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Andrew H. Limper, MD, FCCP
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From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic.

Correspondence to: Andrew H. Limper, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 8-24 Stabile Bldg, 200 First St, Rochester, MN 55905; e-mail: limper.andrew@mayo.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(1):360. doi:10.1378/chest.13-0776
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To the Editor:

I appreciate Dr Besada’s interest in our article on the potential risks of developing Pneumocystis pneumonia (PcP) in immunocompromised patients receiving rituximab.1 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.2-4

We support the general recommendations of Green et al,5 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.

References

Martin-Garrido I, Carmona EM, Specks, U, Limper AH.Pneumocystispneumonia in patients treated with rituximab.Chest 2013;144(1):258-265.
 
Edwards 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(25):2572-2581. [CrossRef] [PubMed]
 
Cohen SB, Emery P, Greenwald MW, et al; REFLEX Trial Group. 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(9):2793-2806. [CrossRef] [PubMed]
 
Coiffier 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(4):235-242. [CrossRef] [PubMed]
 
Green H, Paul M, Vidal L, Leibovici L. Prophylaxis ofPneumocystispneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007;82(9):1052-1059. [CrossRef] [PubMed]
 

Figures

Tables

References

Martin-Garrido I, Carmona EM, Specks, U, Limper AH.Pneumocystispneumonia in patients treated with rituximab.Chest 2013;144(1):258-265.
 
Edwards 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(25):2572-2581. [CrossRef] [PubMed]
 
Cohen SB, Emery P, Greenwald MW, et al; REFLEX Trial Group. 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(9):2793-2806. [CrossRef] [PubMed]
 
Coiffier 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(4):235-242. [CrossRef] [PubMed]
 
Green H, Paul M, Vidal L, Leibovici L. Prophylaxis ofPneumocystispneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007;82(9):1052-1059. [CrossRef] [PubMed]
 
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