RITUXIMAB

(Rituxan®/Mabthera®)

B cell-specific biologic

Anti-CD20 therapy

i.e., monoclonal antibody against the CD20 antigen of B-cells

“potent B-cell depleting chimeric monoclonal IgG1 anti-CD20 antibody (mAb)

that induces

cell-mediated/antibody-dependent cytotoxicity

apoptosis

and

complement-mediated cytotoxicity of B-cells”.

(CD20 is a transmembrane glycoprotein expressed on the surface of most B lymphocytes)

B cell biology:-

There are many populations of B cells in the human body and the site and properties of the B cells
differ according to their stage of development. B cells originate from hematopoietic stem cells in the
bone marrow and develop into immature B cells,each stage marked by changes in cell surface
markers and immunoglobulin heavy and light chains. The immature B cells migrate to the secondary
lymphoid organs (SLOs), such as the spleen and lymph nodes, to complete its development.Major
populations in the SLOs are the transitional B cells,follicular B cells and the marginal zone B cells,
while peripheral blood is home to the activated B cells, such as memory B cells and antibody-
secreting B cells, which are categorized into short-lived, proliferating plasmablasts and long-lived,
non-proliferating plasma cells.

The most important cell surface marker of our discussion, CD20, is found in Pre-B cells up to memory
B cells and is targeted by current anti-B cell biologics.

CD20 is a transmembrane glycoprotein expressed on the surface of most B lymphocytes, from late
pro-B cell to memory B cell and is lost upon plasma cell differentiation.

-in pre-B-cells and mature B-cells, but not by plasma cells.

 (Another important marker, CD19, is found in earlier in Pro-B cells up to memory B cells, but is not a
current target of biologics)

Mechanism of action:-

Upon binding of rituximab to B cells, the B cells are destroyed by a combination of mechanisms

In ADCC, natural killer cell CD16, or FcγRIII, recognizes

and binds the Fc region on rituximab, triggering the

release of lytic enzymes that kill the attached B cell. In CDC,

C1q, a complement protein, attaches to the Fc region of

rituximab, triggering activation of the classical complement

pathway. As CD20 is highly expressed in B cells and does

not become internalized or shed from the cell membrane,

rituximab exerts a long-lasting depleting effect after infusion,

frequently lasting more than 6 months [3]. Rituximab

interrupts the generation of plasmablasts from memory B

cells and interfere with the survival of long-lived, CD20+

plasma cells in SLOs [12, 13].

Likely to exert various immunologic effects

1.Primarily B-lymphocyte depletion (quantitative) by

-antibody-dependent cellular cytotoxicity (ADCC)

-complement-dependent cytotoxicity (CDC) and

-direct apoptosis

Upon binding of rituximab to B cells, the B cells are destroyed by a combination of the above
mechanisms.

In ADCC, natural killer cell CD16, or FcγRIII, recognizes and binds the Fc region on rituximab,
triggering the release of lytic enzymes that kill the attached B cell.

In CDC,C1q, a complement protein, attaches to the Fc region of rituximab, triggering activation of

the classical complement pathway.

What is the basis of long-lasting B cell depletion effect of rituximab after infusion?

As CD20 is highly expressed in B cells and does not become internalized or shed from the cell
membrane,rituximab exerts a long-lasting depleting effect after infusion,frequently lasting more
than 6 months .
Rituximab interrupts the generation of plasmablasts from memory B cells and interfere with the
survival of long-lived, CD20+ plasma cells in SLOs

2.Secondarily

through the loss of the antigen-presenting and immunomodulatory functions of B-cells

(qualitative)

Affects only CD20-bearing B cells, which include pro-B,pre-B cells, and immature B cells in the
bone marrow, B cells in the SLOs and memory B cells in the peripheral blood.

FAQ

What is the basis of relapse and resistance after treatment with rituximab?

Rituximab does not target CD20- antibody secreting plasma cells. Relapse and resistance after
treatment with rituximab may be due to presence of long-lived plasma cells, which can persist for
many years.

What are the causes for variable response to rituximab?

Attributed to several host factors, including

(1) incomplete B cell depletion in bone marrow, spleen, and lymph nodes\

(2) long-lived plasma cells that continue to generate autoantibodies

(3)autoreactive CD4+ Th cells

(4) generation of antibodies to rituximab, or human anti-chimeric antibodies (HACA), that

interfere with rituximab binding

(5) changes in rituximab pharmacokinetics due to dose and schedule

(6)FcγRIIIα polymorphisms and lipid raft signaling alterations that lead to rituximab-mediated ADCC
resistance.

What is the significance of HACA?

HACA have been associated with poor clinical outcome and infusion adverse events in PV patients
treated with rituximab.

How will you confirm relapse in PV?

1.Clinically

2.Laboratory-

Measuring anti-desmoglein 3 antibody titers in patients

Can we administrate rituximab along with a vaccine like for influenza?

As only a small fraction of differentiated plasma cells express CD20, the effect of rituximab on
immune function is minimal.

Hence immunity to diseases, such as influenza, after vaccine administration has been shown to be
preserved in rituximab-treated rheumatoid arthritis patients and comparable to controls.

Indications:-

Rituximab was first approved in 1997 for the treatment of relapsed or refractory low-grade follicular
B-cell lymphoma,but has since expanded to become a major treatment modality of B cell neoplasms
and refractory rheumatoid arthritis.In addition, it is increasingly used off-label in the treatment of a
variety of autoimmune diseases, including PV.

1.Autoimmune skin diseases - pemphigus, bullous pemphigoid and epidermolysis bullosa aquisita.

Cicatricial pemphigoid rituximab+conventional immunosuppression

SLE

Sjogren’s syndrome

Antiphospholipid syndrome (APS)

Cryoglobulinemia

Sarcoid

Adult onset Still’s disease

 Polychondritis

2.RA

3.Vasculitis.

Although some B-cell aggregation has been noted in PsA synovium,B lymphocytes are not
considered to be as prominent a part of the pathophysiology of PsA as RA.

Small cohorts of PsA patients have been treated with rituximab and modest effect on arthritis but
virtually no effect on skin psoriasis.

4.AD

In contrast to autoimmune diseases, Eventhough activated B-cells are clearly present,the role of B-
cells, is not clear in the pathogenesis of AD.

Dosage:-

AD -IV rituximab 1000 mg 2 weeks apart X 4-8 weeks (improvement)

Anti-CD20 Therapy in Pemphigus Vulgaris:-

Immunobullous disorders are characterized by autoantibodies to intercellular adhesion proteins

within the epidermis and dermo-epidermal junction. In the pemphigus group,antibodies are made to
desmosome components, while in subepidermal blistering diseases like bullous pemphigoid (BP),
antibodies are made to hemidesmosome components .
PV is characterized by autoantibodies to desmoglein 1 and desmoglein 3, causing intraepidermal
acantholysis.

The first-line approach to pemphigus vulgaris (PV) varies, but often includes some combination of
systemic corticosteroid,mycophenolate mofetil, rituximab, or intravenous immunoglobulin (IVIG).
Second-line agents include azathioprine,methotrexate, cyclophosphamide, plasmapheresis, and
more recently, protein A immunoadsorption (PAIA)

In the majority of patients, rituximab was administered as adjuvant with immunosuppressive

therapies with a remission rate of 90–95% of patients in less than 6 weeks and complete resolution
within 3–4 months. Although relapse requiring retreatment was common, rituximab has shown
success in inducing remission when conventional immunosuppressive therapies have failed.

Rituximab Therapeutic Regimens in Pemphigus:-

No definitive treatment protocol of rituximab exists for pemphigus vulgaris

Most often been administered as four weekly infusions of 375 mg/m2 on days 1, 8, 15, and 22 which
is the recommended dose and schedule for non-Hodgkin’s lymphoma . However, a lower dose is
approved for use in rheumatoid arthritis (two 1000 mg IV infusions separated by 2 weeks) and has
successfully been used in patients with pemphigus. An even lower dose has been shown to be
effective and safe, in one recent prospective open case series, at a single course of two 500 mg
infusions of rituximab at an interval of 2 weeks [22].

Currently, there are no dose-optimization or cost-effectiveness studies of rituximab therapy in

pemphigus.

Rituximab may be combined with other adjuvant therapies, such as immunoadsorption, high-dose
IVIG (2 g/kg per course), or immunosuppressive therapies.

Infused after diluting 375 mg/m2 rituximab in 500 mL of 0.9% sodium chloride (final concentration:
1–4 mg/mL) and infused intravenously (IV) over 4–5 hrs on days 1, 8, 15, and 22. For the first
infusion, rituximab is administered at 50 mg/h and escalated by 50 mg/h at 30-min intervals to a
maximum of 400 mg/h (an infusion rate of 500 mL/h). In subsequent infusions, infusions are initiated
at 100 mg/h,with a 30-min escalation of 100 mg/h to a maximum infusion rate of 400 mg/h.

To prevent adverse infusion reactions, it is advisable to provide prophylactic treatment with an

antipyretic, antihistamine, and 100 mg IV methylprednisolone about 30 min prior to each infusion.

Other immunomodulators, such as IVIG, are also used to supplement rituximab therapy. For some
time,there has been no consensus on how to optimize immunomodulation.

Should IVIG be administered to keep levels high for an extended period of time?

Should IVIG be administered intermittently in high-dose spikes ?

For some time,there has been no consensus on how to optimize immunomodulation.

A 2003 consensus statement on the use of IVIG in blistering disease recommended a dose of 2
g/kg/cycle, given monthly until clinical control, with a subsequent increase in the time between
cycles to 6, 8, 10, 12, and 14 weeks.

However,these guidelines did not address differences in commercial preparation, management of

partial responders, and differences in concomitant therapies. Currently, clinicians are using various
strategies in IVIG supplementation.

Autoimmune blistering diseases are rare in the pediatric population, but can be potentially fatal
conditions. Although treatment regimens of rituximab for autoimmune blistering diseases have been
well characterized in adult patients, treatment regimens for pediatric patients have, thus far,
consisted of anecdotal evidence and case reports.

Most case reports of pediatric PV treated with rituximab described refractorycases managed with at
least one concomitant drug and the administration of rituximab using the lymphoma protocol (375
mg/m2 weekly for 4 weeks).

Side effects:-

I Cutaneous-

TEN