Evaluating the risk‐to‐benefit ratio of using cotrimoxazole as a pneumocystis pneumonia preventative intervention among pemphigus patients treated with rituximab: A retrospective study with 494 patients

Abstract

Rituximab is widely used as the first‐line treatment for pemphigus patients. Since it depletes the B cells, it increases the risk of infections. Here, we evaluated the prophylactic efficacy of cotrimoxazole in decreasing the risk of pneumocystis pneumonia (PCP) infection in the pemphigus patients treated with rituximab. The medical records of confirmed pemphigus patients receiving rituximab were evaluated in two groups; those who received cotrimoxazole as a prophylactic after rituximab and patients who only received rituximab without any prophylaxis. The occurrence of PCP infection was determined in each group and compared. Medical records of 494 patients, including 301 women and 193 men, with the mean age of 46.74 years were analyzed. The phenotypes of the disease were mucocutaneous (n = 364), mucosal (n = 88), and cutaneous (n = 42). Among them, 235 cases had received cotrimoxazole as a prophylaxis and 259 patients did not. The incidence of PCP in total patients was 2 (0.4%), one in each group. Accordingly, no significant difference was observed in the incidence of PCP between two groups (p = 0.84). Also, no cotrimoxazole‐related side effect was observed in the treated group. It seems that due to the low incidence of PCP in pemphigus patients treated with rituximab, prophylactic cotrimoxazole therapy is not necessary and it only increases the overall therapy cost and might cause cotrimoxazole‐related adverse effects in some patients. However, regarding its probable beneficial effect in patients with long‐term history of immunosuppressive therapy, more studies are required.

Various infections in patients with autoimmune bullous diseases: a retrospective case-control study

“…Besides screening infections before starting glucocorticoid treatment(28, 29), monitoring infection during treatment especially in high-risk patients as known before, our study provided probable infection predictive cutoff values of glucocorticoid dose and suggested combining other immunosuppressive agents to decrease the risk of infection. Preventive therapy had not been shown necessary (30)…”

Elevated serum level of B‐cell activating factor (BAFF) after rituximab therapy in pemphigus vulgaris patients suggests a possible therapeutic efficacy of B‐cell depletion therapies combined with anti‐BAFF agents

“…Regardless of some safety concerns, such as increasing the risk of infection, although it seems much safer than conventional treatments, preventing the disease relapse has remained an issue. 24,25 Rituximab acts through depletion of CD20 positive cells, which covers a broad spectrum of B cells. Depending on several factors, repopulation of B cells could occur usually within 6 to 9 months in most cases, although it takes a longer time to reach the normal number of total CD20+ B cells.…”

“…Although it is effective and not only could induce disease remission in most of the patients, it keeps the patients in the remission phase for a relatively long time on or off minimal therapy. Regardless of some safety concerns, such as increasing the risk of infection, although it seems much safer than conventional treatments, preventing the disease relapse has remained an issue 24,25 . Rituximab acts through depletion of CD20 positive cells, which covers a broad spectrum of B cells.…”

Infections in the era of immunobiologicals

“…The authors concluded that there is no consensus on the need for prophylaxis due to the low incidence of PCP complications in these patients, and it is not mandatory to treat all pemphigus patients with rituximab. 58 …”