Pregnancy

Abatacept is not teratogenic in animals, but there are no adequate studies of its e ffects on human pregnancy to allow an assessment of its risk.

#### **5. Anti-CD 20 Antibody**

Rituximab (RTX) was initially developed for the treatment of hematologic malignancies. Since 2006, RTX is approved for the therapy of RA refractory to a combination therapy of anti-TNF-alpha, an MTX [60]. RTX is a chimeric murine-human monoclonal antibody that binds to the CD20 membrane receptor, leading to the depletion of circulating B cells. It is also able to inhibit the activation of T cells that produce proinflammatory cytokines. A cycle of RTX consists in 1000 mg by intravenous infusion, followed by a second 1000-mg intravenous infusion two weeks later. This is then repeated every 6 months. Di fferent studies showed that particularly patients who are autoantibody-positive benefit from RTX [63,64].

According to results of di fferent studies, patients benefit more from switching to RTX when an initial TNFi was discontinued due to ine fficacy.

One of the common side e ffects is an infusion reaction especially during the first infusion, occurring in up to 30 to 45 percent of patients. Symptoms include headache, fever, skin rash, dyspnea, hypotension, nausea, rhinitis, pruritus, and mild angioedema [65].

Repeated courses of RTX are associated with an increasing risk of hypogammaglobinemia. A meta-analysis in 2009 found no increase in serious infections associated with the use of rituximab with or without MTX compared with MTX plus a placebo, but other studies have found that repeated courses may be associated with a higher rate of serious infections. The risk of serious infections seems to increase with age [65].
