Rituximab (RTX) as an Alternative to TNF-Alpha Antagonists in Patients with Rheumatoid Arthritis and High Risk of Severe Infections: A Systematic Analysis of the Experience in One Center

P Xanthouli, S Sailer, C Fiehn*
ACURA Center for Rheumatic Diseases, Baden-Baden, Germany

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© Xanthouli et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the ACURA Centre for Rheumatic Diseases, Rotenbachtalstr. 5, 76530 Baden-Baden, Germany; Tel: 0049 7221 352401; Fax: 0049 7221 352490; E-mail:



The use of TNF-alpha antagonists may be associated with an increased rate of infections in risk populations of patients with RA. Our hypothesis was that in patients with a high risk of infection Rituximab (RTX) could be a safer alternative.


We analyzed the outcome of RA patients who received RTX instead of TNF-alpha antagonist because of a history of serious infections or frequent infectious events. All patients in a given time period were included in the retrospective analysis.


32 patients were identified according to the above criteria and followedup for a mean period of 16 ± 8 months (range 6 – 36) during treatment with RTX. Only one patient was lost to follow-up. Sixteen patients were anti-TNF-naïve and in the remaining patients the TNF-alpha antagonist was stopped due to infectious complications before starting RTX. RTX was combined with a disease modifying drug in 22 (69%) of the cases. Altogether 4 severe infections occurred (9.5/100 patient years), mainly within the first year of treatment with RTX. Two patients suffered from pneumonia, 1 from a postoperative wound infection, 1 from an ear abscess and bacterial bronchitis. None of our patients with a previous history of bacterial infections of soft tissue, bacterial arthritis or osteomyelitis (n=9) developed recurrent infection. No relapse of a previously diagnosed tuberculosis (n=9) was seen.


In this particular high risk population of RA patients, treatment with RTX seems to be an alternative to TNF-alpha-antagonist and has a relatively low rate of recurrent infection.

Keywords: Rheumatoid arthritis, rituximab, infections, TNF alpha antagonists..