Author Response: Rituximab Treatment and Long-term Outcome of Patients With Autoimmune Encephalitis: Real-world Evidence From the GENERATE Registry
FrankLeypoldt, Neuroimmunologist, Neuroimmunology, Inst. of Clinical Chemistry and Dep. of Neurology, University Hospital Schleswig-Holstein
FranziskaThaler, Neuroimmunologist, Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University Munich
TaniaKümpfel, Neuroimmunologist, Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University Munich
Submitted November 17, 2021
We appreciate the comments on our article.1 We report a considerable interval between first-line and rituximab treatment (median:30d NMDAR-AE, 47d LGI1-AE, 67d CASPR2-AE, 141d GAD65-disease). Only 20% of NMDAR-AE patients received rituximab within two weeks after first-line therapy. This depicts the real world use of rituximab in Autoimmune Encephalitis (AE) and not a generally advisable treatment algorithm. We stated that an early initiation of rituximab is associated with better outcome. However, the changing treatment regimens during the >10-year time frame must be considered. We do observe that rituximab is being used more frequently and earlier in recent years.
We would like to address the statement that “one protocol may not be best for all." An overly cautious approach for patients who require aggressive therapy is likely to cause morbidity. On the other hand, treating all patients independent of age, comorbidity, and subtype with early rituximab would result in overtreatment and unnecessary side effects—especially in pandemic times. While some recommend to treat as early as possible, we would argue for care teams to treat as hard as necessary and as early as possible. However, we also acknowledge that we try to err on the side of too much rather than too little in acute and severe AE.
Disclosure
The authors report no relevant disclosures. Contact journal@neurology.org for full disclosures.
References
Thaler FS, Zimmermann L, Kammermeier S, et al. Rituximab Treatment and Long-term Outcome of Patients With Autoimmune Encephalitis: Real-world Evidence From the GENERATE Registry. Neurol Neuroimmunol Neuroinflamm. 2021;8(6):e1088. doi:10.1212/NXI.0000000000001088.
We appreciate the comments on our article.1 We report a considerable interval between first-line and rituximab treatment (median:30d NMDAR-AE, 47d LGI1-AE, 67d CASPR2-AE, 141d GAD65-disease). Only 20% of NMDAR-AE patients received rituximab within two weeks after first-line therapy. This depicts the real world use of rituximab in Autoimmune Encephalitis (AE) and not a generally advisable treatment algorithm. We stated that an early initiation of rituximab is associated with better outcome. However, the changing treatment regimens during the >10-year time frame must be considered. We do observe that rituximab is being used more frequently and earlier in recent years.
We would like to address the statement that “one protocol may not be best for all." An overly cautious approach for patients who require aggressive therapy is likely to cause morbidity. On the other hand, treating all patients independent of age, comorbidity, and subtype with early rituximab would result in overtreatment and unnecessary side effects—especially in pandemic times. While some recommend to treat as early as possible, we would argue for care teams to treat as hard as necessary and as early as possible. However, we also acknowledge that we try to err on the side of too much rather than too little in acute and severe AE.
Disclosure
The authors report no relevant disclosures. Contact journal@neurology.org for full disclosures.
References