a true alternative to conventional immunosuppressive and biological treatments in SOJIA,” Dr. Kasher-Meron said.

Rituximab normalized many aspects of JIA

Rituximab treatment also:

reduced CRP from 20 mg/dL to 1.5 mg/dL
increased hemoglobin from 9 g/dL to 12.0 g/dL
normalized serum ferritin and D-dimer concentrations

Along with rituximab, the patient was treated with concomitant azathioprine, trimethoprim sulphamethoxazole, estrogen therapy, and bisphosphonate with high-dose vitamin D.

This patient had previously been treated unsuccessfully with methotrexate, cyclophosphamide, hydroxychloroquine, cyclosporin, thalidomide, intravenous immunoglobulins, etanercept, infliximab, and anakinra.

Translating research into practice

Senior author Howard Amital, MD, of Meir Medical Center in Kfar-Saba, Israel told MSKreport.com that the duration of remission is currently 2 years without repeat of the rituximab. “Obviously this shows that B-cells play a certain role in the pathogenesis of SOJIA,” he said.

Next, Dr. Amital says, “We still need to drill down understanding the interactions between the immune cells via cytokines and other cellular interactions.”

Reference

1. Kasher-Meron M, Uziel Y, Amital H. Successful treatment with B-cell depleting therapy therapy for refractory systemic onset juvenile idiopathic arthritis: a case report. Rheumatology 2008; [epub ahead of print] 22 January 2009; doi:10.1093/rheumatology/ken492.

Rituximab B-Cell Depletion Stops JIA | Arthritis Information