Abstract
Introduction::
Rituximab (RTX), a monoclonal antibody that recognizes CD20 on mature B lymphocytes, has demonstrated efficacy in the treatment of lymphomas, systemic lupus erythematosus (SLE), Wegener’s granulomatosis (WG), and rheumatoid arthritis (RA). Its role in the treatment of ocular inflammatory disease has not been extensively studied. We report 4 cases in which RTX appeared beneficial in the treatment of scleritis (2 cases) and orbital inflammation (2 cases).
Methods::
Retrospective case series. RTX treatments comprised: RTX 1g IV x 2, with a 2-week interval between doses for Patients 1-3, while Patient 4 received RTX 375mg/m2 weekly x 4 weeks.
Results::
Patient 1. A 57 y/o male with nodular scleritis failed nonsteroidals, azathioprine (AZA), and mycophenolate mofetil (MMF) monotherapy. After RTX he tapered off prednisone (Pred). He remained quiet on MMF for 11 months before having a mild, unilateral flare that was promptly controlled with low-dose Pred. 17 months s/p RTX a bilateral flare required moderate doses of Pred. Repeat treatment with RTX induced remission and allowed Pred tapering. Patient 2. A 27 y/o female with diabetes, RA, and bilateral anterior scleritis failed anakinra, methotrexate (MTX) monotherapy, hydroxychloroquine, etanercept, adalimumab, minocycline, and leflunomide. RTX treatment allowed Pred tapering from 40mg QD to 30mg QOD while continuing MTX. 5 months after receiving RTX, she required retreatment for recurrent joint and eye symptoms. With continued MTX therapy she tapered Pred to 5mg QD and remained quiet for 2 months before flaring after a hospital admission for hyperglycemia. Patient 3. A 29 y/o female with severe idiopathic orbital inflammation failed MTX, MMF, combination MTX and cyclosporine, and had only transient benefit with cyclophosphamide (CYC). After receiving RTX she tapered off Pred and stopped MTX 3-4 months later due to nausea. She remained quiet off all meds for 1 year before having recurrent orbital inflammation which responded to MTX.Patient 4. A 30 y/o female with ANCA (+) limited WG failed AZA, MTX, and oral CYC. She gained 50 lbs on Pred and required IV solumedrol. Orbital disease continued to worsen despite Pred 50mg QD. Following RTX, both sinus and orbital disease improved. With continued MTX therapy she tapered Pred to 6mg/day. 4 months s/p RTX she had increased nasal crusting requiring a small pulse of Pred 20mg QD, and tapering to 10mg QD over 2 weeks.
Conclusions::
RTX may have a role in treatment of ocular inflammatory disease, specifically refractory scleritis and non-infectious orbital inflammatory disease, two conditions associated with RA, SLE, and WG. Continued study will help define this role.
Keywords: autoimmune disease • immunomodulation/immunoregulation • inflammation