Rituximab in the treatment of refractory rheumatoid arthritis in a tertiary academic hospital
Date
2019
Authors
Lovelock, Tamsin
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Abstract
Background
Significant disability results from rheumatoid arthritis (RA) when treatment is delayed or
inadequate. Rituximab is approved for use in RA in South Africa, but there is a paucity of
data on its use in Sub-Saharan African populations.
Objectives
To determine the response to rituximab in refractory RA patients by measuring disease
activity and functional status over a 6-month period. To describe predictors of response to
rituximab, and to document short term adverse events.
Methods
A single centre retrospective study of adult patients with RA receiving treatment with
rituximab at Chris Hani Baragwanath Academic Hospital, between January 2012 and
September 2016. Demographics, clinical and laboratory data were collected. The European
League Against Rheumatism (EULAR) response criteria and minimal clinically important
improvement (MCII) in Health Assessment Questionnaire Disability Index (HAQ-DI) were
applied as outcome measures. Baseline characteristics of responders to rituximab therapy
were compared with those of non-responders.
Results
Of the 53 patients with RA refractory to at least 3 synthetic disease modifying anti-rheumatic
drugs (DMARDs), 75.5% were African and 88.7% were female. At initiation of rituximab
the mean age (SD) was 50.8 (10.7) years and disease duration was 12.6 (6.6) years. Over
90% of patients were rheumatoid factor and anti-cyclic citrullinated peptide antibody
positive, 41.5% had extra-articular features and the majority (69.8%) had high disease
activity by the simplified disease activity index. The baseline mean (SD) HAQ-DI was 2.3
(0.6). At 3 months, 81.1% of patients achieved a good or moderate EULAR response.
Predictors of response to rituximab included higher tender joint counts (p=0.0473) and higher
SDAI scores (p=0.0467). A clinically meaningful decrease in HAQ-DI scores was observed
in 44 (83%) of patients. Improvements were not sustained at 6 months, although clinical
parameters were still better than at initiation. No early adverse events were recorded.
Conclusion
Rituximab therapy was safe and effective in controlling disease activity in addition to
improving functional disability in this cohort of predominantly African patients with severe
established RA. The findings underscore the need to identify appropriate patients for
predictable responses to biologic therapies in prospective longitudinal studies in southern
Africa.
Description
A research report submitted to the Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree
of Master of Medicine in the branch of Internal Medicine.
Johannesburg, 2019