Rituximab shows promise in management of neuropsychiatric SLE

Treatment with rituximab (RTX) in patients with moderate-to-severe neuropsychiatric (NP) systemic lupus erythematosus (SLE) appears to result in some improvements and to contribute to the use of a much lower steroid dose at 6 months, suggests a study presented at EULAR 2024.

“NP lupus describes a diverse range of clinical manifestations, and it’s likely to result from a variety of pathological mechanisms, including disruption of the blood-brain barrier and passage of proinflammatory mediators, as well as vascular injury, including inflammation,” said lead author Dr Mia Rodziewicz, University of Manchester, Centre for Musculoskeletal Research, Manchester, UK.

In this study, Rodziewicz and her team described the baseline characteristics and early clinical outcomes of NPSLE involvement in a real-world RTX-treated cohort. They recruited a total of 1,779 patients to the British Isles Lupus Assessment Group Biologics Register (BILAG-BR) who initiated treatment with RTX from 2010 to 2023.

Patients with active NPSLE at baseline were characterized as having a score of A or B in the NP domain of the BILAG-2004 or a positive score in an NP domain of the SLEDAI-2K. Some improvement was defined as a decrease in NP-BILAG (from A or B to C or D) or resolution of NP-SLEDAI-2K score.

Rodziewicz and colleagues compared baseline characteristics between patients with NPSLE and the non-NPSLE RTX-treated cohort using X² and Wilcoxon rank sum tests. They also performed a statistical analysis using Stata IC (V14).

Of the patients, 1,311 received RTX, with 146 having active NPSLE at baseline (median age 41 years, median disease duration 4 years, 86 percent female). Twenty-eight patients were excluded due to insufficient follow-up data. [EULAR 2024, abstract OP0043]

Of the remaining participants, 48 (41 percent) received concomitant immunosuppressants, 42 (36 percent) intravenous steroid pulses, and 94 (80 percent) oral steroids. Median prednisolone dose at baseline was 15 mg.

Baseline characteristics

Patients with NPSLE, compared to those with no NP involvement, showed more damage at baseline (median SDI 1) and were more likely to have previous NPSLE (69 percent vs 14 percent) and disease activity (BILAG A or B) in more than one domain (86 percent vs 55 percent)

Some improvement occurred in 77 of 109 (71 percent) and 60 of 81 (74 percent) NPSLE patients at 6 and 12 months, respectively. In addition, the corresponding median prednisolone dose at these time points were 10 and 8 mg.

“This is the largest cohort of rituximab-treated patients with neuropsychiatric disease that we’re aware of, and the drug appears effective in the treatment of this manifestation,” Rodziewicz said.

“Active NP lupus is often seen in individuals with active multisystem disease, previous NP involvement as well as pre-existing damage,” she added.

When asked if there was any control data in the registry for comparison, Rodziewicz said that there was, “but the number is much smaller,” pegged at around 230 patients.

Moreover, “[t]he number of patients with active NP disease is very small. I think it might be two patients … so I’ve not done a comparison,” she added.