title: Rituximab therapy for refractory scleritis: results of a phase I/II dose-ranging, randomized, clinical trial.
abstract: OBJECTIVE
  To determine whether rituximab, a monoclonal antibody against the B-lymphocyte antigen CD20, is effective in the treatment of refractory noninfectious scleritis.
  
  
  METHODS
  Prospective, dose-ranging, randomized, double-masked phase I/II clinical trial.
  
  
  METHODS
  Twelve patients with noninfectious scleritis refractory to systemic corticosteroid and ≥1 other systemic immunosuppressive agent were enrolled from January 2007 to March 2010.
  
  
  METHODS
  Subjects were randomly assigned to 500 (n = 5) or 1000 mg (n = 7) dosing arms of rituximab intravenous infusions (500 or 1000 mg), given at study days 1 and 15. Initial responders with breakthrough inflammation after study week 24 were offered treatment with an additional cycle of 2 open-label rituximab 1000 mg infusions.
  
  
  METHODS
  Primary outcomes were reduction of inflammation, as measured with a validated scleritis disease grading scale (SGS) and reduction in corticosteroid dose by ≥50%. Patients were characterized as responders to study therapy if ≥1 of these endpoints showed improvement and neither showed evidence of worsening. Secondary outcomes were improvement in visual acuity, reduction in pain, and improvement in patient and physician-reported global health assessment.
  
  
  RESULTS
  Of 12 enrolled patients, 9 met the SGS endpoint at or before week 24, and 4 additionally were able to reduce corticosteroid dose by ≥50%. With regard to secondary outcome measures, 11 and 9 patients showed improvement in patient and physician global health scores, respectively, and 7 patients had reduction in pain. Of 9 initial responders, 7 experienced breakthrough inflammation after 24 weeks and were treated with a second cycle of rituximab infusions. Four patients had significant objective or subjective worsening within 8 weeks of receiving rituximab; this event was averted in subsequent patients by treatment with peri-infusional oral corticosteroid. No other significant adverse events were noted. No differences in efficacy, toxicity, or likelihood of retreatment were noted between the dosing arms.
  
  
  CONCLUSIONS
  Rituximab was effective treatment for 9 of 12 enrolled patients with refractory, noninfectious scleritis at 24 weeks, although 7 required reinfusion with rituximab to maintain inflammatory control. The treatment was well-tolerated, and peri-infusional inflammatory exacerbations were managed successfully with oral corticosteroids. Further long-term studies are warranted to determine the safety and efficacy of rituximab in treating noninfectious scleritis and other ocular inflammatory diseases.
authors: Portland Veterans Administration Medical Center, Portland, Oregon; Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon. Electronic address: suhlere@ohsu.edu.
authors: Eric B
authors: EB
authors: Suhler
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon; Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.
authors: Lyndell L
authors: LL
authors: Lim
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Robert M
authors: RM
authors: Beardsley
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Tracy R
authors: TR
authors: Giles
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Sirichai
authors: S
authors: Pasadhika
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Shelly T
authors: ST
authors: Lee
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Alexandre
authors: A
authors: de Saint Sardos
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon.
authors: Nicholas J
authors: NJ
authors: Butler
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon; Department of Developmental Biology, Oregon Health & Science University, Portland, Oregon; Clinical and Molecular Medicine, Flinders University, Adelaide, Australia.
authors: Justine R
authors: JR
authors: Smith
authors: Oregon Health & Science University, Department of Ophthalmology/Casey Eye Institute, Portland, Oregon; Department of Medicine, and Cell and Developmental Biology, Oregon Health & Science University, Portland, Oregon; Department of Developmental Biology, Oregon Health & Science University, Portland, Oregon; Devers Eye Institute, Portland, Oregon.
authors: James T
authors: JT
authors: Rosenbaum
mesh_terms: D000328:Adult; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D007155:Immunologic Factors / Q000008:administration & dosage*; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D000069283:Rituximab; D015423:Scleritis / Q000188:drug therapy*; D012720:Severity of Illness Index; D055815:Young Adult
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D007155:Immunologic Factors; D000069283:Rituximab