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Title Summary
Failure on one TNF inhibitor agent in RA Female patient (47 years) with a family history of Rheumatoid Arthritis, had a disease duration of 8 years. She had received methotrexate plus folic acid, and more recently with etanercept, but her condition was deteriorating with recent flares. She had difficulty with sleeping, with caring for children and using a computer keyboard, along with high levels of fatigue and pain. She was switched to rituximab in combination with methotrexate, resulting in an improvement in her disease activity and functional state.
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Resolution of extra-articular manifestations of RA with rituximab treatment Female patient (55 years) was diagnosed with RF-positive RA in March 1999. Since then she has developed rheumatoid nodules on her hands and elbows which are characteristic of severe erosive arthritis. She had received a series of DMARD treatments (including methotrexate plus folic acid) more recently in combination with etanercept, but there was no improvement in her condition despite treatment with etanercept 75 mg weekly. After an initial course of rituximab treatment, the nodules disappeared and her daily prednisone dosage could be decreased from 10 mg to 2.5 mg.
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When should patients receive repeat courses of rituximab treatment? This patient (female, 73 years) was referred to our clinic in September 2001, with a diagnosis of seropositive, erosive RA since 1998. She had received NSAIDs and glucocorticoids daily along with methotrexate and sulfasalazine, but these medications had not resulted in an adequate clinical response because of lack of efficacy and hepatotoxicity respectively (methotrexate was not withdrawn). Furthermore, no clinical improvement was observed with etanercept treatment, and severe adverse events were seen with infliximab treatment. Treatment with rituximab (plus methotrexate) produced an initial good response, with further improvements after repeat treatment courses. Importantly all three treatment courses were well-tolerated with no infusion reactions reported.
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Patient with inadequate response to TNF inhibitor agents This 52 year old female patient was referred to our clinic with seropositive, erosive RA since 1993. She had received NSAIDs and glucocorticoids daily along with gold, methotrexate and sulfasalazine, but these medications were withdrawn due to a lack of efficacy. Examination of the patient showed synovitis and functional impairment of the joints therefore we initiated treatment with TNF inhibitor agents. No clinical improvement was observed with infliximab treatment, and adalimumab treatment was withdrawn due to the patient experiencing severe adverse events and lack of efficacy. Treatment with rituximab in combination with weekly methotrexate resulted in significant clinical improvement and was well tolerated in this patient.
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Efficacy and safety with repeat courses of rituximab We treated a 24 year old female, who had seropositive, erosive RA for the past 5 years (diagnosis January 2002). We administered sulfasalazine (no response), methotrexate (partial response) and etanercept (initial response then decline in efficacy). Treatment with rituximab in combination with methotrexate produced an initial good response. The response further improved when a second course was given 14 months later. The patient became pregnant 10 months after the last treatment with rituximab, she had not taken methotrexate for the previous few months and her B cells were detectable. She had no flares during the pregnancy and delivered a healthy baby girl, which was breastfed initially.
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Rituximab and vaccination Our patient is a 48 year old female who suffers from a RF positive RA (diagnosed in August 2000). She is successfully managed with six monthly rituximab infusions. She has received vaccination against hepatitis B 3 months before rituximab treatment and is vaccinated yearly against influenza.
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Rituximab in a case of RA with sero-positive RF and anti-CCP This patient (female, 45 years of age) had inflammatory RA with systemic disease for one year. She had raised inflammatory markers, hand and feet radiographs revealed soft tissue swelling of her MCPs and PIPs bilaterally but without erosive propensity. Methotrexate and TNF inhibitor agents had given an inadequate response. After a total of 2 rituximab courses over 6 months, clinical improvement in the signs and symptoms of active RA were observed.
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Repeat rituximab course for rheumatoid arthritis This patient (male, 62 years of age) had suffered seropositive RA with erosive changes for more than 15 years. Previous treatment history revealed that this patient suffered persistent severe disease, despite previous DMARD and biologic treatment. He was treated with rituximab in combination with methotrexate, resulting in a good clinical response, which further improved with repeat treatment courses. Importantly all treatment courses were well tolerated with no infusion reactions reported.
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Rituximab for RA - a practical insight for physicians A female patient (51 years) had a disease duration of 9 years following the diagnosis of sero-positive RA in 1998. From very early on in the course of her disease she suffered from severe synovitis of the wrists, MCPs and knees. A range of different treatments had been tried including methotrexate, salazopyrine, hydroxychloroquin and then the TNF inhibitor agents  infliximab and etanercept, all with very little effect. The patient's functionality deteriorated and in addition she developed massive obesity, hypertension and diabetes secondary to multiple intravenous methylprednisolone injections. She was treated with rituximab in combination with methotrexate, resulting in a good clinical response, which further improved after a repeat treatment course. Importantly both treatment courses were well-tolerated with no infusion reactions reported.
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Should returning symptoms dictate the frequency of rituximab infusions ? A female patient (35 years) had a disease duration of 10 years following a diagnosis of sero-positive erosive RA. Her symptoms had forced her to give up her work as a nurse and she experienced difficulties with activities of daily life, especially caring for her children, aged 5 and 9 years. She had received a range of DMARDs and more recently the TNF inhibitor agents infliximab, etanercept and adalimumab but her condition continued to deteriorate. She was treated with rituximab, in combination with weekly methotrexate, resulting in significant clinical improvement. She experienced a mild infusion reaction with the first dose of the first course. Importantly the infusion reaction did not recur on the second infusion, and subsequent course. At the same time when disease activity increased and a second rituximab course was proposed, dental care with two extractions was indicated. Prophylactic antibiotics were prescribed and the extractions performed. The infusion was postponed until two weeks later. At this time the antibiotic treatment had been completed and there was no infection so the patient received the first infusion of rituximab.
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Patient profile before rituximab treatment Our 42 year old female patient had a disease duration of 5 years following diagnosis of RF-negative anti-CCP positive RA. This patient had developed erosions on her hands, wrist and feet one year after disease onset. A range of different treatments had been tried including methotrexate, and the TNF inhibitor agent infliximab. However, she developed pulmonary tuberculosis, and on stopping the TNF inhibitor her RA deteriorated with flares and worsening of joint erosion. She was treated with rituximab in combination with methotrexate, resulting in a good clinical response, and required a repeat treatment course 8 months later. Importantly both treatment courses were well tolerated with no recurrence of tuberculosis.
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