Rituximab in Refractory Myasthenia Gravis: A Systematic ReviewAuthor(s): Lourdes de Fatima Ibanez Valdes, Sibi Sebastian Joseph and Humberto Foyaca Sibat*
Background: Despite Myasthenia Gravis (MG) is a chronic autoimmune disorder some spontaneous remissions can occur (4-17 years) even before introduction of immunosuppressant. For the past eighty years, remarkable progress in the therapy of MG has been, and currently this condition is one of the most treatable autoimmune disorders worldwide. However, an important number of cases remain refractory or present lack tolerance to steroids and other immune suppressants, in such situations monoclonal antibodies have been contributing to better outcome of that community. To determine the proportion of patients responding well to RTX or presenting adverse responses, complications, or fatal results, we performed a Systematic Review (SR) of the published articles on MG treated with RTX looking for safer and more effective treatment for RMG.
Material and methods: Following PRISMA guidelines, we searched EMBASE, Medline, Scopus online databases, WHO database, Google Scholar, Science Dirct, Scielo, LILACS, BIREME, Web on Science, and Cochrane library to identify articles evaluating rituximab therapy*, refractory MG*, a systematic review on MG*, rituximab in MC*, *from January 1, 2018, to July 30, 2021.
Results: We found 469 publications regarding to these issues. After removing duplicate articles, considering abstracts, titles, and screening full text, PCR positives, symptomatic patients, and manuscripts were written in other languages, only 30 matched all the selected parameters.
Comments and final remarks: Our study confirmed a remarkable clinical improvement of MG/RMG cases after initiating RTX therapy, a better Quality of Life (QOL), and beneficial outcomes in almost all cases reported in the medical literature. We also confirmed that RTX is well tolerated in AChR-MG and MuSK-MG patients. The cases presenting any adverse event after initiating RTX ranged from 26.4% and 42.8% and never were considered severe complications. Patients presenting AChR-RMG also improve when receiving repeated lower doses of RTX. However, multi-centre RCT using different doses of RTX in an extensive series should be performed to confirm its efficacy. The frequency of MGE/MC after initiating RTX therapy has not been determined. Incidence/prevalence of mortality has been no reported after a confident analysis and information from post-mortem examinations were not realized up to date. No evidence-based guidelines and relevant cost-effectiveness have been demonstrated. Apart from the clinical benefits obtained with RTX, a substantial number of patients were able to reduce doses and frequency of administration of associated immunomodulatory agents.