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Evaluation des effets des traitements par Rituximab versus corticothérapie seule sur la réponse auto-réactive des patients atteints de pemphigus.

Abstract : Pemphigus is an autoimmune disease of the skin and mucous membranes caused by autoantibodies (Ab) specific to desmoglein (Dsg) 1 or 3. These pathogenic Ab inhibit cell adhesion of keratinocytes. The development of pemphigus is associated with the conjunction of many uncommon events involving the emergence and then the cooperation of auto-reactive B cells and T cells link to genetic and environmental factors. Until now, the first line of treatment consisted of high doses of corticosteroids. Rituximab (RTX), an anti-CD20 chimeric monoclonal antibody, is an innovative therapy that results in B cells depletion. The RITUX 3 clinical trial was designed to evaluate the efficacy and safety of RTX combined with a short-course glucocorticoid therapy as a first-line treatment of pemphigus versus the standard treatment with standard corticosteroids (CS). As a first step, our clinico-biological analysis of patients after 24 months has shown that the use of RTX combined with short-term prednisone as a first-line treatment in patients with moderate to severe pemphigus is both more effective and better tolerated than the reference treatment with prednisone alone. Respectively, 89% of patients versus 34% in each group and both pemphigus foliaceus and pemphigus vulgaris patients responded. This efficacy was confirmed in the longer term after reconstitution of the B lymphocyte repertoire with a risk of relapse of only 2% at 36 months. The presence of a severe form of pemphigus at diagnosis (PDAI ≥ 45) and an anti-Dsg Ab level at 3 months above threshold values (anti-DSG1 ≥ 20 or anti-DSG3 ≥ 120) are associated with 50% risk of early relapse. These two predictive factors make it possible to identify a subgroup of patients at high risk of relapse requiring a maintenance infusion of RTX at the 6th month. In a second step, we studied the impact of RTX and CS treatments in patients with pemphigus in order to better understand the autoimmune response. The phenotypic characterization of auto-reactive B cells and the analysis of the frequency of B cells able of secreting anti-Dsg immunoglobulin (Ig) G by an ELISPOT approach demonstrated that the efficacy of RTX treatment in pemphigus seems related to the elimination of IgG-switched Dsg memory B-cells. Dsg specific B cells remain detectable after RTX when B cells return, but these B cells have a naïve and non-switched (IgM) phenotype and no longer secrete IgG. On the other hand, the persistence of self-reactive Dsg B cells capable of secreting IgG anti-Dsg after treatment with CS is certainly at the origin of the frequency of relapses. The unicellular targeted gene expression analysis demonstrated that initially, Dsg-specific B cells have a pro-inflammatory profile with the overexpression of three genes encoding Interleukin (IL) -1β, IL-12p35 and IL-23p19 and for the IRF5 gene (Interferon regulatory factor 5) compared to non-self-reactive B cells. RTX and CS have different effects on the expression of these genes, but both reduce the gene expression of IL-1β, which seems to play an important role in the pathophysiology of pemphigus.
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Submitted on : Saturday, November 28, 2020 - 1:02:38 AM
Last modification on : Tuesday, December 8, 2020 - 4:10:59 PM


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  • HAL Id : tel-03029249, version 1


Maud Maho. Evaluation des effets des traitements par Rituximab versus corticothérapie seule sur la réponse auto-réactive des patients atteints de pemphigus.. Immunothérapie. Normandie Université, 2019. Français. ⟨NNT : 2019NORMR132⟩. ⟨tel-03029249⟩



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