Treatment of Rituximab in Pemphigus Vulgaris Patients

Treatment of Rituximab in Pemphigus Vulgaris PatientsPart 3 Clinical Research 2INTRODUCTIONPemphigus is the diagnose of a group of life-threatening sulphurous sicknesss of the skin and mucous membranes. The base of treatment for this infirmity is corticosteroids however, recently, new doses, such as rituximab, have been verified for more severe forms of it.In the authors precedingly unpublished study, the military group of rituximab on magnetic declination in the testing groundoratory indices of pemphigus vulgaris patients is addressed. After probe of the files of pemphigus patients who get rituximab in Razi Hospital, Tehran, Iran from 2008 to 2013, 39 patients were entered into the study. every finis(predicate) patients had lab carpenters planes containing CR (creatinine), urea, ALT (alanine aminotransferase), AST (aspartate aminotransferase), Plt (platelet), Hgb (hemoglobin), and white corpuscle (white alliance cell) in front and later(prenominal) receiving ritu ximab. The patients received rituximab 4 times at a dos mature of 500 mg in 4 successive weeks. The lab results before receiving the first dose of rituximab were compared to the results after receiving treatment. The effect of rituximab on the variation in lab indices with the enrolment effect of age, gender, disease time, sites of involvement, received adjoins, and the background disease were as well as investigated.In the sign abbreviation, rituximab only had a monumental effect on urea reduction. In the CellCept (mycophenolate mofetil) receiving subgroup, the mixed consumption of rituximab led to a brandificant reduction in white cell. In the subgroup having background disease, rituximab had a statistic completelyy evidential meeting on platelet reduction. In the subgroup having no background disease, rituximab had a statistically profound effect on urea reduction.The lab indices were shown to have no satisfying relationship with age and disease duration. Thus, it can be predicted that disease duration and age would have no effect in the relationship between rituximab and lab indices variations.Although in stratified single-variable analysis for adjusting the effect of other variables (involvement sites and received adjoins) on the relation of rituximab and lab indices, some of these variables showed interacting effects with rituximab on the variations of lab indices. However, due to the low volume of sample and non-normal dispersal of most of these variables, it was impossible to do multivariable analysis for investigation of their independent and interactive effects on variations of lab indices in an integrated manner, therefore, we can not make certain comments about their relationships.Chapter 1Pemphigus is the name of a group of life-threatening blistering diseases that have characteristic acantholysis leading to formation of intraepithelial blisters in mucus and skin 1. The acantholysis process is induced via attachments of flowing autoant ibodies to trammel molecules in the cells 2. Patients with pemphigus have mucosal erosions, blisters, papules, and dermal erosions.The different types of pemphigus are pemphigus vulgaris, pemphigus foliaceus, immunoglobulin A (immunoglobulin A) pemphigus, and paraneoplastic pemphigus. Different types of pemphigus are differentiated by clinical symptoms, related autoantigens, and histological methods. Pemphigus vulgaris has mucosal and mucocutaneous involvement. The blisters are acantholytic and suprabasal. The autoantibodies responsible for the disease are against desmoglein (DSG) 1 or both desmoglein 3 and 1.Pemphigus foliaceus only involves the skin. The blisters are acantholytic and subcorneal. The responsible autoantibodies are against desmoglein 1.IgA pemphigus has the form of grouped erythematous crusts, papules, and vesicle plucks. Blisters can be subcorneal or intraepithelial and acantholytic. The responsible autoantibodies are against desmocollin (DSC) 1 3.Paraneoplastic pemphigus involves vast and liberal stomatite along with different cutaneous findings. The responsible autoantibodies are against desmoplakin (DSP) or other desmosomal antigens. Pemphigus vulgaris is the most common type of pemphigus, but is still very rare. The chance of its occurrence is between 0.1 to 0.5 per 100,000 people 4. Pemphigus practically happens among adults and the fair(a) age of attack is 40 to 60 years old. It is very rare among children 5,6. Its prevalence is almost the same in the 2 sexes 7. Almost all the pemphigus vulgaris patients have mucosal involvement. The mouth is the most common site of involvement and is often the first site of involvement. Other mucosal membranes such as conjunctivae, nose, esophagus, vulva, vagina, cervix and anus are rarely involved 8. As mucosal blisters are fragile and burst easily, in clinical examination it is difficult to find intact blisters, and sort of the examiner tends to find mucosal erosions. Buccal and palatal mucos a are the most common sites of blister involvement in the mouth cavity 9.mucosal involvement can be very unspeakable. This pain often increases by chewing and swallowing, which can result in improper alimentation and weight reduction. more or less of the patients also have cutaneous involvement appearing in the form of soft blisters in healthy skin or erythematosus. The blisters easily break, resulting in painful erosions. Pemphigus vulgaris rarely ca occasions pruritis. Almost any part of body skin can be involved, but the palmar aspects of the foot and hands are rarely involved. The Nikolsky sign is often observed among these patients (mechanical pressure on the healthy skin results in blistering). Pemphigus is diagnosed based on the clinical, histological, immuno-pathological symptoms and laboratory findings. Even in cases where the clinical symptoms are intensively supporting pemphigus, laboratory investigation is still needed to confirm the diagnosis, as other diseases may ha ve the same symptoms. The first line of treatment of pemphigus is general corticosteroids, and addition of adjuvants may also be needed. Patients who do not respond to the first line of treatment might need additional interventions. In such patients, cyclophosphamides, rituximab, intravenous immunoglobulin (IVIG) or plasmapheresis may be helpful.Initial treatment of pemphigus vulgaris is systemic glucocorticoid, which is often applied in combination with other non-steroidal immunosuppressants such as azathioprine and mycophenolate mofetil. Pemphigus resistant to treatment is a type of pemphigus that does not respond to the aforementivirtuosod treatments.Pemphigus is a chronic disease that needs long-term treatment. A retro study was conducted during 1982-1993 on 40 patients 8. On just, these patients achieved complete remission after 7.7 years 25% had remission after 2 years 50% after 5 years and 75% after 10 years 8. Most pemphigus vulgaris patients respond to initial treatments 9. The first step, in the patients who do not respond to initial treatment, is increasing the dosage of systemic corticosteroids (1.5-2 mg/kg of prednisolone per day) or adjuvant drug. The adjuvant drug can also be changed (changing azathioprine to mycophenolate mofetil). In resistant cases, cyclophosphamides, rituximab, IVIG, and plasmapheresis could also be employ.As pemphigus is an auto-immune disease caused by autoantibodies, treatments that reduce B cells are investigated 10-13. Rituximab is a monoclonal antibody that targets CD20, located on B-lymphocytes, as its antigen. This drug has been shown to have profound effects on pemphigus treatments 13,14. In a multicenter study conducted on 14 pemphigus vulgaris patients and 7 pemphigus foliaceus patients, both groups were resistant to systemic glucocorticoids and experienced some(prenominal) relapses during glucocorticoid tapering. They were then put on 1 cycle of rituximab with a weekly dosage of 275 mg/m2 for 4 weeks, and th is addition proved advantageous 15. Although, severe infections were account in the patients under rituximab treatment, its effect on risk of infection is not clear, as other immunosuppressants were also concurrently used. Reactions during injection are among the most common side effects of rituximab. Deep vein thrombosis (DVT), pulmonary embolism, long-term hypogammaglobulinemia, and neutropenia were also common among the patients under rituximab treatment. Regarding the excellent impact of this drug on treatment of resistant pemphigus, and also on other diseases such as idiopathic thrombocytopenic purpura (ITP), vasculitis, lymphocytic leukemia, systemic lupus erythematosus (SLE), we decided to evaluate the effects of this drug on the variation of lab parameters such as white neckcloth cell (WBC), Hemoglobin (Hg), platelet (Plt), aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine (CR). So far, no study has been conducted on investigation of th ese variations due to receiving rituximab.OBJECTIVES AND HYPOTHESESMajor ObjectiveInvestigation of laboratory variations after injection of rituximab in pemphigus vulgaris patients.Minor objectives of the project decisiveness of rituximab impact on laboratory indices finding of rituximab impact on laboratory indices by adjusting for the effect of ageDetermination of rituximab impact on laboratory indices by adjusting for the effect of genderDetermination of rituximab impact on laboratory indices by adjusting for the effect of other treatment methodsDetermination of rituximab impact on laboratory indices by adjusting for the effect of disease durationDetermination of rituximab impact on laboratory indices by adjusting for the effect of disease involved sitesDetermination of rituximab impact on laboratory indices by adjusting for the effect of Underlying diseaseApplication objectivesEnhancement of health level among pemphigus vulgaris patients and paying attention to laboratory effect of patients after rituximab consumption.Research questions or hypothesesRituximab affects the laboratory indicesRituximab affects the laboratory indices with age effect adjustmentRituximab affects the laboratory indices with gender effect adjustmentRituximab affects the laboratory indices with disease duration effect adjustmentRituximab affects the laboratory indices with previous treatment effect adjustmentRituximab affects the laboratory indices with other disease effect adjustmentRituximab affects the laboratory indices with involved sites effect adjustmentChapter 2Literature ReviewIn 1997, rituximab was approved by the US Food and Drug Administration (FDA) as a treatment for non-Hodgkins lymphoma of B-cell that was resistant to chemotherapy. After that, it was applied for treatment for other diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegeners granulomatosis, idiopathic thrombocytopenic purpura (ITP), and Sjgrens syndrome. Ten years later, i ts impact on the treatment of blister diseases such as pemphigus was shown 16.In a 2006 study by Larrar et al, 2 children with autoimmune hemolytic anemia who were treated with rituximab experienced acute thrombocytopenia and neutropenia 17. They resolved in several days, which showed that these hematologic effects are at once dependent on the toxicity of rituximab.In a study by Chairwatanatorn et al in 2003, neutropenia following exercise of rituximab was tested in 53 patients 18. All patients except one were under Hodgkins lymphoma treatment. Eight cases of grade 4 neutropenia were observed after 1 to 5 months of rituximab treatment (5 patients only received rituximab and 3 patients were also under additional chemotherapy) 3 patients advanced toward sepsis. Neutropenia was not related to other diseases or treatments, and was related with reduction of neutrophil precursors, except for one of the patients whose bone nerve centre had hypoplasia. All cases of neutropenia occurred a mong the patients whose polymorphonuclear neutrophils (PMN) were normally or weakly reduced 18.In a study by Tesfa et al in 2008, neutropenia occurred 4 or more weeks after rituximab treatment in lymphoma patients 19. However, the mechanism of how rituximab causes neutropenia is still unknown. In a retrospective study of 113 lymphoma patients under rituximab treatment (alone or along with chemotherapy), 8 patients (7%) had neutropenia. The average onset was 88 days after receiving their last dosage of rituximab. The average time interval of neutropenia was 54 days. Four of the 8 patients underwent stem cell transplantation, 3 patients had neutropenia with feverishness and 2 of them needed granulocyte-colony stimulating factor (G-CSF) treatment. In the patients who had neutropenia, a cessation in maturation was observed in the promyelocytes category (the same as inseparable neutropenia or Kostmann disease) 19.A study by Otrock in 2005 addressed 2 patients who had acute thrombocytop enia after receiving rituximab 20. One of the patients had hairy cell leukemia and the other one suffered from mantle cell lymphoma. In these patients, thrombocytopenia improved without the need of any treatment after several days. The reason for this is unknown.A study by social lion et al was conducted in 2004 for look into the safety of rituximab 21. In this study, the mixture of fludarabine, rituximab and cyclophosphamide was applied for treatment of follicular lymphoma. Surprisingly, severe thrombocytopenia with World Health Organization (WHO) grades 3 and 4 were observed in the patients, which resulted in the end of trial. Cytological and serological analysis was based on direct toxicity of rituximab.Chapter 3Investigation mode39 Therapy resistant pemphigus patients in Razi Hospital in Tehran, who had received rituximab from 2008 to 2012 were considered for inclusion in this retrospective cohort study. Data was collected before and after rituximab treatment. The variables i nclude WBC, Hg, Plt, AST, ALT, carbamide, and Cr and age, gender, involved sites, previous therapies, underlying disease, and disease duration. Test sheets associated to before and after rituximab covering, containing WBC, Hg, Plt, AST, ALT, Urea and Cr were compared. guinea pig of StudyThis study is a retrospective cohort study conducted on the pemphigus patients resistant to therapies who had received rituximab in 2008-2012.Studied PopulationTherapy-resistant pemphigus patients who were treated with rituximab in Razi Hospital, Tehran, Iran in 2008-2012.Inclusion CriteriaPemphigus patients who did not respond to the initial therapies (therapy-resistant pemphigus), and then were treated with rituximab.Exclusion CriteriaPatients with no indispensable tests before application of rituximab in their filePatients with no follow-up after receiving rituximabPatients whose first follow-up, after the last dosage of rituximab, is greater than 1 month.Sampling MethodAccording to the availabl e files, files of all the patients who had received rituximab from 2008 to 2012 were considered for inclusion.Data CollectionThe data collection tool include a checklist divided into 2 parts one for the data before and one for the data collection after rituximab treatment. The variables included WBC, Hg, Plt, AST, ALT, Urea, and Cr and age, gender, involved sites, previous therapies, underlying disease, and disease duration.Project ImplementationAfter studying the files of therapy-resistant pemphigus patients, the patients who had required data in their files were entered into the research. Rituximab treatment was defined as receiving 4 doses of 500 mg for 4 weeks, along with normal saline. Test sheets associated to before and after rituximab application, containing WBC, Hg, Plt, AST, ALT, Urea and Cr were compared. (The maximum time interval between the second test sheet and the last dosage of rituximab could be 1 month.)Data AnalysisFinally, the finalized cases that had the inclus ion criteria, were canvass in Stata statistical software (StataCorp, Texas, USA) in terms of variations in WBC, Hg, Plt, AST, ALT, Urea and Cr after application of rituximab as the major(ip) variable and investigation of minor variables.Problems and LimitationsAs the base of this research was on filed files of hospital, inadequacy of data any before or after rituximab application excluded a bunch of samples from the study in a way that among 105 available files, only 39 files had the required data.VariablesMajor variables quantitative measurement of white blood cells (WBC), Hemoglobin (Hgb), platelets (Plt), aspartate aminotransferase (AST), ALT, urea, and creatinine (Cr) before and after application of rituximabMinor variablesGenderAgeInvolved sites preceding(prenominal) therapiesUnderlying diseaseDisease durationThe data of variables were collected according to the positive findings in the patients files (Table 1).Table 1 Patient variables.TitleVariable TypeQuantitativeQualitat iveScientific Practical DefinitionMeasurement MethodScaleIndependentDependentContinuousDiscreteNominalRankingWBCNumber of WBC per (mu)L of bloodFile readingCell/mClHgbAmount of hemoglobinFile readingGr/dlPltNumber of plackets in patient bloodFile readingCell/mclAST*Amount of ASTFile readingIU/LALTAmount of ALTFile readingIU/LUrea mcg of urea per deciliter of bloodFile readingMg/dlCr*Keratin amountFile readingMg/dlage*Years from birthFile readingyeargender*According to patient phenotypeFile readingMale/femaleUnderlying disease* universe of systemic diseaseFile readingHaving/not havingPrevious therapies*Received adjoin before rituximabFile readingAzathioprine, IVIGCyclophosphamide,CellCept, methotrexateInvolved sites*Involved sites before starting rituximabFile readingUpper body, lower body, face. genitals, sculp, mucusDisease DurationMonths passed from onset to receiving rituximabFile readingMonthWBC white blood cell, Hgb hemoglobin, Plt platelet, AST aspartate aminotransferase, ALT alanine aminotransferase, CR creatinine, IVIG intravenous immunoglobulinChapter 4ResultsAmong 105 therapy-resistant pemphigus patients who received rituximab treatment in Razi Hospital, Tehran, Iran from 2008 to 2012, only 39 patients managed to enter the study. The others were excluded due to inadequate data. as well as in the included patient group, the maximum time interval between the last dosage of rituximab and follow-up was 1 month. The data of the remaining 39 patients were analyzed by Stata statistical software (StataCorp, Texas, USA) and the following results were obtainedThe age of the patients ranged from 16 to 67 with a mean of 36.46 years.Their disease duration from the beginning of the disease until receiving rituximab ranged from 5 to 84 months with a mean of 39.30 months.Of the patients, 25 (64%) were men and 14 (36%) were women. It does not seem that the sex difference is related to therapy-resistant pemphigus, it is rather associated with the data collect ion method and riddance of patients with incomplete files.Investigation of the involved sites showed that 25 patients (64%) had mucosal involvement, 20 patients (51.3%) had upper body involvement, 18 patients (46.2%) had lower body involvement, 19 people (48.7%) had genitalia involvement, 23 people had facial involvement, 36 people (92%) had body involvement, and in 22 patients (56.4%) the scalp was involved. The lab result variations of the mentioned patients were investigated in terms of the involved sites.The patients, before application of rituximab, were simultaneously under treatment with prednisolone and other adjoins. To summarize the unsuccessful treatments, 5 patients had cyclophosphamide, 18 of them received CellCept (mycophenolate mofetil), 7 people (17.9%) had intravenous immunoglobulin (IVIG), 5 patients were treated with methotrexate, and 22 patients had azathioprine. All these patients did not respond to corticosteroid and had active disease.In terms of variation in lab test results after receiving rituximab, the patients were investigated in terms of the previous adjuvants as well. Among 9 patients, 12 of them (30.8%) had systemic underlying diseases such as hypertension (HTN), diabetes mellitus (DM), Ischemic Heart Disease (IHD) and many more.The major variables were WBC, Hgb, Plt, AST, ALT, Urea and Cr before and after application of rituximab.Before Receiving RituximabThe WBC range was 4,000-14,800 with average of 10,092.The Hgb range was 9.1-16.8 with average of 13.8.The Plt range was 100,000-683,000 with an average of 243,384.The AST range was 6-64 with average of 24.56.The ALT range was 10-143 with average of 43.92.The Urea range was 12-145 with average of 37.25.The Cr range was 0.5-1.2 with average of 0.87.After Receiving RituximabThe WBC range was 5,400-19,000 with average of 9,964.The Hgb range was 7.4-16.7 with average of 13.42.The Plt range was 110,000-440,000 with average of 232,512.The AST range was 10-121 with average of 25.43.T he ALT range was 12-144 with average of 48.46.The Urea range was 15-54 with average of 29.12.The Cr range was 0.6-1.2 with average of 0.85.The WBC had no statistically world-shaking variations.The Hgb had no statistically significant variations.The Plt had no statistically significant variations.The AST had no statistically significant variations.The ALT had no statistically significant variations.The Urea had statistically significant variations.The Cr had no statistically significant variations.After receiving rituximab and adjusting for the effect of genderThe WBC had no statistically significant variations.The Hgb had no statistically significant variations.The Plt had no statistically significant variations.The AST had no statistically significant variations.The ALT had no statistically significant variations.The Cr had no statistically significant variations.In the case of Urea, we concluded that it depends on gender, as in men the variation was significant while in women the variations were not statistically significant.When investigating the results with adjustment of the involved sites, the following results were obtainedIn patients with lower body involvement, rituximab had no significant effect on WBC, Plt, AST, ALT, Urea and Cr, but it had significant impact on Hgb reduction.In patients whose lower body was not involved, Urea significantly increased after receiving rituximab.In patients whose lower body was involved, rituximab caused a significant reduction in Cr, Urea, and Hgb.In patients whose upper body was not involved, rituximab had no significant effect on the variables.In the patients with or without facial involvement, rituximab had no significant impact on any of the variables.In patients whose genitalia region was involved, rituximab has no significant impact on any of the major variables.In patients with no genitalia involvement, rituximab resulted in significant reduction of urea.In patients with body involvement, rituximab resulted in significant reduction of urea.In patients with scalp involvement, rituximab resulted in significant reduction of urea.The adjustment of previous therapies was also addressed. As all the patients received prednisolone, the effect of adjoins (azathioprine, CellCept, cyclophosphamide, IVIG and methotrexate) was addressedIn patients who had received cyclophosphamide, rituximab has no statistically significant impact on the major variables.In patients who had not received cyclophosphamide, rituximab led to statistically significant reduction of urea.In patients who had received CellCept (mycophenolate mofetil), rituximab has statistically significant impact on reduction of urea and WBC.In patients who did not use IVIG adjoin, rituximab had a significant impact on reduction of urea.In patients who did not use methotrexate adjoin, rituximab had significant impact on reduction of urea.In patients who used azathioprine adjoin, rituximab had significant impact on reduction of urea.The adjust ment impact of systemic underlying diseases (such as HTN, DM, IHD) was also addressed.In patients with systemic underlying disease, rituximab had significant impact on platelet reduction.In patients with no systemic underlying disease, rituximab had significant impact on urea reduction.There was no statistically significant relationship between the lab test result variations and disease duration and age (Table 1 through Table 8).TABLESTable 1 Age statistical distribution in the studied patientsMinMaxStandard DeviationAverageAge166713.4836.48Table 2 Disease duration distribution in the studies patientsMinMaxStandard DeviationAverageDisease duration58420.2829.30Table 3 Absolute and comparative frequence distribution of patients based on their genderNumber%Men2564.1Women1435.9Total39100Table 4 Absolute and relative frequence of involved sites at the time of rituximab injection.Frequency%Upper body2051.3Lower body1846.2Face2359Genitalia1948.7Body3692.3Mucus2564.1Scalp2256.4Table 5 Absolute and relative frequency of received adjoins before application of rituximabFrequency%cyclophosphamide512.8CellCept1846.2IVIG717.9methotrexate512.8azathioprine2256.4IVIG intravenous immunoglobulinTable 6 Absolute and relative frequency of the patients based on having or not having underlying disease.Frequency