Intensive immunoablation and autologous blood stem cell transplantation inpatients with refractory rheumatoid arthritis: The University of Nebraska experience

Two patients with severe rheumatoid arthritis (RA) were treated with high d ose chemotherapy and autologous blood stem cell transplantation. Hematopoie tic stem cells mobilized readily with cyclophosphamide and granulocyte-colo ny stimulating factor. Both patients achieved an American College of Rheuma tology (ACR) 50% response before starting high dose therapy. The transplant ation regimen included 200 mg/kg cyclophosphamide and 6 doses of equine ant ithymocyte globulin. Transplantation was well tolerated and both patients r ecovered neutrophils on day 7 post-transplant. At one month posttransplant both patients had an ACR response of 80%. Both individuals relapsed at 6 mo nths and responded well to a combination of disease modifying antirheumatic drugs that was previously ineffective. At 12 months ACR responses were 80% and 60%, respectively. The first patient developed a flare at 18 months wh en she was found to be hypothyroid; she regained an 80% ACR response at 24 months with therapy of hypothyroidism. The second patient progressed relent lessly 15 months posttransplant. Immunological reconstitution showed a cont inuous inversion of the ratio of CD4 and CD8 lymphocytes with a predominant expansion of memory T cells.