Succesfull sequential therapy with rituximab and belimumab in three patients with active systemic lupus erythematosus

Background and Aims: B cells play an important role in the initiation and progression of systemic lupus erythematosus (SLE). Rituximab, a chimeric monoclonal antibody directed against CD20 expressing B cells, has been reported to be an effective treatment in SLE in several observational and retrospective series. However, in clinical trials in SLE patients, rituximab failed to reach primary endpoints. Belimumab, a human monoclonal antibody directed against-B lymphocyte stimulator (BLyS), is the first biological treatment specifically designed for patients with SLE. Belimumab is effective in reducing disease activity in mild to moderate SLE as demonstrated in several clinical trials. Recently, a sequential use of rituximab and belimumab has been suggested as a more effective treatment than single drugs alone in patients with lupus nephritis, without compromising safety. Method: We describe the clinical and laboratory features of three female patients aged 48, 24 and 37, undergoing sequential therapy with rituximab followed by belimumab. The sequential therapy was necessary due to still active disease or clinical remission depending on treatment with moderate/high dosage steroids. Results: We present three cases of active SLE (see table 1) successfully treated with rituximab followed by belimumab as maintenance therapy. Belimumab therapy was required either for persistent high disease activity (patient 2) or as steroid-sparing drug (patients 1 and 3). Conclusion: Sequential therapy with rituximab followed by belimumab was effective in inducing clinical remission and as steroid-sparing approach in our patients with active disease.