Routine Pneumocystis Pneumonia Prophylaxis in Patients Treated With Rituximab?: Response

Abstract

I appreciate Dr Besada's interest in our article on the potential risks of developing Pneumocystis pneumonia (PcP) in immunocompromised patients receiving rituximab.1Martin-Garrido I Carmona EM Specks U Limper AH Pneumocystis pneumonia in patients treated with rituximab.Chest. 2013; 144: 258-265Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar We too wish to know the overall incidence of this often lethal complication following the administration of this medication. Unfortunately, under the design of the study, this is not currently possible. During this time frame, a significant number of patients received rituximab at outside institutions either before or after care at the Mayo Clinic. Thus, there were no means to accurately obtain the total number of patients who were exposed to rituximab over this time period in the entire patient population. We simply raised concern that PcP may develop as a complication in patients receiving rituximab and that this infection has a high attendant mortality (about 30%). Our study is unique in that three of the patients in the cohort received rituximab as the only immunosuppressive agent associated with the development of PcP. Earlier series reported this infection in patients receiving rituximab in addition to either corticosteroids or cytotoxic agents known to also suppress immunity.2Edwards JC Szczepanski L Szechinski J et al.Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis.N Engl J Med. 2004; 350: 2572-2581Crossref PubMed Scopus (2139) Google Scholar, 3Cohen SB Emery P Greenwald MW REFLEX Trial Group et al.Rituximab for rheumatoid arthritis refractory to anti-tumor necrosis factor therapy: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial evaluating primary efficacy and safety at twenty-four weeks.Arthritis Rheum. 2006; 54: 2793-2806Crossref PubMed Scopus (1387) Google Scholar, 4Coiffier B Lepage E Briere J et al.CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma.N Engl J Med. 2002; 346: 235-242Crossref PubMed Scopus (4374) Google Scholar We support the general recommendations of Green et al,5Green H Paul M Vidal L Leibovici L Prophylaxis of Pneumocystis pneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials.Mayo Clin Proc. 2007; 82: 1052-1059Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar advocating routine prophylaxis in patient populations where the overall incidence of PcP exceeds 3.5%. Unfortunately, at this time, the true incidence of PcP in patients receiving rituximab either alone or in combination with other immunosuppressive drugs remains unknown and must await additional monitoring of patients receiving this medication. However, in light of the potential risk of this infection and the high mortality associated with PcP, we recommend that clinicians use their judgment, carefully weighing the risk of the prophylaxis regimens against the potential risks of PcP. Such decisions are, of course, tempered by the overall clinical setting. It is for these reasons that we intentionally did not use the term “routine” in characterizing the decision to administer prophylaxis to these patients, although antibiotic prophylaxis often may well be considered and offered to many such immunosuppressed individuals. Routine Pneumocystis Pneumonia Prophylaxis in Patients Treated With Rituximab?CHESTVol. 144Issue 1PreviewI was pleased to read the article by Martin-Garrido et al1 in this issue of CHEST (see page 258 ) on Pneumocystis pneumonia (PcP) risk in patients treated with rituximab at the Mayo Clinic in Rochester, Minnesota, from 1998 to 2011. Thirty of 230 patients with PcP had received rituximab, compared with 23 patients with HIV-associated PcP.1 However, to determine the incidence of PcP in patients treated with rituximab, I would like to know how many patients were treated with rituximab during the study period. Full-Text PDF