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Because rituximab reduces the humoral immune response, it should be used with caution during the COVID-19 pandemic as multiple studies suggest a higher risk of mortality from COVID-19 in patients using this medication.
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Fraenkel L et al. Arthritis Care Res (Hoboken). [PMID: 34101387]
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SYSTEMIC LUPUS ERYTHEMATOSUS
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Belimumab is FDA-approved for the treatment of active lupus nephritis.
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Anifrolumab, a type 1 interferon receptor antagonist, is FDA-approved to treat non-renal lupus that has not responded to standard therapies.
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Voclosporin, a novel calcineurin inhibitor, is FDA-approved to treat active lupus nephritis when used in combination with mycophenolate mofetil.
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Evidence increasingly suggests that renal response can be enhanced with combination immunosuppressive therapy.
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Morand EF et al; TULIP-2 Trial Investigators. N Engl J Med. [PMID: 31851795]
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Rovin BH et al. Lancet. [PMID: 33971155]
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SYSTEMIC SCLEROSIS (SCLERODERMA)
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Tocilizumab, an IL-6 inhibitor, slows the rate of decline in pulmonary function and may be used as an alternative for patients who cannot tolerate mycophenolate mofetil. Azathioprine is an additional option for treatment of systemic sclerosis–associated lung disease.
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Khanna D et al; focuSSced Investigators. Lancet Respir Med. [PMID: 32866440]
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High-dose pulse methylprednisolone is recommended as the initial treatment for severe polyarteritis nodosa.
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Chung SA, et al. Arthritis Rheumatol. [PMID: 34235883]
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GRANULOMATOSIS WITH POLYANGIITIS
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American College of Rheumatology/Vasculitis Foundation recommendations favor rituximab as first-line induction therapy. Cyclophosphamide may also be used for induction therapy. Avacopan is FDA-approved as add-on treatment for severe ANCA-associated vasculitis induction therapy in combination with rituximab or cyclophosphamide plus corticosteroids.
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For nonsevere disease without life- or organ-threatening manifestations, methotrexate up to 25 mg oral or subcutaneous weekly, plus corticosteroids may be effective induction therapy.
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Rituximab, dosed at a fixed interval of 1 g every 6 months or 500 mg every 4 months, is favored as first-line maintenance treatment.
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Chung SA et al. Arthritis Rheumatol. [PMID: 34235894]
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Jayne DRW et al; ADVOCATE Study Group. N Engl J Med. [PMID: 33596356]
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RELAPSING POLYCHONDRITIS
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A newly described genetic syndrome, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic), is caused by somatic mutations in UBA1 in hematopoietic progenitor cells. Clinical features include hematologic manifestations (cytopenias, bone marrow failure) and a spectrum of inflammatory features such as chondritis, vasculitis, fever, and arthritis. This rare syndrome (predominately in males because it is X-linked) should be considered in the differential diagnosis of chondritis especially in the presence of an unexplained macrocytosis and evidence of systemic inflammation (ie, high ESR/CRP).
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