What’s the evidence for using Rituximab in refractory Lupus Nephritis?
To date, there is published data from over 20 studies, comprising 300 patients, of cases of refractory lupus or lupus nephritis treated with rituximab, with reported response rates of around 75%. However, positive reporting bias is a real concern, and no randomized trials in renal disease exist.
She continues to have very active serology; what does this mean?
Autoantibody levels in lupus and vasculitis do not predict relapse very well in general. The published studies report that responders will typically demonstrate a fall in anti–double-stranded DNA antibodies, and a correction of complement depletion. So, they appear to have more of a role in predicting response to treatment
This patient has now been in remission for over 1 year. However, I’m concerned about the possibility of an impending relapse. Relapses are reported as occurring after an average of 10 to 13 months, although some patients maintain remission for several years. Also, her peripheral B cells (CD19+ or CD20+ lymphocytes) have recently recovered. Patients who fail to achieve depletion tend to have poor or no clinical response, whereas prolonged B cell depletion is associated with a prolonged clinical response. Protocol re-treatment at 4- or 6-mo intervals is under evaluation, so for now there is no good answer to this question.