Rituximab therapy for primary central nervous system vasculitis: A 6 patient experience and review of the literature

Publication date: Available online 10 February 2019

Source: Autoimmunity Reviews

Author(s): Carlo Salvarani, Robert D. Brown Jr, Francesco Muratore, Teresa J.H. Christianson, Elena Galli, Nicolò Pipitone, Giulia Cassone, John Huston III, Caterina Giannini, Kenneth Warrington, Gene G. Hunder

Abstract

Objectives

To assess the efficacy and safety of Rituximab (RTX) in adult primary central nervous system vasculitis (PCNSV).

Methods

We retrospectively assessed the effect of RTX in 6 patients with PCNSV. Five of the 6 were refractory to high dose glucocorticoids (GCs) and/or conventional immunosuppressants (IS). The sixth was newly diagnosed and received RTX in combination with GCs. Clinical evaluation, laboratory tests, and imaging modalities were performed at initial RTX administration and during the follow-up. Treatment response was assessed using the treating physician's global opinion regarding response and the degree of disability using the modified Rankin scale (mRS). We also performed a literature review for previous use of RTX in PCNSV using PubMed, Ovid Medline, and the Cochrane library.

Results

The six patients (3 females) had a median age at diagnosis of 50.5 years (range 17–68 years). All had active disease when RTX was started. In 4 patients, RTX administration was associated with a marked reduction in the number of flares (from 18 before starting RTX to 3 after). One patient, after an initial improvement, had 2 flares when B cells were depleted and he was not able to reduce prednisone below 20 mg/day. A 6th patient had a flare when B cells recovered and retreatment with RTX re-induced and maintained remission. The median mRS score at last visit (median: 2; range 0–4) was lower than that prior to treatment (median 3; range 1–5). The median prednisone daily dose before RTX administration was significantly higher than that at last follow-up (p = .006). In the literature review, we identified 5 papers describing 7 patients treated with RTX. Six patients responded to RTX with clinical and MRI improvement with no reported flares after RTX treatment.

Conclusions

Our data support a potential role for RTX treatment in selected patients with PCNSV.

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