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Young NA, Schwarz E, Zeno BM, Bruckner S, Mesa RA, Jablonski K, Wu LC, Roberson EDO, Jarjour WN. Inhibition of miRNA associated with a disease-specific signature and secreted via extracellular vesicles of systemic lupus erythematosus patients suppresses target organ inflammation in a humanized mouse model. Front Immunol 2024; 14:1090177. [PMID: 38939646 PMCID: PMC11208704 DOI: 10.3389/fimmu.2023.1090177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2024] Open
Abstract
Introduction Distinct, disease-associated intracellular miRNA (miR) expression profiles have been observed in peripheral blood mononuclear cells (PBMCs) of systemic lupus erythematous (SLE) patients. Additionally, we have identified novel estrogenic responses in PBMCs from SLE patients and demonstrated that estrogen upregulates toll-like receptor (TLR)7 and TLR8 expression. TLR7 and TLR8 bind viral-derived single-stranded RNA to stimulate innate inflammatory responses, but recent studies have shown that miR-21, mir-29a, and miR-29b can also bind and activate these receptors when packaged and secreted in extracellular vesicles (EVs). The objective of this study was to evaluate the association of EV-encapsulated small RNA species in SLE and examine the therapeutic approach of miR inhibition in humanized mice. Methods Plasma-derived EVs were isolated from SLE patients and quantified. RNA was then isolated and bulk RNA-sequencing reads were analyzed. Also, PBMCs from active SLE patients were injected into immunodeficient mice to produce chimeras. Prior to transfer, the PBMCs were incubated with liposomal EVs containing locked nucleic acid (LNA) antagonists to miR-21, mir-29a, and miR-29b. After three weeks, blood was collected for both immunophenotyping and cytokine analysis; tissue was harvested for histopathological examination. Results EVs were significantly increased in the plasma of SLE patients and differentially expressed EV-derived small RNA profiles were detected compared to healthy controls, including miR-21, mir-29a, and miR-29b. LNA antagonists significantly reduced proinflammatory cytokines and histopathological infiltrates in the small intestine, liver, and kidney, as demonstrated by H&E-stained tissue sections and immunohistochemistry measuring human CD3. Discussion These data demonstrate distinct EV-derived small RNA signatures representing SLE-associated biomarkers. Moreover, targeting upregulated EV-encapsulated miR signaling by antagonizing miRs that may bind to TLR7 and TLR8 reveals a novel therapeutic opportunity to suppress autoimmune-mediated inflammation and pathogenesis in SLE.
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Affiliation(s)
- Nicholas A. Young
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Emily Schwarz
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Braden M. Zeno
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Shane Bruckner
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rosana A. Mesa
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kyle Jablonski
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Lai-Chu Wu
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH, United States
| | - Elisha D. O. Roberson
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Genetics, Washington University, St. Louis, MO, United States
| | - Wael N. Jarjour
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Athanassiou P, Athanassiou L. Current Treatment Approach, Emerging Therapies and New Horizons in Systemic Lupus Erythematosus. Life (Basel) 2023; 13:1496. [PMID: 37511872 PMCID: PMC10381582 DOI: 10.3390/life13071496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/18/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Systemic lupus erythematosus (SLE), the prototype of systemic autoimmune diseases is characterized by extreme heterogeneity with a variable clinical course. Renal involvement may be observed and affects the outcome. Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement. Conventional immunosuppressive therapy includes corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus. However, despite conventional immunosuppressive treatment, flares occur and broad immunosuppression is accompanied by multiple side effects. Flare occurrence, target organ involvement, side effects of broad immunosuppression and increased knowledge of the pathogenetic mechanisms involved in SLE pathogenesis as well as the availability of biologic agents has led to the application of biologic agents in SLE management. Biologic agents targeting various pathogenetic paths have been applied. B cell targeting agents have been used successfully. Belimumab, a B cell targeting agent, has been approved for the treatment of SLE. Rituximab, an anti-CD20 targeting agent is also used in SLE. Anifrolumab, an interferon I receptor-targeting agent has beneficial effects on SLE. In conclusion, biologic treatment is applied in SLE and should be further evaluated with the aim of a good treatment response and a significant improvement in quality of life.
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Affiliation(s)
| | - Lambros Athanassiou
- Department of Rheumatology, Asclepeion Hospital, Voula, GR16673 Athens, Greece
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3
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Kretschmann S, Völkl S, Reimann H, Krönke G, Schett G, Achenbach S, Lutzny-Geier G, Müller F, Mougiakakos D, Dingfelder J, Flamann C, Hanssens L, Gary R, Mackensen A, Aigner M. Successful Generation of CD19 Chimeric Antigen Receptor T Cells from Patients with Advanced Systemic Lupus Erythematosus. Transplant Cell Ther 2023; 29:27-33. [PMID: 36241147 DOI: 10.1016/j.jtct.2022.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/16/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
Although it has been shown that the production of functional chimeric antigen receptor T cells is feasible in patients with B-cell malignancies, it is currently unclear whether sufficient amounts of functional autologous CAR T cells can be generated from patients with autoimmune diseases. Intrinsic T-cell abnormalities and T-cell-targeted immune suppression in patients with autoimmunity may hamper the retrieval of sufficient T cells and their transduction and expansion into CAR T cells. Patients with active systemic lupus erythematosus (SLE) underwent leukapheresis after tapering glucocorticoids and stopping T-cell-suppressive drugs. This material was used as source for manufacturing anti-CD19 CAR T-cell products (CAR) in clinical scale. Cells were transduced with a lentiviral anti-CD19 CAR vector and expanded under good manufacturing practice (GMP) conditions using a closed, semi-automatic system. Functionality of these CAR T cells derived from autoimmune patient cells was tested in vitro. Six SLE patients were analyzed. Leukapheresis could be successfully performed in all patients yielding sufficient T-cell numbers for clinical scale CAR T-cell production. In addition, CAR T cells showed high expansion rates and viability, leading to CAR T cells in sufficient doses and quality for clinical use. CAR T cells from all patients showed specific cytotoxicity against CD19+ cell lines in vitro. GMP grade generation of CD19 CAR T-cell products suitable for clinical use is feasible in patients with autoimmune disease.
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Affiliation(s)
- S Kretschmann
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - S Völkl
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - H Reimann
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - G Krönke
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany; Department of Internal Medicine 3 - Rheumatology and Immunology, University Hospital of Erlangen, Erlangen, Germany
| | - G Schett
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany; Department of Internal Medicine 3 - Rheumatology and Immunology, University Hospital of Erlangen, Erlangen, Germany
| | - S Achenbach
- Department of Transfusion Medicine and Haemostaseology, University Hospital of Erlangen, Erlangen, Germany
| | - G Lutzny-Geier
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - F Müller
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - D Mougiakakos
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany; Department of Hematology and Oncology, University of Magdeburg, Magdeburg, Germany
| | - J Dingfelder
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - C Flamann
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - L Hanssens
- Miltenyi Biomedicine GmbH, Bergisch Gladbach, Germany
| | - R Gary
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - A Mackensen
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - M Aigner
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany; Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany.
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Langi Sasongko P, van Kraaij M, So‐Osman C. Using a scenario approach to assess for the current and future demand of immunoglobulins: An interview and literature study from The Netherlands. Transfus Med 2022; 32:410-421. [PMID: 35751376 PMCID: PMC9795925 DOI: 10.1111/tme.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the current and future demand of immunoglobulins globally and specifically for the Netherlands by assessing: (I) which specialties contribute to current demand, (II) new areas of medical need, (III) which transformational factors may impact demand and to what effect, by using a scenario approach. BACKGROUND As immunoglobulin demand continues to increase globally, there is concern of increasing shortages and questions of whether and how future demand will continue based on medical need. METHODS/MATERIALS In line with scenario principles, a scoping review of Pubmed, Web of Science, Embase and Cochrane and grey literature was conducted. Semi-structured interviews with subject matter experts were held. The results of the review and interviews were analysed for major themes. RESULTS The scoping review resulted in 97 articles, 74 regarding clinical uses, and 23 regarding organisational and other themes. Fifteen clinical and non-clinical experts were interviewed. I) Neurology, immunology, and haematology were specialties that contribute most to current demand. II) Regarding potential new areas of medical need, the literature review resulted in more indications than the interviews, for example, post-renal transplants. III) Four groups of key transformational factors were found: factors that could increase immunoglobulin demand (e.g., EMA revisions), decrease demand (e.g., replacement products, Dutch Transfer Act 2021), factors that remain to be seen how it impacts demand (e.g., further evidence), and miscellaneous factors (e.g., supply-related). CONCLUSION Having identified the specialties and relevant transformational factors that affect immunoglobulin demand, more research is needed on what clinical or organisational strategies would be effective in controlling demand in general for the Netherlands and abroad. Other blood establishments may also use a scenario approach to increase preparedness for future (un)expected developments.
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Affiliation(s)
- Praiseldy Langi Sasongko
- Department of Donor Medicine ResearchUnits Transfusion Technology Assessment and Donor Studies, Sanquin ResearchAmsterdamThe Netherlands,Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | | | - Cynthia So‐Osman
- Department of Unit Transfusion MedicineSanquin Blood BankAmsterdamThe Netherlands,Department of HaematologyErasmus Medical CenterRotterdamThe Netherlands
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5
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Villalobos F, Matellan C, Sequeira G, Kerzberg E. Drugs Recommended in Adult Rheumatic Diseases, But Considered for Off-Label Use in Argentina. REUMATOLOGIA CLINICA 2022; 18:286-292. [PMID: 35568442 DOI: 10.1016/j.reumae.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/14/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Off-label (OL) drug use is the prescription of a drug for indications other than those authorised in its technical datasheet. The objective of this study was to identify drugs recommended in rheumatology but considered for off-label use in Argentina. METHODS A list of medications for certain selected rheumatic conditions was compiled. A drug was considered recommended if it was endorsed by a) at least one Argentine or Pan-American treatment guideline or consensus, or b) two international treatment guidelines, or c) one international treatment guideline and one selected textbook. Approval of these drugs for any condition in Argentina until December 31st, 2018 was explored, and medicines were divided into those with on-label indications and those considered for OL use. RESULTS One hundred and thirty-six medications were analysed in 13 clinical conditions. Sixty-seven OL recommendations (49%) were found, and several drugs had more than one. All the conditions included the recommendation of at least 1 OL drug except osteoporosis and rheumatoid arthritis. The frequency of OL recommendations for the following conditions was 100%: calcium pyrophosphate dihydrate crystal deposition disease, polymyalgia rheumatica, Sjögren syndrome, and systemic sclerosis. The drugs with the highest number of OL recommendations were methotrexate (in 7 conditions), and glucocorticoids and mycophenolate (in 4). There were 2 OL recommendations for rituximab and 1 for abatacept. CONCLUSIONS Almost all the rheumatic disorders analysed involved the recommendation of at least 1 OL medication, and in 4 conditions all the recommendations were OL. Most OL drugs recommended in rheumatology are neither biological nor small-molecule therapies.
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Affiliation(s)
- Fernando Villalobos
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carla Matellan
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gabriel Sequeira
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Eduardo Kerzberg
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
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6
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Aringer M, Alarcón-Riquelme ME, Clowse M, Pons-Estel GJ, Vital EM, Dall’Era M. A glimpse into the future of systemic lupus erythematosus. Ther Adv Musculoskelet Dis 2022; 14:1759720X221086719. [PMID: 35368371 PMCID: PMC8972918 DOI: 10.1177/1759720x221086719] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/23/2022] [Indexed: 12/17/2022] Open
Abstract
This viewpoint article on a forecast of clinically meaningful changes in the management of systemic lupus erythematosus (SLE) in the next 10 years is based on a review of the current state of the art. The groundwork has been laid by a robust series of classification criteria and treatment recommendations that have all been published since 2019. Building on this strong foundation, SLE management predictably will take significant steps forward. Assessment for lupus arthritis will presumably include musculoskeletal sonography. Large-scale polyomics studies are likely to unravel more of the central immune mechanisms of the disease. Biomarkers predictive of therapeutic success may enter the field; the type I interferon signature, as a companion for use of anifrolumab, an antibody against the common type I interferon receptor, is one serious candidate. Besides anifrolumab for nonrenal SLE and the new calcineurin inhibitor voclosporin in lupus nephritis, both of which are already approved in the United States and likely to become available in the European Union in 2022, several other approaches are in advanced clinical trials. These include advanced B cell depletion, inhibition of costimulation via CD40 and CD40 ligand (CD40L), and Janus kinase 1 (Jak1) and Tyrosine kinase 2 (Tyk2) inhibition. At the same time, essentially all of our conventional therapeutic armamentarium will continue to be used. The ability of patients to have successful SLE pregnancies, which has become much better in the last decades, should further improve, with approaches including tumor necrosis factor blockade and self-monitoring of fetal heart rates. While we hope that the COVID-19 pandemic will soon be controlled, it has highlighted the risk of severe viral infections in SLE, with increased risk tied to certain therapies. Although there are some data that a cure might be achievable, this likely will remain a challenge beyond 10 years from now.
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Affiliation(s)
- Martin Aringer
- Professor of Medicine (Rheumatology), Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine, TU Dresden, 01307 Dresden, Germany
| | - Marta E. Alarcón-Riquelme
- Department of Medical Genomics, GENYO, Pfizer-University of Granada-Andalusian Government Center for Genomics and Oncological Research, Granada, Spain
| | - Megan Clowse
- Division of Rheumatology & Immunology, Duke University, Durham, NC, USA
| | - Guillermo J. Pons-Estel
- Department of Rheumatology, Grupo Oroño–Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Edward M. Vital
- University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maria Dall’Era
- Lupus Clinic and Rheumatology Clinical Research Center, Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Karasawa K, Ogura S, Takabe T, Miyabe Y, Iwabuchi Y, Akiyama K, Sato M, Moriyama T, Uchida K, Nitta K. Successful Treatment with Belimumab in a Patient with Refractory Systemic Lupus Erythematosus after Initiation of Hemodialysis: Considering the Synergistic Effect of Belimumab and Immunological Burn-Out Phenomenon in End-Stage Renal Disease Patients on Hemodialysis. Blood Purif 2021; 51:182-188. [PMID: 33895749 DOI: 10.1159/000512585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with systemic lupus erythematosus (SLE), disease activity can persist even after initiating dialysis. However, guidelines for the treatment of patients with SLE after dialysis is initiated have not yet been established. CASE PRESENTATION We describe the case of a 54-year-old Japanese woman who was diagnosed with SLE at age 12, progressed to end-stage renal disease (ESRD), and initiated hemodialysis for lupus nephritis. However, SLE activity persisted after hemodialysis. Cyclophosphamide and mycophenolate mofetil were administered in addition to prednisolone and immunoadsorption, but this treatment strategy was limited by side effects. The patient was subsequently treated with belimumab, and the activity of SLE decreased rapidly. CONCLUSIONS ESRD patients with SLE show no significant decrease in transitional B cells and have elevated levels of B-cell activating factor (BAFF). Both transitional B cells and BAFF are important therapeutic targets for belimumab, indicating that patients with ESRD may benefit from belimumab therapy. However, the effects of belimumab may be potentiated in patients with uremia, who may be more susceptible to adverse events such as infections. Patients with SLE who receive belimumab after initiation of hemodialysis therefore require careful follow-up. Here, we report the first case of belimumab administration in a patient with SLE after initiation of hemodialysis.
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Affiliation(s)
- Kazunori Karasawa
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shota Ogura
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomo Takabe
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoei Miyabe
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuko Iwabuchi
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenichi Akiyama
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayo Sato
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahito Moriyama
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Keiko Uchida
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
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Villalobos F, Matellan C, Sequeira G, Kerzberg E. Drugs Recommended in Adult Rheumatic Diseases, But Considered for Off-Label Use in Argentina. REUMATOLOGIA CLINICA 2021; 18:S1699-258X(21)00030-9. [PMID: 33640322 DOI: 10.1016/j.reuma.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/19/2020] [Accepted: 01/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Off-label (OL) drug use is the prescription of a drug for indications other than those authorised in its technical datasheet. The objective of this study was to identify drugs recommended in rheumatology but considered for off-label use in Argentina. METHODS A list of medications for certain selected rheumatic conditions was compiled. A drug was considered recommended if it was endorsed by a) at least one Argentine or Pan-American treatment guideline or consensus, or b) two international treatment guidelines, or c) one international treatment guideline and one selected textbook. Approval of these drugs for any condition in Argentina until December 31st, 2018 was explored, and medicines were divided into those with on-label indications and those considered for OL use. RESULTS One hundred and thirty-six medications were analysed in 13 clinical conditions. Sixty-seven OL recommendations (49%) were found, and several drugs had more than one. All the conditions included the recommendation of at least 1 OL drug except osteoporosis and rheumatoid arthritis. The frequency of OL recommendations for the following conditions was 100%: calcium pyrophosphate dihydrate crystal deposition disease, polymyalgia rheumatica, Sjögren syndrome, and systemic sclerosis. The drugs with the highest number of OL recommendations were methotrexate (in 7 conditions), and glucocorticoids and mycophenolate (in 4). There were 2 OL recommendations for rituximab and 1 for abatacept. CONCLUSIONS Almost all the rheumatic disorders analysed involved the recommendation of at least 1 OL medication, and in 4 conditions all the recommendations were OL. Most OL drugs recommended in rheumatology are neither biological nor small-molecule therapies.
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Affiliation(s)
- Fernando Villalobos
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carla Matellan
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gabriel Sequeira
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Eduardo Kerzberg
- Servicio de Reumatología, Hospital J. M. Ramos Mejia, Urquiza 609, Ciudad Autónoma de Buenos Aires, Argentina
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10
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Winthrop KL, Weinblatt ME, Bathon J, Burmester GR, Mease PJ, Crofford L, Bykerk V, Dougados M, Rosenbaum JT, Mariette X, Sieper J, Melchers F, Cronstein BN, Breedveld FC, Kalden J, Smolen JS, Furst D. Unmet need in rheumatology: reports from the Targeted Therapies meeting 2019. Ann Rheum Dis 2019; 79:88-93. [PMID: 31662322 PMCID: PMC6937409 DOI: 10.1136/annrheumdis-2019-216151] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/04/2019] [Indexed: 12/30/2022]
Abstract
Objectives To detail the greatest areas of unmet scientific and clinical needs in rheumatology. Methods The 21st annual international Advances in Targeted Therapies meeting brought together more than 100 leading basic scientists and clinical researchers in rheumatology, immunology, epidemiology, molecular biology and other specialties. During the meeting, breakout sessions were convened, consisting of 5 disease-specific groups with 20–30 experts assigned to each group based on expertise. Specific groups included: rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, systemic lupus erythematosus and other systemic autoimmune rheumatic diseases. In each group, experts were asked to identify unmet clinical and translational research needs in general and then to prioritise and detail the most important specific needs within each disease area. Results Overarching themes across all disease states included the need to innovate clinical trial design with emphasis on studying patients with refractory disease, the development of trials that take into account disease endotypes and patients with overlapping inflammatory diseases, the need to better understand the prevalence and incidence of inflammatory diseases in developing regions of the world and ultimately to develop therapies that can cure inflammatory autoimmune diseases. Conclusions Unmet needs for new therapies and trial designs, particularly for those with treatment refractory disease, remain a top priority in rheumatology.
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Affiliation(s)
| | | | - Joan Bathon
- Columbia University, College of Physicians & Surgeons, New York City, New York, USA
| | | | - Philip J Mease
- Swedish Medical Center, University of Washington, Seattle, Washington, USA
| | | | - Vivian Bykerk
- Hospital for Special Surgery, New York City, New York, USA
| | | | - James Todd Rosenbaum
- Oregon Health Sciences University, Portland, Oregon, USA.,Legacy Devers Eye Institute, Portland, Oregon, USA
| | - Xavier Mariette
- Paris-Sud University, APHP Université Paris-Saclay, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité, Berlin, Germany
| | - Fritz Melchers
- Max Planck Institute for Infection Biology, Berlin, Germany
| | | | | | | | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of, Vienna, Vienna, Austria
| | - Daniel Furst
- Swedish Medical Center, University of Washington, Seattle, Washington, USA.,University of California, Los Angeles Medical Center, Los Angeles, CA, USA.,University of Florence, Florence, Italy
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Scolnik M, Scaglioni V, Pons-Estel GJ, Soriano ER. Management of non-renal non-neurologic persistent lupus activity in real world patients from Argentina. Lupus 2019; 28:1167-1173. [PMID: 31299882 DOI: 10.1177/0961203319861687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Management of systemic lupus erythematosus patients is challenging because of disease heterogeneity. Although treatment of renal nephritis is more standardized, treating non-renal lupus activity remains controversial. Our objective was to identify non-renal, non-neurologic persistent active systemic lupus erythematosus patients in our cohort and described therapeutic behaviors in them. All systemic lupus erythematosus patients (American College of Rheumatology and/or Systemic Lupus Erythematosus International Collaborating Clinics criteria) seen at a university hospital between 2000 and 2017 were included and electronic medical records manually reviewed. Persistent lupus activity was defined as a patient with a Systemic Lupus Erythematosus Disease Activity Index score ≥ 6 (without renal and central nervous system manifestations) despite being on a stable treatment regimen for ≥ 30 days. Stable treatment could include prednisone alone (7.5-40 mg/d) or combined with antimalarial drugs and immunosuppressant therapies. A total of 257 lupus patients were included, 230 females (89.5%, 95% confidence interval 85.1-92.7), mean age at diagnosis 29.9 years (SD 16.4). After a median cohort follow-up of 5.7 years (interquartile range 2.4-10.2), 14 patients (5.4%, 95% confidence interval 3.2-9.0) showed persistent non-renal non neurologic lupus activity, with a median disease duration of 11.3 years (interquartile range 3.6-19.4). At that time, 12/14 (85.7 %, 95% confidence interval 52.6-97.0%) had low complement and 11/14 (78.6 %, 95% confidence interval 46.5-93.9%) had positive antiDNA antibodies. The main reasons for being refractory were mucocutaneous disease (50%, 95% confidence interval 23.5-76.5) and arthritis (42.9%, 95% confidence interval 18.5-71.2). Therapeutic choices after being refractory were: only increasing corticosteroid dose in one patient, starting rituximab in four, belimumab in eight, and in one mycophenolate and rituximab; with good response in all of them. In conclusion, 5.4% of systemic lupus erythematosus patients in our cohort were considered to have non-renal non neurologic persistent lupus activity, with mucocutaneous and arthritis the main manifestations. In total, 92.8% of these patients started a biologic treatment at this point (rituximab or belimumab).
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Affiliation(s)
- M Scolnik
- 1 Rheumatology Section, Hospital Italiano de Buenos Aires, Argentina.,2 Department of Medicine, Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
| | - V Scaglioni
- 1 Rheumatology Section, Hospital Italiano de Buenos Aires, Argentina.,2 Department of Medicine, Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
| | - G J Pons-Estel
- 3 Internal Medicine Department, Centro Regional de Enfermedades Autoinmunes y Reumáticas, Rosario, Argentina.,4 Rheumatology Service, Hospital Provincial de Rosario, Rosario, Argentina
| | - E R Soriano
- 1 Rheumatology Section, Hospital Italiano de Buenos Aires, Argentina.,2 Department of Medicine, Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
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12
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Berlit P, Krämer M. Cerebral involvement in systemic vasculitides: Extracts from the guideline of the German neurological society. Neurol Res Pract 2019; 1:13. [PMID: 33324879 PMCID: PMC7650123 DOI: 10.1186/s42466-019-0016-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/22/2019] [Indexed: 01/09/2023] Open
Abstract
Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of cerebral manifestations of systemic vasculitides and rheumatic diseases. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies. This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y.
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Affiliation(s)
- Peter Berlit
- Deutsche Gesellschaft für Neurologie, Reinhardtstr. 27 C, 10117 Berlin, Germany
| | - Markus Krämer
- Neurologie, Alfried-Krupp-Krankenhaus Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
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13
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Sattwika PD, Mustafa R, Paramaiswari A, Herningtyas EH. Stem cells for lupus nephritis: a concise review of current knowledge. Lupus 2018; 27:1881-1897. [PMID: 30099942 DOI: 10.1177/0961203318793206] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Lupus nephritis (LN), a common manifestation of systemic lupus erythematosus (SLE), accounts for significant morbidity and mortality in SLE patients. Since the available standard therapies and biologic agents for LN are yet to achieve the desired response and have considerable secondary effects, stem cell therapy has now emerged as a new approach. This therapy involves the transplantation of hematopoietic stem cells (HSCs) and mesenchymal stem cells (MSCs). Our current review will highlight the progress of stem cell therapy for LN, along with the challenges encountered and the future direction of this approach.
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Affiliation(s)
- P D Sattwika
- 1 Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/Dr Sardjito General Hospital, Indonesia
| | - R Mustafa
- 2 Clinical Epidemiology and Biostatistics Unit, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/Dr Sardjito General Hospital, Indonesia
| | - A Paramaiswari
- 3 Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/Dr Sardjito General Hospital, Indonesia
| | - E H Herningtyas
- 4 Department of Clinical Pathology and Laboratory Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia
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14
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Aringer M, Denton CP. Systemic sclerosis phase III clinical trials: Hope on the horizon? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:193-200. [DOI: 10.1177/2397198318775353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/15/2018] [Indexed: 12/19/2022]
Abstract
While significant progress has been made in treating systemic sclerosis, many patients still have an outcome that is far from satisfactory. For the first time in history, several drugs are now in phase III randomized controlled trials. Approaches tested include the anti-B cell antibody rituximab, the anti-interleukin-6 receptor antibody tocilizumab, the antifibrotic drugs nintedanib and pirfenidone, and the cannabinoid receptor mimetic lenabasum. That all these drugs are in advanced clinical trials despite the relatively low incidence of the disease therefore is good news. Not only is there realistic hope that at least some of the approaches will work, this also indicates growing industry interest, for most of the trials are company-sponsored. This review attempts to delineate the ongoing trials and to summarize the underlying evidence of these candidate systemic sclerosis drugs.
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Affiliation(s)
- Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christopher P Denton
- Royal Free Hospital and Centre for Rheumatology and Connective Tissue Diseases, University College London, London, UK
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15
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Interleukin-1 receptor associated kinase 1 is a potential therapeutic target of anti-inflammatory therapy for systemic lupus erythematosus. Mol Immunol 2017; 87:94-101. [DOI: 10.1016/j.molimm.2017.03.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/17/2017] [Accepted: 03/27/2017] [Indexed: 02/06/2023]
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16
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Crepeau RL, Ford ML. Challenges and opportunities in targeting the CD28/CTLA-4 pathway in transplantation and autoimmunity. Expert Opin Biol Ther 2017; 17:1001-1012. [PMID: 28525959 DOI: 10.1080/14712598.2017.1333595] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION T cell activation is a complex process that requires multiple cell signaling pathways, including a primary recognition signal and additional costimulatory signals. One of the best-characterized costimulatory pathways includes the Ig superfamily members CD28 and CTLA-4 and their ligands CD80 and CD86. Areas covered: This review discusses past, current and future biological therapies that have been utilized to block the CD28/CTLA-4 cosignaling pathway in the settings of autoimmunity and transplantation, as well the challenges facing successful implementation of these therapies. Expert opinion: The development of CD28 blockers Abatacept and Belatacept provided a more targeted therapy approach for transplant rejection and autoimmune disease relative to calcineurin inhibitors and anti-proliferatives, but overall efficacy may be limited due to their collateral effect of simultaneously blocking CTLA-4 coinhibitory signals. As such, current investigations into the potential of selective CD28 blockade to block the costimulatory potential of CD28 while exploiting the coinhibitory effects of CTLA-4 are promising. However, as selective CD28 blockade inhibits the activity of both effector and regulatory T cells, an important goal for the future is the design of therapies that will maximize the attenuation of effector responses while preserving the suppressive function of T regulatory cells.
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Affiliation(s)
- Rebecca L Crepeau
- a Emory Transplant Center and Department of Surgery , Emory University , Atlanta , GA , USA
| | - Mandy L Ford
- a Emory Transplant Center and Department of Surgery , Emory University , Atlanta , GA , USA
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17
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Aqel SI, Hampton JM, Bruss M, Jones KT, Valiente GR, Wu LC, Young MC, Willis WL, Ardoin S, Agarwal S, Bolon B, Powell N, Sheridan J, Schlesinger N, Jarjour WN, Young NA. Daily Moderate Exercise Is Beneficial and Social Stress Is Detrimental to Disease Pathology in Murine Lupus Nephritis. Front Physiol 2017; 8:236. [PMID: 28491039 PMCID: PMC5405126 DOI: 10.3389/fphys.2017.00236] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 04/04/2017] [Indexed: 12/21/2022] Open
Abstract
Daily moderate exercise (DME) and stress management are underemphasized in the care of patients with lupus nephritis (LN) due to a poor comprehensive understanding of their potential roles in controlling the inflammatory response. To investigate these effects on murine LN, disease progression was monitored with either DME or social disruption stress (SDR) induction in NZM2410/J mice, which spontaneously develop severe, early-onset LN. SDR of previously established social hierarchies was performed daily for 6 days and DME consisted of treadmill walking (8.5 m/min for 45 min/day). SDR significantly enhanced kidney disease when compared to age-matched, randomly selected control counterparts, as measured by histopathological analysis of H&E staining and immunohistochemistry for complement component 3 (C3) and IgG complex deposition. Conversely, while 88% of non-exercised mice displayed significant renal damage by 43 weeks of age, this was reduced to 45% with exercise. DME also reduced histopathology in kidney tissue and significantly decreased deposits of C3 and IgG complexes. Further examination of renal infiltrates revealed a macrophage-mediated inflammatory response that was significantly induced with SDR and suppressed with DME, which also correlated with expression of inflammatory mediators. Specifically, SDR induced IL-6, TNF-α, IL-1β, and MCP-1, while DME suppressed IL-6, TNF-α, IL-10, CXCL1, and anti-dsDNA autoantibodies. These data demonstrate that psychological stressors and DME have significant, but opposing effects on the chronic inflammation associated with LN; thus identifying and characterizing stress reduction and a daily regimen of physical activity as potential adjunct therapies to complement pharmacological intervention in the management of autoimmune disorders, including LN.
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Affiliation(s)
- Saba I Aqel
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Jeffrey M Hampton
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Michael Bruss
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Kendra T Jones
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Giancarlo R Valiente
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Lai-Chu Wu
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | | | - William L Willis
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Stacy Ardoin
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Sudha Agarwal
- Ohio State University Wexner Medical CenterColumbus, OH, USA.,The Biomechanics and Tissue Engineering Laboratory, College of Dentistry, Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Brad Bolon
- Ohio State University Wexner Medical CenterColumbus, OH, USA.,Department of Veterinary Biosciences and the Comparative Pathology and Mouse Phenotyping Shared ResourceColumbus, OH, USA
| | - Nicole Powell
- Ohio State University Wexner Medical CenterColumbus, OH, USA.,Institute for Behavioral Medicine Research, Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - John Sheridan
- Ohio State University Wexner Medical CenterColumbus, OH, USA.,Institute for Behavioral Medicine Research, Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Naomi Schlesinger
- Division of Rheumatology, Department of Medicine, Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, NJ, USA
| | - Wael N Jarjour
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
| | - Nicholas A Young
- Department of Internal Medicine Division of Rheumatology and Immunology, Ohio State University Wexner Medical CenterColumbus, OH, USA.,Ohio State University Wexner Medical CenterColumbus, OH, USA
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International and multidisciplinary expert recommendations for the use of biologics in systemic lupus erythematosus. Autoimmun Rev 2017; 16:650-657. [PMID: 28434948 DOI: 10.1016/j.autrev.2017.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/26/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE Despite conventional immunosuppressants, active and steroid-dependent systemic lupus erythematosus (SLE) represents a therapeutic challenge. Only one biologic, belimumab, has been approved, but other biologics are sometimes used off-label. Given the lack of evidence-based data in some clinical situations encountered in real life, we developed expert recommendations for the use of biologics for SLE. METHODS The recommendations were developed by a formal consensus method. This method aims to formalize the degree of agreement among experts by identifying, through iterative ratings with feedback, the points on which experts agree, disagree or are undecided. Hence, the recommendations are based on the agreed-upon points. We gathered the opinion of 59 French-speaking SLE experts from 3 clinical networks dedicated to systemic autoimmune diseases (FLEUR, IMIDIATE, FAI2R) from Algeria, Belgium, France, Italy, Morocco, Switzerland and Tunisia. Represented medical specialities were internal medicine (49%), rheumatology (34%), nephrology (7%), dermatology (5%), pediatrics (3%) and cardiology (2%). Two methodologists and 3 strictly independent SLE expert groups contributed to developing these recommendations: a steering group (SG) (n=9), an evaluation group (EG) (n=28) and a reading group (RG) (n=22). Preliminary recommendations were drafted by the SG, then proposed to the EG. Each EG member rated the degree of agreement from 1 to 9 (1: lowest; 9: strongest) for each recommendation. After 2 rating rounds, the SG submitted a new version of the recommendations to the RG. With comments from the RG, the SG finalised the recommendations. RESULTS A total of 17 final recommendations were formulated by the SG, considering all agreement scores and comments by the EG and RG members and the two methodologists. These recommendations define the subset of patients who require a biologic; the type of biologics to use (belimumab, rituximab, etc.) depending on the organ involvement and associated co-treatments; what information should be given to patients; and how to evaluate treatment efficacy and when to consider discontinuation. CONCLUSION Overall, 17 recommendations for the good use of biologics in SLE were formulated by a large panel of SLE experts to provide guidance for clinicians in daily practice. These recommendations will be regularly updated according to the results of new randomized trials and increasing real life experience.
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Aringer M, Leuchten N, Fischer-Betz R. Ausschleichen und Beenden von immunsuppressiven Therapien. Z Rheumatol 2017; 76:27-32. [DOI: 10.1007/s00393-016-0258-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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20
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Partizipative Entscheidungsfindung auch bei komplexen systemischen Autoimmunerkrankungen wie dem systemischen Lupus erythematodes (SLE)? Z Rheumatol 2016; 76:219-227. [DOI: 10.1007/s00393-016-0208-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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21
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Postal M, Sinicato NA, Appenzeller S, Niewold TB. Drugs in early clinical development for Systemic Lupus Erythematosus. Expert Opin Investig Drugs 2016; 25:573-83. [PMID: 26950689 DOI: 10.1517/13543784.2016.1162291] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION While immunosuppressive therapy has positively impacted the prognosis of systemic lupus erythematosus (SLE), many patients still do not respond to traditional therapy. Thus, active SLE disease remains a significant problem. Furthermore, conventional immunosuppressive treatments for SLE are associated a high risk of side effects. These issues call for improvement in our current therapeutic armamentarium. AREAS COVERED In this review, the authors highlight the recent developments in therapies for SLE, and present an overview of drugs which are in early clinical development for SLE. There are many new therapeutic approaches being developed, including those focused on B-cell targets, T-cell downregulation, co-stimulatory blockade, anti-cytokine agents, and kinase inhibition, and Toll-like receptor inhibition. They also discuss peptide therapy as a potential method to re-establish immune tolerance, and some of the challenges ahead in developing and testing novel agents for SLE. EXPERT OPINION Many novel agents are currently in development for SLE, but this encouraging news is tempered by several disappointments in clinical trials and provides a timely moment to reflect on the future of therapeutic development in SLE. It seems likely that biological heterogeneity between patients is a major contributor to difficulty in drug design in SLE.
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Affiliation(s)
- Mariana Postal
- a Rheumatology Unit, Department of Medicine, Faculty of Medical Science , State University of Campinas , Campinas , Brazil
| | - Nailú Angélica Sinicato
- a Rheumatology Unit, Department of Medicine, Faculty of Medical Science , State University of Campinas , Campinas , Brazil
| | - Simone Appenzeller
- a Rheumatology Unit, Department of Medicine, Faculty of Medical Science , State University of Campinas , Campinas , Brazil
| | - Timothy B Niewold
- b Division of Rheumatology, Department of Immunology , Mayo Clinic , Rochester , MN , USA
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22
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Pimentel-Quiroz VR, Ugarte-Gil MF, Alarcón GS. Abatacept for the treatment of systemic lupus erythematosus. Expert Opin Investig Drugs 2016; 25:493-9. [PMID: 26878310 DOI: 10.1517/13543784.2016.1154943] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Due to improvements in our understanding of the pathogenesis of systemic lupus erythematosus (SLE), several target drugs have been and are being developed. One of the possible targets in SLE is co-stimulation between antigen-presenting cells and T cells. Abatacept is a co-stimulation moderator approved for the treatment of several autoimmune diseases. There is an unmet need for drugs with a better efficacy and safety profile when treating patients with SLE. AREAS COVERED In this review, the authors discuss the mechanism of action of abatacept including its role in the immune system and glomeruli, and relevant information about its clinical efficacy and safety. Possible explanations for the failure of previous randomized clinical trials are also discussed. EXPERT OPINION Abatacept has demonstrated efficacy in other autoimmune diseases, but in SLE, randomized clinical trials have failed to achieve their primary outcome. Despite these disappointing results and based on its mechanism of action, abatacept seems to have a role in lupus nephritis and arthritis. This should be corroborated with new trials which hopefully will overcome the design pitfalls of the ones conducted to date.
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Affiliation(s)
| | - Manuel F Ugarte-Gil
- a Rheumatology Department , Hospital Guillermo Almenara Irigoyen, EsSalud , Lima , Peru.,b School of Medicine, Universidad Científica del Sur , Lima , Peru
| | - Graciela S Alarcón
- c Division of Clinical Immunology and Rheumatology, School of Medicine , The University of Alabama at Birmingham , Birmingham , AL , USA
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Tunnicliffe DJ, Singh-Grewal D, Kim S, Craig JC, Tong A. Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus: A Systematic Review of Clinical Practice Guidelines. Arthritis Care Res (Hoboken) 2015; 67:1440-52. [DOI: 10.1002/acr.22591] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/05/2015] [Accepted: 03/10/2015] [Indexed: 12/16/2022]
Affiliation(s)
| | - Davinder Singh-Grewal
- University of Sydney, Sydney Children's Hospital's Network, and University of New South Wales; Sydney Australia
| | - Siah Kim
- University of Sydney and Children's Hospital at Westmead; Sydney Australia
| | - Jonathan C. Craig
- University of Sydney and Children's Hospital at Westmead; Sydney Australia
| | - Allison Tong
- University of Sydney and Children's Hospital at Westmead; Sydney Australia
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Photosensitivity, apoptosis, and cytokines in the pathogenesis of lupus erythematosus: a critical review. Clin Rev Allergy Immunol 2015; 47:148-62. [PMID: 24420508 DOI: 10.1007/s12016-013-8403-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The underlying pathomechanisms of lupus erythematosus (LE), a multifactorial autoimmune disease, remain elusive. Due to the clinical evidence demonstrating a clear relationship between ultraviolet (UV) light exposure and skin lesions of LE, photosensitivity has been proven to be an important factor in the pathogenesis of the disease. Standardised photoprovocation with UVA and UVB irradiation has been shown to be a reliable model for evaluating photosensitivity in patients with cutaneous LE (CLE) and analysing the underlying medical conditions of the disease. In this respect, UV irradiation can cause aberrant induction of apoptosis in keratinocytes and contribute to the appearance of excessive apoptotic cells in the skin of CLE patients. Moreover, apoptotic cells that cannot be cleared by phagocytes may undergo secondary necrosis and release proinflammatory compounds and potential autoantigens, which may contribute to the inflammatory micromilieu that leads to formation of skin lesions in the disease. In addition to UV-mediated induction of apoptosis, the molecular and cellular factors that may cause the abnormal long-lasting photoreactivity in CLE include mediators of inflammation, such as cytokines and chemokines. In particular, interferons (IFNs) are important players in the early activation of the immune system and have a specific role in the immunological interface between the innate and the adaptive immune system. The fact that treatment with recombinant type I IFNs (α and β) can induce not only systemic organ manifestations but also LE-like skin lesions provides additional evidence for a pathogenetic role of these IFNs in the disease.
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Fassbinder T, Saunders U, Mickholz E, Jung E, Becker H, Schlüter B, Jacobi AM. Differential effects of cyclophosphamide and mycophenolate mofetil on cellular and serological parameters in patients with systemic lupus erythematosus. Arthritis Res Ther 2015; 17:92. [PMID: 25890338 PMCID: PMC4422597 DOI: 10.1186/s13075-015-0603-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 03/17/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Disease activity and therapy show an impact on cellular and serological parameters in patients with systemic lupus erythematosus (SLE). This study was performed to compare the influence of mycophenolate mofetil (MMF) and cyclophosphamide (CYC) therapy on these parameters in patients with flaring, organ-threatening disease. METHODS SLE patients currently receiving CYC (n = 20), MMF (n = 25) or no immunosuppressive drugs (n = 22) were compared using a cross-sectional design. Median disease activity and daily corticosteroid dose were similar in these treatment groups. Concurrent medication, organ manifestations, and disease activity were recorded, and cellular and serological parameters were determined by routine diagnostic tests or flow cytometric analysis. In addition follow-up data were obtained from different sets of patients (CYC n = 24; MMF n = 23). RESULTS Although both drugs showed a significant effect on disease activity and circulating B cell subsets, only MMF reduced circulating plasmablasts and plasma cells as well as circulating free light chains within three months of induction therapy. Neither MMF nor CYC were able to reduce circulating memory B cells. MMF lowered IgA levels more markedly than CYC. We did not observe a significant difference in the reduction of IgG levels or anti-dsDNA antibodies comparing patients receiving MMF or CYC. In contrast to MMF, induction therapy with CYC was associated with a significant increase of circulating CD8+ effector T cells and plasmacytoid dendritic cells (PDCs) after three months. CONCLUSIONS The results indicate differences between MMF and CYC with regard to the mechanism of action. MMF, but not CYC, treatment leads to a fast and enduring reduction of surrogate markers of B cell activation, such as circulating plasmablasts, plasma cells and free light chains but a comparable rate of hypogammaglobulinemia.
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Affiliation(s)
- Till Fassbinder
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Ute Saunders
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Eva Mickholz
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Elisabeth Jung
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Heidemarie Becker
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Bernhard Schlüter
- Center for Laboratory Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Annett Marita Jacobi
- Division of Rheumatology and Clinical Immunology/ Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany. .,Division of Rheumatology and Clinical Immunology, Brandenburg Medical School, Fehrbelliner Str. 38, 16816, Neuruppin, Germany.
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Sakai R, Cho SK, Nanki T, Watanabe K, Yamazaki H, Tanaka M, Koike R, Tanaka Y, Saito K, Hirata S, Amano K, Nagasawa H, Sumida T, Hayashi T, Sugihara T, Dobashi H, Yasuda S, Sawada T, Ezawa K, Ueda A, Fujii T, Migita K, Miyasaka N, Harigai M. Head-to-head comparison of the safety of tocilizumab and tumor necrosis factor inhibitors in rheumatoid arthritis patients (RA) in clinical practice: results from the registry of Japanese RA patients on biologics for long-term safety (REAL) registry. Arthritis Res Ther 2015; 17:74. [PMID: 25880658 PMCID: PMC4384380 DOI: 10.1186/s13075-015-0583-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/24/2015] [Indexed: 01/12/2023] Open
Abstract
Introduction The objective of this study was to directly compare the safety of tocilizumab (TCZ) and TNF inhibitors (TNFIs) in rheumatoid arthritis (RA) patients in clinical practice. Methods This prospective cohort study included RA patients starting TCZ [TCZ group, n = 302, 224.68 patient-years (PY)] or TNFIs [TNFI group, n = 304, 231.01 PY] from 2008 to 2011 in the registry of Japanese RA patients on biologics for long-term safety registry. We assessed types and incidence rates (IRs) of serious adverse events (SAEs) and serious infections (SIs) during the first year of treatment. Risks of the biologics for SAEs or SIs were calculated using the Cox regression hazard analysis. Results Patients in the TCZ group had longer disease duration (P <0.001), higher disease activity (P = 0.019) and more frequently used concomitant corticosteroids (P <0.001) than those in the TNFI group. The crude IR (/100 PY) of SIs [TCZ 10.68 vs. TNFI 3.03; IR ratio (95% confidence interval [CI]), 3.53 (1.52 to 8.18)], but not SAEs [21.36 vs. 14.72; 1.45 (0.94 to 2.25)], was significantly higher in the TCZ group compared with the TNFI group. However, after adjusting for covariates using the Cox regression hazard analysis, treatment with TCZ was not associated with higher risk for SAEs [hazard ratio (HR) 1.28, 95% CI 0.75 to 2.19] or SIs (HR 2.23, 95% CI 0.93 to 5.37). Conclusions The adjusted risks for SAEs and SIs were not significantly different between TCZ and TNFIs, indicating an influence of clinical characteristics of the patients on the safety profile of the biologics in clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0583-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ryoko Sakai
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Soo-Kyung Cho
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, South Korea.
| | - Toshihiro Nanki
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Kaori Watanabe
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Hayato Yamazaki
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Michi Tanaka
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Ryuji Koike
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Clinical Research Center, Tokyo Medical and Dental University Hospital, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Yoshiya Tanaka
- The First Department of Internal medicine, University of Occupational and Environmental Health, 1-1, Iseigaoka, Kitakyushu Yahatanishi-ku, Fukuoka, 807-0804, Japan.
| | - Kazuyoshi Saito
- The First Department of Internal medicine, University of Occupational and Environmental Health, 1-1, Iseigaoka, Kitakyushu Yahatanishi-ku, Fukuoka, 807-0804, Japan.
| | - Shintaro Hirata
- The First Department of Internal medicine, University of Occupational and Environmental Health, 1-1, Iseigaoka, Kitakyushu Yahatanishi-ku, Fukuoka, 807-0804, Japan.
| | - Koichi Amano
- Department of Rheumatology/Clinical Immunology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan.
| | - Hayato Nagasawa
- Department of Rheumatology/Clinical Immunology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan.
| | - Takayuki Sumida
- Division of Clinical Immunology, Doctoral Program in Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-0006, Japan.
| | - Taichi Hayashi
- Division of Clinical Immunology, Doctoral Program in Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-0006, Japan.
| | - Takahiko Sugihara
- Department of Rheumatology, Tokyo Metropolitan Geriatric Hospital, 35-2, Sakaecho, Itabashi-ku, Tokyo, 173-0015, Japan.
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Shinsuke Yasuda
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Kita 15. Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University, Nishi-Shinjuku 6-7-1, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kazuhiko Ezawa
- Department of Internal Medicine, Kurashiki Kousai Hospital, 3542-1, Nakasho, Kurashiki-shi, Okayama, 710-0016, Japan.
| | - Atsuhisa Ueda
- Department of Internal Medicine and Clinical Immunology, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Takao Fujii
- Department of the Control for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto, 606-8501, Japan.
| | - Kiyoshi Migita
- Department of Rheumatology, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura, Nagasaki, 856-8562, Japan.
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Global Center of Excellence (GCOE) Program, International Research Center for Molecular Science in Tooth and Bone Diseases, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Masayoshi Harigai
- Department of Pharmacovigilance, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Nasonov E, Soloviev S, Davidson JE, Lila A, Togizbayev G, Ivanova R, Baimukhamedov C, Omarbekova Z, Iaremenko O, Gnylorybov A, Shevchuk S, Vasylyev A, Pereira MHS. Standard medical care of patients with systemic lupus erythematosus (SLE) in large specialised centres: data from the Russian Federation, Ukraine and Republic of Kazakhstan (ESSENCE). Lupus Sci Med 2015; 2:e000060. [PMID: 25717382 PMCID: PMC4336862 DOI: 10.1136/lupus-2014-000060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/18/2014] [Accepted: 01/26/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe disease characteristics and treatment regimens for adult patients with systemic lupus erythematosus (SLE) with autoantibody positive disease in three countries (the Russian Federation, Ukraine and Republic of Kazakhstan). METHODS The Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events (ESSENCE) study was a 1-year, retrospective, multicentre, observational study. Data included patients' characteristics, disease activity and severity, and healthcare resource use in 2010. RESULTS Twelve centres enrolled 436 eligible patients: 232 in Russia, 110 in Kazakhstan and 94 in Ukraine. Mean age ranged from 36 to 42 years and median SLE duration from 3 to 6.8 years. According to study definitions, 69.2% of patients in Russia, 72.7% in Kazakhstan and 55.4% in Ukraine had severe disease at diagnosis. SLE activity (Nasonova classification, 1972) decreased from diagnosis to the last visit in 2010 in all countries. At the last visit, mean (SD) Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index score was 13.8 (10.5) in Russia, 19.4 (16.9) in Kazakhstan and 7.2 (6.8) in Ukraine, and Systemic Lupus International Collaborative Clinics/American College of Rheumatology damage index was 2.0 (2.2), 3.3 (3.2) and 2.2 (2.0), respectively. Treatment regimens included predominantly glucocorticoids (96.7-99.1%), immunosuppressants or cytotoxic drugs, for example, azathioprine and cyclophosphamide (20.7-53.2%), and antimalarial drugs (18.3-40.8%). CONCLUSIONS The study provides reliable insight into the SLE clinical profiles in the referenced countries. Patients were 4-10 years younger in the study and had 3-7 years shorter SLE duration than in Western European countries and both SLE activity and severity were higher with higher rate of hospitalisations, but decreased during treatment. Local and international scales demonstrated correlation in SLE activity and organ damage evaluation. There were differences in clinical characteristics and healthcare features across the countries.
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Affiliation(s)
- E Nasonov
- Institute of Rheumatology at Russian Academy of Medical Science , Moscow , Russian Federation
| | - S Soloviev
- Institute of Rheumatology at Russian Academy of Medical Science , Moscow , Russian Federation
| | - J E Davidson
- Worldwide Epidemiology, GlaxoSmithKline R&D, Stockley Park , London , UK
| | - A Lila
- North-Western Medical University named after I.I. Mechnikov , St Petersburg , Russian Federation
| | - G Togizbayev
- Kazakh Medical University of Continuing Education , Almaty , Kazakhstan
| | - R Ivanova
- Internal Medicine Department, Semey State Medical University , Semey , Kazakhstan
| | - Ch Baimukhamedov
- Kazakh Medical University of Continuing Education , Almaty , Kazakhstan
| | - Zh Omarbekova
- Kazakh Medical University of Continuing Education , Almaty , Kazakhstan
| | - O Iaremenko
- National Medical University named after O.O. Bogomolets , Kyiv , Ukraine
| | - A Gnylorybov
- Institute of Urgent and Recovery Surgery named after V.K. Gusak, National Academy of Medical Sciences of Ukraine , Donetsk , Ukraine
| | - S Shevchuk
- Scientific Research institute of Rehabilitation of Disabled, Vinnytsia National Medical University named after Pirogov , Vinnitsa , Ukraine
| | - A Vasylyev
- Commonwealth of Independent States Medical Department, GlaxoSmithKline , London , UK
| | - M H S Pereira
- Commonwealth of Independent States Medical Department, GlaxoSmithKline , London , UK
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28
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Nasonov E, Soloviev S, Davidson JE, Lila A, Togizbayev G, Ivanova R, Baimukhamedov C, Omarbekova Z, Iaremenko O, Gnylorybov A, Shevchuk S, Vasylyev A, Pereira MHS. Standard medical care of patients with systemic lupus erythematosus (SLE) in large specialised centres: data from the Russian Federation, Ukraine and Republic of Kazakhstan (ESSENCE). Lupus Sci Med 2015. [DOI: doi 10.1136/lupus-2014-000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Aringer M, Smolen JS. Safety of off-label biologicals in systemic lupus erythematosus. Expert Opin Drug Saf 2014; 14:243-51. [DOI: 10.1517/14740338.2015.986455] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Karonitsch T, Aringer M. [Biologics in SLE]. Wien Med Wochenschr 2014; 165:40-5. [PMID: 25411010 DOI: 10.1007/s10354-014-0322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/02/2014] [Indexed: 11/24/2022]
Abstract
Biologics have become indispensable in the last decade in the treatment of the more common rheumatic diseases. For treating systemic lupus erythematodes (SLE), B-cell depletion, albeit off-label, has been a well-accepted strategy in severe and refractory disease. Unexpectedly, however, the results of the first randomized controlled rituximab trials in SLE were negative. New trials with improved study protocols are ongoing, which should resolve this issue. In 2012, with the approval of belimumab, SLE finally entered the era of approved biological therapies. The anti-Blys/BAFF antibody belimumab showed prevention of SLE flares, glucocorticoid sparing, and significant improvement in the quality of life of SLE patients, in part by drastically reducing immune complex mediated fatigue. Positive reports on further targeting approaches give hope that additional biological agents will be available for SLE therapy soon.
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Affiliation(s)
- Thomas Karonitsch
- Klinische Abteilung für Rheumatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich,
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Liu Y, Anders HJ. Lupus nephritis: from pathogenesis to targets for biologic treatment. Nephron Clin Pract 2014; 128:224-31. [PMID: 25401461 DOI: 10.1159/000368581] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Lupus nephritis is an organ manifestation of systemic autoimmunity. Current treatment algorithms are still based on unselective immunosuppressive drugs. There is hope that highly selective biological drugs could be as or even more effective but less toxic. A profound understanding of the pathogenesis of lupus nephritis is necessary to identify the optimal molecular targets. METHODS PubMed and www.clincialtrials.gov were searched using 'lupus nephritis' as the key word. RESULTS The pathogenesis of lupus nephritis is based (1) on the mechanisms that lead to loss of tolerance against nuclear autoantigens, i.e. systemic lupus, and then (2) on the mechanisms of immune complex-induced intrarenal inflammation. Systemic lupus develops when genetic variants allow autoimmunization against nuclear autoantigens, e.g. by impairing lymphocyte depletion via apoptosis, opsonization, and rapid phagocytic clearance. This allows endogenous nucleic acids to directly activate Toll-like receptors on dendritic cells or B cells, a process that drives IFN-α-driven immunity, antigen presentation, and the activation of autoreactive lymphocyte subsets. Activation of B cells and their maturation to plasma cells promotes autoantibody production and subsequent immune complex glomerulonephritis. Complement and numerous proinflammatory cytokines drive the inflammatory process that can cause kidney injury, scarring, and chronic kidney disease. CONCLUSION Systemic lupus is more a variable syndrome than a single disorder based on heterogeneous genetic variants and complex aberrant immune alterations. This makes it less likely that a single specific biological drug will be as efficient as currently used unselective immunosuppressive drugs. Autoantibody production and intrarenal immune complex formation are the hallmark of lupus nephritis. However, kidney injury and scarring also result from local amplification of tissue inflammation. Therefore, a combination of unselective immunosuppressive and biological drugs that block immune cell recruitment or proinflammatory cytokines may be promising to improve disease outcomes in lupus nephritis.
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Affiliation(s)
- Yujuan Liu
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, München, Munich, Germany
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32
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Goh KG, Ong SG. Recurrent spontaneous subdural hematoma secondary to immune thrombocytopenia in a patient with overlap syndrome. Lupus 2014; 24:90-3. [PMID: 25305213 DOI: 10.1177/0961203314554248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with autoimmune connective tissue disease may manifest as overlap syndrome with features of systemic lupus erythematosus (SLE), systemic sclerosis, rheumatoid arthritis and myositis. Those presenting with active SLE can present with immune thrombocytopenia (IT) and may be complicated with subdural hematoma which, though rare, is potentially life-threatening. We report here a patient with overlap syndrome who had recurrent spontaneous subdural hematoma due to severe thrombocytopenia which did not respond to corticosteroids and azathioprine. Her platelet count became normal with three doses of low-dose intravenous cyclophosphamide (IV CYC) given at 3-weekly intervals. She remained in remission with maintenance therapy with azathioprine.
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Affiliation(s)
- K G Goh
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - S G Ong
- Department of Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
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Allogeneic mesenchymal stem cell transplantation for lupus nephritis patients refractory to conventional therapy. Clin Rheumatol 2014; 33:1611-9. [PMID: 25119864 DOI: 10.1007/s10067-014-2754-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 07/07/2014] [Accepted: 07/17/2014] [Indexed: 12/29/2022]
Abstract
Allogeneic mesenchymal stem cell transplantation (MSCT) has been shown to be clinically efficacious in the treatment of various autoimmune diseases. Here, we analyzed the role of allogeneic MSCT to induce renal remission in patients with active and refractory lupus nephritis (LN). This is an open-label and single-center clinical trial conducted from 2007 to 2010 in which 81 Chinese patients with active and refractory LN were enrolled. Allogeneic bone marrow- or umbilical cord-derived mesenchymal stem cells (MSCs) were administered intravenously at the dose of 1 million cells per kilogram of bodyweight. All patients were then monitored over the course of 12 months with periodic follow-up visits to evaluate renal remission, as well as possible adverse events. The primary outcome was complete renal remission (CR) and partial remission (PR) at each follow-up, as well as renal flares. The secondary outcome included renal activity score, total disease activity score, renal function, and serologic index. During the 12-month follow-up, the overall rate of survival was 95 % (77/81). Totally, 60.5 % (49/81) patients achieved renal remission during 12-month visit by MSCT. Eleven of 49 (22.4 %) patients experienced renal flare by the end of 12 months after a previous remission. Renal activity evaluated by British Isles Lupus Assessment Group (BILAG) scores significantly declined after MSCT (mean ± SD, from 4.48 ± 2.60 at baseline to 1.09 ± 0.83 at 12 months), in parallel with the obvious amelioration of renal function. Glomerular filtration rate (GFR) improved significantly 12 months after MSCT (mean ± SD, from 58.55 ± 19.16 to 69.51 ± 27.93 mL/min). Total disease activity evaluated by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores also decreased after treatment (mean ± SD, from 13.11 ± 4.20 at baseline to 5.48 ± 2.77 at 12 months). Additionally, the doses of concomitant prednisone and immunosuppressive drugs were tapered. No transplantation-related adverse event was observed. Allogeneic MSCT resulted in renal remission for active LN patients within 12-month visit, confirming its use as a potential therapy for refractory LN.
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Sthoeger Z, Sharabi A, Mozes E. Novel approaches to the development of targeted therapeutic agents for systemic lupus erythematosus. J Autoimmun 2014; 54:60-71. [PMID: 24958634 DOI: 10.1016/j.jaut.2014.06.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/04/2014] [Indexed: 01/29/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem disease in which various cell types and immunological pathways are dysregulated. Current therapies for SLE are based mainly on the use of non-specific immunosuppressive drugs that cause serious side effects. There is, therefore, an unmet need for novel therapeutic means with improved efficacy and lower toxicity. Based on recent better understanding of the pathogenesis of SLE, targeted biological therapies are under different stages of development. The latter include B-cell targeted treatments, agents directed against the B lymphocyte stimulator (BLyS), inhibitors of T cell activation as well as cytokine blocking means. Out of the latter, Belimumab was the first drug approved by the FDA for the treatment of SLE patients. In addition to the non-antigen specific agents that may affect the normal immune system as well, SLE-specific therapeutic means are under development. These are synthetic peptides (e.g. pConsensus, nucleosomal peptides, P140 and hCDR1) that are sequences of conserved regions of molecules involved in the pathogenesis of lupus. The peptides are tolerogenic T-cell epitopes that immunomodulate only cell types and pathways that play a role in the pathogenesis of SLE without interfering with normal immune functions. Two of the peptides (P140 and hCDR1) were tested in clinical trials and were reported to be safe and well tolerated. Thus, synthetic peptides are attractive potential means for the specific treatment of lupus patients. In this review we discuss the various biological treatments that have been developed for lupus with a special focus on the tolerogenic peptides.
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Affiliation(s)
- Zev Sthoeger
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel; Department of Internal Medicine B and Clinical Immunology, Kaplan Medical Center, Rehovot, Israel
| | - Amir Sharabi
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel
| | - Edna Mozes
- Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel.
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Gottenberg JE, Lorenzo N, Sordet C, Theulin A, Chatelus E, Sibilia J. When biologics should be used in systemic lupus erythematosus? Presse Med 2014; 43:e181-5. [PMID: 24933678 DOI: 10.1016/j.lpm.2014.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 12/27/2022] Open
Abstract
Recently, the use and evaluation of biologics increased in systemic lupus erythematosus (SLE). However, no international recommendation is available concerning the use of biologics with regards to the subset of patients who should be treated, the optimal time to treat, the objective of treatment and the manner to discontinue it. To address these complex questions, we focused on biologics already evaluated in at least two published randomized controlled trials. We summarized the results of these trials and available observational data in registries. Taking into account the clinical evidence, we proposed some guidance on the way biologics could be used in SLE. Many areas of uncertainty persist and require intensifying efforts from the academic world to set up new trials, and develop international recommendations.
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Affiliation(s)
- Jacques-Eric Gottenberg
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France.
| | - Noël Lorenzo
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France
| | - Christelle Sordet
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France
| | - Arnaud Theulin
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France
| | - Emmanuel Chatelus
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France
| | - Jean Sibilia
- Hôpitaux universitaires de Strasbourg, Centre de référence national pour les maladies auto-immunes systémiques rares, service de rhumatologie, 67000 Strasbourg, France
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Abstract
PURPOSE OF REVIEW This article discusses the specific neurologic issues that arise in patients with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, and Sjögren syndrome. Diagnosis and management are discussed. RECENT FINDINGS Advances include advanced imaging, serologic and CSF markers, and targeted immune-modulating therapies. The use of these modalities are discussed in detail. SUMMARY Rheumatic disorders are quite common and can result in disabling but many times treatable neurologic sequelae. The key is early diagnosis and management. Awareness of the common presentations and current modalities of diagnosis and treatment is critical to improved outcomes.
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Aringer M, Fischer-Betz R, Hiepe F. [Statement on the use of mycophenolate mofetil for systemic lupus erythematosus]. Z Rheumatol 2014; 72:575-80. [PMID: 23756593 DOI: 10.1007/s00393-013-1213-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Mycophenolate mofetil (MMF) is among the few immunosuppressive drugs with sufficient data from controlled studies on the therapy of systemic lupus erythematosus (SLE). In the light of results from recently published randomized controlled trials on the effectiveness of MMF in the treatment of lupus nephritis, it has become necessary to revise the statement of the Germany Society of Rheumatology on the use of MMF for SLE. In the induction therapy of lupus nephritis MMF has been shown to be equivalent in effectiveness to i.v. cyclophosphamide and superior to azathioprine in the maintenance phase. Cyclophosphamide is inferior to MMF and probably also to azathioprine as maintenance therapy and should therefore, not be considered for this purpose and also because of its toxicity. For other organ manifestations MMF also constitutes an alternative when approved immunosuppressants are not able to control the disease and glucocorticoids cannot be reduced to 7.5 mg prednisolone daily equivalents or less.
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Affiliation(s)
- M Aringer
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
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Amoura Z, Deligny C, Pennaforte JL, Hamidou M, Blanco P, Hachulla E, Pourrat J, Queyrel V, Garofano A, Maurel F, Levy-Bachelot L, Boucot I. [Cost of systemic lupus erythematosus for adult patients with active and treated disease in France (LUCIE study)]. Rev Med Interne 2014; 35:700-8. [PMID: 24630588 DOI: 10.1016/j.revmed.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 01/23/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate in France the annual direct medical cost of adult patients with active systemic lupus erythematosus (SLE) on medication and estimate the cost of a flare. METHODS A two-year, observational, retrospective, multicenter study, carried out between December 2010 and February 2011. Patients' characteristics, SLE disease activity and severity, rate of flares, healthcare consumption (medications, hospitalisations, etc.) were evaluated. Medical costs were assessed from the national Health Insurance perspective. Cost predictors were estimated using multivariate regression models. RESULTS Eight centres specialized in SLE management included 93 eligible patients (including 50.5% severe). The mean age was 39.9 (11.9) years and 93.5% were women. At baseline, the mean SLE duration was 9.8 (6.6) years. The mean scores of the SELENA-SLEDAI instrument and the SLICC/ACR index were higher in severe patients (9.8 vs 5.6, and 1.2 vs 0.4 respectively; P<0.001). Over the study period, 51% of patients received the combination containing at least corticosteroids or immunosuppressants. The mean annual direct medical cost of severe patients was €4660 versus €3560 for non-severe patients (non-significant difference). The cost of medications (61.8% of the annual cost) was higher in severe patients (€3214 vs €1856; P<0.05). Immunosuppressants and biologics represented 26.5% and 4.6% of the annual total cost respectively. Patients experienced on average 1.10 (0.59) flares/year, of which 0.50 were severe flare. The occurrence of a new severe flare incremented the annual cost of €1330 (P<0.05). CONCLUSION Medications represented the major component of the annual direct medical cost. Severe flares increase significantly the cost of SLE care management.
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Affiliation(s)
- Z Amoura
- Service de médecine interne 2, Centre national de référence lupus, hôpital La Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| | - C Deligny
- Service de médecine interne et rhumatologie, CHU de Fort-de-France, BP 63297261, Fort-de-France cedex, Martinique
| | - J-L Pennaforte
- Service de médecine interne, hôpital Robert-Debré, rue du Général-Koenig, 51090 Reims, France
| | - M Hamidou
- Service de médecine interne, hôpital Hôtel-Dieu, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - P Blanco
- Service de médecine interne, hôpital Pèllegrin, place Amélie-Rabat-léon, 33076 Bordeaux cedex, France
| | - E Hachulla
- Service de médecine interne, hôpital Huriez, 1, place de Verdun, 59037 Lille cedex, France
| | - J Pourrat
- Service de néphrologie et immunologie clinique, hôpital Rangueil, 1, avenue du Professeur-Jean-Pouhlès TSA 50032, 31059 Toulouse cedex 9, France
| | - V Queyrel
- Service de médecine interne, hôpital l'Archet, 151, route Saint-Antoine-Ginestière BP 79, 06202 Nice cedex 3, France
| | - A Garofano
- IMS Real-World Evidence Solutions, Health Economics & Outcomes Research, Tour Ariane, 5-7, place de la Pyramide, 92088 La Défense cedex, France
| | - F Maurel
- IMS Real-World Evidence Solutions, Health Economics & Outcomes Research, Tour Ariane, 5-7, place de la Pyramide, 92088 La Défense cedex, France
| | - L Levy-Bachelot
- GlaxoSmithKline, 100, route de Versailles, 78163 Marly-le-Roi cedex, France
| | - I Boucot
- GlaxoSmithKline, 100, route de Versailles, 78163 Marly-le-Roi cedex, France
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Cervera R, Doria A, Amoura Z, Khamashta M, Schneider M, Guillemin F, Maurel F, Garofano A, Roset M, Perna A, Murray M, Schmitt C, Boucot I. Patterns of systemic lupus erythematosus expression in Europe. Autoimmun Rev 2014; 13:621-9. [PMID: 24418306 DOI: 10.1016/j.autrev.2013.11.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 11/13/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To analyse the differences in disease expression of European SLE patients based on gender, age at diagnosis, and ethnicity. METHODS A two-year, retrospective, multicentre, observational study was carried out in five countries (France, Germany, Italy, Spain and the UK). Patients' clinical manifestations including disease activity, organ involvement, organ damage and flares were analysed. RESULTS Thirty-one centres enrolled 412 consecutive eligible patients (90.5% of women), with active disease, stratified by disease severity (half severe and half non-severe). Baseline characteristics included; mean (SD) age: 43.3 (13.6) years, SLE duration: 10.7 (8.0) years and age at disease diagnosis: 32.6 (13.0) years old. The mean (SD) SELENA-SLEDAI and SLICC/ACR scores were: 8.1 (6.7) and 0.82 (1.36), respectively. Over half of patients experienced flares (54.9%). The average number of annual flares was 1.01 (0.71) flares/year. In males compared to females, the renal system was more frequently active (53.8% vs 30.0%, p=0.002), the mean SLICC/ACR score was higher (1.15 vs 0.79, p=0.039) and the pulmonary system was more likely to be damaged (12.8% vs 3.8%, p=0.010). Furthermore, patients diagnosed at younger age displayed more renal system activity (young: 56.3% vs adult: 33.4% vs elder: 8.9%, p<0.001) and renal damage (25.0% vs 6.9% vs 2.2%, p=0.018) compared to the others. The annual number of flares (1.13 vs 1.05 vs 0.81 flares/year, p<0.0001), including the occurrence of severe flares (0.58 vs 0.51 vs 0.20, p<0.0001), was also higher in these patients. Conversely, greater organ damage was observed in patients diagnosed at an older age compared to the others. The mean SLICC/ACR score was higher (1.31 vs young: 0.88 and adult: 0.78, p<0.001) in patients diagnosed in the older age groups. The pulmonary (13.3% vs younger: 0% vs adult: 3.7%, p=0.030) and cardiovascular (17.8% vs younger: 0% vs adult: 2.9%, p<0.001) systems were more frequently damaged in these patients. Black African descents showed greater disease activity compared to Caucasian patients. They flared more often (77.1% vs 48.6%, p=0.001) and experienced a greater number of annual flares (1.57 vs 0.89 flares/year, p<0.0001), mainly more severe flares (0.89 vs 0.38/year, p<0.0001). They also were more likely to experience renal system damage. CONCLUSION The study showed clearly two patient subsets. The disease was the most active in Black African descents, and this phenomenon has never been described before in continental Europe. The disease was also more active in patients diagnosed at a younger or adult. Greater disease damage was observed in males and in patients diagnosed at an older age.
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Affiliation(s)
- R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain, Carrer Villarroel, 170, 08036 Barcelona, Catalonia, Spain.
| | - A Doria
- Division of Rheumatology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Z Amoura
- Internal Medecine Department 2, La Pitié Salpétrière Hospital, 47-83 Bd. de l'Hôpital, 75651 Paris cedex 13, France
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute Lambeth Wing, St Thomas' Hospital, London SE1 7EH, England, United Kingdom
| | - M Schneider
- Policlinic of Rheumatology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - F Guillemin
- Inserm CIC-EC, University Hospital, CHU of Nancy, 54505 Nancy, France
| | - F Maurel
- Health Economics & Outcomes Research, IMS Real-World Evidence Solutions, Tour Ariane 5-7, place de la Pyramide, 92088 Paris La défense cedex, France
| | - A Garofano
- Health Economics & Outcomes Research, IMS Real-World Evidence Solutions, Tour Ariane 5-7, place de la Pyramide, 92088 Paris La défense cedex, France
| | - M Roset
- Health Economics & Outcomes Research, IMS Real-World Evidence Solutions, C/Doctor Ferran 25-27, Barcelona 08034, Catalonia, Spain
| | - A Perna
- Immuno Inflammation & Infectious Diseases Global Franchise, GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, England, United Kingdom
| | - M Murray
- Access to Medicine Centre of Excellence, GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex, TW8 9GS England, United Kingdom
| | - C Schmitt
- Global Health Outcomes, GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, England, United Kingdom
| | - I Boucot
- Medical Department, GlaxoSmithKline, 100 route de Versailles, 78163 Marly-le-Roi Cedex, France
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Kötter I, Henes JC. [Established medications : new areas of application]. Z Rheumatol 2013; 72:853-66. [PMID: 24193188 DOI: 10.1007/s00393-013-1137-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
During the last 10 years several new medications from hemato-oncology and transplantation medicine have been transferred to rheumatology. Additionally, medications which are approved for rheumatoid arthritis were increasingly also studied and used for other systemic inflammatory rheumatic diseases. This is especially the case for rituximab and mycophenolate and to a lesser extent also for leflunomide, tumor necrosis factor (TNF) antagonists, tocilizumab and abatacept. Recently, rituximab was approved for severe granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) after the publication of two prospective randomized trials in 2010. The situation concerning rituximab is much more problematic for systemic lupus erythematosus (SLE) where randomized placebo-controlled trials exist but unfortunately did not meet the primary endpoint requirements (too many highly effective additional forms of treatment in both arms and unsuitable endpoints), although data from registries suggest efficacy especially in cases resistant to treatment. In the case of mycophenolate (MPS) the problem with SLE is totally different. All prospective trials met the endpoints and in one trial MPS was even superior to azathioprine for treatment of lupus nephritis (LN) which led to the recommendation of MPS for induction and maintenance in LN by EULAR and EDTRA as well as more recently by the ACR. However, MPS still is not approved for SLE or LN. The present manuscript gives an overview of existing data for selected connective tissue diseases and vasculitides (for which at least larger retrospective case series or registry data exist) being treated with medications approved for other indications.
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Affiliation(s)
- I Kötter
- Rheumatologische Schwerpunktpraxis und Rheumatologie, Robert-Bosch-Krankenhaus, Abt. Allgemeine Innere Medizin und Nephrologie, Auerbachstr. 110, 70376, Stuttgart, Deutschland,
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Di Caro V, Phillips B, Engman C, Harnaha J, Trucco M, Giannoukakis N. Retinoic acid-producing, ex-vivo-generated human tolerogenic dendritic cells induce the proliferation of immunosuppressive B lymphocytes. Clin Exp Immunol 2013; 174:302-17. [PMID: 23865694 PMCID: PMC3828834 DOI: 10.1111/cei.12177] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 01/27/2023] Open
Abstract
While much is known about tolerogenic dendritic cell effects on forkhead box protein 3 (FoxP3)⁺ regulatory T cells, virtually nothing is known about their effects on another arm of immunoregulation that is mediated by a subpopulation of immunosuppressive B cells. These cells suppress rheumatoid arthritis, lupus and inflammatory bowel disease in mice, and functional defects have been reported in human lupus. We show that co-stimulation-impaired tolerogenic dendritic cells that prevent and reverse type 1 diabetes mellitus induce the proliferation of human immunosuppressive B cells in vitro. We also show that the suppressive properties of these B cells concentrate inside the CD19⁺ CD24⁺ B cell population and more specifically inside the CD19⁺ CD24⁺ CD38⁺ regulatory B cell population. We discovered that B cell conversion into suppressive cells in vitro is partially dependent on dendritic cell production of retinoic acid and also that CD19⁺ CD24⁺ CD38⁺ B regulatory cells express retinoic acid receptors. Taken together, our data suggest a model whereby part of the immunosuppressive properties of human tolerogenic dendritic cells could be mediated by retinoic acid which, in addition to its known role in favouring T cell differentiation to FoxP3⁺ regulatory T cells, acts to convert B cells into immunosuppressive cells.
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Affiliation(s)
- V Di Caro
- Department of Pediatrics, Division of Immunogenetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; RiMed Foundation, Palermo, Italy
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Furtado J, Isenberg DA. Reprint of: B cell elimination in systemic lupus erythematosus. Clin Immunol 2013; 148:344-58. [DOI: 10.1016/j.clim.2013.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
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Abstract
Lupus nephritis is an immune complex GN that develops as a frequent complication of SLE. The pathogenesis of lupus nephritis involves a variety of pathogenic mechanisms. The extrarenal etiology of systemic lupus is based on multiple combinations of genetic variants that compromise those mechanisms normally assuring immune tolerance to nuclear autoantigens. This loss of tolerance becomes clinically detectable by the presence of antinuclear antibodies. In addition, nucleic acids released from netting or apoptotic neutrophils activate innate and adaptive immunity via viral nucleic acid-specific Toll-like receptors. Therefore, many clinical manifestations of systemic lupus resemble those of viral infection. In lupus, endogenous nuclear particles trigger IFN-α signaling just like viral particles during viral infection. As such, dendritic cells, T helper cells, B cells, and plasma cells all contribute to the aberrant polyclonal autoimmunity. The intrarenal etiology of lupus nephritis involves antibody binding to multiple intrarenal autoantigens rather than the deposition of circulating immune complexes. Tertiary lymphoid tissue formation and local antibody production add to intrarenal complement activation as renal immunopathology progresses. Here we provide an update on the pathogenic mechanisms that lead to lupus nephritis and provide the rationale for the latest and novel treatment strategies.
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Affiliation(s)
- Maciej Lech
- Department of Nephrology, Medical Clinic and Polyclinic IV, University of Munich, Germany
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Abstract
Systemic lupus erythematosus, Sjögren's syndrome, and dermatomyositis are systemic autoimmune diseases that develop after environmental triggering of genetically susceptible individuals. The precise cellular and molecular mechanisms leading to autoimmune disease, and what factors determine which organs are involved, remain poorly understood. Recent insights into genetic susceptibility now make obvious that environmental triggers often act via cellular pathways containing disease-associated polymorphisms. In the breaking of tolerance, the initiating tissue--including dendritic cells--provides a decisive microenvironment that affects immune-cell differentiation, leading to activation of adaptive immunity. Type 1 interferon produced by innate immune cells has a central role in systemic autoimmunity and activates B cells and T cells. In turn, B-cell-derived autoantibodies stimulate dendritic cells to produce type 1 interferon; thus, a positive feedforward loop is formed that includes both the innate and adaptive systems. New treatments could simultaneously and specifically target several such vital pathways in autoimmunity.
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Aringer M, Günther C, Lee-Kirsch MA. Innate immune processes in lupus erythematosus. Clin Immunol 2013; 147:216-22. [DOI: 10.1016/j.clim.2012.11.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 11/23/2012] [Accepted: 11/24/2012] [Indexed: 11/30/2022]
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Current World Literature. Curr Opin Rheumatol 2013; 25:398-409. [DOI: 10.1097/bor.0b013e3283604218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Winter O, Dame C, Jundt F, Hiepe F. Pathogenic long-lived plasma cells and their survival niches in autoimmunity, malignancy, and allergy. THE JOURNAL OF IMMUNOLOGY 2013; 189:5105-11. [PMID: 23169863 DOI: 10.4049/jimmunol.1202317] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Long-lived plasma cells survive in a protected microenvironment for years or even a lifetime and provide humoral memory by establishing persistent Ab titers. Long-lived autoreactive, malignant, and allergen-specific plasma cells are likewise protected in their survival niche and are refractory to immunosuppression, B cell depletion, and irradiation. Their elimination remains an essential therapeutic challenge. Recent data indicate that long-lived plasma cells reside in a multicomponent plasma cell niche with a stable mesenchymal and a dynamic hematopoietic component, both providing essential soluble and membrane-bound survival factors. Alternative niches with different hematopoietic cell components compensate fluctuations of single cell types but may also harbor distinct plasma cell subsets. In this Brief Review, we discuss conventional therapies in autoimmunity and multiple myeloma in comparison with novel drugs that target plasma cells and their niches. In the future, such strategies may enable the specific depletion of pathogenic plasma cells while leaving the protective humoral memory intact.
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Affiliation(s)
- Oliver Winter
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, 10117 Berlin, Germany.
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Abstract
PURPOSE OF REVIEW Lupus nephritis is a complex autoimmune disease that develops its own dynamic upon damaging the renal ultrastructure. Here, we summarize the latest pathophysiological concepts of lupus nephritis and how these translate into novel therapeutic options. RECENT FINDINGS Multidisciplinary research activities form a better understanding about how lupus develops from an unfortunate combination of gene variants that promote the loss of tolerance, that impair the clearance of dying cells, that regulate the immune interpretation of autoantigens as well as the peripheral control of autoreactive lymphocytes. As a new entry, nuclear particles also act as autoadjuvants mimicking viral particles and triggering interferon-alpha-dependent antiviral immune responses that cause symptoms similar to viral infection. SUMMARY A set of novel drugs have the potential to more specifically interfere with these pathomechanisms and raise hope to more efficiently treat lupus nephritis with fewer side-effects in the near future.
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