Efficacy and safety of rituximab in moderately-to-severely active systemic lupus erythematosus: the randomized, double-blind, phase II/III systemic lupus erythematosus evaluation of rituximab trial.

OBJECTIVE: B cells are likely to contribute to the pathogenesis of systemic lupus erythematosus (SLE), and rituximab induces depletion of B cells. The Exploratory Phase II/III SLE Evaluation of Rituximab (EXPLORER) trial tested the efficacy and safety of rituximab versus placebo in patients with moderately-to-severely active extrarenal SLE. METHODS: Patients entered with >or=1 British Isles Lupus Assessment Group (BILAG) A score or >or=2 BILAG B scores despite background immunosuppressant therapy, which was continued during the trial. Prednisone was added and subsequently tapered. Patients were randomized at a ratio of 2:1 to receive rituximab (1,000 mg) or placebo on days 1, 15, 168, and 182. RESULTS: In the intent-to-treat analysis of 257 patients, background treatment was evenly distributed among azathioprine, mycophenolate mofetil, and methotrexate. Fifty-three percent of the patients had >or=1 BILAG A score at entry, and 57% of the patients were categorized as being steroid dependent. No differences were observed between placebo and rituximab in the primary and secondary efficacy end points, including the BILAG-defined response, in terms of both area under the curve and landmark analyses. A beneficial effect of rituximab on the primary end point was observed in the African American and Hispanic subgroups. Safety and tolerability were similar in patients receiving placebo and those receiving rituximab. CONCLUSION: The EXPLORER trial enrolled patients with moderately-to-severely active SLE and used aggressive background treatment and sensitive cutoffs for nonresponse. No differences were noted between placebo and rituximab in the primary and secondary end points. Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials.

Dialysis-associated systemic fibrosis (nephrogenic fibrosing dermopathy): study of inflammatory cells and transforming growth factor beta1 expression in affected skin.

OBJECTIVE: Nephrogenic fibrosing dermopathy (NFD) is a newly recognized cutaneous fibrotic disorder occurring in individuals with end-stage renal disease (ESRD). The aim of the present study was to describe the clinical and histopathologic features of 9 new cases and to characterize the inflammatory cells and expression of transforming growth factor beta1 (TGFbeta1) in affected skin. METHODS: Clinical and laboratory assessments, including serology and pulmonary function studies, were performed in 9 patients undergoing long-term dialysis (8 hemodialysis; 1 peritoneal dialysis) for ESRD of diverse etiologies. Skin, fascia, striated muscles, lungs, and heart were examined by histopathology. Inflammatory cells were characterized by immunophenotyping using specific monoclonal antibodies. TGFbeta1 expression was determined by in situ hybridization. RESULTS: All patients displayed cutaneous features resembling both systemic sclerosis and diffuse fasciitis, with severe loss of motion and flexion contractures in multiple joints. Six patients displayed woody induration of the muscles of the legs, thighs, and forearms. Five of the 6 patients with lung involvement had a reduced diffusion capacity for carbon monoxide on pulmonary function testing. Marked elevations of the erythrocyte sedimentation rate and/or C-reactive protein level were found in 6 patients. Antinuclear antibodies were present at low titers in 4 patients. Histopathologic studies indicated that in addition to the dermis, the fibrotic process affected the subcutaneous tissue, fascia, striated muscles, lungs, and myocardium. Large numbers of CD68+/factor XIIIa+ dendritic cells and increased expression of TGFbeta1 were found in affected skin and muscle. CONCLUSION: Our findings indicate that the fibrotic process of NFD affects not only the dermis, but also the subcutaneous tissues, fascia, and other organs, including striated muscles, heart, and lungs. We therefore believe this is a systemic fibrosing process, and we suggest that dialysis-associated systemic fibrosis would be a better term for the condition.

Upcoming biologic agents for the treatment of rheumatic diseases.

The development of biologic agents has provided rheumatologists with a variety of new and effective treatment options. The success of early biologics, especially etanercept and infliximab for the treatment of rheumatoid arthritis, has spurred research into novel targets for the management of systemic inflammatory and autoimmune diseases. In addition, existing biologics approved for use in other diseases, such as rituximab, are now under study for the treatment of new indications. This article reviews ongoing research on the treatment of rheumatic diseases with new and existing biologic agents.

Tumor necrosis factor-alpha blockade: a novel therapy for rheumatic disease.

Overproduction of tumor necrosis factor-alpha (TNF) plays a key role in the pathogenesis of rheumatoid arthritis (RA) and other chronic inflammatory diseases. In RA, excessive production of TNF-alpha can drive synovial inflammation and proliferation as well as degradation of articular cartilage and bone. The importance of TNF-alpha in these mechanisms is supported by the results of clinical trials. In these studies, treatment with etanercept and infliximab, two recently approved TNF-alpha inhibitors, has been shown to significantly decrease the signs and symptoms of joint inflammation and slow the progression of radiological joint damage. Although TNF-alpha inhibitors have had acceptable toxicity in clinical trials, commercial use of these agents has produced growing concerns about the potential risk for opportunistic infections, most notably the reactivation of latent tuberculosis. The TNF-alpha inhibitors stand as a powerful example of the therapeutic potential of a targeted biological agent. Longer-term clinical experience with these cytokine antagonists will illuminate their optimal use in RA and other rheumatic diseases.