Patients with IgG4-related disease (IgG4-RD) typically have elevated serum 
concentrations of IgG4 and share histopathologic features that are similar 
across affected organ(s). IgG4-RD patients frequently require prolonged 
treatment with glucocorticoids and are often unable to taper these medications. 
Traditional disease-modifying antirheumatic drugs (DMARDs) are generally 
ineffective. We assessed the clinical and serologic responses to B lymphocyte 
depletion therapy in 10 consecutive patients with steroid- and DMARD-refractory 
IgG4-RD.Ten patients with IgG4-RD were treated with rituximab (RTX) (2 infusions 
of 1000 mg, 15 days apart). Clinical improvement was assessed by monitoring the 
patient's ability to taper prednisone to discontinuation and to stop DMARDs; by 
serial measurements of total IgG and IgG subclasses; and by follow-up radiologic 
assessments guided by the patient's particular pattern of organ involvement. We 
also developed and retrospectively applied the IgG4-RD Disease Activity Index 
and Flare Tool.Organ involvement included the pancreas, biliary tree, aorta, 
salivary glands (submandibular and parotid), lacrimal glands, lymph nodes, 
thyroid gland, and retroperitoneum. Nine of 10 patients demonstrated striking 
clinical improvement within 1 month of starting RTX. One patient with advanced 
thyroid fibrosis associated with Riedel thyroiditis and a history of disease in 
multiple other organ systems did not have improvement in the thyroid gland, but 
the disease did not progress to involve new organs. All 10 patients were able to 
discontinue prednisone and DMARDs following RTX therapy. Significant decreases 
in IgG concentrations were observed for the IgG4 subclass only. Four patients 
were re-treated with RTX after 6 months because of either symptom recurrence and 
increasing IgG4 concentration at the time of peripheral B cell reconstitution (n 
= 2) or because of physician discretion (n = 2). Repeated courses of RTX 
maintained their effectiveness and resulted in further decreases in IgG4 
concentrations. In patients who had an increased IgG4 concentration at the time 
of presentation, the level of serum IgG4 appeared to be a reliable measure of 
disease activity.IgG4-RD is an idiopathic, multiorgan inflammatory disease in 
which diverse organ manifestations are linked by characteristic histopathologic 
and immunohistochemical features. Treatment with RTX led to prompt clinical and 
serologic improvement in refractory IgG4-RD in all patients with active 
inflammation. Serial treatments with RTX may lead to progressive declines in 
serum IgG4 concentrations and better disease control. Serum IgG4 concentrations 
may remain low, and clinical disease activity may remain quiescent even after B 
cell reconstitution in a significant proportion of patients.