De-escalation of anti-CD20 monoclonal antibody (Rituximab) protocols in Pemphigus Vulgaris - a systematic review.

Introduction This review assesses current evidence supporting dose de-escalated rituximab therapy in pemphigus vulgaris, compared to standard lymphoma and rheumatoid arthritis protocols. Primary outcome measures were remission and relapse rates. Adverse effects, cumulative steroid dosages and serological markers of disease activity, including B-cell count and Dsg1 and Dsg3 antibody levels, were also reported. Areas covered A literature search was performed to look for reports describing the use of de-escalated rituximab therapy in pemphigus vulgaris. Results from heterogenous studies showed a large variation in remission and relapse rates. Complete remission rates from de-escalated treatment ranged from 41.7-100.0%, while rates in the control groups ranged from 60.0-90.9%. Relapse rates varied from 8.0-81.3% in the de-escalated group and from 0.0-72.4% in the control group. Of the 165 patients included in this report, only 2 major adverse effects were reported. Expert opinion Overall, dose de-escalated rituximab protocols reported to date appear effective and safe. However, it is unclear if treatment effect parallels that of standard regimens in regard to disease control in the long term. A lower limit of effective dosing for rituximab in pemphigus vulgaris has not yet been reached or defined. The role for and timing of repeated cycles of low dose rituximab therapy requires further exploration.