An update on the considerations for patients with rheumatic disease being treated with rituximab during the COVID-19 pandemic and the potential drug treatment strategies

ABSTRACT

Introduction

Over the last two decades, rituximab has become an increasingly popular drug in the treatment of a wide range of rheumatic diseases. However, with the advent of the COVID-19 pandemic, clinicians face challenges in weighing risk against benefit in its use.

Areas covered

A review of existing data was performed to examine the relationship between rituximab use, morbidity and mortality from COVID-19, and vaccine efficacy in patients with rheumatic diseases, aiming to guide clinicians in continued use of the medication and consider the direction of future research. A literature review was performed through a search of the PubMed database, using the terms ((SARS-CoV-2) OR (COVID-19)) AND (rituximab) AND (rheumatic), which generated an initial 55 results, with relevant articles then selected for inclusion.

Expert opinion

In order to safeguard patients with an ongoing need for rituximab therapy, vaccination remains the primary concern. A target of performing booster doses 6 months after last rituximab dose is a reasonable estimate, which may be made more precise by use of B cell counts, although primary immunization should not be delayed. In those patients who remain seronegative, the use of newer antivirals and broadly neutralizing antibody infusions may help provide further safeguards.

KEYWORDS:

• COVID-19
• SARS-CoV-2
• rituximab
• rheumatic
• inflammatory
• vaccination

Article highlights

• Rituximab is highly correlated with increased morbidity and mortality from COVID-19 across an array of studies in patients with rheumatic disease.

• Patients treated with rituximab often fail to mount an effective humoral response to both primary SARS-CoV-2 vaccination and booster programs.

• SARS-CoV-2 vaccination nevertheless produces a T cell response even in patients who fail to seroconvert.

• Where disease activity allows, some patient groups may benefit from having rituximab delayed to allow full vaccination to take place.

• Neutralizing antibody therapies may be used in treatment and prophylaxis of COVID-19.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.