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Randomised placebo-controlled trial of rituximab (anti-CD20) in active ulcerative colitis
  1. Keith Leiper1,
  2. Kate Martin1,
  3. Anthony Ellis1,
  4. Sreedhar Subramanian1,
  5. Alastair J Watson1,2,
  6. Steve E Christmas3,
  7. Deborah Howarth3,
  8. Fiona Campbell4,
  9. Jonathan M Rhodes1,2
  1. 1Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
  2. 2Institute of Translational Medicine, University of Liverpool, Liverpool, UK
  3. 3Division of Immunology, University of Liverpool, Liverpool, UK
  4. 4Department of Pathology, Royal Liverpool University Hospital, Liverpool, UK
  1. Correspondence to Professor Jonathan Rhodes, Department of Gastroenterology, University of Liverpool, Duncan Building, Daulby St, Liverpool L69 3GA, UK; rhodesjm{at}liverpool.ac.uk

Abstract

Objective To assess the safety and efficacy of the B lymphocyte (anti-CD20) antibody, rituximab, in the treatment of steroid-resistant moderately active ulcerative colitis (UC).

Methods A double-blinded, randomised controlled trial with a 2:1 ratio of treatment:placebo (phase II) was carried out in the setting of a University teaching hospital. The subjects comprised 24 patients with moderately active UC who have either failed to respond to conventional corticosteroid therapy or who have relapsed during corticosteroid withdrawal. Five of 8 placebo-treated patients and 12 of 16 rituximab-treated patients were receiving azathioprine, 6-mercaptopurine or methotrexate. Two infusions of rituximab 1 g in 500 ml of 0.9% saline intravenously over 4 h (n=16) or saline placebo (n=8) were given at 0 and 2 weeks. Patients still receiving corticosteroids on entry (placebo group 7/8; rituximab group 14/16) continued a standard steroid tapering regimen. The primary end point was remission (Mayo score ≤2) at 4 weeks. Secondary end points included response (Mayo score reduced ≥3) at 4 and 12 weeks.

Results Mayo score at entry was higher in rituximab-treated patients (mean 9.19; 95% CI 8.31 to 10.06) than for placebo patients (7.63; 6.63 to 8.62, p=0.03). At week 4 only 1/8 placebo-treated patients and 3/16 rituximab-treated patients were in remission (p=1.0), but 8/16 rituximab-treated patients had responded compared with 2/8 placebo-treated patients, with a median reduction in Mayo score of 2.5 (rituximab) compared with 0 (placebo; p=0.07). This response was only maintained to week 12 in 4/16. Mucosal healing was seen at week 4 in 5/16 rituximab-treated patients and 2/8 placebo-teated patients (non-significant). Rituximab was well tolerated, with one chest infection, three mild infusion reactions plus one case of (probably unrelated) non-fatal pulmonary embolism.

Conclusions Rituximab has no significant effect on inducing remission in moderately active UC not responding to oral steroids. There was a possible short-term response that was not sustained. Rituximab is well tolerated in UC.

Clinical trial number NCT00261118.

  • Colitis
  • ulcerative/therapy
  • colitis ulcerative/pathology
  • randomised controlled trial
  • rituximab
  • human
  • adult
  • B cell
  • clinical trials
  • inflammatory bowel disease
  • ulcerative colitis

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Footnotes

  • Funding The costs of the rituximab and placebo were provided by an unrestricted grant from Roche, UK. The company had no other involvement in the trial. The trial was designed, conducted and results analysed by the authors.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Liverpool medical research ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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