How do you manage pemphigus patients who have persistent disease and circulating autoantibodies despite two full courses of rituximab?

I currently manage two recalcitrant pemphigus patients, both of whom have undergone various courses of typical systemic immunosuppression (e.g., CellCept, MTX, steroids) but continued to flare. Combinations of these traditional therapies, along with topicals, were not particularly helpful.

While dis...

Patients with persistent pemphigus disease and circulating autoantibodies after two full rituximab courses should be re-treated with an additional cycle of rituximab 2000 mg, with consideration for alternative immunosuppressive therapies or intravenous immunoglobulin (IVIG) if rituximab remains inef...