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Costa E, Cunha-Santos F, Dourado E, Oliveira D, Falzon L, Romão V, Duarte AC, Cordeiro A, Santiago T, Sepriano A. Systematic literature review to inform the Portuguese recommendations for the management of Raynaud's phenomenon and digital ulcers in systemic sclerosis and other connective tissue diseases. ARP RHEUMATOLOGY 2024; 3:128-144. [PMID: 38306796 DOI: 10.63032/yhbl8967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
OBJECTIVE To perform a systematic literature review (SLR) aimed at evaluating the efficacy and safety of pharmacological and non-pharmacological treatments for Raynaud's phenomenon (RP) and digital ulcers (DU) in patients with systemic sclerosis (SSc) and other connective tissue diseases (CTD), in order to inform the Portuguese recommendations for managing RP and DU in these patients. METHODS A SLR was conducted until May 2022 to identify studies assessing the efficacy and safety of pharmacological and non-pharmacological interventions for RP and DU in SSc and other CTD. Eligible study designs included randomized controlled trials (RCTs), controlled clinical trials, and their extensions for assessing efficacy and safety of interventions. Observational studies with a comparator were included for evaluating the efficacy and safety of non-pharmacological interventions and safety of pharmacological interventions. The risk of bias of each study was assessed using standard tools. RESULTS Out of 71 publications meeting the inclusion criteria, 59 evaluated pharmacological and 12 non-pharmacological interventions. We found moderate quality evidence supporting the efficacy of calcium channel blockers, phosphodiesterase-5 inhibitors, and intravenous prostacyclin analogues in reducing RP frequency, severity, and duration. Intravenous iloprost had a small to moderate effect size in improving DU healing. Phosphodiesterase-5 inhibitors were effective in reducing total DU count, new DU occurrence, and enhancing DU healing. Bosentan effectively prevented new DU in SSc patients. No new safety concerns were associated with these treatments. The studies on non-pharmacological interventions were, in general, of low quality, and had a small sample size. Warming measures decreased frequency and duration of RP attacks; laser therapy improved RP-related outcomes; local oxygen-ozone therapy improved RP outcomes as an add-on therapy; bone marrow mononuclear cell implantation improved DU-associated pain; periarterial sympathectomy and vascular bypass reduced DU number and finger amputation risk. CONCLUSION The available evidence supports the efficacy and safety of pharmacological interventions, namely nifedipine, sildenafil, iloprost, and bosentan in treating RP and DU in patients with SSc and other CTD. Scarce and low-quality evidence does support the use of some non-pharmacological interventions but with only a modest effect size. This SLR underscores the limited availability of high-quality evidence for determining the optimal treatment.
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Affiliation(s)
| | | | | | | | | | - Vasco Romão
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | | | | | - Tânia Santiago
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Zhang MD, Huang WY, Luo JY, He RQ, Huang ZG, Li JD, Qin F, Chen G, Lei L. The 'whole landscape' of research on systemic sclerosis over the past 73 years. Autoimmun Rev 2024; 23:103538. [PMID: 38556034 DOI: 10.1016/j.autrev.2024.103538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study aimed to analyse existing research on systemic sclerosis (SSc) conducted over the past 73 years to develop an essential reference for a comprehensive and objective understanding of this field of inquiry. METHODS Using the Web of Science Core Collection, PubMed, and Scopus databases as data sources for the bibliometric analysis, we searched for published literature related to SSc over the past 73 years. The Bibliometrix package was used to analyse key bibliometric indicators, such as annual publication volume, countries, journals, author contributions, and research hotspots. RESULTS From 1970 to 2022, the number of SSc articles steadily increased, reaching its peak in 2020-2022, with approximately 1200 papers published in each of these three years. Matucci-Cerinic et al.'s team published the most articles (425). The United States (11,282), Italy (7027), and France (5226) were the most predominant contexts. The most influential scholars in the field were Denton, Leroy, Steen, and Khanna, with H-indices of 86, 84, and 83, respectively. Arthritis and Rheumatism was the most influential journal in this field (H-index 142). High-frequency keywords in the SSc field included fibrosis (738), inflammation (242), vasculopathy (145), fibroblasts (120), and autoantibodies (118) with respect to pathogenesis, and interstitial lung disease (ILD, 708), pulmonary arterial hypertension (PAH, 696), and Raynaud's phenomenon (326) with regards to clinical manifestations. CONCLUSION In the past three years, SSc research has entered a period of rapid development, mainly driven by research institutions in Europe and the United States. The most influential journal has been Arthritis and Rheumatism, and autoimmune aspects, vasculopathy, fibrogenesis, PAH, and ILD remain the focus of current research and indicate trends in future research.
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Affiliation(s)
- Meng-Di Zhang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Wan-Ying Huang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Jia-Yuan Luo
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Rong-Quan He
- Department of Medical Oncology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Zhi-Guang Huang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Jian-Di Li
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Fang Qin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Gang Chen
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China.
| | - Ling Lei
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China.
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Curtiss P, Svigos K, Schwager Z, Lo Sicco K, Franks AG. Part II: The treatment of primary and secondary Raynaud's phenomenon. J Am Acad Dermatol 2024; 90:237-248. [PMID: 35809802 DOI: 10.1016/j.jaad.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/15/2022] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
Raynaud phenomenon (RP) presents with either primary or secondary disease, and both have the potential to negatively impact patient quality of life. First-line management of RP should include lifestyle modifications in all patients. Some patients with primary RP and most with secondary RP require pharmacologic therapies, which may include calcium channel blockers, topical nitrates, phosphodiesterase 5 inhibitors, or endothelin antagonists. Additional approaches to treatment for those with signs of critical ischemia or those who fail pharmacologic therapy include botulinum toxin injection and digital sympathectomy. Herein, we describe in detail the treatment options for patients with RP as well as provide treatment algorithms for each RP subtype.
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Affiliation(s)
- Paul Curtiss
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Katerina Svigos
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Zachary Schwager
- Department of Dermatology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kristen Lo Sicco
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York.
| | - Anrdew G Franks
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; Division of Rheumatology, Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York
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Tanzadehpanah H, Lotfian E, Avan A, Saki S, Nobari S, Mahmoodian R, Sheykhhasan M, Froutagh MHS, Ghotbani F, Jamshidi R, Mahaki H. Role of SARS-COV-2 and ACE2 in the pathophysiology of peripheral vascular diseases. Biomed Pharmacother 2023; 166:115321. [PMID: 37597321 DOI: 10.1016/j.biopha.2023.115321] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
The occurrence of a novel coronavirus known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), created a serious challenge worldwide. SARS-CoV-2 has high infectivity, the ability to be transmitted even during the asymptomatic phase, and relatively low virulence, which has resulted in rapid transmission. SARS-CoV-2 can invade epithelial cells, hence, many patients infected with SARS-CoV-2 have suffered from vascular diseases (VDs) in addition to pulmonary manifestations. Accordingly, SARS-CoV-2 may can worsen the clinical condition of the patients with pre-existing VDs. Endothelial cells express angiotensin-converting enzyme 2 (ACE2). ACE2 is a biological enzyme that converts angiotensin (Ang)- 2 to Ang-(1-7). SARS-CoV-2 uses ACE2 as a cell receptor for viral entry. Thus, the SARS-CoV-2 virus promotes downregulation of ACE2, Ang-(1-7), and anti-inflammatory cytokines, as well as, an increase in Ang-2, resulting in pro-inflammatory cytokines. SARS-CoV-2 infection can cause hypertension, and endothelial damage, which can lead to intravascular thrombosis. In this review, we have concentrated on the effect of SARS-CoV-2 in peripheral vascular diseases (PVDs) and ACE2 as an enzyme in Renin-angiotensin aldosterone system (RAAS). A comprehensive search was performed on PubMed, Google Scholar, Scopus, using related keywords. Articles focusing on ("SARS-CoV-2", OR "COVID-19"), AND ("Vascular disease", OR "Peripheral vascular disease", OR interested disease name) with regard to MeSH terms, were selected. According to the studies, it is supposed that vascular diseases may increase susceptibility to severe SARS-CoV-2 infection due to increased thrombotic burden and endothelial dysfunction. Understanding SARS-CoV-2 infection mechanism and vascular system pathogenesis is crucial for effective management and treatment in pre-existing vascular diseases.
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Affiliation(s)
- Hamid Tanzadehpanah
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences; Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elham Lotfian
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences; Medical Genetics Research Center, Mashhad University of Medical Sciences; Medical Genetics Research center, Mashhad University of Medical Sciences; Basic Sciences Research Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sahar Saki
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Sima Nobari
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Roghaye Mahmoodian
- Molecular Medicine Research Center, Hamadan University of Medical Science, Hamadan Iran
| | - Mohsen Sheykhhasan
- Department of Mesenchymal Stem Cells, Academic Center for Education, Culture and Research, Qom, Iran
| | | | - Farzaneh Ghotbani
- Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Raoufeh Jamshidi
- Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Hanie Mahaki
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Kadian-Dodov D. Cold Hands or Feet: Is It Raynaud's or Not? Med Clin North Am 2023; 107:829-844. [PMID: 37541711 DOI: 10.1016/j.mcna.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Raynaud's phenomenon is an exaggerated response to cold stimuli that may be primary or secondary. The diagnosis relies on patient history and physical examination to distinguish RP from other vasomotor dysfunction (e.g. acrocyanosis, pernio, small fiber neuropathy with vasomotor symptoms, and complex regional pain syndrome). Achenbach syndrome, or spontaneous venous hemorrhage, may also be mistaken for RP but is a self-limiting phenomenon. Laboratory evaluation and vascular diagnostic testing may identify SRP causes. Regardless of etiology, treatment includes warming with trigger avoidance, and consideration of vasodilators (eg. calcium channel, alpha-1 blockers). SRP with digital ulceration may require PDE5i, endothelin-1 receptor blockers, and prostanoids. Refractory cases may require pneumatic arterial pumps, botulinum toxin administration, or surgical sympathectomy.
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Affiliation(s)
- Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1030, New York, NY 10029, USA.
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Maltez N, Hughes M, Brown E, Hickey V, Shea B, Herrick AL, Proudman S, Merkel PA, Pauling JD. Domain reporting in systemic sclerosis-related Raynaud's phenomenon: An OMERACT scoping review. Semin Arthritis Rheum 2023; 61:152208. [PMID: 37202251 DOI: 10.1016/j.semarthrit.2023.152208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Raynaud's phenomenon (RP) is a cardinal feature of SSc and is associated with significant disease-related morbidity that impacts on quality of life. The assessment of SSc-RP is challenging. The aim of this scoping review was to evaluate the outcome domains studied and outcome measures used in clinical studies of SSc-RP. METHODS Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify randomized control trials (RCTs), quasi-randomized studies, case-control studies, prospective and retrospective cohort studies, case series, and cross-sectional studies of adult participants with SSc-associated RP, written in English. A minimum of 25 participants for studies of imaging modalities and 40 participants for questionnaire-based studies was required for inclusion. Basic laboratory and genetic studies were excluded. No limitations were imposed based on intervention, comparator, or study setting. Study characteristics and primary and secondary target domains in each study were recorded. RESULTS 58 studies (24 randomized clinical trials) were included in the final analysis. The commonest domains captured were severity of attacks (n=35), frequency of attacks (n=28), and duration of attacks (n=19). Objective assessments of digital perfusion were also commonly used in studies of SSc-RP. CONCLUSION The outcome domains and the associated outcomes used to assess the impact of SSc-RP in research studies are broad and have varied across studies. The results of this study will inform the OMERACT Vascular Disease in Systemic Sclerosis Working Group to establish a core set of disease domains encompassing the impact of RP in SSc.
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Affiliation(s)
- Nancy Maltez
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Michael Hughes
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Beverley Shea
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susanna Proudman
- Discipline of Medicine, University of Adelaide and Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Pauling
- North Bristol NHS Trust, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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Domsic RT, Pokrzywinski R, Stassek L, Benton WW, Vampola CL, Furst DE, Chung L, Steen V, Mayes MD, Shah AA, Molitor JA, Oliver K, Nagaraja V, Khanna D. Qualitative Interviews to Assess the Content Validity and Usability of the Electronic Raynaud Diary in Patients with Systemic Sclerosis. ACR Open Rheumatol 2023; 5:132-141. [PMID: 36727567 PMCID: PMC10010488 DOI: 10.1002/acr2.11522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To better understand the symptoms and impacts of Raynaud phenomenon (RP) in patients with systemic sclerosis (SSc) and to evaluate the content validity and usability of a new electronic patient-reported outcome (PRO) measure for RP: the Raynaud Diary. METHODS The Raynaud Diary was developed as a daily eDiary for assessing the number and duration of symptomatic Raynaud attacks; worst pain, numbness, tingling, and discomfort in the fingers; and overall disease severity, captured using the Raynaud's Condition Score. The Raynaud Diary was debriefed in two waves of qualitative interviews with adults with self-reported RP secondary to SSc. All interviews included open-ended questions about participants' experiences of RP. RESULTS Participants (N = 39) had a mean age of 55.1 years, and 87% were female. Frequently reported RP symptoms were color change (reported by all participants), numbness (90%), tingling (82%), pain (77%), and discomfort (72%). Common attack triggers included temperature-related factors and stress. Participants reported being unable to be outside or do outdoor activities and had problems gripping objects. All participants demonstrated understanding of the Raynaud Diary instructions. Most participants indicated that they would be able to use the Raynaud Diary to record the worst severity of individual RP symptoms in the previous 24 hours. CONCLUSION Patients with RP secondary to SSc bear a heavy symptom burden. The Raynaud Diary is a content valid PRO measure that captures the most frequent symptoms of RP in patients with SSc.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ami A Shah
- Johns Hopkins University School of Medicine, Maryland, Baltimore
| | | | | | - Vivek Nagaraja
- University of Michigan Scleroderma Program, Ann Arbor, Michigan
| | - Dinesh Khanna
- Eicos Sciences, Inc., San Mateo, California, and University of Michigan Scleroderma Program, Ann Arbor, Michigan
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Herrick AL, Batta R, Overbeck K, Raud J, Manning J, Murray A, Dinsdale G, Tornling G. A phase 2 trial investigating the effects of the angiotensin II type 2 receptor agonist C21 in systemic sclerosis-related Raynaud's. Rheumatology (Oxford) 2023; 62:824-828. [PMID: 35894657 PMCID: PMC9891408 DOI: 10.1093/rheumatology/keac426] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/17/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Our main aim was to investigate the effect of a single oral dose of C21, a selective angiotensin II type 2 receptor agonist, on cold-induced vasoconstriction in SSc-related RP. METHODS This was a phase IIa, randomized, double-blind, cross-over, single-dose, placebo-controlled, single-centre study. Twelve female patients with SSc (median age 58.5 years, median duration of RP 19.0 years) attended on four occasions: screening, treatment visits 1 and 2 (separated by 3-7 days) and follow-up. At the first treatment visit, patients were randomized to receive either a single oral dose of C21 (200 mg) or placebo, then the opposite treatment on the second visit. Forty min after each treatment, each patient underwent a standard hand cold challenge. The primary end point was the area under the curve (AUC) for rewarming for each finger (eight fingers) over 15 min. Secondary end points included the maximum finger temperature after rewarming (MAX). Statistical analyses were performed by multiplicative ANCOVA models. RESULTS For all eight fingers combined, mean AUC for rewarming was higher after treatment with C21 than after placebo (geometric mean 20 046°C*s vs 19 558°C*s), but not significantly (P = 0.380) and MAX (at 15 min) was also higher (geometric mean 23.5°C vs 22.5°C; P = 0.036). C21 was well tolerated. CONCLUSION Despite the small trial size, a signal emerged suggesting that even in patients with established SSc, C21 may confer benefit for RP and deserves further investigation. TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT04388176.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Northern Care Alliance NHS Foundation Trust
- NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Johan Raud
- Vicore Pharma AB, Gothenburg
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joanne Manning
- Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Andrea Murray
- Centre for Musculoskeletal Research, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Graham Dinsdale
- Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Göran Tornling
- Respiratory Medicine Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Greene BHC, Gudimella R, Corkum JP, Boone H, Samargandi OA, Williams J. Managing cold intolerance after hand injury: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:109-114. [PMID: 36720347 DOI: 10.1016/j.hansur.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This systematic review seeks to understand whether cold intolerance (CI) improves with time and if there is any role for management strategies such as behavioural therapy, surgery, or pharmacotherapy. METHODS Two independent reviewers used a predefined search strategy to query MEDLINE, PubMed, Embase, CINAHL, Cochrane Library, Web of Science and Google Scholar databases. Articles written in English, Studies of interventions (such as pharmacotherapy or behavioural therapy) for cold intolerance in adult patients with a history of hand injury along with prevalence over time were included for review. RESULTS Seventeen studies were included, with twelve prognostic studies of the effect of time on CI, four studies of self management/behavioural therapies, and a single study of surgical treatment of neuromas. No studies of pharmacotherapies were identified for inclusion in the hand injury literature. Most studies (76.4%) were either prevalence or prospective cohort studies; no level I or II evidence studies were included. CONCLUSIONS Cold intolerance does not resolve over time for the vast majority of patients. Behavioral and self-management studies have low efficacy and studies presented had a high risk of bias. There is a lack of evidence for the use of pharmacotherapy in CI and this could be considered for future studies.
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Affiliation(s)
- Bradley H C Greene
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Rakesh Gudimella
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joseph P Corkum
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hannah Boone
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Osama A Samargandi
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Surgery, King Abduaziz University, Jeddah, Saudi Arabia
| | - Jason Williams
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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11
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Sarkar R, Swarnkar B. Raynaud's phenomenon: A brush up! Indian Dermatol Online J 2023; 14:248-255. [PMID: 37089827 PMCID: PMC10115340 DOI: 10.4103/idoj.idoj_311_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 03/12/2023] Open
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Ramahi A, Hughes M, Khanna D. Practical management of Raynaud's phenomenon - a primer for practicing physicians. Curr Opin Rheumatol 2022; 34:235-244. [PMID: 35699336 PMCID: PMC9246963 DOI: 10.1097/bor.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Raynaud's phenomenon (RP) is a common vasospastic condition that results in digital hypoperfusion in response to cold and/or emotional stress and is associated with significant pain and disability. The aim of our review is to provide a practical approach for clinicians to inform assessment and management of patients with RP. RECENT FINDINGS Autoantibodies and nailfold capillaroscopy are key investigations to stratify the risk of progression to systemic sclerosis (SSc) in patients RP, which was recently confirmed in the multicenter, very early diagnosis of systemic sclerosis (VEDOSS) project. Research has explored the complex lived-patient experience of RP including digital vasculopathy in SSc and has highlighted the need for outcome measure development to facilitate research in the field. Pharmacological treatment strategies vary significantly internationally and there is continued interest in developing surgical approaches. SUMMARY We provide a practical and up-to-date approach to inform the assessment and management of patients with RP including guidance on drug initiation and escalation. Calcium channel blockers are first-line treatment and can be initiated by primary care physicians. We also highlight second-line drug therapies used for refractory RP and the potential role for surgical intervention.
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Affiliation(s)
- Ahmad Ramahi
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Michael Hughes
- Tameside Hospital, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, United Kingdom
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
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Lo Y, Tsai TF. Angiotensin II receptor blockers in dermatology: a narrative review. J DERMATOL TREAT 2022; 33:2894-2898. [PMID: 35695256 DOI: 10.1080/09546634.2022.2089332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Angiotensin II receptor blockers (ARBs) are commonly used for cardiovascular diseases, especially for patients who can't tolerate the side effects of cough and angioedema caused by angiotensin converting enzyme inhibitors (ACEIs). However, the evidence of using ARBs in dermatology is mostly anecdotal and limited to case reports or small case series. Here we present a narrative review focusing on the therapeutic use of ARBs in dermatology and adverse cutaneous reactions due to the administration of ARBs.
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Affiliation(s)
- Yang Lo
- Department of Dermatology, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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14
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Klein-Weigel P, Ruttloff A, König D, Nielitz J, Steindl J, Sander O, Richter JG. [Functional vascular acrosyndromes]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:591-600. [PMID: 35925129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Vascular acrosyndromes are characterized by sparse, uniform clinical manifestations and a variety of possible pathomechanisms. The present article focuses on the functional entities. Raynaud phenomenon is based on cold- or stress-induced vasospasms of acral arteries. It is defined by the color changes of the skin, in the typical case white-blue-red (tricolore). The long fingers are most commonly affected. The etiology is unknown, and the pathophysiology is poorly understood. A distinction is made between primary and a secondary Raynaud phenomenon. The most important underlying diseases include collagenosis, primarily systemic sclerosis, and malignancies; furthermore, medications and drugs may promote vasospasm. Treatment is aimed at preventing or breaking the vasospasm, but has been only partially effective in doing so. Acrocyanosis is a vasospastic dystonic acral disorder that results in permanent reddish-livid discoloration, especially of the hands and feet. Secondary forms occur in collagenosis, malignancies, and myelodysplastic syndromes. The etiology and pathophysiology are virtually unknown. Targeted pharmacological intervention is not possible. Unlike all other vascular acrosyndromes, erythromelalgia is characterized by hyperemia. The primary form is a genetic sodium channelopathy, while secondary forms include malignancies, connective tissue diseases, and myelodysplastic syndromes. The symptoms are often distressing and disabling. Therapy requires a multimodal approach that includes both nonpharmacological and pharmacological strategies. Close interdisciplinary collaboration is essential for the management of this disease.
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Affiliation(s)
- Peter Klein-Weigel
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland.
| | - Andreas Ruttloff
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Dana König
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Jessica Nielitz
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Julia Steindl
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Oliver Sander
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Jutta G Richter
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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15
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Maciejewska M, Sikora M, Maciejewski C, Alda-Malicka R, Czuwara J, Rudnicka L. Raynaud's Phenomenon with Focus on Systemic Sclerosis. J Clin Med 2022; 11:jcm11092490. [PMID: 35566614 PMCID: PMC9105786 DOI: 10.3390/jcm11092490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
Raynaud’s phenomenon is a painful vascular condition in which abnormal vasoconstriction of the digital arteries causes blanching of the skin. The treatment approach can vary depending on the underlying cause of disease. Raynaud’s phenomenon can present as a primary symptom, in which there is no evidence of underlying disease, or secondary to a range of medical conditions or therapies. Systemic sclerosis is one of the most frequent causes of secondary Raynaud’s phenomenon; its appearance may occur long before other signs and symptoms. Timely, accurate identification of secondary Raynaud’s phenomenon may accelerate a final diagnosis and positively alter prognosis. Capillaroscopy is fundamental in the diagnosis and differentiation of primary and secondary Raynaud’s phenomenon. It is helpful in the very early stages of systemic sclerosis, along with its role in disease monitoring. An extensive range of pharmacotherapies with various routes of administration are available for Raynaud’s phenomenon but a standardized therapeutic plan is still lacking. This review provides insight into recent advances in the understanding of Raynaud’s phenomenon pathophysiology, diagnostic methods, and treatment approaches.
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Affiliation(s)
- Magdalena Maciejewska
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Mariusz Sikora
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
- Correspondence:
| | - Cezary Maciejewski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Rosanna Alda-Malicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Joanna Czuwara
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
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Branco J, Branco R, Siqueira T, de Souza L, Dalago K, Andrade A. Clinical applicability of infrared thermography in rheumatic diseases: A systematic review. J Therm Biol 2022; 104:103172. [DOI: 10.1016/j.jtherbio.2021.103172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 01/05/2023]
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Abstract
Vasospastic disorders are prevalent in the general population and can affect individuals of any age. Primary (or idiopathic) vasospastic disorders often have a benign course; treatment focuses on the control of symptoms. Secondary vasospastic disorders occur owing to an underlying condition and have an increased risk of complications, including tissue loss and digital ulcerations; treatment should focus on the underlying condition. In this review, we discuss the pathophysiology, clinical presentation, diagnosis, and management of vasospastic disorders, including Raynaud syndrome, acrocyanosis, livedo reticularis, and pernio.
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Affiliation(s)
- Ana I Casanegra
- Vascular Medicine Division, Cardiovascular Department, Gonda Vascular Center, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - Roger F Shepherd
- Vascular Medicine Division, Cardiovascular Department, Gonda Vascular Center, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
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18
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Torok KS. Updates in Systemic Sclerosis Treatment and Applicability to Pediatric Scleroderma. Rheum Dis Clin North Am 2021; 47:757-780. [PMID: 34635303 DOI: 10.1016/j.rdc.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Juvenile-onset systemic sclerosis (jSSc) is a complex multisystem inflammatory-driven disease of fibrosis, requiring multifaceted treatment including pharmacologic therapy, supportive care, and lifestyle modification. Most regimens are adapted from adult SSc treatment given the rarity of the disease. Landmark trials over the past decade in adult SSc have led to 2 Food and Drug Administration-approved therapies for SSc-associated interstitial lung disease, and several ongoing trials of other biological agents are underway. Resetting the immune system with autologous stem cell transplant to halt this disease earlier in its course, especially in pediatric onset where disease burden can accumulate, is on the horizon.
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Affiliation(s)
- Kathryn S Torok
- Division of Pediatric Rheumatology, UPMC & University of Pittsburgh Scleroderma Center; Pediatric Scleroderma Clinic, University of Pittsburgh |UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA.
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19
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Crespo MM, Claridge T, Domsic RT, Hartwig M, Kukreja J, Stratton K, Chan KM, Molina M, Ging P, Cochrane A, Hoetzenecker K, Ahmad U, Kapnadak S, Timofte I, Verleden G, Lyu D, Quddus S, Davis N, Porteous M, Mallea J, Perch M, Distler O, Highland K, Magnusson J, Vos R, Glanville AR. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part III: Pharmacology, medical and surgical management of post-transplant extrapulmonary conditions statements. J Heart Lung Transplant 2021; 40:1279-1300. [PMID: 34474940 DOI: 10.1016/j.healun.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022] Open
Abstract
Patients with connective tissues disease (CTD) are often on immunomodulatory agents before lung transplantation (LTx). Till now, there's no consensus on the safety of using these agents perioperative and post-transplant. The International Society for Heart and Lung Transplantation-supported consensus document on LTx in patients with CTD addresses the risk and contraindications of perioperative and post-transplant management of the biologic disease-modifying antirheumatic drugs (bDMARD), kinase inhibitor DMARD, and biologic agents used for LTx candidates with underlying CTD, and the recommendations and management of non-gastrointestinal extrapulmonary manifestations, and esophageal disorders by medical and surgical approaches for CTD transplant recipients.
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Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Tamara Claridge
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robyn T Domsic
- Division of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jasleen Kukreja
- Division of Thoracic Surgery, University of California San Francisco, San Francisco, California
| | - Kathleen Stratton
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin M Chan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Maria Molina
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Adam Cochrane
- Department of Pharmacy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Siddhartha Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Irina Timofte
- Division of Pulmonary, University of Maryland Medical System, Baltimore, Maryland
| | - Geert Verleden
- Lung Transplant Unit, University Hospital of Gasthuisberg, Leuven, Belgium
| | - Dennis Lyu
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Sana Quddus
- Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Nicole Davis
- Lung Transplant Program, Tampa General Hospital, Tampa, Florida
| | - Mary Porteous
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jorge Mallea
- Division of Pulmonary, Allergy, and Critical Care, Mayo Clinic Florida, Jacksonville, Florida
| | - Michael Perch
- Lung Transplant Program, Rigshospitalet, Copenhagen, Denmark
| | - Olivier Distler
- Department of Rheumatology, University of Zurich Medical Center, Zurich, Switzerland
| | | | - Jesper Magnusson
- Department of Pulmonology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robin Vos
- Lung Transplant Unit, University Hospital of Gasthuisberg, Leuven, Belgium
| | - Allan R Glanville
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
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20
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Su KY, Sharma M, Kim HJ, Kaganov E, Hughes I, Abdeen MH, Ng JHK. Vasodilators for primary Raynaud's phenomenon. Cochrane Database Syst Rev 2021; 5:CD006687. [PMID: 33998674 PMCID: PMC8127538 DOI: 10.1002/14651858.cd006687.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. OBJECTIVES To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. SELECTION CRITERIA We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed studies using the Cochrane "Risk of bias" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin-converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low-certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD -0.17, 95% CI -4.66 to 4.31; 34 participants, 2 studies; low-certainty evidence); duration of attacks (MD 0.54, 95% CI -2.42 to 1.34; 14 participants, 1 study; low-certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low-certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD -8.82, 95% CI -11.04 to -6.60; 31 participants, 1 study; moderate-certainty evidence) and may improve severity scores (MD -0.41, 95% CI -0.62 to -0.30; moderate-certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate-certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI -0.35 to 4.35; 118 participants, low-certainty evidence) or severity (MD -0.06, 95% CI -0.34 to 0.22; 118 participants, low-certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low-certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI -1.81 to 3.41; 6 participants; very low-certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD -14.0, 95% CI -27.72 to -0.28; 41 participants; very low-certainty evidence) and reduced severity score (MD -133.00, 95% CI -162.40 to -103.60; 41 participants; very low-certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD -4.00, 95% CI -14.82 to 6.82; 41 participants; very low-certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low-certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta-analysis demonstrated no evidence of effect on frequency of attacks per week (MD -1.57, 95% CI -4.31 to 1.17; 86 participants, 2 studies; very low-certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF-00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] -0.05, 95% CI -6.71 to 6.61; 111 participants, 2 studies; low-certainty evidence), severity of attacks (MD -0.03, 95% CI -1.04 to 0.97; 111 participants, 2 studies; very low-certainty evidence), duration of attacks (MD -1.60, 95% CI -7.51 to 4.31; 73 participants, 1 study; low-certainty evidence), or RCS (SMD -0.8, 95% CI -1.74 to 0.13; 79 participants, 2 studies; low-certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF-00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF-00489791) versus nine participants (placebo). AUTHORS' CONCLUSIONS The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease.
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Affiliation(s)
- Kevin Yc Su
- Department of Rheumatology, Gold Coast University Hospital, Southport, Australia
| | - Meghna Sharma
- Department of Rheumatology, Gold Coast University Hospital, Southport, Australia
- School of Medicine, Bond University, Robina, Australia
| | - Hyunjun Jonathan Kim
- Department of Rheumatology, Gold Coast University Hospital, Southport, Australia
| | - Elizabeth Kaganov
- Department of Rheumatology, Gold Coast University Hospital, Southport, Australia
- School of Medicine, Bond University, Robina, Australia
| | - Ian Hughes
- Office for Research Governance and Development, Gold Coast University Hospital, Southport, Australia
- School of Medicine, The University of Queensland, St Lucia, Australia
| | | | - Jennifer Hwee Kwoon Ng
- Department of Rheumatology, Gold Coast University Hospital, Southport, Australia
- School of Medicine, Griffith University, Gold Coast Campus, Southport, Australia
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21
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Bruni C, Cometi L, Gigante A, Rosato E, Matucci-Cerinic M. Prediction and primary prevention of major vascular complications in systemic sclerosis. Eur J Intern Med 2021; 87:51-58. [PMID: 33551291 DOI: 10.1016/j.ejim.2021.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In Systemic Sclerosis (SSc), vasculopathy is the background of major vascular complications (MVCs), like digital ulcers (DUs), pulmonary arterial hypertension (PAH) and scleroderma renal crisis (SRC). We aimed to identify the predictors and to test the primary preventive effect of vasoactive/vasodilating drugs (VVD) for the development of MVCs in SSc MVCs-naïve patients. METHODS patients fulfilling the ACR/EULAR 2013 classification criteria for SSc without history of MVCs were eligible. Data about clinical manifestations, laboratory and instrumental assessments and treatments were retrospectively collected at baseline and latest available follow-up. RESULTS 134 SSc patients were enrolled (mean age 56.5 years ± 14.2, females 88.1%, limited subset 61.9%, ACA positivity 60.4%). In a mean of 43 ± 19 months of follow-up 12 (9.0%) patients developed at least 1 MVC (10 DU, 2 PAH and 1 SRC). Dyspnoea and arthritis at baseline were independent predictors for MVCs development (p = 0.012, and p = 0.002 respectively). No primary preventive effect of VVD on MVCs development was found. However, sildenafil reduced the renal resistive index increase (p = 0.042) and alprostadil slowed the DLco decline (p = 0.029). Both iloprost and angiotensin-receptor blockers (ARBs) delayed MVCs development, while angiotensin converting enzyme inhibitors (ACEi) determined an earlier onset of such MCVs. CONCLUSIONS in SSc patients, our data confirm the role of arthritis and dyspnea as independent predictors of major vascular complications, in particular in MVCs-naïve patients. Prostanoids, sildenafil and ARBs, even in absence of a primary preventive action, might help in slowing disease progression and postponing the onset of MVCs.
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Affiliation(s)
- Cosimo Bruni
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy.
| | - Laura Cometi
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy
| | - Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Matucci-Cerinic
- Div. Rheumatology, Department of Experimental and Clinical Medicine, AOU Careggi, University of Florence, Florence, Italy
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22
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Klein-Weigel P, Sander O, Reinhold S, Nielitz J, Steindl J, G. Richter J. Raynaud's Phenomenon: A Vascular Acrosyndrome That Requires Long-Term Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0023. [PMID: 33632387 PMCID: PMC8287761 DOI: 10.3238/arztebl.m2021.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Some 5-10% of the German population are affected by Raynaud's phenomenon (RP). In around 10-20% of cases RP arises from an underlying disease, most commonly a connective tissue disease. This review encompasses the diagnosis and differential diagnosis of RP and examines the efficacy of the currently available pharmaceutical and non-pharmaceutical treatment options. METHODS We conducted a selective literature search in PubMed using the search terms "Raynaud's phenomenon", "Raynaud's syndrome," "vasospasm," "vascular acrosyndrome," and "systemic sclerosis," together with a search of the Cochrane Database of Systematic Reviews up to April 2020. RESULTS Raynaud's phenomenon mainly affects the fingers or toes and is typically triggered by cold or emotional stressors. The most important diagnostic steps are demonstration of a tendency towards digital vasospasm, exclusion of occlusions in the afferent arteries and acral vessels, nail-fold capillaroscopy, and determination of autoantibody status. Tumor screening should be arranged in the presence of B symptoms or first manifestation of RP in old age. The onset of RP in childhood is a rare occurrence and points to a secondary origin. The principal options for treatment are protection against cold and administration of calcium antagonists, which reduces the occurrence of RP by around 20-40 %. The treatment of RP in patients with systemic sclerosis is described in the recommendations of the European League Against Rheumatism (EULAR). CONCLUSION At onset or after years of latency, patients with Raynaud phenomenon may have an underlying disease (most commonly a connective tissue disease). Long-term specialist care is necessary for asymptomatic patients with risk factors and for those with clinically manifest symptoms of an underlying condition alike.
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Affiliation(s)
- Peter Klein-Weigel
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Oliver Sander
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
| | - Simone Reinhold
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jessica Nielitz
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Julia Steindl
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jutta G. Richter
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
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Pauling JD, Hackett N, Guida A, Merkel PA. Performance of laser-derived imaging for assessing digital perfusion in clinical trials of systemic sclerosis-related digital vasculopathy: A systematic literature review. Semin Arthritis Rheum 2020; 50:1114-1130. [DOI: 10.1016/j.semarthrit.2020.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/10/2020] [Accepted: 06/30/2020] [Indexed: 01/16/2023]
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Abstract
Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.
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Fujimoto M, Asai J, Asano Y, Ishii T, Iwata Y, Kawakami T, Kodera M, Abe M, Amano M, Ikegami R, Isei T, Isogai Z, Ito T, Inoue Y, Irisawa R, Ohtsuka M, Omoto Y, Kato H, Kadono T, Kaneko S, Kanoh H, Kawaguchi M, Kukino R, Kono T, Koga M, Sakai K, Sakurai E, Sarayama Y, Shintani Y, Tanioka M, Tanizaki H, Tsujita J, Doi N, Nakanishi T, Hashimoto A, Hasegawa M, Hayashi M, Hirosaki K, Fujita H, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Motegi SI, Yatsushiro H, Yamasaki O, Yoshino Y, Pavoux AJLE, Tachibana T, Ihn H. Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers. J Dermatol 2020; 47:1071-1109. [PMID: 31960490 DOI: 10.1111/1346-8138.15186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 11/30/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
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Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Jun Asai
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yohei Iwata
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masanari Kodera
- Department of Dermatology, JCHO Chukyo Hospital, Nagoya, Japan
| | | | - Masahiro Amano
- Department of Dermatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuta Ikegami
- Department of Dermatology, JCHO Osaka Hospital, Osaka, Japan
| | - Taiki Isei
- Department of Dermatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Zenzo Isogai
- Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuji Inoue
- Suizenji Dermatology Clinic, Kumamoto, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoichi Omoto
- Department of Dermatology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Hiroshi Kato
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takafumi Kadono
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sakae Kaneko
- Department of Dermatology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Hiroyuki Kanoh
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Takeshi Kono
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzei, Japan
| | - Monji Koga
- Department of Dermatology, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Sakai
- Department of Dermatology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | | | | | | | | | - Hideaki Tanizaki
- Department of Dermatology, Osaka Medical College, Takatsuki, Japan
| | - Jun Tsujita
- Department of Dermatology, Social Insurance Inatsuki Hospital, Fukuoka Prefecture Social Insurance Hospital Association, Fukuoka, Japan
| | - Naotaka Doi
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Hideki Fujita
- Division of Dermatological Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate, School of Medical and Dental Sciences, Niigata, Japan.,Department of Dermatology, Uonuma Kikan Hospital, Minamiuonuma, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Shimotsuke, Japan
| | | | - Naoki Madokoro
- Department of Dermatology, MAZDA Hospital, Aki-gun, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Osamu Yamasaki
- Department of Dermatology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Drerup C, Maier A, Ehrchen J. [Raynaud's phenomenon : Practical management]. Z Rheumatol 2019; 78:967-978. [PMID: 31712897 DOI: 10.1007/s00393-019-00723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Raynaud's phenomenon (RP) is a frequent and painful vasospasm of small arteries localized in acral body regions (most frequently the fingers). The more frequent so-called primary RP is caused merely by a functional dysregulation of the tonus of vascular walls. In contrast, the rarer secondary RP is additionally associated with structural abnormalities of blood vessels. Knowledge of RP is important for rheumatologists because secondary RP can be associated with the presence or development of severe underlying diseases, especially with systemic sclerosis. Thus, the rheumatologist has to be aware of this condition. In this article the diagnostic procedures and the most important treatment approaches are summarized.
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Affiliation(s)
- C Drerup
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland
| | - A Maier
- Rheumatologisches Kompetenzzentrum Nordwestdeutschland, Klinik für Rheumatologie, St. Josef-Stift Sendenhorst, Westtor 7, 48324, Sendenhorst, Deutschland
| | - J Ehrchen
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
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27
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Abstract
Raynaud's phenomenon (RP) is a painful vasospasm of small arteries, localised in fingers and toes. Typically these body parts turn white (ischemia), then blue (deoxygenation) and then red (reperfusion). Two different types of RP exist: the common primary RP without underlying disease and the rare secondary RP, mostly associated with rheumatoid diseases such as systemic sclerosis. Thus, the dermatologist has to be aware of this condition. In this article the clinical criteria, differential diagnoses, diagnostic considerations and treatment options are discussed.
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Pauling JD, Hughes M, Pope JE. Raynaud's phenomenon-an update on diagnosis, classification and management. Clin Rheumatol 2019; 38:3317-3330. [PMID: 31420815 DOI: 10.1007/s10067-019-04745-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Raynaud's phenomenon (RP) is used to describe a symptom complex caused by digital vascular compromise. RP is a clinical diagnosis. The typically episodic nature of RP has resulted in a reliance upon patient self-report for diagnosis. The term 'primary RP' is generally applied when no underlying pathology can be demonstrated. Whilst 'primary RP' is currently considered a distinct disorder, there is evidence that the term may comprise several entities that include a functional vasospastic disorder, a physiologically appropriate thermoregulatory response, subclinical atherosclerosis and 'cold intolerance'. Optimal management may differ depending on cause. The term 'secondary RP' encompasses a broad range of rheumatological, haematological, endocrinological and vascular pathology. RP can range from relatively benign but intrusive vasospasm, to the progressive obliterative microangiopathy of systemic sclerosis (SSc), in which severe digital ischaemia can threaten tissue viability. SSc has formed the focus of much of the research into RP but, consistent with most medical symptom complexes, the aetiopathogenesis of RP varies greatly dependent on cause. Vasospasm within the digital macro- and microvasculature occurs in SSc, but digital ischaemia is further compounded by a progressive obliterative microangiopathy. Recent work exploring the patient experience of SSc-RP is challenging the 'episodic' paradigm of 'Raynaud's', with important implications for clinical trials utilising diary-based patient-reported outcome instruments for assessing Raynaud's symptoms. This review shall examine the causes, pathogenesis, clinical features, classification and management of RP. A practical approach to the evaluation and management of RP is outlined, highlighting important knowledge gaps and unmet research needs where applicable. Key Points • Raynaud's phenomenon is a symptom complex related to digital vascular compromise secondary to broad-ranging pathology. • Raynaud's phenomenon, as currently classified, likely encompasses a number of aetiopathogenic processes. • Raynaud's phenomenon causes significant disease-related morbidity in autoimmune rheumatic diseases such as systemic sclerosis.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Upper Borough Walls, Bath, BA1 1RL, UK.
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.
| | - Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Janet E Pope
- University of Western Ontario, London, ON, Canada
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Satteson ES, Chung MP, Chung LS, Chang J. Microvascular Hand Surgery for Digital Ischemia in Scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 5:130-136. [PMID: 34095502 DOI: 10.1177/2397198319863565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Periarterial sympathectomy and arterial bypass are microsurgical techniques which the literature suggests can provide improvement in digital pain and ulceration in patients with systemic sclerosis (SSc) who have persistent symptoms despite medication management. This review summarizes the relevant anatomy, medical therapies, operative techniques, and surgical outcomes and complications associated with the management of the vascular manifestations of SSc in the hand. Multidisciplinary collaboration between dermatology, rheumatology, and hand surgery can facilitate optimal medical and surgical management for SSc patients.
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Affiliation(s)
- Ellen S Satteson
- Division of Plastic Surgery, Department of Surgery, The Robert A. Chase Hand Center, Stanford University Medical Center, Palo Alto, CA, USA
| | - Melody P Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Lorinda S Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA.,Division of Rheumatology, Department of Medicine, Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - James Chang
- Division of Plastic Surgery, Department of Surgery, The Robert A. Chase Hand Center, Stanford University Medical Center, Palo Alto, CA, USA
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30
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Herrick AL. Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:89-101. [PMID: 35382391 PMCID: PMC8922643 DOI: 10.1177/2397198319826467] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/27/2018] [Indexed: 09/05/2023]
Abstract
Raynaud's phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud's phenomenon is very common, affecting approximately 3%-5% of the general population. Although much rarer, systemic sclerosis-related Raynaud's phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud's phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis-related Raynaud's phenomenon (which is the most researched form of Raynaud's phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from 'isolated' to systemic sclerosis-related Raynaud's phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both 'uncomplicated' and 'complicated' Raynaud's phenomena (i.e. Raynaud's phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5-10 years are highlighted.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
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Management of Raynaud’s phenomenon in systemic sclerosis—a practical approach. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:102-110. [DOI: 10.1177/2397198318823951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
Abstract
Raynaud’s phenomenon is nearly universal in systemic sclerosis. Vasculopathy is part of systemic sclerosis. Raynaud’s phenomenon can cause of complications and impairment, especially when tissue ischemia and digital ulcers develop. There are many treatment options for Raynaud’s phenomenon in systemic sclerosis often with sparse data and few robust studies comparing the different treatment options. Recommendations from guidelines usually include calcium channel blockers as first-line pharmacological treatment. In the clinical setting, multiple variables such as financial factors, geography where access to medications varies, and patient factors, baseline hypotension, can influence the treatment for Raynaud’s phenomenon and digital ulcers. Prostacyclins and PDE-5 inhibitors are reserved for more severe Raynaud’s phenomenon or healing of digital ulcers. Prevention of digital ulcers may also include endothelin receptor blocker (bosentan) in some countries. Other treatments had less consensus. Algorithms developed by systemic sclerosis experts might be helpful in deciding which treatment to choose for each setting, using a step-wise strategy, which intends to complement guidelines. This review focuses on a practical approach to the treatment of Raynaud’s phenomenon and digital ulcers in systemic sclerosis, based on algorithms designed by systemic sclerosis experts using consensus, and we review the evidence that supports treatment from initial to second and third-line options.
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Medina S, Gómez-Zubiaur A, Valdeolivas-Casillas N, Polo-Rodríguez I, Ruíz L, Izquierdo C, Guirado C, Cabrera A, Trasobares L. Botulinum toxin type A in the treatment of Raynaud's phenomenon: A three-year follow-up study. Eur J Rheumatol 2018; 5:224-229. [PMID: 30501848 PMCID: PMC6267752 DOI: 10.5152/eurjrheum.2018.18013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/06/2018] [Indexed: 01/18/2023] Open
Abstract
Objective Raynaud’s phenomenon consists of vasospastic disease of the digital arteries after exposure to cold or stress. It causes an important reduction in the patient’s quality of life when severe. The available treatments do not always offer favorable results. Methods A 3-year retrospective study was presented. A total of 15 patients with severe Raynaud’s phenomenon who required infiltration with botulinum toxin type A participated in the study. In the first and follow-up visits (30 min, 7 days, 3 months, 6 months, and annual), the overall response by the patient was assessed as was the reduction in the number of weekly episodes of Raynaud’s phenomenon, improvement in pain by means of the Visual Analogue Scale, and resolution of ulcers and necrosis as efficacy variables. Results A total of 15 patients were included in the study. After 30 min of infiltration, the immediate results showed a very good perception of response in four patients. After 1 month of treatment, eight patients had obtained and maintained a very good response, persisting throughout the study. A statistically significant reduction in pain was obtained, as well as the number of weekly episodes of Raynaud’s phenomenon. Of the seven patients with basal ulcers, five were completely healed at 3 months. Of the patients, 64.3% showed an overall satisfaction level of >8 at the end of treatment. No serious adverse events were observed. Conclusion Botulinum toxin is a useful treatment for severe Raynaud’s phenomenon that is generally well tolerated. Its mechanism of action is not based exclusively on vasodilation. Further studies are necessary to define the ideal patient for this treatment, the most appropriate method of administration, and the number of units and frequency of the infiltrations.
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Affiliation(s)
- Susana Medina
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alba Gómez-Zubiaur
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Isabel Polo-Rodríguez
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lucia Ruíz
- Department of Rheumatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Carmen Izquierdo
- Department of Radiology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Cristina Guirado
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alicia Cabrera
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lidia Trasobares
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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34
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Pauling JD, Domsic RT, Saketkoo LA, Almeida C, Withey J, Jay H, Frech TM, Ingegnoli F, Dures E, Robson J, McHugh NJ, Herrick AL, Matucci-Cerinic M, Khanna D, Hewlett S. Multinational Qualitative Research Study Exploring the Patient Experience of Raynaud's Phenomenon in Systemic Sclerosis. Arthritis Care Res (Hoboken) 2018; 70:1373-1384. [PMID: 29473715 DOI: 10.1002/acr.23475] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/14/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Raynaud's phenomenon (RP) is the most common manifestation of systemic sclerosis (SSc). RP is an episodic phenomenon, not easily assessed in the clinic, leading to reliance on self-report. A thorough understanding of the patient experience of SSc-RP is essential to ensuring that patient-reported outcome (PRO) instruments capture domains important to the target patient population. We report the findings of an international qualitative research study investigating the patient experience of SSc-RP. METHODS Focus groups of SSc patients were conducted across 3 scleroderma centers in the US and UK, using a topic guide and a priori purposive sampling framework devised by qualitative researchers, SSc patients, and SSc experts. Focus groups were audio recorded, transcribed, anonymized, and analyzed using inductive thematic analysis. Focus groups were conducted until thematic saturation was achieved. RESULTS Forty SSc patients participated in 6 focus groups conducted in Bath (UK), New Orleans (Louisiana), and Pittsburgh (Pennsylvania). Seven major themes were identified that encapsulate the patient experience of SSc-RP: physical symptoms, emotional impact, triggers and exacerbating factors, constant vigilance and self-management, impact on daily life, uncertainty, and adaptation. The interrelationship of the 7 constituent themes can be arranged within a conceptual map of SSc-RP. CONCLUSION We have explored the patient experience of SSc-RP in a diverse and representative SSc cohort and identified a complex interplay of experiences that result in significant impact. Work to develop a novel PRO instrument for assessing the severity and impact of SSc-RP, comprising domains/items grounded in the patient experiences of SSc-RP identified in this study, is underway.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and University of Bath, Bath, UK
| | - Robyn T Domsic
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Jane Withey
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK
| | - Hilary Jay
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK
| | - Tracy M Frech
- University of Utah and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City
| | | | - Emma Dures
- University of the West of England, Bristol, UK
| | | | - Neil J McHugh
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and University of Bath, Bath, UK
| | - Ariane L Herrick
- University of Manchester, Salford Royal Hospital NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
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Williams AA, Carl HM, Lifchez SD. The Scleroderma Hand: Manifestations of Disease and Approach to Management. J Hand Surg Am 2018; 43:550-557. [PMID: 29691079 DOI: 10.1016/j.jhsa.2018.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 03/17/2018] [Indexed: 02/02/2023]
Abstract
Scleroderma is a rare autoimmune connective tissue disorder that often affects the hands. Manifestations in the hands include calcium deposits within the soft tissues that cause pain and may ulcerate through the skin, digital ischemia resulting in chronic wounds and digital gangrene, and joint contracture. Because of the underlying disease, patients with scleroderma have poorly vascularized tissue and a deficient soft tissue envelope, which make surgery particularly challenging. However, when undertaken with care, surgical intervention is often the best option for addressing the disabling hand conditions that so often accompany this disease.
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Affiliation(s)
- Ariel A Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Hannah M Carl
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott D Lifchez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD.
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36
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
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Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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Pearson DR, Werth VP, Pappas-Taffer L. Systemic sclerosis: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:459-474. [PMID: 30047430 DOI: 10.1016/j.clindermatol.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.
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Affiliation(s)
- David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Raynaud's phenomenon (RP) is a transient, acral, vasospastic phenomenon that manifests with characteristic color changes. This vasospasm, classically triggered by cold temperatures, may also be driven by shifts in temperature, climate, or emotional state. Primary RP (PRP) is a common condition without severe sequelae. Secondary RP (SRP), which may be driven by vascular, autoimmune, hematologic, or endocrine etiologies, can result in digital ulceration, irreversible ischemia and necrosis, and secondary infection. This review delineates the clinical manifestations of both primary and secondary RP, as well as the current understanding of RP epidemiology and pathogenesis. Proper examination, including nailfold capillary microscopy, and laboratory workup for secondary causes of RP are also discussed. The traditional armamentarium of therapies used for RP, as well as newer medical and surgical options, is also summarized with particular regard to the clinical evidence for their efficacy.
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Affiliation(s)
- Thomas Stringer
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Alisa N Femia
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA.
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Rodríguez-Franco K, Miranda-Díaz AJ, Hoyos-Restrepo JD, Meléndez GL. Systemic scleroderma: An approach from plastic surgery. REVISTA DE LA FACULTAD DE MEDICINA 2018. [DOI: 10.15446/revfacmed.v66n2.58618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introducción. La esclerosis sistémica (ES) es una enfermedad autoinmune del tejido conectivo que se caracteriza clínicamente por un engrosamiento cutáneo, el cual se da debido a la acumulación de tejido conectivo y puede afectar a otros órganos y a las extremidades. La etiología multifactorial de esta enfermedad corresponde a la interacción de alteraciones en el remodelamiento de la matriz extracelular, función inmunitaria y presencia de vasculopatía proliferativa bajo influencia genética y medioambiental.Objetivo. Realizar una revisión sobre el manejo médico y quirúrgico desde el punto de vista de la cirugía plástica de las lesiones en piel y manos y las alteraciones faciales de los pacientes con ES.Materiales y métodos. Se realizó una búsqueda bibliográfica en las bases de datos Medline, LILACS, PubMed, EMBASE y Current contents con las palabras claves esclerodermia sistémica, cirugía plástica, mano y ulceras.Resultados. La ES requiere manejo multidisciplinario; se presentan casos en los que se indica terapia farmacológica y otros en los que el manejo es quirúrgico complementario.Conclusión. Esta patología afecta de manera importante la piel al provocar lesiones que van desde ulceras digitales hasta atrofia facial, las cuales son susceptibles de manejo por el área de cirugía plástica.
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Ranugha PSS, Betkerur J. Antihypertensives in dermatology Part I - Uses of antihypertensives in dermatology. Indian J Dermatol Venereol Leprol 2018; 84:6-15. [DOI: 10.4103/ijdvl.ijdvl_991_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rirash F, Tingey PC, Harding SE, Maxwell LJ, Tanjong Ghogomu E, Wells GA, Tugwell P, Pope J. Calcium channel blockers for primary and secondary Raynaud's phenomenon. Cochrane Database Syst Rev 2017; 12:CD000467. [PMID: 29237099 PMCID: PMC6486273 DOI: 10.1002/14651858.cd000467.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Raynaud's phenomenon is a vasospastic disease characterized by digital pallor, cyanosis, and extremity pain. Primary Raynaud's phenomenon is not associated with underlying disease, but secondary Raynaud's phenomenon is associated with connective tissue disorders such as systemic sclerosis, systemic lupus erythematosus, and mixed connective tissue disease. Calcium channel blockers promote vasodilation and are commonly used when drug treatment for Raynaud's phenomenon is required. OBJECTIVES To assess the benefits and harms of calcium channel blockers (CCBs) versus placebo for treatment of individuals with Raynaud's phenomenon with respect to Raynaud's type (primary vs secondary) and type and dose of CCBs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (May 19, 2017), MEDLINE (1946 to May 19, 2017), Embase (1947 to May 19, 2017), clinicaltrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Portal. We applied no language restrictions. We also searched bibliographies of retrieved articles and contacted key experts for additional and unpublished data. SELECTION CRITERIA All randomized controlled trials (RCTs) comparing calcium channel blockers versus placebo. DATA COLLECTION AND ANALYSIS Two review authors independently assessed search results and risk of bias and extracted trial data. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS This review contains 38 RCTs (33 cross-over RCTs) with an average duration of 7.4 weeks and 982 participants; however, not all trials reported all outcomes of interest. Nine of the identified trials studied patients with primary Raynaud's phenomenon (N = 365), five studied patients with secondary Raynaud's phenomenon (N = 63), and the rest examined a mixture of patients with primary and secondary Raynaud's phenomenon (N = 554). The most frequently encountered risk of bias types were incomplete outcome data and poor reporting of randomization and allocation methods.When researchers considered both primary and secondary Raynaud's phenomenon, evidence of moderate quality (downgraded for inconsistency) from 23 trials with 528 participants indicates that calcium channel blockers (CCBs) were superior to placebo in reducing the frequency of attacks. CCBs reduced the average number of attacks per week by six ( weighted mean difference (WMD) -6.13, 95% confidence interval (CI) -6.60 to - 5.67; I² = 98%) compared with 13.7 attacks per week with placebo. When review authors excluded Kahan 1985C, a trial showing a very large reduction in the frequency of attacks, data showed that CCBs reduced attack frequency by 2.93 per week (95% CI -3.44 to -2.43; I² = 77%).Low-quality evidence (downgraded for imprecision and inconsistency) from six trials with 69 participants suggests that the average duration of attacks did not differ in a statistically significant or clinically meaningful way between CCBs and placebo (WMD -1.67 minutes, 95% CI -3.29 to 0); this is equivalent to a -9% difference (95% CI -18% to 0%).Moderate-quality evidence (downgraded for inconsistency) based on 16 trials and 415 participants showed that CCBs reduced attack severity by 0.62 cm (95% CI -0.72 to - 0.51) on a 10-cm visual analogue scale (lower scores indicate less severity); this was equivalent to absolute and relative percent reductions of 6% (95% CI -11% to -8%) and 9% (95% CI -11% to -8%), respectively, which may not be clinically meaningful.Improvement in Raynaud's pain (low-quality evidence; downgraded for imprecision and inconsistency) and in disability as measured by a patient global assessment (moderate-quality evidence; downgraded for imprecision) favored CCBs (pain: WMD -1.47 cm, 95% CI -2.21 to -0.74; patient global: WMD -0.37 cm, 95% CI -0.73 to 0, when assessed on a 0 to 10 cm visual analogue scale, with lower scores indicating less pain and less disability). However, these effect estimates were likely underpowered, as they were based on limited numbers of participants, respectively, 62 and 92. For pain assessment, absolute and relative percent improvements were 15% (95% -22% to -7%) and 47% (95% CI -71% to -24%), respectively. For patient global assessment, absolute and relative percent improvements were 4% (95% CI -7% to 0%) and 9% (95% CI -19% to 0%), respectively.Subgroup analyses by Raynaud's type, CCB class, and CCB dose suggest that dihydropyridine CCBs in higher doses may be more effective for primary Raynaud's than for secondary Raynaud's, and CCBs likely have a greater effect in primary than in secondary Raynaud's. However, differences were small and were not found for all outcomes. Dihydropyridine CCBs were studied as they are the subgroup of CCBs that are not cardioselective and are traditionally used in RP treatment whereas other CCBs such as verapamil are not routinely used and diltiazem is not used as first line subtype of CCBs. Most trial data pertained to nifedipine.Withdrawals from studies due to adverse effects were inconclusive owing to a wide CI (risk ratio [RR] 1.30, 95% CI 0.51 to 3.33) from two parallel studies with 63 participants (low-quality evidence downgraded owing to imprecision and a high attrition rate); absolute and relative percent differences in withdrawals were 6% (95% CI -14% to 26%) and 30% (95% CI -49% to 233%), respectively. In cross-over trials, although a meta-analysis was not performed, withdrawals were more common with CCBs than with placebo. The most common side effects were headache, dizziness, nausea, palpitations, and ankle edema. However, in all trials, no serious adverse events (death or hospitalization) were reported. AUTHORS' CONCLUSIONS Randomized controlled trials with evidence of low to moderate quality showed that CCBs (especially the dihydropyridine class) may be useful in reducing the frequency, duration, severity of attacks, pain and disability associated with Raynaud's phenomenon. Higher doses may be more effective than lower doses and these CCBs may be more effective in primary RP. Although there were more withdrawals due to adverse events in the treatment groups, no serious adverse events were reported.
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Affiliation(s)
- Fadumo Rirash
- University of Western OntarioDepartment of Medicine268 Grosvenor StreetLondonONCanadaN6A 4V2
| | - Paul C Tingey
- University of Western OntarioDepartment of Medicine268 Grosvenor StreetLondonONCanadaN6A 4V2
| | - Sarah E Harding
- University of Tennessee at ChattanoogaDepartment of Pediatrics910 Blackford StChattanoogaTennesseeUSA37405
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | | | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - Janet Pope
- University of Western OntarioDepartment of Medicine and Epidemiology and BiostatisticsSt. Joseph's Health Care268 Grosvenor StLondonONCanadaN6A 4V2
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Herrick AL. Evidence-based management of Raynaud's phenomenon. Ther Adv Musculoskelet Dis 2017; 9:317-329. [PMID: 29201156 PMCID: PMC5700788 DOI: 10.1177/1759720x17740074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
Raynaud's phenomenon (RP) is relevant to the rheumatologist because it may signify an underlying connective tissue disease and also because it can be very challenging to treat, especially when it has progressed to digital ulceration or critical ischaemia. This review article discusses diagnosis (does this patient have an underlying connective tissue disease?), including the role for nailfold capillaroscopy, and treatment. Management of 'uncomplicated' RP is first described and then treatment of RP complicated by progression to digital ulceration or critical ischaemia, highlighting recent advances (including phosphodiesterase type 5 inhibition, and endothelin 1 receptor antagonism) and the evidence base underpinning these. Possible future therapies are briefly discussed.
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Affiliation(s)
- Ariane L. Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK, M13 9PT and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK
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Cutolo M, Smith V, Furst DE, Khanna D, Herrick AL. Points to consider-Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v45-v48. [PMID: 28992170 DOI: 10.1093/rheumatology/kex199] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 11/13/2022] Open
Abstract
RP is an exaggerated vasospastic response to cold or emotion. Randomized, double-blind, placebo-controlled trials with either parallel group or cross-over trials should be mainly considered. Cross-over design, which is good for early phase trials of immediate or very short-term outcomes, is important in a condition as heterogeneous as RP: a wash-out period between treatment arms should always be included to minimize the possibility of a period (carry-over) effect. Duration of RP trials is usually constrained by the need to complete these over a single season, usually winter when the weather is colder. For cross-over trials, each treatment arm tends to be 4 weeks or less. Frequency and duration of attacks, and the Raynaud's Condition Score are widely used outcome measures. There is increasing interest in physiological laboratory endpoints, for example laser Doppler imaging at least for early phase trials.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS, University of Genova, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital.,Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Daniel E Furst
- Department of Rheumatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine University of Michigan, University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust, Manchester and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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45
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Bouquet É, Urbanski G, Lavigne C, Lainé-Cessac P. Unexpected drug-induced Raynaud phenomenon: Analysis from the French national pharmacovigilance database. Therapie 2017; 72:547-554. [PMID: 28336160 DOI: 10.1016/j.therap.2017.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/19/2016] [Accepted: 01/12/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To estimate the association between exposure to medicinal products and Raynaud phenomenon. METHODS The study used the data of all adverse drug reactions notified to the French national pharmacovigilance database. All cases reported between 1st January 1995 and 10th December 2012 were selected. A case/non-case method was used to measure disproportionality of the association between drug exposure and Raynaud phenomenon. The cases concerned all observations involving Raynaud phenomenon. Non-cases comprised all other reports of adverse drug reactions over the same period. RESULTS/DISCUSSION Among the 307,128 adverse drug reaction reports selected from the French national pharmacovigilance database, 175 involved Raynaud phenomenon, most of them affecting women (61.1%). The mean age was 50.1 years, and 8% had a past medical history of Raynaud phenomenon. According to the summaries of product characteristics, 42.3% of these cases were exposed to drugs known to induce Raynaud phenomenon. Unexpected Raynaud phenomenons (unlisted in the summaries of product characteristics) were associated with exposure to drugs for which Raynaud phenomenons are published (interferons, ribavirin, gemcitabine) or for which Raynaud phenomenons are not published (hepatitis B vaccine, isotretinoin, leflunomide, hydroxycarbamide, rofecoxib, telmisartan, zolmitriptan). CONCLUSION The case/non-case method is usually used to generate signals. Further epidemiological studies are now necessary to confirm these findings.
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Affiliation(s)
- Émilie Bouquet
- Regional pharmacovigilance centre, Angers university hospital, 49933 Angers, France.
| | - Geoffrey Urbanski
- Department of internal and vascular medicine, Angers university hospital, 49933 Angers cedex 9, France
| | - Christian Lavigne
- Department of internal and vascular medicine, Angers university hospital, 49933 Angers cedex 9, France
| | - Pascale Lainé-Cessac
- Regional pharmacovigilance centre, Angers university hospital, 49933 Angers, France
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Wood HM, Ernst ME. Renin—Angiotensin System Mediators and Raynaud's Phenomenon. Ann Pharmacother 2016; 40:1998-2002. [PMID: 17003081 DOI: 10.1345/aph.1h201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in the treatment of Raynaud's phenomenon (RP). Data Sources: Biomedical literature was accessed through July 2006 via PubMed, the Iowa Drug Information System (OS), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus. PubMed database terms included Raynaud's disease, angiotensin-converting enzyme inhibitors, and angiotensin II type 1 receptor blockers [pharmacological action]; IDIS terms included hypotensive agents-ace inhib 24080200, raynaud's syndrome 443.0, and hypotensive agents-angioten II 24080400; and CINAHL Plus terms included Raynaud's disease, angiotensin-converting enzyme inhibitors, losartan, and irbesartan. Study Selection and Data Extraction: All clinical trials published in English that reported both subjective and objective outcomes of efficacy were reviewed. Data Synthesis: Several small, short-term studies have evaluated captopril, enalapril, and losartan in the treatment of RP. The studies of ACE inhibitors have found conflicting results in their ability to improve digit blood flow and reduce both frequency and severity of RP attacks. Two studies have focused on the use of losartan for RP treatment, with both finding a statistically significant reduction in attacks and one showing improvement in symptoms of RP in comparison with the commonly utilized calcium-channel blocker, nifedipine. Most of the studies were short term (≤2 wk) and included a limited number of patients (CONCLUSIONS: ACE inhibitors and ARBs may provide some minor benefits in the relief of RP, although no definite evidence exists to suggest that they are superior to traditionally used treatments such as calcium-channel blockers. Larger, randomized controlled trials of longer duration are needed to compare the effectiveness of ACE inhibitors and ARBs with conventional treatment.
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Affiliation(s)
- Heidi M Wood
- College of Pharmacy, The University of Iowa, Iowa City, IA 52242-1009, USA
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Fardoun MM, Nassif J, Issa K, Baydoun E, Eid AH. Raynaud's Phenomenon: A Brief Review of the Underlying Mechanisms. Front Pharmacol 2016; 7:438. [PMID: 27899893 PMCID: PMC5110514 DOI: 10.3389/fphar.2016.00438] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/03/2016] [Indexed: 11/28/2022] Open
Abstract
Raynaud’s phenomenon (RP) is characterized by exaggerated cold-induced vasoconstriction. This augmented vasoconstriction occurs by virtue of a reflex response to cooling via the sympathetic nervous system as well as by local activation of α2C adrenoceptors (α2C-AR). In a cold-initiated, mitochondrion-mediated mechanism involving reactive oxygen species and the Rho/ROCK pathway, cytoskeletal rearrangement in vascular smooth muscle cells orchestrates the translocation of α2C-AR to the cell membrane, where this receptor readily interacts with its ligand. Different parameters are involved in this spatial and functional rescue of α2C-AR. Of notable relevance is the female hormone, 17β-estradiol, or estrogen. This is consistent with the high prevalence of RP in premenopausal women compared to age-matched males. In addition to dissecting the role of these various players, the contribution of pollution as well as genetic background to the onset and prevalence of RP are also discussed. Different therapeutic approaches employed as treatment modalities for this disease are also highlighted and analyzed. The lack of an appropriate animal model for RP mandates that more efforts be undertaken in order to better understand and eventually treat this disease. Although several lines of treatment are utilized, it is important to note that precaution is often effective in reducing severity or frequency of RP attacks.
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Affiliation(s)
- Manal M Fardoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Joseph Nassif
- Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Khodr Issa
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Elias Baydoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Ali H Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
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A Randomized Controlled Trial of Acupressure for the Treatment of Raynaud's Phenomenon: The difficulty of conducting a trial in Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016; 1:226-233. [PMID: 27840853 DOI: 10.5301/jsrd.5000206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of acupressure on Raynaud's phenomenon (RP) in a randomized controlled clinical trial (RCT) and to evaluate the difficulties of conducting a RP RCT. METHODS A pilot single center RCT of acupressure vs. targeted patient education was conducted for the treatment of RP. Patients with either primary (N = 15) or secondary (N = 8) RP were randomized in an 8-week study. The primary endpoints included a decrease in the frequency and duration of RP. Secondary endpoints included several serum biomarkers including endothelial dysfunction, Raynaud's attack symptoms, Raynaud's Condition Score, and patient and physician global assessments of RP. Primary data analysis was conducted using the last observation carried forward and t-tests or a Wilcoxon rank test was used to compare the two groups. RESULTS 23 patients were randomized and 7 discontinued prematurely. 78% of patients were female, 96% were Caucasian, and the mean age was 49.8 (SD=16) years. No statistically significant differences were detected between the acupressure vs. education groups in primary and secondary outcomes (p> 0.05). Frequency of attacks decreased by 6.7 attacks (SD=8.8) in the acupressure group vs. 7.2 (SD=12.8) in the education group (p=0.96), and the duration of attacks decreased by 11.4 (SD=19.9) minutes in the acupressure group vs. an increase of 0.8 minutes (SD=11.2) in the education group (p=0.14). There were no adverse events noted in the RCT. CONCLUSION This pilot study does not support efficacy of acupressure for RP.
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Affiliation(s)
- Fredrick M Wigley
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
| | - Nicholas A Flavahan
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
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Cruz JE, Ward A, Anthony S, Chang S, Bae HB, Hermes-DeSantis ER. Evidence for the Use of Epoprostenol to Treat Raynaud's Phenomenon With or Without Digital Ulcers. Ann Pharmacother 2016; 50:1060-1067. [PMID: 27465880 DOI: 10.1177/1060028016660324] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To review the evidence for using intravenous (IV) epoprostenol to treat Raynaud's phenomenon (RP). DATA SOURCES The databases MEDLINE (1946 to March 2016), PubMed, and International Pharmaceutical Abstracts were searched using the terms epoprostenol, Flolan, Raynaud's disease, and CREST syndrome. Further literature sources were identified by reviewing article citations. STUDY SELECTION AND DATA EXTRACTION All English-language, clinical trials and case series evaluating IV epoprostenol for the management or treatment of RP were included. Lower-quality evidence were incorporated due to limited information. DATA SYNTHESIS Seven small uncontrolled studies/case series, 1 small placebo controlled study, and 1 larger randomized trial were identified and included. There was no consistent measurement of efficacy utilized, but improvements in hand temperature, RP attack duration and frequency were commonly associated with IV epoprostenol treatment (5 trials). There were conflicting data regarding effect sustainability, with 5 trials showing long-term effects and 3 showing immediate effects. Fewer ischemic ulcers developed during treatment with IV epoprostenol in 1 trial compared to conventional treatment. Ulcer healing ocurred in 2 trials. Common adverse effects included hypotension, headache, flushing, gastrointestinal symptoms, and jaw pain. CONCLUSIONS Available evidence supports the use of IV epoprostenol for treatment of severe RP in patients refractory or intolerant to standard therapies. The dose, titration schedule, and duration of IV epoprostenol utilized in studies varied, but a conservative approach to initiation should be considered. Patients who do not respond to intermittent infusions and have severe digital ischemia may require more aggressive regimens.
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Affiliation(s)
- Joseph E Cruz
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA .,Department of Pharmacy, Englewood Hospital Medical Center, Englewood, NJ, USA
| | - Ashley Ward
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Shannon Anthony
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | | | | | - Evelyn R Hermes-DeSantis
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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