Rituxan in Chronic Demyelinating Polyneuropathy (CDIP) – pro

Rituximab is a chimeric monoclonal antibody that targets the CD20 antigen on B lymphocytes. Depletion of B lymphocytes may interfere with antibody-dependent, cell-mediated cytotoxicity involving peripheral nerve. Several recent reports have suggested that rituximab is beneficial in patients with immune-mediated neuropathies.Evidence for Rituxna’s efficacy in CDIP comes mainly from case reports and series and a small placebo controlloed study(Dalakas et al 2009). A recent retrospective study and literature review found that nine patients (seven with haematological diseases) responded to rituximab: six of them, who were non-responders to conventional therapies, improved clinically, and the other three maintained the improvement that they usually achieved with intravenous immunoglobulin or plasma exchange. Significantly associated with shorter disease duration, rituximab responses started after a median period of 2.0 months (range, 1–6) and lasted for a median period of 1 year (range, 1–5). The authors concluded: ” Rituximab seems to be a promising therapeutic choice when it targets both CIDP and co-occurring haematological diseases. Timely post-onset administration of rituximab seems to be associated with better responses.”

However, another recent review(Mnin-Sook) notes the absence of prospective clinical trials and says: “Only three treatment regimens for CIDP have demonstrated benefit in randomized, controlled studies: corticosteroids, plasma exchange, and intravenous immunoglobulins (IVIg). Approximately 25% of patients respond inadequately to corticosteroids, plasma exchange or IVIg. Large placebo-controlled trials with alternative immunosuppressive compounds, e.g. mycophenolate mofetil, cyclosporine, cyclophosphamide, or monoclonal antibodies, are lacking.”

Dalakas MC. Invited article: inhibition of B cell functions: implications for neurology. Neurology. 2008;70(23):2252-60.

Dalakas MC, Rakocevic G, Salajegheh M, Dambrosia JM, Hahn AF, Raju R, McElroy BPlacebo-controlled trial of rituximab in IgM anti-myelin-associated glycoprotein antibody demyelinating neuropathy.Ann Neurol. 2009 Mar;65(3):286-93.

Münch C, Anagnostou P, Meyer R, Haas J. Rituximab in chronic inflammatory demyelinating polyneuropathy associated with diabetes mellitus.J Neurol Sci. 2007 May 15;256(1-2):100-2.

Kenneth C. Gorson et al, Rituximab treatment in patients with IVIg-dependent immune polyneuropathy: A prospective pilot trial
Muscle & Nerve Volume 35, Issue 1, pages 66–69, January 2007

L Benedetti, Rituximab in patients with chronic inflammatory demyelinating polyradiculoneuropathy: a report of 13 cases and review of the literature
J Neurol Neurosurg Psychiatry 2011;82:306-308 doi:10.1136/jnnp.2009.188912

Min-Suk Yoon, Standard and escalating treatment of chronic inflammatory demyelinating polyradiculoneuropathy
Therapeutic Advances in Neurological Disorders May 2011 vol. 4 no. 3 193-200

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