Remission rates not affected by adjuvant immunoadsorption in pemphigus

Key takeaways:

• A trial of adjuvant immunoadsorption for pemphigus diseases was ended early due to adverse events.
• The time to remission was not affected; however, prednisolone doses were reduced with adjuvant IA.

In patients with pemphigus vulgaris and pemphigus foliaceus, adjuvant immunoadsorption did not lessen the time to clinical remission, according to a study.

“Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are severe autoimmune blistering skin diseases characterized by IgG autoantibodies against the two desmosomal proteins desmoglein (Dsg)1 and Dsg3,” Nina van Beek, MD, of the department of dermatology, allergology and venereology at University of Lübeck in Lübeck, Germany, and colleagues wrote. “In addition, autoantibodies to other target antigens, including cholinergic receptors and annexins, have been reported.”

The potentially life-threatening diseases are usually treated with high doses of glucocorticosteroids along with immunosuppressants, such as azathioprine or mycophenolate, or rituximab.

Adjuvant immunoadsorption (IA) previously reduced desmoglein-specific serum autoantibody levels, according to the study.

In this multicenter, randomized, controlled trial, 72 patients with PV or PF were randomly assigned to receive either the current standard of best medical treatment (BMT), which is prednisolone 1 mg/kg daily plus azathioprine or mycophenolate, or to receive BMT and adjuvant IA on 4 consecutive days.

Clinical remission occurred in 16 of 34 (47%) patients in the BMT+IA group, and in 17 of 38 (45%) in the BMT group, which the researchers said was not a statistically significant difference.

However, those in the BMT+IA treatment group vs. BMT group did show a cumulative reduction in prednisone dosing (median dose, 3,055 mg vs. 4,835 mg, respectively). Further, a post-hoc analysis showed a trend toward shorter time to remission in the BMT+IA group for those with more extensive PV or PF (HR = 1.87).

Due to safety concerns, including a death in the BMT+IA group, the study was discontinued.

Additionally, 220 adverse events were recorded, with severe adverse events occurring more often in the BMT+IA group.

“Our study does not show a clear clinical benefit of IA in pemphigus and indicated that IA may be associated with severe infections,” the authors wrote. “Secondary endpoints and post-hoc analyses suggest that IA has a corticosteroid-sparing effect and, in the group of patients with severe PV/PF, may possibly lead to more rapid complete remission on therapy.”

The researchers suggest the use of IA as adjuvant therapy in patients with severe PV/PF while possible risks are weighed and examined.