Rituxan for anti-phosholipid syndrome – pro
The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is still controversial, because any therapeutic decision potentially faces the risk of an insufficient or excessive antithrombotic coverage associated with anticoagulation and its major adverse effects. Many agenst have been tried with variable success. The thrombotic and non-thrombotic complications may respond differently to different treatments.
A recent guideline by Danowsli et al posed and responded to nine questions. One of them was about the use of rituximab. It is as follows:
“Is the association of other medications (corticosteroid, immune globulin, rituximab) with anticoagulants in the catastrophic antiphospholipid syndrome (CAPS) advantageous?
Considering the presence or absence of one single treatment, improvement occurs in 63.1% of the episodes of CAPS treated with anticoagulants versus 22.2% of episodes not treated with anticoagulants (NNT:2). In addition, there is no difference in improvement between presence and absence of individual treatment with other agents, such as corticosteroids, plasmapheresis, immune globulin or antiplatelet agents. The individual use of corticosteroids produces the poorest recovery (B).
When treatments are associated, the most common combination is anticoagulants and corticosteroids, followed by anticoagulants, corticosteroids, plasmapheresis and/or immune globulin. The recovery rate showed no difference between the several combinations, and no difference between combining with anticoagulants or not (B).”
Recommendation
There are no good quality studies confirming the benefit of the association of other medications with anticoagulants in the treatment of patients with CAPS. Despite the limited good quality scientific evidence, the authors recommend, based on case series, case reports and personal experience, the association of corticosteroid, plasmapheresis and/or rituximab with anticoagulant therapy, because of the high mortality of that condition.
I conclude that adding Rituxan to the anticoagulation may be shown to be effective in the future but thus far has not been shown to be so.
Erkan D, Vega J, Ramón G, Kozora E, Lockshin MD
A Pilot Open-Label Phase II Trial of Rituximab for Non-criteria Manifestations of Antiphospholipid Syndrome
Arthritis Rheum. 2013;65:464-471
Adriana Danowski et al, Guidelines for the treatment of antiphospholipid syndrome Rev. Bras. Reumatol. vol.53 no.2 São Paulo Mar./Apr. 2013