|Trade names||Mabthera / Rituxan|
|intravenous infusion only (never bolus or "push")|
|Biological half-life||30 to 400 hours (varies by dose and length of treatment)|
|Excretion||Uncertain: may undergo phagocytosis and catabolism in RES|
|CAS Registry Number|
|Molecular mass||143859.7 g/mol|
|(what is this?)|
Rituximab (trade names Rituxan, MabThera and Zytux) is a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of immune system B cells. Rituximab destroys B cells and is therefore used to treat diseases which are characterized by excessive numbers of B cells, overactive B cells, or dysfunctional B cells. This includes many lymphomas, leukemias, transplant rejection, and autoimmune disorders.
Based on its safety and effectiveness in clinical trials, rituximab was approved by the U.S. Food and Drug Administration in 1997 to treat B-cell non-Hodgkin lymphomas resistant to other chemotherapy regimens. Rituximab, in combination with CHOP chemotherapy, is superior to CHOP alone in the treatment of diffuse large B-cell lymphoma and many other B-cell lymphomas. In 2010 it was approved by the European Commission for maintenance treatment after initial treatment of follicular lymphoma.
It is on the World Health Organization's List of Essential Medicines, a list of the most important medications needed in a basic health system.
Rituximab destroys both normal and malignant B cells that have CD20 on their surfaces, and is therefore used to treat diseases which are characterized by having too many B cells, overactive B cells, or dysfunctional B cells.
In multiple myeloma, treatment with rituximab fails to deplete circulating CD20+ B or plasma cells, even after up to four cycles of treatment; in some patients, rituximab treatment increases the number of circulating CD20+ B cells.
Rituximab has been shown to be an effective rheumatoid arthritis treatment in three randomised controlled trials and is now licensed for use in refractory rheumatoid disease. In the United States, it has been FDA-approved for use in combination with methotrexate (MTX) for reducing signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more anti-TNF-alpha therapy. In Europe, the license is slightly more restrictive: it is licensed for use in combination with MTX in patients with severe active RA who have had an inadequate response to one or more anti-TNF therapy.
There is some evidence for efficacy, but not necessarily safety, in a range of other autoimmune diseases, and rituximab is widely used off-label to treat difficult cases of multiple sclerosis, systemic lupus erythematosus, chronic inflammatory demyelinating polyneuropathy and autoimmune anemias. The most dangerous, although among the most rare, side effect is progressive multifocal leukoencephalopathy (PML) infection, which is usually fatal; however only a very small number of cases have been recorded occurring in autoimmune diseases.
Other autoimmune diseases that have been treated with rituximab include autoimmune hemolytic anemia, pure red cell aplasia, idiopathic thrombocytopenic purpura (ITP), Evans syndrome, vasculitis (for example granulomatosis with polyangiitis, formerly Wegener's), bullous skin disorders (for example pemphigus, pemphigoid—with very encouraging results of approximately 85% rapid recovery in pemphigus, according to a 2006 study), type 1 diabetes mellitus, Sjogren's syndrome, anti-NMDA receptor encephalitis and Devic's disease, Graves' ophthalmopathy, autoimmune pancreatitis, and IgG4-related disease. There is some evidence that it is ineffective in treating IgA-mediated autoimmune diseases.
In October 2011, a double-blind controlled study was published in PLOS ONE which suggests that rituximab can help patients with chronic fatigue syndrome, leading to a proposed theory relating chronic fatigue syndrome to other autoimmune conditions, however more research is required to verify if such a link exists. A new multi-centre double-blinded trial with 152 patients began in October 2014, after a follow-up open study published in July 2015 suggested a longer acting effect when four maintenance doses were added to the dosing schedule. Two-thirds of the patients responded favorably to the drug, in accordance with previous findings. There are also plans and campaigns running to try and set up a smaller UK trial at University College London.
Anti-rejection treatment for organ transplants
Rituximab is now being used off-label in the management of kidney transplant recipients. This drug may have some utility in transplants involving incompatible blood groups. It is also used as induction therapy in highly sensitized patients going for kidney transplantation. The use of rituximab has not been proven to be efficacious in this setting and like all depleting agents, carries with it the risk of infection.
The antibody binds to CD20. CD20 is widely expressed on B cells, from early pre-B cells to later in differentiation, but it is absent on terminally differentiated plasma cells. CD20 does not shed, modulate or internalise. Although the function of CD20 is unknown, it may play a role in Ca2+ influx across plasma membranes, maintaining intracellular Ca2+ concentration and allowing activation of B cells.
Rituximab tends to stick to one side of B cells, where CD20 is, forming a cap and drawing proteins over to that side. The presence of the cap changed the effectiveness of natural killer (NK) cells in destroying these B cells. When an NK cell latched onto the cap, it had an 80% success rate at killing the cell. In contrast, when the B cell lacked this asymmetric protein cluster, it was killed only 40% of the time.
The following effects have been found:
- The Fc portion of rituximab mediates antibody-dependent cellular cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC).
- Rituximab has a general regulatory effect on the cell cycle.
- It increases MHC II and adhesion molecules LFA-1 and LFA-3 (lymphocyte function-associated antigen).
- It elicits shedding of CD23.
- It downregulates the B cell receptor.
- It induces apoptosis of CD20+ cells.
The combined effect results in the elimination of B cells (including the cancerous ones) from the body, allowing a new population of healthy B cells to develop from lymphoid stem cells.
- Severe infusion reaction.
- Cardiac arrest
- Cytokine release syndrome
- Tumor lysis syndrome, causing acute renal failure
- Immune toxicity, with depletion of B cells in 70% to 80% of lymphoma patients
- Pulmonary toxicity
- Bowel obstruction and perforation
Two patients with systemic lupus erythematosus died of progressive multifocal leukoencephalopathy (PML) after being treated with rituximab. PML is caused by activation of JC virus, a common virus in the brain which is usually latent. Reactivation of the JC virus usually results in death or severe brain damage.
Rituximab has been reported as a possible cofactor in a chronic Hepatitis E infection in a person with lymphoma. Hepatitis E infection is normally an acute infection, suggesting the drug in combination with lymphoma may have weakened the body's immune response to the virus.
Other anti-CD20 monoclonals
The efficacy and success of Rituximab has led to some other anti-CD20 monoclonal antibodies being developed:
- ocrelizumab, humanized (90%-95% human) B cell-depleting agent.
- ofatumumab (HuMax-CD20) a fully human B cell-depleting agent.
- Third-generation anti-CD20s such as obinutuzumab have a glycoengineered Fc fragment (Fc) with enhanced binding to Fc gamma receptors, which increase ADCC (antibody-dependent cellular cytotoxicity). This strategy for enhancing a monoclonal antibody's ability to induce ADCC takes advantage of the fact that the displayed Fc glycan controls the antibody's affinity for Fc receptors.
The added value of a humanized molecule in oncology, compared to the original design, has not been demonstrated to this date.
Another approach to B cell diseases is to block the interaction of B cell survival or growth factors with their receptors on B cells. The monoclonal antibody Belimumab and atacicept are examples of such an approach.
- "Why San Diego Has Biotech", Fikes, Bradley J. San Diego Metropolitan, April 1999. Accessed June 20, 2008.
- DrugBank DB00073
- Maloney DG, Grillo-López AJ, White CA et al. (September 1997). "IDEC-C2B8 (Rituximab) anti-CD20 monoclonal antibody therapy in patients with relapsed low-grade non-Hodgkin's lymphoma". Blood 90 (6): 2188–95. PMID 9310469.
- Scott SD (1998). "Rituximab: a new therapeutic monoclonal antibody for non-Hodgkin's lymphoma". Cancer Pract 6 (3): 195–7. doi:10.1046/j.1523-5394.1998.006003195.x. PMID 9652253.
- Harrison's Principles of Internal Medicine, Longo et al. McGraw Hill Medical 2011 page 931
- "Roche Gets EC Nod for Follicular Lymphoma Maintenance Therapy". October 29, 2010.
- "www.who.int" (PDF).
- Saini KS, Azim HA Jr, Cocorocchio E, Vanazzi A, Saini ML, Raviele PR, Pruneri G, Peccatori FA (2011). "Rituximab in Hodgkin lymphoma: Is the target always a hit?". Cancer Treat Rev 37 (5): 385–90. doi:10.1016/j.ctrv.2010.11.005. PMID 21183282.
- Multiple myeloma includes CD20+ B and plasma cells that persist in patients treated with rituximab. LM Pilarski, E Baigorri, MJ Mant, PM Pilarski, P Adamson, H Zola, AR Belch. Clinical Medicine:Oncology, 2:275-281, 2008
- Edwards J, Szczepanski L, Szechinski J, Filipowicz-Sosnowska A, Emery P, Close D, Stevens R, Shaw T (2004). "Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis". N Engl J Med 350 (25): 2572–81. doi:10.1056/NEJMoa032534. PMID 15201414.
- Tak PP, Kalden JR (2011). "Advances in rheumatology: new targeted therapeutics". Arthritis Res Ther 13 (Suppl 1): S5. doi:10.1186/1478-6354-13-S1-S5. PMC 3123966. PMID 21624184.
- NEJM - B-Cell Depletion with Rituximab in Relapsing-Remitting Multiple Sclerosis
- Paul, Marla (May 20, 2009). "Popular Cancer Drug Linked to Often Fatal 'Brain Eating' Virus". Northwestern University News and Information. Retrieved 2009-05-22.
- "Press Announcements". Fda.gov. Retrieved 2013-04-29.
- Braendstrup P, Bjerrum OW, Nielsen OJ et al. (April 2005). "Rituximab chimeric anti-CD20 monoclonal antibody treatment for adult refractory idiopathic thrombocytopenic purpura". Am. J. Hematol. 78 (4): 275–80. doi:10.1002/ajh.20276. PMID 15795920.
- Patel V, Mihatov N, Cooper N, Stasi R, Cunningham-Rundles S, Bussel JB,Long-term responses seen with rituximab in patients with ITP, Community Oncology Vol. 4 No. 2, February 2007:107 PDF
- Shanafelt, Tait D, MD; Madueme, Hans L, MD; Wold, Robert C, PharmD; Tefferi, Ayalew, MD Rituximab for Immune Cytopenia in Adults: Idiopathic Thrombocytopenic Purpura, Autoimmune Hemolytic Anemia, and Evans Syndrome Mayo Clinic Proc. 2003;78:1340-1346 PDF
- A. Razzaque Ahmed, M.D.; Zachary Spigelman, M.D.; Lisa A. Cavacini, Ph.D.; Marshall R. Posner, M.D. (October 26, 2006). "Treatment of Pemphigus Vulgaris with Rituximab and Intravenous Immune Globulin". N Engl J Med 355: 1772–1779. doi:10.1056/nejmoa062930.
- Jacob A, Weinshenker BG, Violich I, McLinskey N, Krupp L, Fox RJ, Wingerchuk DM, Boggild M, Constantinescu CS, Miller A, De Angelis T, Matiello M, Cree BA (2008). "Treatment of neuromyelitis optica with rituximab: retrospective analysis of 25 patients". Arch Neurol 65 (11): 1443–1448. doi:10.1001/archneur.65.11.noc80069. PMID 18779415.
- "Rituximab Treatment of Patients with Severe, Corticosteroid-Resistant Thyroid-Associated Ophthalmopathy". Retrieved 2011-10-19.
- "Immunomodulators and Rituximab in the Management of Autoimmune Pancreatitis". Retrieved 2014-04-30.
- Arezou Khosroshahi, Z. S. Wallace, J. L. Crowe, T. Akamizu, A. Azumi, M. N. Carruthers, S. T. Chari, E. Della-Torre, L. Frulloni, H. Goto, P. A. Hart, T. Kamisawa, S. Kawa, M. Kawano, M. H. Kim, Y. Kodama, K. Kubota, M. M. Lerch, M. Löhr, Y. Masaki, S. Matsui, T. Mimori, S. Nakamura, T. Nakazawa, H. Ohara, K. Okazaki, J.H. Ryu, T. Saeki, N. Schleinitz, A. Shimatsu, T. Shimosegawa, H. Takahashi, M. Takahira, A. Tanaka, M. Topazian, H. Umehara, G. J. Webster, T. E. Witzig, M. Yamamoto, W. Zhang, T. Chiba, John H. Stone (July 2015). "International Consensus Guidance Statement on the Management and Treatment of IgG4-Related Disease". Arthritis & Rheumatology 67 (7): 1688–1699. doi:10.1002/art.39132. PMID 25809420.
- He Y, Shimoda M, Ono Y, Villalobos IB, Mitra A, Konia T, Grando SA, Zone JJ, Maverakis E (2015). "Persistence of Autoreactive IgA-Secreting B Cells Despite Multiple Immunosuppressive Medications Including Rituximab". JAMA Dermatol 151 (6): 646–50. doi:10.1001/jamadermatol.2015.59. PMID 25901938.
- Fluge O, Mella O (July 2009). "Clinical impact of B-cell depletion with the anti-CD20 antibody rituximab in chronic fatigue syndrome: a preliminary case series". BMC Neurology 9: 28. doi:10.1186/1471-2377-9-28. PMC 2711959. PMID 19566965.
- Drug Intervention in Chronic Fatigue Syndrome
- "Benefit from B-Lymphocyte Depletion Using the Anti-CD20 Antibody Rituximab in Chronic Fatigue Syndrome. A Double-Blind and Placebo-Controlled Study". Plos One. Retrieved 2013-04-29.
- "Rituximab Trial Shows Promise". Retrieved 2011-11-04.
- "Scientists discover why a specific cancer drug is so effective". KurzweilAI. doi:10.1182/blood-2013-02-482570. Retrieved 2013-04-29.
- Rudnicka, D; Oszmiana, A; Finch, DK; Strickland, I; Schofield, DJ; Lowe, DC; Sleeman, MA; Davis, DM (Jun 6, 2013). "Rituximab causes a polarization of B cells that augments its therapeutic function in NK-cell-mediated antibody-dependent cellular cytotoxicity.". Blood 121 (23): 4694–702. doi:10.1182/blood-2013-02-482570. PMID 23613524.
- T Shaw, J Quan, and M Totoritis, "B cell therapy for rheumatoid arthritis: the rituximab (anti-CD20) experience", Ann Rheum Dis. 2003 November; 62(Suppl 2): ii55–ii59.
- Binder M, Otto F, Mertelsmann R, Veelken H, Trepel M. (2006). "The epitope recognized by rituximab". Blood 108 (6): 1975–1978. doi:10.1182/blood-2006-04-014639. PMID 16705086.
- "Genentech: Products - Product Information - Immunology - Rituxan RA Full Prescribing Information". Retrieved 2007-12-03.
- Burton C, Kaczmarski R, Jan-Mohamed R (2003). "Interstitial pneumonitis related to rituximab therapy". N Engl J Med 348 (26): 2690–1; discussion 2690–1. doi:10.1056/NEJM200306263482619. PMID 12826649.
- "Reports of Bowel Obstruction and Perforation with RITUXAN (rituximab)" (PDF). Roche Canada. 2006-11-10.
- "Rituximab (marketed as Rituxan) Information". Retrieved 15 November 2009.
- "Rituximab, RA and PML" (PDF). Retrieved 2008-09-14.
- "Chronic Hepatitis After Hepatitis E Virus Infection in a Patient With Non-Hodgkin Lymphoma Taking Rituximab" (PDF). Retrieved 2008-09-14.
- "Genmab.com / HuMax-CD20 (ofatumumab)". Archived from the original on 2007-09-11. Retrieved 2007-12-03.
- "Fc-structure". Retrieved 2007-12-03.
- Eccles, SA (2001). "Monoclonal antibodies targeting cancer: 'magic bullets' or just the trigger?". Breast cancer research : BCR 3 (2): 86–90. doi:10.1186/bcr276. PMC 138676. PMID 11250751.
- Maverakis E, Kim K, Shimoda M, Gershwin M, Patel F, Wilken R, Raychaudhuri S, Ruhaak LR, Lebrilla CB (2015). "Glycans in the immune system and The Altered Glycan Theory of Autoimmunity". J Autoimmun 57 (6): 1–13. doi:10.1016/j.jaut.2014.12.002. PMID 25578468.
- "monoclonal domains". Retrieved 2007-12-03.
- MabThera.com Official website for use against lymphoma
- MabThera for Rheumatoid Arthritis Official website for use against rheumatoid arthritis (for non-US physicians and scientific media only)
- Rituxan.com Official website (for US residents only)
- Rituximab Information from the US Food and Drug Administration
- U.S. National Library of Medicine: Drug Information Portal - Rituximab