Saturday, March 22, 2014

An Excellent Question

I love hanging out in my little corner reading letters from y'all. 

A reader sent this question via email the other day, and it was one often asked frequently of me by others: Can you tell me if there is any hope for this drug (rituximab) for Sjogrens? Here's an improved version what I told her:

Regarding the use of rituximab: This drug has been used for many years in the treatment of cancers such as chronic lymphocytic leukemia and non-Hodgkins lymphoma. It has also been used often in patients with rheumatoid arthritis. It works to interrupt the autoimmune response by targeting a very specific subset of the white blood cells (CD20 B Lymphocyte). This process is called B cell depletion therapy. You can read more about this type of therapy here.

Rituximab has been used in the treatment of Sjogren's syndrome for several years. It is not considered an experimental use of this drug, BUT neither is it a first-line drug. Read this found here:
...However, while we await the results of larger trials, RTX should only be considered as a rescue therapy in patients who exhibit involvements refractory to standard treatment. (Ramos-Casals and Brito-Zeron, 2007).
When my rheumotologist prescribed it for me, he did so based on a few things: my disease was demonstrably active at the time, I had tried and failed numerous other DMARD medications, and I was willing to take it despite some risks of significant side effects. It's not a first line drug since by altering our white blood cells and is made with mouse proteins that have been partially humanized, has potential to cause serious side effects such as infusion reactions and increased susceptibility to infections.

There has been several good studies proving it's efficacy. Here's this study's conclusion:
This paper reports the first prospective, multi-center, follow-up study performed in a large cohort of active pSS patients, with recent disease onset carried out for a period of 120 weeks, to assess safety and efficacy of RTX compared with DMARD treatment, and correlating the clinical response to the immune-histological and molecular patterns before and after treatments. Our study shows that B-cell depleting therapy by RTX offers a promising and safe treatment for these patients, significantly ameliorating clinical features, when compared with other therapies, and restoring B-cell disturbance, by reducing immune infiltrate and lymphoid organization in target tissues. In fact, this therapy is able to interfere with the formation of tertiary lymphoid tissue, not only depleting B cells but also tuning the delicate equilibrium between cells, molecules and receptors, partially affecting the pro-B-cell inflammatory milieu that is typical of the inflamed glands. (Bolding mine.)
Other smaller studies, while acknowledging it's benefit for some patients, concluded that rituximab carries too much expense and risk to justify treatment for temporary relief of fatigue. My rheumatologist told me that this conclusion "is a matter of opinion", and feels that ritux may be of some benefit to me. (Yesssss, Dr. Young Guy!)

It is also a very expensive drug not only for cost of the drug itself, but the fact that it must be administered IV and under fairly close observation by medical personnel. I am very fortunate that my insurance coverage pays for this, but I have heard from other people around the country that some insurances do not.

Rituximab is helpful for some of us, me included, but not for others. Why this happens is not understood, probably because there is still so much that is not known about Sjogren's syndrome and autoimmune diseases in general.

So. Rituximab: A complex drug in the treatment of a complex disease. I hope that this explains a bit more about this therapy for all those that have asked.

No comments: