Rituximab in the Treatment of Patients With Bullous Pemphigoid
Study Details
Study Description
Brief Summary
This study will determine the safety of treatment of bullous pemphigoid in patients resistant to therapy with systemic corticosteroids, with rituximab plus systemic corticosteroids.
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
Phase 1/Phase 2 |
Detailed Description
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized clinically by the presence of severely itchy, tense blisters located over the trunk and extremities. BP is the most common of the autoimmune blistering diseases with an incidence of approximately 10 per 1,000,000 population(1;2). In addition, BP occurs more frequently in the elderly. Routine histopathology reveals a sub-epidermal blister most often with large numbers of eosinophils. Direct immunofluorescence of the skin of patients with BP reveals a linear band of C3 and IgG at the basement membrane zone. Examination of the sera of patients shows the presence of a circulating anti-basement membrane zone autoantibody. This antibody has been found to be directed against a 180 kd protein of the basement membrane zone type XVII collagen (BPAg2) and against a 230 kd protein (BPAg1) found in the epidermal hemi-desmosome(3;4).
BP is a severe disease most often requiring therapy with high dose systemic corticosteroids (0.75 - 1.0 mg/kg/day) often for months(5). In addition, relapses are common and the additional use of immunosuppressive drugs such as azathioprine, methotrexate, cyclosporine A and others are needed to minimize the dose of systemic corticosteroids. The 1-year mortality of BP has been estimated to range from 10 - 30%(1;6). Currently treatment of patients with BP consists of initial use of systemic corticosteroids (0.75 - 1.0 mg/kg/day). Control of symptoms and new blister formation is most often achieved within 1 month and systemic corticosteroids are then tapered. As many as 33 - 50% of patients may not be able to be tapered to clinically acceptable levels of systemic corticosteroids, requiring the addition of systemic immunosuppression often with azathioprine. Approximately 66% of patients require long term treatment with immunosuppressive medication to maintain control of their blistering.(5;7;8) The need for long term systemic corticosteroid therapy often with systemic immunosuppression in an elderly population results in a significant morbidity and mortality in patients with BP. New therapeutic interventions that would potentially allow for the more rapid discontinuation of prednisone, avoidance of systemic immuno- suppression and perhaps earlier clinical relapse would be of substantial benefit to patients with BP. The clinical and laboratory data has demonstrated that BP is an autoantibody mediated blistering disease. Taken together these observations suggest that the use of anti-CD20 antibody (Rituxan) may be useful in the treatment of patients with BP. We have previously treated a patient with BP and graft versus host disease with anti-CD20 and anti-CD25 and were able to achieve clinical and serological remission within 4 weeks of initiation of therapy(9). In addition, others and we have successfully utilized Rituxan for the treatment of pemphigus vulgaris, another autoantibody mediated, autoimmune blistering disease(10-15)
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Experimental: Treatment Rituximab Open label study all subjects treated with rituximab |
Drug: Rituximab
Infusion of 1000 mg of rituximab on day 0 and day 14
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Primary Safety Endpoint [1 year]
The primary safety endpoint is the occurrence of treatment emergent adverse events including infections, infusion reactions and disease progression. These were determined by clinical evaluation and laboratory questions. Disease progression is defined as development of new blisters despite therapy. These are reported as the number of participants with a study related SAE.
Secondary Outcome Measures
- Number of Days to Cessation of New Blister [1 year]
The first study visit in which patient reported and was confirmed to have no new blister or lesion formation .
- Systemic Corticosteroid Dose of 25% of Starting Dose or 10 mg/Day by Week 24 [24 weeks]
Subject systemic corticosteroid dosage at week 24 was 25% of starting dose or 10 mg/day of prednisone or less
- IgG Anti Bullous Pemphigoid (BP) 180 Measured in Units by ELISA at Week 24. [Week 0 and at 24 weeks]
IgG antibodies against BP 180 measured in units (by ELISA) for each participant at week 0 compared to value at week 24,
- B Cell Number at Week 24 [Week 0 and at 24 weeks]
Peripheral blood B cell number at week 24 compared to B cell number at week 0
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Patients with autoimmune blistering skin diseases with clinical, histologic and immunological criteria confirming the diagnosis of bullous pemphigoid
-
Ongoing disease activity on 17.5 mg/day of prednisone or more
Exclusion Criteria:
- Current use of other immunosuppressive therapy such as azathioprine, cytoxan or mycophenolate mofetil within the last 4 weeks.
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Duke University Medical Center | Durham | North Carolina | United States | 27710 |
Sponsors and Collaborators
- Duke University
- Genentech, Inc.
Investigators
- Principal Investigator: Russell Hall, III, MD, Duke University
Study Documents (Full-Text)
None provided.More Information
Publications
- Anolik JH, Campbell D, Felgar RE, Young F, Sanz I, Rosenblatt J, Looney RJ. The relationship of FcgammaRIIIa genotype to degree of B cell depletion by rituximab in the treatment of systemic lupus erythematosus. Arthritis Rheum. 2003 Feb;48(2):455-9.
- Bernard P, Bedane C, Bonnetblanc JM. Anti-BP180 autoantibodies as a marker of poor prognosis in bullous pemphigoid: a cohort analysis of 94 elderly patients. Br J Dermatol. 1997 May;136(5):694-8.
- Cooper HL, Healy E, Theaker JM, Friedmann PS. Treatment of resistant pemphigus vulgaris with an anti-CD20 monoclonal antibody (Rituximab). Clin Exp Dermatol. 2003 Jul;28(4):366-8.
- Diaz LA, Ratrie H 3rd, Saunders WS, Futamura S, Squiquera HL, Anhalt GJ, Giudice GJ. Isolation of a human epidermal cDNA corresponding to the 180-kD autoantigen recognized by bullous pemphigoid and herpes gestationis sera. Immunolocalization of this protein to the hemidesmosome. J Clin Invest. 1990 Oct;86(4):1088-94.
- Dupuy A, Viguier M, Bédane C, Cordoliani F, Blaise S, Aucouturier F, Bonnetblanc JM, Morel P, Dubertret L, Bachelez H. Treatment of refractory pemphigus vulgaris with rituximab (anti-CD20 monoclonal antibody). Arch Dermatol. 2004 Jan;140(1):91-6.
- Gault MH, Purchase L. Would decreased aluminum ingestion reduce the incidence of Alzheimer's disease? CMAJ. 1992 Sep 15;147(6):845-7.
- Giudice GJ, Liu Z, Diaz LA. An animal model of bullous pemphigoid: what can it teach us? Proc Assoc Am Physicians. 1995 Jul;107(2):237-41. Review.
- Goebeler M, Herzog S, Bröcker EB, Zillikens D. Rapid response of treatment-resistant pemphigus foliaceus to the anti-CD20 antibody rituximab. Br J Dermatol. 2003 Oct;149(4):899-901.
- Gupta N, Kavuru S, Patel D, Janson D, Driscoll N, Ahmed S, Rai KR. Rituximab-based chemotherapy for steroid-refractory autoimmune hemolytic anemia of chronic lymphocytic leukemia. Leukemia. 2002 Oct;16(10):2092-5.
- Herrmann G, Hunzelmann N, Engert A. Treatment of pemphigus vulgaris with anti-CD20 monoclonal antibody (rituximab). Br J Dermatol. 2003 Mar;148(3):602-3.
- Khumalo NP, Murrell DF, Wojnarowska F, Kirtschig G. A systematic review of treatments for bullous pemphigoid. Arch Dermatol. 2002 Mar;138(3):385-9. Review.
- Korman NJ. Bullous pemphigoid. The latest in diagnosis, prognosis, and therapy. Arch Dermatol. 1998 Sep;134(9):1137-41. Review.
- Leandro MJ, Edwards JC, Cambridge G. Clinical outcome in 22 patients with rheumatoid arthritis treated with B lymphocyte depletion. Ann Rheum Dis. 2002 Oct;61(10):883-8.
- Liu Z, Diaz LA, Troy JL, Taylor AF, Emery DJ, Fairley JA, Giudice GJ. A passive transfer model of the organ-specific autoimmune disease, bullous pemphigoid, using antibodies generated against the hemidesmosomal antigen, BP180. J Clin Invest. 1993 Nov;92(5):2480-8.
- Maloney DG, Grillo-López AJ, Bodkin DJ, White CA, Liles TM, Royston I, Varns C, Rosenberg J, Levy R. IDEC-C2B8: results of a phase I multiple-dose trial in patients with relapsed non-Hodgkin's lymphoma. J Clin Oncol. 1997 Oct;15(10):3266-74.
- McLaughlin P, Grillo-López AJ, Link BK, Levy R, Czuczman MS, Williams ME, Heyman MR, Bence-Bruckler I, White CA, Cabanillas F, Jain V, Ho AD, Lister J, Wey K, Shen D, Dallaire BK. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol. 1998 Aug;16(8):2825-33.
- Nousari HC, Anhalt GJ. Pemphigus and bullous pemphigoid. Lancet. 1999 Aug 21;354(9179):667-72. Review.
- Pestronk A, Florence J, Miller T, Choksi R, Al-Lozi MT, Levine TD. Treatment of IgM antibody associated polyneuropathies using rituximab. J Neurol Neurosurg Psychiatry. 2003 Apr;74(4):485-9.
- Piro LD, White CA, Grillo-López AJ, Janakiraman N, Saven A, Beck TM, Varns C, Shuey S, Czuczman M, Lynch JW, Kolitz JE, Jain V. Extended Rituximab (anti-CD20 monoclonal antibody) therapy for relapsed or refractory low-grade or follicular non-Hodgkin's lymphoma. Ann Oncol. 1999 Jun;10(6):655-61.
- Reff ME, Carner K, Chambers KS, Chinn PC, Leonard JE, Raab R, Newman RA, Hanna N, Anderson DR. Depletion of B cells in vivo by a chimeric mouse human monoclonal antibody to CD20. Blood. 1994 Jan 15;83(2):435-45.
- Roujeau JC, Lok C, Bastuji-Garin S, Mhalla S, Enginger V, Bernard P. High risk of death in elderly patients with extensive bullous pemphigoid. Arch Dermatol. 1998 Apr;134(4):465-9.
- Rzany B, Partscht K, Jung M, Kippes W, Mecking D, Baima B, Prudlo C, Pawelczyk B, Messmer EM, Schuhmann M, Sinkgraven R, Büchner L, Büdinger L, Pfeiffer C, Sticherling M, Hertl M, Kaiser HW, Meurer M, Zillikens D, Messer G. Risk factors for lethal outcome in patients with bullous pemphigoid: low serum albumin level, high dosage of glucocorticosteroids, and old age. Arch Dermatol. 2002 Jul;138(7):903-8.
- Salopek TG, Logsetty S, Tredget EE. Anti-CD20 chimeric monoclonal antibody (rituximab) for the treatment of recalcitrant, life-threatening pemphigus vulgaris with implications in the pathogenesis of the disorder. J Am Acad Dermatol. 2002 Nov;47(5):785-8.
- Stanley JR, Hawley-Nelson P, Yuspa SH, Shevach EM, Katz SI. Characterization of bullous pemphigoid antigen: a unique basement membrane protein of stratified squamous epithelia. Cell. 1981 Jun;24(3):897-903.
- Stasi R, Pagano A, Stipa E, Amadori S. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura. Blood. 2001 Aug 15;98(4):952-7.
- Stasi R, Stipa E, Forte V, Meo P, Amadori S. Variable patterns of response to rituximab treatment in adults with chronic idiopathic thrombocytopenic purpura. Blood. 2002 May 15;99(10):3872-3.
- Szabolcs P, Reese M, Yancey KB, Hall RP, Kurtzberg J. Combination treatment of bullous pemphigoid with anti-CD20 and anti-CD25 antibodies in a patient with chronic graft-versus-host disease. Bone Marrow Transplant. 2002 Sep;30(5):327-9.
- Venning VA, Wojnarowska F. Lack of predictive factors for the clinical course of bullous pemphigoid. J Am Acad Dermatol. 1992 Apr;26(4):585-9.
- Wojnarowska F, Kirtschig G, Highet AS, Venning VA, Khumalo NP; British Association of Dermatologists. Guidelines for the management of bullous pemphigoid. Br J Dermatol. 2002 Aug;147(2):214-21.
- Zaja F, Iacona I, Masolini P, Russo D, Sperotto A, Prosdocimo S, Patriarca F, de Vita S, Regazzi M, Baccarani M, Fanin R. B-cell depletion with rituximab as treatment for immune hemolytic anemia and chronic thrombocytopenia. Haematologica. 2002 Feb;87(2):189-95. Erratum in: Haematologica 2002 Mar;87(3):336.
- Pro00013763
Study Results
Participant Flow
Recruitment Details | Patients with bullous pemphigoid were recruited in dermatology clinics from 2005 - 2009. |
---|---|
Pre-assignment Detail | Patient were screened for appropriate diagnosis, disease activity, prednisone dosage before entry into the study |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Period Title: Overall Study | |
STARTED | 8 |
COMPLETED | 8 |
NOT COMPLETED | 0 |
Baseline Characteristics
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Overall Participants | 8 |
Age (Count of Participants) | |
<=18 years |
0
0%
|
Between 18 and 65 years |
5
62.5%
|
>=65 years |
3
37.5%
|
Age (years) [Mean (Standard Deviation) ] | |
Mean (Standard Deviation) [years] |
61
(9.7)
|
Sex: Female, Male (Count of Participants) | |
Female |
6
75%
|
Male |
2
25%
|
Region of Enrollment (participants) [Number] | |
United States |
8
100%
|
Outcome Measures
Title | Number of Days to Cessation of New Blister |
---|---|
Description | The first study visit in which patient reported and was confirmed to have no new blister or lesion formation . |
Time Frame | 1 year |
Outcome Measure Data
Analysis Population Description |
---|
Excluded subject with diagnosis of epidermolysis bullosa acquisita , made after study entry. |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Measure Participants | 7 |
Median (Full Range) [Days] |
57
|
Title | Primary Safety Endpoint |
---|---|
Description | The primary safety endpoint is the occurrence of treatment emergent adverse events including infections, infusion reactions and disease progression. These were determined by clinical evaluation and laboratory questions. Disease progression is defined as development of new blisters despite therapy. These are reported as the number of participants with a study related SAE. |
Time Frame | 1 year |
Outcome Measure Data
Analysis Population Description |
---|
The safety analysis was performed on all subjects |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Measure Participants | 8 |
Treatment emergent adverse events |
0
0%
|
Infusion reactions |
0
0%
|
Disease Progression |
1
12.5%
|
Title | Systemic Corticosteroid Dose of 25% of Starting Dose or 10 mg/Day by Week 24 |
---|---|
Description | Subject systemic corticosteroid dosage at week 24 was 25% of starting dose or 10 mg/day of prednisone or less |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
Excluded subject with epidermolysis bullosa acquisita diagnosed after study entry. |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Measure Participants | 7 |
Number [participants] |
7
87.5%
|
Title | IgG Anti Bullous Pemphigoid (BP) 180 Measured in Units by ELISA at Week 24. |
---|---|
Description | IgG antibodies against BP 180 measured in units (by ELISA) for each participant at week 0 compared to value at week 24, |
Time Frame | Week 0 and at 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
Excluded subject with diagnosis of epidermolysis bullosa acquisita made after study entry, excluded one subject with no circulating antibodies measured at either time point. |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Measure Participants | 6 |
Median (Full Range) [Elisa Units] |
40.5
|
Statistical Analysis 1
Statistical Analysis Overview | Comparison Group Selection | Treated |
---|---|---|
Comments | Wilcoxon comparing week zero antibody value in units to week 24 antibody value in units | |
Type of Statistical Test | Superiority or Other | |
Comments | ||
Statistical Test of Hypothesis | p-Value | =0.0156 |
Comments | ||
Method | Wilcoxon (Mann-Whitney) | |
Comments |
Title | B Cell Number at Week 24 |
---|---|
Description | Peripheral blood B cell number at week 24 compared to B cell number at week 0 |
Time Frame | Week 0 and at 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
excluded subject with epidermolysis bullosa acquisita diagnosed after study entry |
Arm/Group Title | Treated |
---|---|
Arm/Group Description | Open label study subjects all treated with rituximab |
Measure Participants | 7 |
Median (Full Range) [B cells per microliter] |
3.99
|
Statistical Analysis 1
Statistical Analysis Overview | Comparison Group Selection | Treated |
---|---|---|
Comments | Comparison of B cell number at week 0 to b cell number in participants at week 24 | |
Type of Statistical Test | Superiority or Other | |
Comments | ||
Statistical Test of Hypothesis | p-Value | =0.0078 |
Comments | ||
Method | Wilcoxon (Mann-Whitney) | |
Comments |
Adverse Events
Time Frame | 1 year | |
---|---|---|
Adverse Event Reporting Description | Adverse events related or possibly related to study drug | |
Arm/Group Title | Treated | |
Arm/Group Description | Open label study subjects all treated with rituximab | |
All Cause Mortality |
||
Treated | ||
Affected / at Risk (%) | # Events | |
Total | / (NaN) | |
Serious Adverse Events |
||
Treated | ||
Affected / at Risk (%) | # Events | |
Total | 0/8 (0%) | |
Other (Not Including Serious) Adverse Events |
||
Treated | ||
Affected / at Risk (%) | # Events | |
Total | 0/8 (0%) |
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
Name/Title | Dr. Russell P Hall |
---|---|
Organization | Duke University Medical Center |
Phone | 919-684-3110 |
hall0009@mc.duke.edu |
- Pro00013763