Rituximab Protocol for Pemphigus Vulgaris

Induction and Maintenance Therapy

• The British Journal of Dermatology recommends a pemphigus vulgaris protocol that differs from the older rheumatoid arthritis protocol, with 2 x 1 g infusions of rituximab 1
• Combining rituximab with prednisolone starting at 0.5-1 mg/kg/day achieves 89% complete remission off all treatment at 2 years, according to Praxis Medical Insights 2

Relapse Management and Adjuvant Immunosuppression

• Expect relapse in 40-65% of patients, typically occurring 13-17 months after rituximab, with a range of 13-145 months, as reported by Praxis Medical Insights 2, 3
• Reduce doses of adjuvant immunosuppressants, such as azathioprine and mycophenolate mofetil, to minimize infection risk when adding rituximab, as recommended by Praxis Medical Insights 2, 3

Clinical Response and Monitoring

• Clinical improvement typically begins within 6 weeks of rituximab administration, with complete healing of skin and mucosal lesions averaging 15 weeks, according to Praxis Medical Insights 2
• Mean time to disease control is 11 months, with remission achieved at 58 months on average, as reported by Praxis Medical Insights 2

Pre-Treatment Screening and Infection Prophylaxis

• Perform hepatitis B screening before rituximab initiation, as reactivation can be fatal, and obtain chest radiograph to evaluate for active or latent tuberculosis, as recommended by Praxis Medical Insights 2
• Consider PCP prophylaxis during and following rituximab treatment, particularly when using triple immunosuppression or with additional risk factors, according to Praxis Medical Insights 2

Management of Serious Infections and Alternative Protocols

• Temporarily discontinue tacrolimus or other adjuvant immunosuppressants if serious infection develops requiring antibiotics, and resume at reduced doses once infection resolves, as recommended by Praxis Medical Insights 2
• For patients resistant to or intolerant of rituximab, consider immunoadsorption combined with rituximab, which can reduce circulating desmoglein antibody levels by up to 95%, as reported by Praxis Medical Insights 3