There is increasing interest in
rituximab (RTX) as an alternative to
cyclophosphamide (CYC) for
remission induction in
systemic vasculitis. Recent studies have reported high remission rates, but it is not clear how long the initial remission lasts [1, 2]. A retrospective study was undertaken of 15 cases of refractory
systemic vasculitis (11
Wegener's granulomatosis, 1
Churg-Strauss syndrome, 1 cutaneous
polyarteritis nodosa and 2 cryoglobulinaemic
vasculitis) treated with RTX, with a mean follow-up of 34 months. All had previously received CYC, and 14, at least one other immunosuppressive
drug. All had active disease when treated (median Birmingham
Vasculitis Activity Score (BVAS) 2003, 13). All cases achieved remission (BVAS 2003, 0). Thirteen required re-treatment, nine due to relapse (mean, 9 months after initial treatment) and four because of repopulation or rising
ANCA in the context of CYC intolerance or previous CYC refractory disease. Relapsing cases have been successfully re-treated up to five further cycles, either at B cell repopulation or at six monthly intervals.
Infections were rare. Mean
IgG levels fell significantly, and
IgM levels became subnormal in six cases. There were three cases of
neutropenia, one severe at 10 months post-treatment. These results provide further evidence that RTX is an effective induction agent in
systemic vasculitis. The optimal and long-term outcome of re-treatment remains to be defined.