Pilot study of patient satisfaction with nonfluorinated topical steroids compared with a topical immunomodulator in atopiform dermatitis

BACKGROUND

There is clinical uncertainty concerning the effectiveness of the new topical immunomodulators vs. the conventional use of topical steroids for the treatment of atopic dermatitis.

OBJECTIVES

To assess patient satisfaction with these two prescription topical remedies for atopic eczema.

METHODS

In an open-label, 2-week, comparative study, 10 patients demonstrating atopiform dermatitis were given tacrolimus and 0.1% hydrocortisone butyrate in a 70% oil-in-water base to apply to the eczema on opposite sides of the body. After 2 weeks of applying the agents twice daily to their respective sides of the body surface, the study subjects completed a 12-question survey to assess their opinions of the two products.

RESULTS

There was a preference for the nonfluorinated topical steroid over tacrolimus in this cursory head-to-head study. There were no withdrawals from the study or side-effects reported with either product.

CONCLUSIONS

Trials of short duration with small numbers of patients do not adequately inform practitioners regarding the use of these topical remedies. However, the higher satisfaction of patients with 0.1% hydrocortisone butyrate in a 70% oil-in-water base over tacrolimus certainly warrants further investigation.

Aktuelle Indikationsstellung und Sicherheit beim Einsatz des koronaren Sirolimus-Stents im klinischen Alltag in Deutschland

BACKGROUND

Although randomized, controlled clinical trials (RCTs) showed a reduced target vessel revascularization rate and a good safety profile for the sirolimus-eluting coronary Cypher stent, at least the safety data need to be confirmed by larger data in clinical practice. Under the circumstances of frozen medical budgets in Germany, there may also be a shift toward implantation of a drug-eluting stent (DES) for indications not yet evaluated by RCTs.

METHODS

The authors analyzed the data of the German Cypher Registry a nationwide registry which was initiated in parallel to the launch of the first DES, the Cypher stent, in April 2002.

RESULTS

From April 2002 until December 2003, 3,579 interventions using a Cypher stent at 102 centers were included in the German Cypher Registry. This reflects a proportion of this DES compared to all stents implanted at the participating centers of < 10%. Patients' median age was 63.4 years (quartiles: 55-70 years) with 75% men. Renal insufficiency was seen in 10.1%, previous myocardial infarction in 37%, prior percutaneous coronary intervention (PCI) in 54.6%, and prior coronary artery bypass grafting (CABG) in 18.7%. In a large proportion of interventions, Cypher stents were implanted in lesions or in clinical situations not yet evaluated by RCTs: 10.1% ST elevation myocardial infarction, 1.8% cardiogenic shock, 2.1% left main stenoses, 5.5% CABG lesions, 23.2% in-stent stenosis, and 6% chronic total occlusions. PCI before DES implantation was performed in 65.5% of cases, a mean of 1.02 +/- 0.43 Cypher stents per lesion were implanted with a median sum length of all Cypher stents per lesion of 18 mm (quartiles: 13-21 mm). Maximum median balloon diameter during stent implantation was 3.00 mm (quartiles: 2.75-3.00 mm). Acute complication rate was low, with 0.2% deaths, 0.3% subacute stent thromboses, 1.3% myocardial infarctions, 2.1% urgent PCIs, and 0.2% CABGs.

CONCLUSION

In about one half of the patients included into the German Cypher Registry, the DES were implanted in lesions that were excluded from RCTs. The use of this sirolimus-eluting coronary stent in "real life" conditions was found to be safe concerning acute complications.

Simulect induction facilitates neoral-based steroid-free immunosuppression in primary kidney transplant recipients

This study compares outcomes of kidney transplantation with two distinct induction protocols Basiliximab (Simulect) versus Muromonab (OTK 3) in the setting of cyclosporine (Neoral)-based immunosuppression. Postinduction protocols included either total prednisone avoidance or prednisone sparing versus standard prednisone dosing. Two hundred forty five adult patients receiving kidney transplantation between 1995 and 2000 were included in the study. Treatment in group 1 was OKT 3 + Neoral + adjunct + standard prednisone; group 2, Simulect + Neoral + adjunct + steroid sparing; group 3, Simulect + Neoral + adjunct + no prednisone. The demographics between all groups were similar. The mean (+/- SD) trough cyclosporine levels at 1 month were 276 +/- 128 versus 291 +/- 180 versus 398 +/- 365 (P=.020); at 3 months were 261 +/- 120 versus 280 +/- 152 versus 399 +/- 408 (P=.32); at 12 month were 235 +/- 144 versus 245 +/- 154 versus 234 +/- 132 (P=.96). Creatinine clearance at 1 month was 59 +/- 24 versus 58 +/- 18 versus 47 +/- 23 mL/min (P=.004); at 3 months was 66 +/- 28 versus 62 +/- 22 versus 53 +/- 25 mL/min (P=.007); at 12 months was 68 +/- 38 versus 65 +/- 22 versus 64 +/- 29 mL/min (P=.556). Serum creatinine at 1 month was 1.8 +/- 0.9 versus 1.6 +/- 1.2 versus 2.8 +/- 2.21 mg/dL (P=.005); at 3 months was 1.7 +/- 0.6 versus 1.9 +/- 1.0 versus 2.3 +/- 1.3 mg/dL (P=.007); at 12 months was 1.9 +/- 1.3 versus 2.1 +/- 1.0 versus 2.3 +/- 1.7 mg/dL (P=.179). The incidence of acute rejection within 1 year in the respective groups were 28% versus 15% versus 16%. Therefore, we conclude that using Simulect in transplant recipients results in long-term patient and graft survival similar to those achieved with OKT 3. The use of Simulect resulted in significant reduction in clinical rejection incidence within the first year regardless of steroid use. Thus, the use of Simulect allows complete steroid avoidance in Neoral-based immunosuppression regimen.

The Canadian study of the sirolimus-eluting stent in the treatment of patients with long de novo lesions in small native coronary arteries (C-SIRIUS)

OBJECTIVES

We assessed the safety and effectiveness of the sirolimus-eluting stent (SES) in treating single de novo long lesions in small native coronary arteries compared to an identical bare metal stent (BMS).

BACKGROUND

The SES was previously demonstrated to reduce restenosis significantly. However, patients with long lesions in small vessels have not been well studied and may define a group at very high risk.

METHODS

The Canadian Study of the Sirolimus-Eluting Stent in the Treatment of Patients With Long De Novo Lesions in Small Native Coronary Arteries (C-SIRIUS) was a multicenter, randomized, double-blind trial comparing SES versus identical BMS. The primary end point was in-stent minimal lumen diameter (MLD) at eight months. Secondary end points included angiographic restenosis at 8 months, target lesion revascularization (TLR), and major adverse cardiac events (MACE) at 270 days.

RESULTS

A total of 100 patients were enrolled at eight Canadian sites. The in-stent MLD at eight months was 2.46 +/- 0.37 mm in the SES compared with 1.49 +/- 0.75 mm in the BMS (a 65% increase, p < 0.001). Angiographic restenosis occurred in 1 of 44 SES patients (2.3%, with no in-stent restenosis) and in 23 of 44 BMS patients (52.3%, p < 0.001). At 270 days, there were two clinically driven TLRs in the SES (4%) and nine in the BMS (18%, p = 0.05). The Kaplan-Meier estimate of freedom from MACE at 270 days was 96.0% for SES patients and 81.7% for BMS patients (p = 0.029).

CONCLUSIONS

Patients with long lesions in small vessels are at very high risk of restenosis. In these patients, the SES dramatically reduces the risk of restenosis at eight months, translating into an excellent clinical outcome at nine months.

Rapamycin Analogs for Stent-Based Local Drug Delivery

The inhibitory action of the sirolimus-like agent everolimus on smooth muscle cell proliferation, evidenced in animal models, has triggered the interest in everolimus as stent coating for local inhibition of in-stent restenosis. For preclinical and clinical evaluation of safety and efficacy of an everolimus-eluting stent design, a new stent has recently been introduced by Biosensors International Inc, covered by a resorbable "composite" coating, that contains the immunosuppressive drug within a polyhydroxyacid biodegradable polymer matrix with roughly equal resorption rates. FUTURE I, the feasibility trial of this new stent concept, revealed a 30-day MACE (major adverse cardiac events) rate of 0% as well as a restenosis rate of 0% at 6-month follow-up in a total of 32 patients included. The more sensitive QCA (quantitative computerized analysis) and IVUS (intravascular ultrasound) parameters showed an 88% reduction of in-stent late loss and an 87% reduction of the neointimal volume. Adding a second feasibility trial including diabetics, the multicenter trial FUTURE II confirmed the initial beneficial findings of FUTURE I in a total of 64 patients in a 1 : 2 randomization to a bare metal control stent. Based on these results, the FUTURE program has now been expanded by Guidant with two large-scale multicenter studies, FUTURE III and IV, which evaluate this stent design in a larger patient population. Furthermore, FUTURE IV is addressed to demonstrate the non-inferiority of this stent concept in a head-to-head comparison to an approved drug-eluting stent (DES) concept. In contrast to everolimus, tacrolimus is a well-known potent antiproliferative agent, already used in various therapeutic areas. Preclinical studies on tacrolimus-eluting stents for treatment of native coronary artery lesions demonstrated safety and efficacy of this stent concept with significant reduction of neointimal proliferation within the implanted study stents. However, the clinical trial program of the first tacrolimus-eluting stent system in the treatment of native coronary lesions (PRESENT I, II) and saphenous vein graft lesions (EVIDENT) failed to prove the clinical benefit of the stent systems tested and demonstrated the impact of specific stent designs, especially the drug carrier characteristics, on the patient outcome. The progressive PRESET study, evaluating a directly coated tacrolimus-eluting stent, will provide important insights, that will clarify the potential of tacrolimus for prevention of neointimal proliferation in clinical practice without being affected by any additional artificial surface compounds.

Tacrolimus therapy in pediatric patients with treatment-resistant nephrotic syndrome

This is a retrospective analysis of 16 children started on tacrolimus with various types of treatment-resistant nephrotic syndrome. There are 13 patients with focal glomerulosclerosis, 1 minimal change disease, and 2 IgA nephropathy with nephrosis. The mean age of the children was 11.4 years (range 3.5-18.1 years) with a mean age at diagnosis of 5.6 years (range 1.6-13.3 years). All patients initially received prednisone 2 mg/kg per day. Other therapies for 15 of 16 included cyclosporine (n=15), chlorambucil (n=5), mycophenolate mofetil (n=5), levamisole (n=3), i.v. methylprednisolone (n=3), and cyclophosphamide (n=2). The major indication for the initiation of tacrolimus included treatment resistance/dependence (n=15) and intolerable side effects from other therapies (n=1). The average time from the diagnosis to initiation of tacrolimus was 5.3 years (range 0.3-13.3 years, median 6 years). The initial dosage of tacrolimus utilized was 0.1 mg/kg per day divided into two doses. The mean follow-up period was 6.5 months (range 2.5-18 months). Thirteen patients (81%) went into a complete remission within an average of 2 months (range 0.5-5.5 months), with 3 patients relapsing while on treatment. Three patients did not respond. Of these, 2 had partial remissions (13%) and 1 failed to respond. Adverse events included anemia (n=1), seizure (n=1), worsening or new-onset hypertension (n=5), and sepsis (n=1). All patients remain on tacrolimus. Tacrolimus is an effective, well-tolerated medication for treatment-resistant forms of nephrotic syndrome in children, with a complete remission rate of 81% and a partial remission rate of 13% (totaling 94%).

Sirolimus-eluting coronary stent

PURPOSE

The mechanism of action and pharmacokinetics of sirolimus when used as part of a drug-eluting stent (DES) and the efficacy and cost of using DESs versus bare-metal stents are discussed.

SUMMARY

The use of balloon angioplasty with or without coronary artery stenting is limited by the phenomenon of in-stent restenosis (ISR). Until very recently, most efforts to overcome ISR had been ineffective. The search to prevent or reduce the frequency of ISR has led to the recent development of novel coronary artery stents designed to deliver a drug that acts locally. The first DES was approved by FDA in April 2003. This stent releases sirolimus, an agent that inhibits vascular smooth-muscle-cell proliferation. To date, four major clinical trials have demonstrated the sirolimus-eluting stent to be safe and effective in preventing restenosis in de novo coronary artery lesions.

CONCLUSION

The sirolimus-eluting coronary stent is associated with less ISR than non-drug-containing stents, but further investigation is needed to determine its exact place in the treatment of coronary artery occlusion.

Treatment of very small vessels with 2.25-mm diameter sirolimus-eluting stents (from the RESEARCH registry)

A total of 91 patients with 112 lesions received 2.25-mm sirolimus-eluting stents (SESs), and these lesions were compared with those treated with SESs of > or =2.5-mm diameter in the same procedure (n = 109). The reference diameters were 1.88 +/- 0.34 and 2.52 +/- 0.57 mm, respectively (p <0.01). At follow-up, the late lumen loss was 0.07 +/- 0.48 mm for the 2.25-mm SES versus 0.03 +/- 0.38 mm for the larger SES (p = 0.5), and the binary restenosis rate was 10.7% versus 3.9%, respectively (p = 0.1). The 12-month target lesion revascularization rate was 5.5%. In conclusion, 2.25-mm SESs were associated with low rates of clinical and angiographic late complications.

Drug-Eluting Stents: Are They Really Safe?

Drug-eluting stents have reduced the frequency of in-stent restenosis. However, most of the results have been derived from simple lesions in noncomplex patients. In preclinical normal pig and rabbit studies, bare-metal stents show complete healing at 28 days, whereas drug-eluting stents show incomplete healing with persistence of fibrin and incomplete coverage of the stent struts by endothelial cells. In human beings similar delayed healing has been observed at 6 and 12 months in atherectomy specimens or at autopsy. The US Food and Drug Administration posted adverse event information for physicians regarding subacute thrombosis and hypersensitivity reaction following deployment of sirolimus-eluting stents in human beings. The authors have seen, at autopsy, late (18 months) stent thrombosis, aneurysm formation, and extensive inflammatory reaction limited to the arterial wall surrounding the stent that they interpret as a hypersensitivity reaction to the polymer. The authors advocate caution and aggressive use of nontoxic systemic drugs to prevent the complications of atherosclerosis along with better postmarket surveillance of patients and histologic examination of tissue from patients with drug-eluting stents.

Head and neck lesions in the immunocompromised host

Head and neck lesions are encountered in more than 40-50% in patients with immunosuppression (HIV-infected individuals, diabetes mellitus, transplant recipients, patients treated with immunosuppressive drugs or post-radiotherapy). The organs affected are the salivary glands, the lymph nodes, the sinonasal tract, the orbits, the temporal bones, and the pharyngo-laryngeal mucosa. They are mainly involved by granulation tissue, perivascular and perineural inflammation, and neoplasms. In the pediatric population the temporal bone is the most frequent target organ. The most common clinical manifestation of salivary gland involvement is non-specific bilateral painless enlargement of the parotid gland and xerostomia. Lymphoepithelial cyst, sialosis, and lymphoma may be present. The high rate of salivary gland involvement is probably related to the presence of the human immunodeficiency virus within the saliva. Surgery, sclerotherapy by doxycycline, or low-dose radiotherapy may prevent further growth of tumoral lesions. Sinonasal diseases are the most frequent lesions which manifest in immunosuppressed adult patients (66%). They are associated with a trend of decreased survival rate. Invasive aspergillosis is defined by hyphae in the submucosa, and tumor necrosis without host inflammatory response; it may be lethal in 50-80%, especially when the skull base is involved. Computed tomography shows erosion of bone and extrasinonasal extension. The hypointensity of the lesion on T2-weighted images may suggest the diagnosis. Fungal sinus disease can affect 1-10% of transplant recipients and should be suspected when organ rejection is considered. The temporal bone is the most frequent target organ in the immunosuppressed pediatric population due to Eustachian,tube dysfunction. Otomastoïditis, necrotizing external otitis, and otosyphilis are reported. Prompt treatment may avoid lateral sinus thrombosis. Epithelial neoplasms, lymphomas, and Kaposi's sarcoma may also be considered. Kaposi's sarcoma, the most common neoplasm encountered in patients with AIDS, is an indicator of the progression of human immunodeficiency virus infection to AIDS. The lesions are often multifocal at presentation and may affect the skin, the mucosa, and visceral organs. The pathogenesis is unclear, but cytokines and growth factors may play a role. In conclusion, immunosuppressed patients are likely to develop virulent infection with vascular complications.

A randomized trial of topical cyclosporin 0.05% in topical steroid–resistant atopic keratoconjunctivitis

OBJECTIVE

To evaluate the short-term efficacy and safety of topical cyclosporin A 0.05% in the treatment of patients with severe, steroid-resistant atopic keratoconjunctivitis (AKC).

DESIGN

Multicenter, placebo-controlled, double-masked, randomized trial.

PARTICIPANTS

Twenty-two patients with AKC refractory to topical steroid treatment.

INTERVENTION

Patients were randomly assigned (1:1) to treatment with topical 0.05% cyclosporin A eyedrops or a placebo (artificial tears) for a period of 28 days, 6 times daily during the first 2 weeks and 4 times daily during the last 2 weeks.

MAIN OUTCOME MEASURES

Symptoms (itching, tearing, discomfort, mucous discharge, and photophobia) and signs (bulbar conjunctival hyperemia, upper tarsal conjunctival papillae, punctate keratitis, corneal neovascularization, cicatrizing conjunctivitis, and blepharitis) of AKC recorded on the day of enrollment and at the end of the treatment period.

RESULTS

A composite score computed by summing the severity grade over all 5 symptoms and 6 signs of AKC for each patient indicated a greater improvement in the cyclosporin A group relative to the placebo at the end of the 4-week treatment period (P = 0.048 and P = 0.002, for symptoms and signs, respectively). No adverse effects of the treatment with cyclosporin A 0.05% eyedrops were observed.

CONCLUSIONS

Topical cyclosporin A 0.05% seems to be safe and have some effect in alleviating signs and symptoms of severe AKC refractory to topical steroid treatment.

Preservation of post-transplant lung function with aerosol cyclosporin

Post-lung transplant use of aerosol cyclosporin (ACsA) is considered by examining the relationship between deposited aerosol dose and effect. In a sub-study of placebo controlled trials of ACsA as a rejection prophylaxis, 15 drug subjects received aerosol dose quantification tests to gage their ability to effectively deposit the nebulised drug in their transplanted lung(s). A total of seven placebo subjects received mock deposition tests. The deposited doses and mock doses were compared to changes in the forced expiratory volume in one second, at six time points during the 2-yr trial period (ACsA was started within 6 weeks post-transplant). Linear relationships were demonstrated between deposited dose and improvement in lung function in the drug subjects at all intervals. Mock dose data from placebo subjects did not demonstrate similar correlation. Based on these results, subjects were grouped by dose and compared. Subjects depositing > or = 5 mg of the drug in the periphery of their transplant(s) had improving pulmonary function on average. Low-dose and placebo subjects demonstrated declines, more A2-A4 rejection events in the latter portion of the trial, and more chronic rejection beyond the end of the trial. A dose-to-effect relationship is demonstrated for aerosol cyclosporin in terms of pulmonary function and biopsy proven rejection.

Inhibition of Th1- and Th2-mediated airway inflammation by the sphingosine 1-phosphate receptor agonist FTY720

The sphingosine 1-phosphate receptor agonist FTY720 is a novel immunomodulator that sequesters lymphocytes in secondary lymphoid organs and thereby prevents their migration to sites of inflammation. However, there is currently no information available on whether this drug affects Th1 or Th2 cell-mediated lung-inflammatory responses. The effect of FTY720 was therefore investigated in a murine airway inflammation model using OVA-specific, in vitro differentiated, and adoptively transferred Th1 and Th2 cells. Both Th1 and Th2 cells express a similar pattern of FTY720-targeted sphingosine 1-phosphate receptors. The OVA-induced Th1-mediated airway inflammation characterized by increased numbers of lymphocytes and neutrophils in bronchoalveolar lavage fluid was significantly inhibited by oral FTY720 treatment. Similarly, FTY720 suppressed the Th2 cell-induced bronchoalveolar lavage fluid eosinophilia and the infiltration of T lymphocytes and eosinophils into the bronchial tissue. Moreover, the Ag-induced bronchial hyperresponsiveness to inhaled metacholine was almost completely blocked. The inhibitory effect of FTY720 on airway inflammation, induction of bronchial hyperresponsiveness, and goblet cell hyperplasia could be confirmed in an actively Ag-sensitized murine asthma model, clearly indicating that Th2 cell-driven allergic diseases such as asthma could benefit from such treatment.

The current situation in human pancreatic islet transplantation: problems and prospects

In 2000, seven cases of pancreatic islet transplantation were documented by the researchers at the University of Alberta (Edmonton, Canada). The transplantation was performed using a protocol with a novel immunosuppressive regimen later named the Edmonton Protocol. The results showed that all seven patients became free of the need for insulin therapy. The success of the Edmonton Protocol has enhanced expectations for and interest in islet transplantation all over the world. Islet transplantation seems to be an almost ideal therapy for insulin-dependent patients. In our recent participation in transplant-related conferences in Europe or the USA, we have felt great enthusiasm for islet transplantation among clinicians, researchers, as well as medical staff. In Japan, the Organ Transplant Law that allows transplants from brain-dead patients was enacted in 1997. Since the passing of the law, people's interest in tissue and organ transplantation, particularly islet transplantation, has been growing. Here we present general information on islet transplantation and discuss its problems and prospects.

Aerosol cyclosporin therapy in lung transplant recipients with bronchiolitis obliterans

The majority of patients who develop bronchiolitis obliterans, after lung transplantation, die within 2-3 yrs after onset since treatment with conventional immunosuppression is typically ineffective. A case/control study was conducted in lung transplant recipients with biopsy-documented bronchiolitis obliterans to determine whether aerosol cyclosporin use contributed to increased survival. The cases comprised 39 transplant recipients who received open-label aerosol cyclosporin treatment in addition to conventional immunosuppression. The controls were transplant recipients treated with conventional immunosuppression alone. There were 51 controls from the University of Pittsburgh Medical Center and 100 from a large multicentric database (Novartis Lung Transplant Database). Forced expiratory volume in one second expressed as a percentage of the predicted value was an independent predictor of survival in all patients with bronchiolitis obliterans. Cox proportional-hazards analysis revealed a survival advantage for aerosol cyclosporin cases compared to the Pittsburgh control group. A survival advantage was also seen when comparing study cases to multicentric controls. Aerosol cyclosporin, given with conventional immunosuppression to lung transplant recipients with bronchiolitis obliterans, provides a survival advantage over conventional therapy alone.

Long-term kidney transplant outcomes in patients receiving oil-based or microemulsion formulations of cyclosporine

In the last 20 years long-term experience with cyclosporine use in kidney transplantation has increased, allowing a more precise identification of its benefits.

METHODS

We performed a retrospective analysis of 1619 kidney transplants that received cyclosporine-based immunosuppressive therapy. Patients were divided into three groups (1) oil-based cyclosporine (SIM) with trough monitoring (GI, n=617); (2) microemulsion formulation (NEO) with trough monitoring (GII, n=962); and (3) NEO with C2 monitoring (GIII, n=40). Information was obtained on transplant demography; adjunctive immunosuppressive agent; living (LD) versus cadaveric (CAD) recipients; delayed graft function; any treated acute rejection; graft function at 3, 6, and 12 months, patient and graft survival, as well as causes of graft loss and death.

RESULTS

At 15 years follow-up, patient and graft survival were 67.5% and 41.6%, being superior, among LD versus CAD recipients (patient: 78.7% vs 57.7%, P<.001; graft: 56.4% vs 30.5%, P<.001). In LD (54% vs 32%, P<.001) and CAD (69% vs 55%, P<.001) NEO reduced the incidence of AR and improved 8-year patient (LD: 81.8% vs 94.7%; CAD: 66.4 vs 79.9%, P<.01) and graft survival (LD: 58.3 vs. 80%; CAD: 40.2% vs. 59.5%, P<.01), compared to SIM. Overall 8-year graft survival was inferior among patients with increased 1-year creatinine values (< or =1.5, 1.6-2.5 and >2.5 mg/dL) level (74% vs 63.9% vs 22.4%, P<.001) or change in Cr (< or =0.1, 0.2-0.4, >0.5 mg/dL) level (73.1% vs 61.9% vs 37.2%, P<.001). In patients at the same level of graft function, those receiving NEO showed superior 8-year patient and graft survival compared with SIM.

CONCLUSION

Compared to SIM, NEO reduced the incidence of acute rejection and produced superior long-term patient and graft survival.

Tailoring immunosuppressive therapy in interstitial lung diseases

An increasing number of immunosuppressive drugs have become available for clinical use over the past few years. Respiratory medicine has not been excluded from the growing enthusiasm devoted to the use of novel immunosuppressants. New agents are currently undergoing clinical trials in pulmonary disorders characterized by acute or chronic inflammation, the "optimal" immunosuppressive strategy for the cure of interstitial lung diseases in the next decade being forthcoming. An example of this fervour may be found in this issue of the Journal; data have been provided on the effectiveness in clinical use of an inhibitor of nucleotide synthesis, leflunomide, in chronic sarcoidosis. The great choice of available agents could allow us to select the best therapeutic regimen for an individual patient, however, this requires a comprehensive knowledge of the modes of action of the immunosuppressants we are planning to use. The present review provides an update of current understanding on the molecular mechanisms of some important immunosuppressants that are expected to play a role in the therapy of interstitial lung diseases.

Pharmacokinetic and immunosuppressive effects of tacrolimus-loaded biodegradable microspheres

The objective of this study was to characterize the pharmacokinetics and immunosuppression of a tacrolimus-loaded biodegradable microsphere (TLBM) in rats. We prepared TLBM. DA/Slc rats were given TLBM at a dose of 1.6 mg/kg (n = 9), 2.4 mg/kg (n = 5), or 7.2 mg/kg (n = 7) tacrolimus contents by a single subcutaneous administration to achieve sustained release over a long period. DA/Slc rats were given TLBM by a single subcutaneous administration at a dose of 4.8 mg/kg (n = 6) tacrolimus contents to clarify the main site of TLBM uptake in the organs. In the rat liver transplantation model, the recipients were given TLBM at a dose of 0.16 mg/kg (n = 5), 2.4 mg/kg (n = 4), or 4.8 mg/kg (n = 5) tacrolimus contents by a single subcutaneous administration on the first day after operation. Overall survival days were compared. Continuous flat parallel concentration profiles were significant for 10 days from the first day after a single subcutaneous administration of TLBM (P <.01). The relationship between the dosages of TLBM administration and area under the concentration-time curve (AUC) up to 18 days demonstrated a linear regression line (P <.01). In addition, the relationship between the dose of TLBM and the survival days of the recipients in the liver transplantation model showed a positive correlation. The current pharmacokinetic study of TLBM revealed significantly increased tacrolimus levels in the regional lymph nodes compared with other organs except bone marrow (P <.01). In conclusion, TLBM allowed tacrolimus to release gradually in a very stable manner for 10 days, with dose-dependent immunosuppression after a single subcutaneous administration. The main site of TLBM uptake after subcutaneous administration was the regional lymph node of administration site.

Enteric-coated mycophenolate sodium: safe conversion from mycophenolate mofetil in maintenance renal transplant recipients

Mycophenolate mofetil (MMF), in combination with cyclosporine and corticosteroids, improves long-term graft function and survival in renal transplant recipients. However, optimal MMF therapy may be limited by gastrointestinal (GI) intolerance, which may result in the need for MMF dose reduction, interruption, or discontinuation, leading to increased risk of acute rejection. Enteric-coated mycophenolate sodium (EC-MPS) is an advanced formulation delivering mycophenolic acid (MPA), developed with the objective of improving MPA-related upper GI adverse events. A pivotal, 12-month, phase III, randomized, multicenter, double-blind, double-dummy, parallel group study investigated whether stable renal transplant patients can be converted from MMF to EC-MPS therapy without compromising tolerability or efficacy. Stable renal transplant recipients received either MMF, 1000 mg b.i.d. (n=159), or EC-MPS, 720 mg b.i.d. (n=163), for 12 months. The incidence of GI adverse events was comparable between both treatment groups at 3 and 6 months, but there was a trend toward reduced severity of GI side effects in the EC-MPS group. There were fewer serious adverse events with EC-MPS and significantly fewer serious infections (P<.05). This comparable safety profile for EC-MPS and MMF also extended to elderly patients and patients with diabetes at baseline. For the composite efficacy variable of biopsy-proven acute rejection, graft loss, death, or loss to follow-up, EC-MPS had a lower 12-month efficacy failure rate (EC-MPS: 7.5% vs MMF: 12.3%; P=ns). These data demonstrate that stable renal transplant recipients receiving MMF can be converted to EC-MPS with no efficacy or tolerability compromise.