title: Longterm effects of rituximab on B cell counts and autoantibody production in rheumatoid arthritis: use of high-sensitivity flow cytometry for more sensitive assessment of B cell depletion.
abstract: OBJECTIVE
  To assess the efficacy and safety of longterm rituximab (RTX) therapy for rheumatoid arthritis (RA) and study correlations among B cell depletion, clinical response, and autoantibody production.
  
  
  METHODS
  Seventy-seven patients with moderate or high RA activity received RTX and were re-treated every 6 months regardless of clinical response. All patients received at least 5 cycles. We assessed 28-joint Disease Activity Score (DAS28), IgM rheumatoid factor (RF), and anticitrullinated protein antibody (ACPA) levels at baseline, after 15 days, and then every 6 months for 24 months. Absolute CD19+ B lymphocyte counts were determined in 50 patients using high-sensitivity flow cytometry (hsFACS) by reading 100,000 events.
  
  
  RESULTS
  After 6, 12, 18, and 24 months, 51.6%, 51.9%, 73.3%, and 83.8% of patients, respectively, showed good European League Against Rheumatism responses. Significant and sustained decreases in IgM RF and ACPA levels were observed as early as 6 months and 12 months, respectively. The baseline mean absolute B cell number was 0.234 g/l. B cell numbers diminished significantly after the very first infusion by Day 15 (0.104 g/l; p = 0.007); they further decreased until 24 months (0.0013 g/l; p < 0.001). One RTX infusion resulted in incomplete depletion in 76.7% of patients. Upon RTX treatment, changes in CD19+ B cell numbers positively correlated with changes in DAS28 (r = 0.963, p = 0.008) and IgM RF (r = 0.859, p = 0.028), but not with changes in ACPA production (r = 0.726, p = 0.102). The correlations between B cell numbers and DAS28 were observed in both ACPA-seropositive (r = 0.999, p < 0.0001) and ACPA-negative patient subpopulations (r = 0.962, p = 0.009). The correlation between CD19+ cell numbers and IgM RF was observed only in the ACPA-positive population (r = 0.944, p = 0.005) but not in seronegative patients (r = 0.398, p = 0.435). No safety issues arose.
  
  
  CONCLUSIONS
  In RA, clinical response to RTX is associated with the extent of B cell depletion and with autoantibody production. Changes in CD19+ B cell numbers correlate with those in disease activity and, in seropositive patients, also with IgM RF, but not with ACPA production. We found that hsFACS may be a useful method to more accurately assess incomplete B cell depletion.
authors.affiliation: Department of Rheumatology, Division of Hematology, Institute of Medicine, University of Debrecen Medical and Health Sciences Center, Debrecen, Hungary. andrea.vancsa@gmail.com
authors.forename: Andrea
authors.initials: A
authors.lastname: Váncsa
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Szabó
authors.forename: Szilvia
authors.initials: S
authors.lastname: Szamosi
authors.forename: Nóra
authors.initials: N
authors.lastname: Bodnár
authors.forename: Edit
authors.initials: E
authors.lastname: Végh
authors.forename: Lajos
authors.initials: L
authors.lastname: Gergely
authors.forename: Gabriella
authors.initials: G
authors.lastname: Szucs
authors.forename: Sándor
authors.initials: S
authors.lastname: Szántó
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Szekanecz
mesh_terms: D000328:Adult; D000368:Aged; D058846:Antibodies, Monoclonal, Murine-Derived / Q000009:adverse effects*; D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000097:blood / Q000188:drug therapy* / Q000276:immunology; D001323:Autoantibodies / Q000097:blood; D001402:B-Lymphocytes / Q000187:drug effects* / Q000473:pathology; D002452:Cell Count; D002469:Cell Separation; D005260:Female; D005434:Flow Cytometry; D006304:Health Status; D006801:Humans; D007958:Leukocyte Count; D008212:Lymphocyte Depletion; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015203:Reproducibility of Results; D000069283:Rituximab; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D018501:Antirheumatic Agents; D001323:Autoantibodies; D000069283:Rituximab
keywords: B CELL DEPLETION; B CELL NUMBER; BIOLOGICAL THERAPY; FLOW CYTOMETRY; RHEUMATOID ARTHRITIS; RITUXIMAB