B cell depletion therapy in rheumatic disease

B cell depletion therapy was introduced for auto-antibody associated rheumatic disease in 1998. Encouraging pilot studies in rheumatoid arthritis were followed by randomised controlled trials confirming major benefit. Licensing for use in patients unable to benefit from tumour necrosis factor alpha (TNF alpha) neutralising agents is envisaged shortly. Open studies in other disorders, in particular systemic lupus erythematosus (SLE), have also suggested benefit and its use in life-threatening situations is becoming widespread. Toxicity appears to compare favourably with other agents, but respiratory problems may be more common. Repeated therapy is effective, but may lead to hypogammaglobulinemia. Rituximab is currently the main agent used but other agents are in development. Optimal protocols are not well characterised and will probably be different for different conditions.