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Shima Y, Watanabe A, Inoue N, Maruyama T, Kunitomo E, Kumanogoh A. Heating of the neck or elbows alleviates Raynaud's phenomenon but has different effects on different types of patients with systemic sclerosis. Mod Rheumatol 2024; 34:750-755. [PMID: 37706545 DOI: 10.1093/mr/road091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES We previously reported that heating of the neck or elbows alleviated Raynaud's phenomenon in patients with systemic sclerosis and upregulated capillary extension factor angiopoietin-1 (Angpt-1) in the fingertips. In this study, we investigated which cases responded better to the effect of heating of the neck or elbows. METHODS The pre- to postheating change in the visual analogue scale (ΔVAS) for Raynaud's phenomenon was examined for correlation with age, disease duration, autoantibodies, disease types, corticosteroid dose, capillaroscopic nailfold capillary damage, fingertip Angpt-1 concentrations at baseline, and increased rate of Angpt-1 concentration. RESULTS The ΔVAS for elbow heating correlated positively with the baseline Angpt-1 concentration, whereas opposite correlation was observed for neck heating. The other items did not significantly correlate with the ΔVAS; however, the ΔVAS for elbow heating tended to be larger in patients with advanced capillary damage, whereas an opposite trend was observed for neck heating. CONCLUSIONS Elbow and neck heating alleviated Raynaud's phenomenon to a similar extent, but their mechanism was different. Heating of the elbows had a greater effect on patients with advanced capillary damage and lower fingertip Angpt-1 concentrations.
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Affiliation(s)
- Yoshihito Shima
- Laboratory of Thermo-therapeutics for Vascular Dysfunction, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akane Watanabe
- Laboratory of Thermo-therapeutics for Vascular Dysfunction, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Nobuto Inoue
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd., Ibaraki, Japan
| | - Tetsuya Maruyama
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd., Ibaraki, Japan
| | - Eiji Kunitomo
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd., Ibaraki, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
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Pauling JD, Yu L, Frech TM, Herrick AL, Hummers LK, Shah AA, Denton CP, Saketkoo LA, Withey J, Khanna D, Domsic RT. Construct validity and reliability of the Assessment of Systemic Sclerosis-Associated Raynaud's Phenomenon (ASRAP) questionnaire. Rheumatology (Oxford) 2024; 63:1281-1290. [PMID: 37481713 DOI: 10.1093/rheumatology/kead371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/27/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVES Assessment of construct validity and reliability of a novel patient-reported outcome (PRO) instrument for assessing the severity and impact of RP in SSc. METHODS An international multicentre study validation study of the 27-item Assessment of Systemic Sclerosis-Associated Raynaud's Phenomenon (ASRAP) and 10-item short-form (ASRAP-SF) questionnaires. The relationship between ASRAP questionnaires and demographics, clinical phenotype and legacy instruments for assessing SSc-RP severity, disability and pain was assessed. Repeatability was evaluated at 1 week. Anchor-based statements of health status facilitated assessment of ASRAP thresholds of meaning. RESULTS A total of 420 SSc subjects were enrolled. There was good correlation between ASRAP (and ASRAP-SF) with RP visual analogue scale (VAS) and Scleroderma Health Assessment Questionnaire RP VAS (rho range 0.648-0.727, P < 0.001). Correlation with diary-based assessment of SSc-RP attack frequency and duration was lower (rho range 0.258-0.504, P < 0.001). ASRAP questionnaires had good correlation with instruments for assessing disability, hand function, pain and global health assessment (rho range 0.427-0.575, P < 0.001). Significantly higher ASRAP scores were identified in smokers, patients with active digital ulceration (DU), previous history of DU and calcinosis (P < 0.05 for all comparisons). There was excellent repeatability at 1 week among patients with stable SSc-RP symptoms (intra-class coefficients of 0.891 and 0.848, P < 0.001). Patient-acceptable symptom state thresholds for ASRAP and ASRAP-SF were 45.34 and 45.77, respectively. A preliminary Minimally Important Clinical Difference threshold of 4.17 (95% CI 0.53, 7.81, P = 0.029) was estimated. CONCLUSION ASRAP and ASRAP-SF questionnaires are valid and reliable novel PRO instruments for assessing the severity and impact of SSc-RP.
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Affiliation(s)
- John D Pauling
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases (part of the Royal United Hospitals NHS Foundation Trust), Bath, UK
| | - Lan Yu
- Department of Medicine, University of Pittsburgh, PA, USA
| | | | - Ariane L Herrick
- The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Laura K Hummers
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ami A Shah
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Lesley Ann Saketkoo
- Department of Rheumatology, University of Tulane Medical Center, New Orleans, LA, USA
| | - Jane Withey
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases (part of the Royal United Hospitals NHS Foundation Trust), Bath, UK
| | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor, MI, USA
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
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Maltez N, Hughes M, Brown E, Hickey V, Shea B, Herrick AL, Proudman S, Merkel PA, Pauling JD. Domain reporting in systemic sclerosis-related Raynaud's phenomenon: An OMERACT scoping review. Semin Arthritis Rheum 2023; 61:152208. [PMID: 37202251 DOI: 10.1016/j.semarthrit.2023.152208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Raynaud's phenomenon (RP) is a cardinal feature of SSc and is associated with significant disease-related morbidity that impacts on quality of life. The assessment of SSc-RP is challenging. The aim of this scoping review was to evaluate the outcome domains studied and outcome measures used in clinical studies of SSc-RP. METHODS Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify randomized control trials (RCTs), quasi-randomized studies, case-control studies, prospective and retrospective cohort studies, case series, and cross-sectional studies of adult participants with SSc-associated RP, written in English. A minimum of 25 participants for studies of imaging modalities and 40 participants for questionnaire-based studies was required for inclusion. Basic laboratory and genetic studies were excluded. No limitations were imposed based on intervention, comparator, or study setting. Study characteristics and primary and secondary target domains in each study were recorded. RESULTS 58 studies (24 randomized clinical trials) were included in the final analysis. The commonest domains captured were severity of attacks (n=35), frequency of attacks (n=28), and duration of attacks (n=19). Objective assessments of digital perfusion were also commonly used in studies of SSc-RP. CONCLUSION The outcome domains and the associated outcomes used to assess the impact of SSc-RP in research studies are broad and have varied across studies. The results of this study will inform the OMERACT Vascular Disease in Systemic Sclerosis Working Group to establish a core set of disease domains encompassing the impact of RP in SSc.
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Affiliation(s)
- Nancy Maltez
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Michael Hughes
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Beverley Shea
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susanna Proudman
- Discipline of Medicine, University of Adelaide and Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Pauling
- North Bristol NHS Trust, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
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Yu L, Domsic RT, Saketkoo LA, Withey J, Frech TM, Herrick AL, Hummers LK, Shah AA, Denton CP, Khanna D, Pauling JD. Assessment of the Systemic Sclerosis-Associated Raynaud's Phenomenon Questionnaire: Item Bank and Short-Form Development. Arthritis Care Res (Hoboken) 2022. [PMID: 36214062 DOI: 10.1002/acr.25038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/12/2022] [Accepted: 10/04/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To develop, refine, and score a novel patient-reported outcome instrument to assess the severity and impact of Raynaud's phenomenon (RP) in systemic sclerosis (SSc). METHODS The Assessment of Systemic Sclerosis-Associated Raynaud's Phenomenon (ASRAP) questionnaire items were developed with patient insight partner support and grounded in the lived patient experience of SSc-RP. ASRAP items underwent formal qualitative assessment and linguistic testing. An international multicenter study was undertaken to field test the preliminary ASRAP questionnaire. RESULTS A preliminary 37-item ASRAP questionnaire was supplemented with 2 additional items following expert review to enhance content coverage before undergoing formal linguistic testing to optimize readability. Patient cognitive debriefing interviews were undertaken to enhance comprehension, ambiguity, cognitive difficulty, relevance, and content coverage of both the ASRAP items and instructions. We enrolled 420 SSc patients from scleroderma centers in the UK and US over 2 consecutive winters. Factor analysis with item response theory was undertaken to remove redundant and poorly fitting items. The retained 27-item long-form ASRAP questionnaire was calibrated and scored using the graded response model. A fixed 10-item short-form ASRAP questionnaire was developed using computerized adaptive testing simulations. CONCLUSION The ASRAP questionnaire has been developed with extensive SSc patient input, with items grounded in the lived experience of SSc-RP to ensure strong content validity, with a focus on how patients feel and function. An advanced psychometric approach with expert input has removed redundant and/or poorly fitting items without eroding content validity. Long- and short-form ASRAP questionnaires have been calibrated and scored to permit formal validation.
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Affiliation(s)
- Lan Yu
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Jane Withey
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | | | - Ariane L Herrick
- The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK, and Salford Royal NHS Foundation Trust, Salford, UK
| | - Laura K Hummers
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ami A Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UK, and North Bristol NHS Trust and University of Bristol, Bristol, UK
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Maciejewska M, Sikora M, Maciejewski C, Alda-Malicka R, Czuwara J, Rudnicka L. Raynaud's Phenomenon with Focus on Systemic Sclerosis. J Clin Med 2022; 11:jcm11092490. [PMID: 35566614 PMCID: PMC9105786 DOI: 10.3390/jcm11092490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
Raynaud’s phenomenon is a painful vascular condition in which abnormal vasoconstriction of the digital arteries causes blanching of the skin. The treatment approach can vary depending on the underlying cause of disease. Raynaud’s phenomenon can present as a primary symptom, in which there is no evidence of underlying disease, or secondary to a range of medical conditions or therapies. Systemic sclerosis is one of the most frequent causes of secondary Raynaud’s phenomenon; its appearance may occur long before other signs and symptoms. Timely, accurate identification of secondary Raynaud’s phenomenon may accelerate a final diagnosis and positively alter prognosis. Capillaroscopy is fundamental in the diagnosis and differentiation of primary and secondary Raynaud’s phenomenon. It is helpful in the very early stages of systemic sclerosis, along with its role in disease monitoring. An extensive range of pharmacotherapies with various routes of administration are available for Raynaud’s phenomenon but a standardized therapeutic plan is still lacking. This review provides insight into recent advances in the understanding of Raynaud’s phenomenon pathophysiology, diagnostic methods, and treatment approaches.
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Affiliation(s)
- Magdalena Maciejewska
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Mariusz Sikora
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
- Correspondence:
| | - Cezary Maciejewski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Rosanna Alda-Malicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Joanna Czuwara
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
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Shima Y, Watanabe A, Inoue N, Maruyama T, Kunitomo E, Hamano K, Kawanishi T, Takasugi M, Kumanogoh A. Proximal heat stress up-regulates angiopoietin-1 in fingers and reduces the severity of Raynaud's phenomenon in systemic sclerosis: a single-centre pilot study. Mod Rheumatol 2021; 32:351-357. [PMID: 34894267 DOI: 10.1093/mr/roab014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Raynaud's phenomenon (RP) is a peripheral vascular disorder that frequently occurs in systemic sclerosis (SSc). Although therapeutic heating seems reasonable given that RP is elicited by cold stimuli, the effects of heating are still unclear. We examined the effects of heating applied on various body parts in SSc patients with RP of fingers. METHODS Fourteen SSc patients heated their neck, elbows, and wrists with disposable heating pads for 1 week each. The visual analogue scale (VAS) for RP during each heating period was compared with that of each 1-week pre-treatment interval. On the day after the expiration of each heating period, their finger temperature, the finger blood flow, and angiogenesis-related factors (vascular endothelial growth factor, endostatin, angiopoietin-1, and angiopoietin-2) obtained from the cubital vein and fingertip were measured. RESULTS The mean VAS was significantly reduced during the heating of the neck and elbows. Fingertip blood samples showed significantly increased angiopoietin-1 after each of the heating periods and increased endostatin after wrist heating. After the termination of heating, changes in finger temperature or blood flow could not be detected. CONCLUSIONS Heating the neck or elbows can alleviate RP in SSc. The heat up-regulates angiopoietin-1 in the fingers.
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Affiliation(s)
- Yoshihito Shima
- Laboratory of Thermo-therapeutics for Vascular Dysfunction, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akane Watanabe
- Laboratory of Thermo-therapeutics for Vascular Dysfunction, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Nobuto Inoue
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Tetsuya Maruyama
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Eiji Kunitomo
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Kunihiko Hamano
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Takashi Kawanishi
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Masashi Takasugi
- Central R&D Laboratory, Kobayashi Pharmaceutical Co., Ltd, Ibaraki, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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8
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Pauling JD, Caetano J, Campochiaro C, De Luca G, Gheorghiu AM, Lazzaroni MG, Khanna D. Patient-reported outcome instruments in clinical trials of systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 5:90-102. [PMID: 35382020 PMCID: PMC8922614 DOI: 10.1177/2397198319886496] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 10/04/2019] [Indexed: 09/01/2023]
Abstract
Patient-reported outcome instruments provide valuable insight into disease-related morbidity known only to the patient and complement more objective outcome tools in the clinical trial setting. They are of particular importance in systemic sclerosis owing to the challenges around defining disease activity, the episodic nature of many disease-specific manifestations and the paucity of validated objective surrogate outcome measures for use in clinical trials. Early clinical trials of systemic sclerosis often incorporated legacy patient-reported outcome instruments, but the last 20 years has witnessed the emergence of several scleroderma-specific instruments that are now being routinely used alongside other outcomes in systemic sclerosis clinical trials. More recently, the value of patient-reported outcomes has been highlighted by their prominence in the American College of Rheumatology Combined Response Index for Systemic Sclerosis that has been utilized as the primary endpoint of recent clinical trials of early diffuse systemic sclerosis. This review considers the role and performance of the various patient-reported outcome instruments utilized in systemic sclerosis clinical trials, the current positioning of patient-reported outcome instruments within clinical trial endpoint models across the range of systemic sclerosis disease manifestations and, where applicable, we shall highlight areas for future research.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases, Bath, UK
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Joana Caetano
- Systemic Immune-Mediated Diseases Unit, Department of Medicine IV, Fernando Fonseca Hospital, Amadora, Portugal
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Ana Maria Gheorghiu
- Internal Medicine and Rheumatology, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Dinesh Khanna
- Scleroderma Program, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
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Argula RG, Ward C, Feghali-Bostwick C. Therapeutic Challenges And Advances In The Management Of Systemic Sclerosis-Related Pulmonary Arterial Hypertension (SSc-PAH). Ther Clin Risk Manag 2019; 15:1427-1442. [PMID: 31853179 PMCID: PMC6916691 DOI: 10.2147/tcrm.s219024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disorder with multi-organ involvement. SSc-associated pulmonary arterial hypertension (SSc-PAH) is one of the leading causes of morbidity and mortality in the SSc population. With advances in our understanding of pulmonary arterial hypertension (PAH) diagnosis and treatment, outcomes for all PAH patients have significantly improved. While SSc-PAH patients have also benefited from these advances, significant challenges remain. Diagnosis of PAH is a challenging endeavor in SSc patients who often have many co-existing pulmonary and cardiac comorbidities. Given the significantly elevated prevalence and lifetime risk of PAH in the SSc population, screening for SSc-PAH is a critically useful strategy. Treatment with pulmonary arterial (PA) vasodilators has resulted in a dramatic improvement in the survival and quality of life of PAH patients. While therapy with PA vasodilators is beneficial in SSc-PAH patients, therapy effects appear to be attenuated when compared to responses in patients with idiopathic PAH (IPAH). This review attempts to chronicle and summarize the advances in our understanding of the optimal screening strategies to identify PAH in patients with SSc. The article also reviews the advances in the therapeutic and risk stratification strategies for SSc-PAH patients.
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Affiliation(s)
- Rahul G Argula
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Celine Ward
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
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10
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Khouri C, Lepelley M, Bailly S, Blaise S, Herrick AL, Matucci-Cerinic M, Allanore Y, Trinquart L, Cracowski JL, Roustit M. Comparative efficacy and safety of treatments for secondary Raynaud's phenomenon: a systematic review and network meta-analysis of randomised trials. THE LANCET. RHEUMATOLOGY 2019; 1:e237-e246. [PMID: 38229380 DOI: 10.1016/s2665-9913(19)30079-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several pharmacological treatments are available for secondary Raynaud's phenomenon, but there is uncertainty regarding the best options. We aimed to assess and compare the benefits and harms of treatments available for secondary Raynaud's phenomenon. METHOD We did a systematic review and network meta-analysis of randomised controlled trials (RCTs) of pharmacological treatments. We searched for systematic reviews published in MEDLINE and the Cochrane Database of Systematic Reviews up to Jan 31, 2017, and for RCTs published from inception to Sept 24, 2019 in MEDLINE, Embase, and ClinicalTrials.gov. We included double-blind RCTs (parallel or crossover) that compared two or more pharmacological treatments or placebo in patients with secondary Raynaud's phenomenon. Individual patient data were obtained for one unpublished RCT. Three researchers independently screened the texts and extracted the data. Efficacy outcomes included severity (on a ten-point scale), daily frequency, and mean duration of Raynaud's phenomenon attacks. We also examined tolerability and acceptability. Pairwise meta-analyses and Bayesian random-effects network meta-analyses were used to synthesise data. This study is registered with PROSPERO (CRD42017057518). FINDINGS We included 58 RCTs in the analysis, comprising 3867 patients (3540 [91·5%] with secondary Raynaud's phenomenon) and 15 classes of drugs. Phosphodiesterase 5 (PDE5) inhibitors were more effective than placebo for frequency (mean difference -0·36 [95% credibility interval -0·69 to -0·04]), severity (-0·34 [-0·66 to -0·03]), and duration (-3·42 [-6·62 to -0·29]) of attacks (low to moderate level of evidence). Calcium channel blockers (CCBs) were superior to placebo for frequency (-0·35 [-0·67 to -0·02]) and severity (-0·84 [-1·25 to -0·45]) of attacks (low level of evidence). For severity of attacks, selective serotonin-reuptake inhibitors (-1·54 [-2·68 to -0·41]; very low level of evidence) and oral prostacyclin receptor agonists (-0·48 [-0·80 to -0·16]; low level of evidence) were superior to placebo. No other drug classes were significantly superior to placebo with regard to efficacy outcomes. Compared with placebo, tolerability was lower for PDE5 inhibitors (incidence rate ratio for serious adverse events or early study exit due to adverse events 3·30 [95% CrI 1·49 to 7·55]) and CCBs (3·13 [1·33 to 7·04]). For all outcomes, global heterogeneity and between-study variance ranged from low (I2=0% and τ2=0·0 for attack severity and duration) to moderate (I2=41% and τ2=0·2 for tolerability). The overall risk of bias was judged to be low in 22 (38%), high in ten (17%), and unclear in 26 (45%) RCTs. INTERPRETATION PDE5 inhibitors and CCBs are the most effective pharmacological options, albeit with moderate efficacy and a low level of evidence. Current evidence does not support the use of any other drug in secondary Raynaud's phenomenon. FUNDING None.
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Affiliation(s)
- Charles Khouri
- Pharmacovigilance Unit, Grenoble Alpes University Hospital, Grenoble, France; Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Marion Lepelley
- Pharmacovigilance Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Sebastien Bailly
- EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Sophie Blaise
- Department of Vascular Medicine, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Careggi University Hospital, Florence, Italy
| | - Yannick Allanore
- INSERM U1016 UMR8104 Cochin Institute, Paris Descartes University, Paris, France; Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jean-Luc Cracowski
- Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Matthieu Roustit
- Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France.
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11
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Pauling JD, Saketkoo LA, Matucci-Cerinic M, Ingegnoli F, Khanna D. The patient experience of Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2019. [PMID: 29538754 DOI: 10.1093/rheumatology/key026] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RP is the most common manifestation of SSc and a major cause of disease-related morbidity. This review provides a detailed appraisal of the patient experience of SSc-RP and potential implications for disease classification, patient-reported outcome instrument development and SSc-RP clinical trial design. The review explores the clinical features of SSc-RP, the severity and burden of SSc-RP symptoms and the impact of SSc-RP on function, work and social participation, body image dissatisfaction and health-related quality of life in SSc. Where management of SSc-RP is concerned, the review focuses on the 'patient experience' of interventions for SSc-RP, examining geographic variation in clinical practice and potential barriers to the adoption of treatment recommendations concerning best-practice management of SSc-RP. Knowledge gaps are highlighted that could form the focus of future research. A more thorough understanding of the patient experience could support the development of novel reported outcome instruments for assessing SSc-RP.
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Affiliation(s)
- John D Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.,Royal National Hospital for Rheumatic Diseases (part of Royal United Hospitals), Upper Borough Walls, Bath, UK
| | - Lesley Ann Saketkoo
- School of Medicine, University of Tulane Medical Center, New Orleans, LA, USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine, Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Ingegnoli
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Universita degli Studi di Milano, Milano, Italy
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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12
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Pauling JD, Reilly E, Smith T, Frech TM. Evolving Symptom Characteristics of Raynaud's Phenomenon in Systemic Sclerosis and Their Association With Physician and Patient-Reported Assessments of Disease Severity. Arthritis Care Res (Hoboken) 2019; 71:1119-1126. [PMID: 30133174 DOI: 10.1002/acr.23729] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/14/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assessment of Raynaud's phenomenon (RP) in systemic sclerosis (SSc) is reliant on self-report. The Raynaud's Condition Score (RCS) diary assumes discrete episodic RP attacks, although not all SSc patients identify with this paradigm. We investigated the clinical associations of SSc-RP symptom characteristics and the evolution of SSc-RP symptoms with disease progression. METHODS A cross-sectional study at UK and US sites captured digital color changes of SSc-RP and patients' ability to identify with diagrammatic representations (and descriptive stems) of 4 distinct theoretical SSc-RP patterns (progressing severity A through D) reflecting progressively severe SSc-RP experiences. SSc-RP self-management and symptom evolution were explored. Patient demographics, the clinical phenotype, the Scleroderma Health Assessment Questionnaire (SHAQ), the 2-week RCS diary, and patient and physician global assessments were collected. RESULTS We enrolled 107 patients with SSc (with questionnaires returned by 94). A higher number of self-reported digital color changes of SSc-RP were associated with increased SSc-RP symptom severity but not with the SSc clinical phenotype. Patients could identify with distinct patterns of SSc-RP. These patterns were associated with disease duration, global disease severity, and conceptually linked physician and patient assessments of peripheral vascular severity (e.g., SHAQ RP subscale and RCS diary parameters), but not with conceptually unrelated outcomes (e.g., SHAQ breathing subscale). SSc-RP characteristics and symptom severity evolve during the disease course. CONCLUSION Patients identify with distinct patterns of SSc-RP that may relate to progression of the obliterative microangiopathy of SSc. Difficulty distinguishing discrete SSc-RP attacks from persistent digital ischemia in patients with advanced SSc could influence diary-based approaches to assessing SSc-RP, with implications for future clinical trials.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, and University of Bath, Bath, UK
| | - Elizabeth Reilly
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, and University of Bath, Bath, UK
| | | | - Tracy M Frech
- Salt Lake Regional Veterans Affairs Medical Center and University of Utah, Salt Lake City
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13
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Khouri C, Blaise S, Guigui A, Cracowski C, Allanore Y, Hachulla E, Senet P, Roustit M, Cracowski JL. French translation and linguistic validation of the Raynaud's condition score. Therapie 2019; 74:627-631. [PMID: 31023622 DOI: 10.1016/j.therap.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/15/2019] [Indexed: 11/18/2022]
Abstract
The Raynaud's condition score is a 11-point scale severity score used in Raynaud's phenomenon clinical trials since 1998. The Raynaud's condition score diary has been recommended for use in clinical trials assessing efficacy of interventions on scleroderma related Raynaud's phenomenon. However, this score has never been formally validated in French. We thus performed a translation and a linguistic validation of the Raynaud's condition score through a forward/backward translations process followed by an expert review and cognitive patient interviews. The translations led to a French version of the Raynaud's condition score that was linguistically valid, and conceptually equivalent to the original English version. This "Score de Raynaud" will be usable to perform and harmonize clinical trials in French-speaking patients with secondary Raynaud's phenomenon.
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Affiliation(s)
- Charles Khouri
- Pharmacovigilance unit, Grenoble Alpes university hospital, 38000 Grenoble, France; Inserm CIC1406, clinical pharmacology department, Grenoble Alpes university hospital, 38000 Grenoble, France; Inserm, UMR 1042-HP2, university Grenoble Alpes, 38000 Grenoble, France.
| | - Sophie Blaise
- Inserm, UMR 1042-HP2, university Grenoble Alpes, 38000 Grenoble, France; Department of vascular medicine, Grenoble university hospital, 38000 Grenoble, France
| | - Alicia Guigui
- Inserm CIC1406, clinical pharmacology department, Grenoble Alpes university hospital, 38000 Grenoble, France
| | - Claire Cracowski
- Inserm CIC1406, clinical pharmacology department, Grenoble Alpes university hospital, 38000 Grenoble, France
| | - Yannick Allanore
- Service de rhumatologie A, hôpital Cochin, université Paris Descartes, 75014 Paris, France
| | - Eric Hachulla
- Service de médecine interne, Centre de référence des maladies auto-immunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), hôpital Claude Huriez, CHU de Lille, 59045 Lille, France
| | - Patricia Senet
- Service de dermatologie et allergologie, hôpital Tenon, groupe hospitalier universitaire Paris Est, Assistance publique-Hôpitaux de Paris, 75020 Paris, France
| | - Mathieu Roustit
- Inserm CIC1406, clinical pharmacology department, Grenoble Alpes university hospital, 38000 Grenoble, France; Inserm, UMR 1042-HP2, university Grenoble Alpes, 38000 Grenoble, France
| | - Jean-Luc Cracowski
- Inserm CIC1406, clinical pharmacology department, Grenoble Alpes university hospital, 38000 Grenoble, France; Inserm, UMR 1042-HP2, university Grenoble Alpes, 38000 Grenoble, France
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14
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Ruaro B, Pizzorni C, Paolino S, Alessandri E, Sulli A. Aminaphtone Efficacy in Primary and Secondary Raynaud's Phenomenon: A Feasibility Study. Front Pharmacol 2019; 10:293. [PMID: 31019461 PMCID: PMC6458253 DOI: 10.3389/fphar.2019.00293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/11/2019] [Indexed: 01/18/2023] Open
Abstract
Objectives The aim of this six-month open feasibility study was to evaluate skin blood perfusion and clinical symptom changes during aminaphtone treatment in patients with either primary or secondary Raynaud’s phenomenon to systemic sclerosis. Methods Ninety-two patients referring for Raynaud’s phenomenon have been enrolled in November during routine clinical assessment, after informed consent. Aminaphtone was administered 75 mg twice daily in addition to current treatments to forty-six patients. Skin blood perfusion was measured by Laser Speckle Contrast Analysis (LASCA) at the level of fingertips, periungual areas, dorsum and palm of hands, and face at baseline (W0), after one (W1), four (W4), twelve (W12) and twenty-four (W24) weeks of treatment. Raynaud’s condition score (RCS) and both frequency and duration of Raynaud’s attacks were assessed at the same time. Results Compared with the control group, despite colder period of the year, aminaphtone treated patients showed a progressive statistically significant increase of blood perfusion, as well as a decrease of RCS, frequency of Raynaud’s attacks/day and their duration, from W0 to W12 in all skin areas. From W12 to W24 no further increase of blood perfusion was observed. The results were similar in both primary and secondary Raynaud’s phenomenon patients. Five weeks after aminaphtone discontinuation blood perfusion values were significantly higher than those at baseline in the majority of skin areas. Conclusion This study demonstrates that aminaphtone treatment increases skin blood perfusion and improves Raynaud’s phenomenon clinical symptoms, with sustained efficacy up to 6 months, even in patients with systemic sclerosis. A randomized, blind, controlled, clinical trial including a larger number of subjects is advisable to confirm these early results.
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Affiliation(s)
- Barbara Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
| | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
| | - Elisa Alessandri
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genova, Italy
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15
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Pauling JD, Reilly E, Smith T, Frech TM. Factors Influencing Raynaud Condition Score Diary Outcomes in Systemic Sclerosis. J Rheumatol 2019; 46:1326-1334. [PMID: 30824643 DOI: 10.3899/jrheum.180818] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Raynaud phenomenon (RP) in systemic sclerosis (SSc) could be influenced by clinical phenotype, environmental factors (e.g., season), and personal factors (e.g., coping strategies and ill-health perceptions). We studied the relative influence of a range of putative factors affecting patient-reported assessment of SSc-RP severity. METHODS SSc patients were enrolled at UK and US sites. Participants completed the 2-week Raynaud Condition Score (RCS) diary alongside collection of patient demographics, clinical phenotype, the Coping Strategies Questionnaire, Pain Catastrophizing Scale, Scleroderma Health Assessment Questionnaire (SHAQ), and both patient/physician visual analog scale (VAS) assessments for RP, digital ulcer disease, and global disease. Environmental temperature data were obtained at each site. A second RCS diary was completed 6 months after enrollment. RESULTS We enrolled 107 patients (baseline questionnaires returned by 94). There were significant associations between RCS diary variables and both catastrophizing and coping strategies. There were significant associations between RCS diary outcomes and both environmental temperature and season of enrollment. Age, disease duration, sex, disease subtype, smoking, and vasodilator use were not associated with RCS diary outcomes. The best-fitting multivariate model identified the patient RP VAS, SHAQ pain VAS, and SHAQ gastrointestinal VAS subscales as the strongest independent predictors of the RCS. CONCLUSION Patient-reported assessment of SSc-RP severity is associated with a number of factors including pain, catastrophizing, and coping strategies. The effects of seasonal variation in environmental temperature on SSc-RP burden has implications for clinical trial design. Treatments targeting SSc-RP pain and the development of behavioral interventions enhancing coping strategies may reduce the burden of SSc-RP.
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Affiliation(s)
- John D Pauling
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA. .,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center.
| | - Elizabeth Reilly
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
| | - Theresa Smith
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
| | - Tracy M Frech
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
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16
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Pauling JD, Nagaraja V, Khanna D. Insight into the Contrasting Findings of Therapeutic Trials of Digital Ischaemic Manifestations of Systemic Sclerosis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00118-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Management of Raynaud’s phenomenon in systemic sclerosis—a practical approach. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:102-110. [DOI: 10.1177/2397198318823951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
Abstract
Raynaud’s phenomenon is nearly universal in systemic sclerosis. Vasculopathy is part of systemic sclerosis. Raynaud’s phenomenon can cause of complications and impairment, especially when tissue ischemia and digital ulcers develop. There are many treatment options for Raynaud’s phenomenon in systemic sclerosis often with sparse data and few robust studies comparing the different treatment options. Recommendations from guidelines usually include calcium channel blockers as first-line pharmacological treatment. In the clinical setting, multiple variables such as financial factors, geography where access to medications varies, and patient factors, baseline hypotension, can influence the treatment for Raynaud’s phenomenon and digital ulcers. Prostacyclins and PDE-5 inhibitors are reserved for more severe Raynaud’s phenomenon or healing of digital ulcers. Prevention of digital ulcers may also include endothelin receptor blocker (bosentan) in some countries. Other treatments had less consensus. Algorithms developed by systemic sclerosis experts might be helpful in deciding which treatment to choose for each setting, using a step-wise strategy, which intends to complement guidelines. This review focuses on a practical approach to the treatment of Raynaud’s phenomenon and digital ulcers in systemic sclerosis, based on algorithms designed by systemic sclerosis experts using consensus, and we review the evidence that supports treatment from initial to second and third-line options.
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18
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Daniels J, Pauling JD, Eccleston C. Behaviour change interventions for the management of Raynaud's phenomenon: a systematic literature review. BMJ Open 2018; 8:e024528. [PMID: 30552281 PMCID: PMC6303561 DOI: 10.1136/bmjopen-2018-024528] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/06/2018] [Accepted: 11/02/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Raynaud's phenomenon (RP) is a significant cause of morbidity. Vasodilator medications cause unwanted adverse effects, with behavioural and lifestyle changes forming the mainstay of self-management; this is difficult to implement successfully. The objectives of this study were to evaluate the efficacy of behaviour change interventions for RP and identify learning points for future treatment development. DESIGN Systematic literature review and narrative synthesis of findings. DATA SOURCES EMBASE, MEDLINE, Cochrane and PsycINFO were searched for eligible studies on 22 August 2017. ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) of behaviour change interventions with at least one control comparator arm. DATA EXTRACTION AND SYNTHESIS Study selection, data extraction and risk of bias were assessed independently by two reviewers, reaching consensus with a third when necessary. Primary outcomes of interest included severity/impact, frequency and duration of RP episodes, pain, disability, adverse events and study withdrawal. RESULTS Of 638 articles retrieved, eight studies fulfilled criteria for inclusion. Biofeedback was the active behaviour change treatment arm for seven studies, with one study reporting a behavioural intervention. Studies were published 1978-2002; six were USA-based studies, one German and one Swedish. Using Cochrane Risk of Bias assessment, studies were assessed to be overall at high risk of bias, with the exception of one large RCT. The total sample included 495 participants (study median=29), with a median age of 39.5 years and preponderance towards females (73%). Five studies reported significant effects in primary outcomes of interest; however, due to missing data, relative efficacy of interventions could not be reliably assessed. CONCLUSIONS There is no evidence to support or refute claims of the efficacy of behaviour change interventions for the management of RP. There remains a strong case for developing and testing behaviour change interventions that focus on self-management; however, theoretical development and advancement in trial quality is imperative to underpin future work. PROSPERO REGISTRATION NUMBER CRD42017049643.
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Affiliation(s)
- Jo Daniels
- Department of Psychology, The University of Bath, Bath, UK
| | - John D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
- Department of Pharmacy and Pharmacology, The University of Bath, Bath, UK
| | - Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK
- Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
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19
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Pauling JD, Domsic RT, Saketkoo LA, Almeida C, Withey J, Jay H, Frech TM, Ingegnoli F, Dures E, Robson J, McHugh NJ, Herrick AL, Matucci-Cerinic M, Khanna D, Hewlett S. Multinational Qualitative Research Study Exploring the Patient Experience of Raynaud's Phenomenon in Systemic Sclerosis. Arthritis Care Res (Hoboken) 2018; 70:1373-1384. [PMID: 29473715 DOI: 10.1002/acr.23475] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/14/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Raynaud's phenomenon (RP) is the most common manifestation of systemic sclerosis (SSc). RP is an episodic phenomenon, not easily assessed in the clinic, leading to reliance on self-report. A thorough understanding of the patient experience of SSc-RP is essential to ensuring that patient-reported outcome (PRO) instruments capture domains important to the target patient population. We report the findings of an international qualitative research study investigating the patient experience of SSc-RP. METHODS Focus groups of SSc patients were conducted across 3 scleroderma centers in the US and UK, using a topic guide and a priori purposive sampling framework devised by qualitative researchers, SSc patients, and SSc experts. Focus groups were audio recorded, transcribed, anonymized, and analyzed using inductive thematic analysis. Focus groups were conducted until thematic saturation was achieved. RESULTS Forty SSc patients participated in 6 focus groups conducted in Bath (UK), New Orleans (Louisiana), and Pittsburgh (Pennsylvania). Seven major themes were identified that encapsulate the patient experience of SSc-RP: physical symptoms, emotional impact, triggers and exacerbating factors, constant vigilance and self-management, impact on daily life, uncertainty, and adaptation. The interrelationship of the 7 constituent themes can be arranged within a conceptual map of SSc-RP. CONCLUSION We have explored the patient experience of SSc-RP in a diverse and representative SSc cohort and identified a complex interplay of experiences that result in significant impact. Work to develop a novel PRO instrument for assessing the severity and impact of SSc-RP, comprising domains/items grounded in the patient experiences of SSc-RP identified in this study, is underway.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and University of Bath, Bath, UK
| | - Robyn T Domsic
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Jane Withey
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK
| | - Hilary Jay
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK
| | - Tracy M Frech
- University of Utah and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City
| | | | - Emma Dures
- University of the West of England, Bristol, UK
| | | | - Neil J McHugh
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and University of Bath, Bath, UK
| | - Ariane L Herrick
- University of Manchester, Salford Royal Hospital NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
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20
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Baron M, Kahaleh B, Bernstein EJ, Chung L, Clements PJ, Denton C, Domsic RT, Ferdowsi N, Foeldvari I, Frech T, Gordon JK, Hudson M, Johnson SR, Khanna D, McMahan Z, Merkel PA, Narain S, Nikpour M, Pauling JD, Ross L, Valenzuela Vergara AM, Vacca A. An Interim Report of the Scleroderma Clinical Trials Consortium Working Groups. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 4:17-27. [PMID: 30906878 DOI: 10.1177/2397198318783926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Scleroderma Clinical Trials Consortium (SCTC) represents many of the clinical researchers in the world who are interested in improving the efficiency of clinical trials in Systemic Sclerosis (SSc). The SCTC has established 11 working groups (WGs) to develop and validate better ways of measuring and recording multiple aspects of this heterogeneous disease. These include groups working on arthritis, disease damage, disease activity, cardiac disease, juvenile SSc, the gastrointestinal tract, vascular component, calcinosis, scleroderma renal crisis, interstitial lung disease, and skin measurement. Members of the SCTC may join any one or more of these groups. Some of the WGs have only recently started their work, some are nearing completion of their mandated tasks and others are in the midst of their projects. All these projects, which are described in this paper, will help to improve clinical trials and observational studies by improving or developing better, more sensitive ways of measuring various aspects of the disease. As Lord Kelvin stated, "To measure is to know. If you cannot measure it you cannot improve it." The SCTC is dedicated to improving the lives of patients with SSc and it is our hope that the contributions of the WGs will be one important step in this process.
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Affiliation(s)
- Murray Baron
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Bashar Kahaleh
- Faculty of Rheumatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Elana J Bernstein
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Philip J Clements
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; University College London, London, United Kingdom
| | - Christopher Denton
- Insitute of Immunity and Transplantation, University College London, London, United Kingdom
| | - Robyn T Domsic
- Arthritis and Autoimmunity Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nava Ferdowsi
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric Rheumatology, Hamburg, Germany
| | - Tracy Frech
- Department of Rheumatology, University of Utah, UT, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Sindhu R Johnson
- Department of Rheumatology, Toronto Western Hospital, Toronto, Canada
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, MI, USA
| | | | - Peter A Merkel
- Department of Medicine, University of Pennsylvania, PA, USA
| | - Sonali Narain
- Department of Rheumatology, Hosfra Northwell School of Medicine
| | - Mandana Nikpour
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - John D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases University of Bath
| | - Laura Ross
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
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21
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Hinze AM, Wigley FM. Pharmacotherapy Options in the Management of Raynaud's Phenomenon. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018; 4:235-254. [PMID: 31538045 DOI: 10.1007/s40674-018-0102-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose of review Multiple classes of medications have been studied for the treatment of Raynaud's phenomenon (RP) with or without digital ischemia. The goal of this review is to discuss the outcomes of recent studies and to report on our approach to the management of RP in light of the available evidence. Recent findings Comparing treatments for RP remains a challenge as efficacy endpoint vary widely among trials. While calcium channel blockers are used first-line in the pharmacologic management of RP, phosphodiesterase 5 inhibitors have also been shown to be beneficial in reducing symptoms. In the setting of digital ischemia, administration of intravenous prostanoids is the standard of care. Bosentan has shown benefit in the prevention of future ulcers in patients with scleroderma. Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients. Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common. Summary Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP. Based on the available evidence, we start with CCBs and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist in cases of recurrent digital ulcers. A surgical sympathectomy may be used in refractory cases of digital ischemia. A digital block may also be a less invasive, but temporary, intervention allowing for titration of medical therapy.
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Affiliation(s)
- Alicia M Hinze
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
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Pauling JD, Frech TM, Hughes M, Gordon JK, Domsic RT, Anderson ME, Ingegnoli F, McHugh NJ, Johnson SR, Hudson M, Boin F, Ong VH, Matucci-Cerinic M, Altorok N, Scolnik M, Nikpour M, Shah A, Pope JE, Khanna D, Herrick AL. Patient-reported outcome instruments for assessing Raynaud's phenomenon in systemic sclerosis: A SCTC Vascular Working Group Report. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:249-252. [PMID: 30705970 DOI: 10.1177/2397198318774307] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The episodic nature of Raynaud's phenomenon (RP) in systemic sclerosis (SSc) has led to a reliance on patient-reported outcome (PRO) instruments such as the Raynaud's Condition Score (RCS) diary. Little is known about the utilisation in routine clinical practice and health professional attitudes towards existing PRO instruments for assessing SSc-RP. Members of the Scleroderma Clinical Trials Consortium Vascular Working Group (SCTC-VWG, n=28) were invited to participate in a survey gauging attitudes towards the RCS diary and the perceived need for novel PRO instruments for assessing SSc-RP. Nineteen SCTC-VWG members (68% response rate) from academic units based in North America (n=9), Europe (n=8), South America (n=1) and Australasia (n=1) took part in the survey. There was broad consensus that RCS diary returns could be influenced by factors including seasonal variation in weather, efforts made by patients to avoid or ameliorate attacks of RP, habituation to RP symptoms, evolution of RP symptom characteristics with progressive obliterative microangiopathy, patient coping strategies, respondent burden and placebo effect. There was consensus that limitations of the RCS diary might be a barrier to drug development (79% of respondents agree/strongly agree) and that a novel PRO instrument for assessing SSc-RP should be developed with the input of both clinicians and patients (84% agree/strongly agree). Perceived potential limitations of the RCS diary have been identified along with concerns that such factors might impede drug development programs for SSc-RP. There is support within the systemic sclerosis community for the development of a novel PRO instrument for assessing SSc-RP.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Tracy M Frech
- University of Utah and Salt Lake Regional Veterans Affair Medical Center, Salt Lake City, UT
| | - Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | | | | | - Marina E Anderson
- Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool & Aintree University Hospital
| | - Francesca Ingegnoli
- Division of Rheumatology, Dept. of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Neil J McHugh
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marie Hudson
- Jewish General Hospital, Lady Davis Institute and McGill University, Montreal, Canada
| | - Francesco Boin
- UCSF Scleroderma Center, University of California San Francisco, San Francisco, CA
| | - Voon H Ong
- University College London Medical School, Royal Free Hospital, London, UK
| | | | | | - Marina Scolnik
- Rheumatology Section, Hospital Italiano de Buenos Aires, Argentina
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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23
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Cutolo M, Ruaro B, Montagna P, Brizzolara R, Stratta E, Trombetta AC, Scabini S, Tavilla PP, Parodi A, Corallo C, Giordano N, Paolino S, Pizzorni C, Sulli A, Smith V, Soldano S. Effects of selexipag and its active metabolite in contrasting the profibrotic myofibroblast activity in cultured scleroderma skin fibroblasts. Arthritis Res Ther 2018; 20:77. [PMID: 29720235 PMCID: PMC5932791 DOI: 10.1186/s13075-018-1577-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/26/2018] [Indexed: 01/06/2023] Open
Abstract
Background Myofibroblasts contribute to fibrosis through the overproduction of extracellular matrix (ECM) proteins, primarily type I collagen (COL-1) and fibronectin (FN), a process which is mediated in systemic sclerosis (SSc) by the activation of fibrogenic intracellular signaling transduction molecules, including extracellular signal-regulated kinases 1 and 2 (Erk1/2) and protein kinase B (Akt). Selexipag is a prostacyclin receptor agonist synthesized for the treatment of pulmonary arterial hypertension. The study investigated the possibility for selexipag and its active metabolite (ACT-333679) to downregulate the profibrotic activity in primary cultures of SSc fibroblasts/myofibroblasts and the fibrogenic signaling molecules involved. Methods Fibroblasts from skin biopsies obtained with Ethics Committee (EC) approval from patients with SSc, after giving signed informed consent, were cultured until the 3rd culture passage and then either maintained in normal growth medium (untreated cells) or independently treated with different concentrations of selexipag (from 30 μM to 0.3 μM) or ACT-333679 (from 10 μM to 0.1 μM) for 48 h. Protein and gene expressions of α-smooth muscle actin (α-SMA), fibroblast specific protein-1 (S100A4), COL-1, and FN were investigated by western blotting and quantitative real-time PCR. Erk1/2 and Akt phosphorylation was investigated in untreated and ACT-333679-treated cells by western botting. Results Selexipag and ACT-333679 significantly reduced protein synthesis and gene expression of α-SMA, S100A4, and COL-1 in cultured SSc fibroblasts/myofibroblasts compared to untreated cells, whereas FN was significantly downregulated at the protein level. Interestingly, ACT-333679 significantly reduced the phosphorylation of Erk1/2 and Akt in cultured SSc fibroblasts/myofibroblasts. Conclusions Selexipag and mainly its active metabolite ACT-333679 were found for the first time to potentially interfere with the profibrotic activity of cultured SSc fibroblasts/myofibroblasts at least in vitro, possibly through the downregulation of fibrogenic Erk1/2 and Akt signaling molecules.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy.
| | - Barbara Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Paola Montagna
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Renata Brizzolara
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Emanuela Stratta
- Oncologic Surgery, Department of Surgery, Polyclinic San Martino Hospital, Genoa, Italy
| | - Amelia Chiara Trombetta
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Stefano Scabini
- Oncologic Surgery, Department of Surgery, Polyclinic San Martino Hospital, Genoa, Italy
| | - Pier Paolo Tavilla
- Department of Health Science, Unit of Dermatology, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Aurora Parodi
- Department of Health Science, Unit of Dermatology, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Claudio Corallo
- Department of Medicine, Surgery and Neurosciences, Scleroderma Unit, University of Siena, Siena, Italy
| | - Nicola Giordano
- Department of Medicine, Surgery and Neurosciences, Scleroderma Unit, University of Siena, Siena, Italy
| | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Stefano Soldano
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Polyclinic San Martino Hospital, Genoa, Italy
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24
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Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
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Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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25
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Pearson DR, Werth VP, Pappas-Taffer L. Systemic sclerosis: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:459-474. [PMID: 30047430 DOI: 10.1016/j.clindermatol.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.
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Affiliation(s)
- David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Denton CP, Hachulla É, Riemekasten G, Schwarting A, Frenoux JM, Frey A, Le Brun FO, Herrick AL. Efficacy and Safety of Selexipag in Adults With Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Randomized, Placebo-Controlled, Phase II Study. Arthritis Rheumatol 2017; 69:2370-2379. [PMID: 29193819 PMCID: PMC6099416 DOI: 10.1002/art.40242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 08/22/2017] [Indexed: 01/03/2023]
Abstract
Objective To determine the effect of selexipag, an oral, selective IP prostacyclin receptor agonist, on the frequency of attacks of Raynaud's phenomenon (RP) in patients with systemic sclerosis (SSc). Methods Patients with SSc‐related RP were randomized 1:1 to placebo (n = 38) or selexipag (n = 36) in individualized doses (maximum of 1,600 μg twice daily) during a 3‐week titration period. The primary end point was the weekly average number of RP attacks during the study maintenance period, analyzed using a Bayesian approach with a negative binomial model adjusted for baseline number of RP attacks. Other outcome measures included Raynaud's Condition Score (RCS), RP attack duration, and treatment‐emergent adverse events (AEs). Results Baseline characteristics were comparable between treatment groups. For 83.3% of patients, the individualized maintenance dosage of selexipag was ≤800 μg twice daily. No significant difference was observed between placebo and selexipag in weekly average number of electronic diary (eDiary)–recorded RP attacks during the maintenance period (14.2 attacks during the maintenance period and 21.5 attacks during the baseline week in the placebo group [n = 32] versus 18.0 attacks during the maintenance period and 22.4 attacks during the baseline week in the selexipag group [n = 27]; adjusted mean treatment difference of 3.4 in favor of placebo). No significant treatment effect was observed on RCS or RP attack duration. In the double‐blind period, 86.8% of placebo‐treated patients and 100% of selexipag‐treated patients reported ≥1 AE; 55.3% and 91.7%, respectively, reported ≥1 prostacyclin‐associated AE. Conclusion Treatment with selexipag did not reduce the number of RP attacks compared with placebo. The safety profile of selexipag was similar to that previously reported. This study provides important information about the feasibility of eDiary reporting of RP attacks in clinical trials.
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Affiliation(s)
| | - Éric Hachulla
- National Referral Centre for Rare Systemic Auto-immune Diseases, Department of Internal Medicine, Hôpital Huriez, University of Lille, Lille, France
| | | | - Andreas Schwarting
- Johannes Gutenberg University, Mainz, and ACURA Rheumatology Centre RLP, Bad Kreuznach, Germany
| | | | - Aline Frey
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust and NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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27
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Seibold JR, Wigley FM. Editorial: Clinical Trials in Raynaud's Phenomenon: A Spoonful of Sugar (Pill) Makes the Medicine Go Down (in Flames). Arthritis Rheumatol 2017; 69:2256-2258. [PMID: 28859256 DOI: 10.1002/art.40307] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 08/28/2017] [Indexed: 11/08/2022]
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28
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Cutolo M, Smith V, Furst DE, Khanna D, Herrick AL. Points to consider-Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v45-v48. [PMID: 28992170 DOI: 10.1093/rheumatology/kex199] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 11/13/2022] Open
Abstract
RP is an exaggerated vasospastic response to cold or emotion. Randomized, double-blind, placebo-controlled trials with either parallel group or cross-over trials should be mainly considered. Cross-over design, which is good for early phase trials of immediate or very short-term outcomes, is important in a condition as heterogeneous as RP: a wash-out period between treatment arms should always be included to minimize the possibility of a period (carry-over) effect. Duration of RP trials is usually constrained by the need to complete these over a single season, usually winter when the weather is colder. For cross-over trials, each treatment arm tends to be 4 weeks or less. Frequency and duration of attacks, and the Raynaud's Condition Score are widely used outcome measures. There is increasing interest in physiological laboratory endpoints, for example laser Doppler imaging at least for early phase trials.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS, University of Genova, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital.,Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Daniel E Furst
- Department of Rheumatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine University of Michigan, University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust, Manchester and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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29
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Use of intravenous epoprostenol as a treatment for the digital vasculopathy associated with the scleroderma spectrum of diseases. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction Intravenous prostanoid therapy is recommended for severe systemic sclerosis-related digital vasculopathy. The evidence supporting this recommendation is limited. The aim of this study was to evaluate the safety and efficacy of treating scleroderma spectrum digital vasculopathy with intravenous epoprostenol. Methods Patients with a diagnosis of systemic sclerosis who had received intravenous epoprostenol for scleroderma spectrum digital vasculopathy between 1st October 2003 and 1st September 2015 at Boston University Medical Center were identified using ICD-9 code search, and their charts were reviewed in this retrospective case series. Results Of 47 encounters for intravenous epoprostenol infusion for scleroderma spectrum digital vasculopathy, 29 had documentation of improvement as indicated by any of the following: pain relief, increased perfusion of digits as assessed by warmth or color, reduced digital ulcer number or size. In 16 encounters, there was no documentation on whether the indicative condition had improved. No deterioration of the indicative condition was documented in any encounters. Intravenous epoprostenol infusion was well tolerated with few significant adverse effects. Conclusions Intravenous epoprostenol infusion in the treatment of scleroderma spectrum digital vasculopathy is safe. The condition improved with intravenous epoprostenol infusion, although there were study design constraints. We describe our protocol for administering intravenous epoprostenol infusion for scleroderma spectrum digital vasculopathy to improve consistency of patient care.
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30
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Ingegnoli F, Carmona L, Castrejon I. Systematic review of systemic sclerosis-specific instruments for the EULAR Outcome Measures Library: An evolutional database model of validated patient-reported outcomes. Semin Arthritis Rheum 2017; 46:609-614. [DOI: 10.1016/j.semarthrit.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/30/2016] [Accepted: 10/07/2016] [Indexed: 01/28/2023]
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31
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Abstract
INTRODUCTION Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.
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Affiliation(s)
- Ariane L Herrick
- a Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,b NIHR Manchester Musculoskeletal Biomedical Research Unit , Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
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32
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Digital Ulcers in Ssc Treated with Oral Treprostinil: A Randomized, Double-Blind, Placebo-Controlled Study with Open-Label Follow-up. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000232] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Prostacyclins are routinely used to treat vascular features of systemic sclerosis (SSc, scleroderma) but require parenteral infusion or inhalation. This study evaluated the safety and efficacy of oral treprostinil in digital ulcers secondary to SSc. Methods This was a randomized (1:1) placebo-controlled, multicenter study in adults with SSc and at least one active digital ulcer at entry. Oral treprostinil was administered twice daily and titrated to maximum tolerated dose with clinical assessments at Weeks 5, 10, 15 and 20. The primary endpoint was change in net digital ulcer burden. Secondary outcomes included ulcer healing and prevention, measures of hand function, quality of life, Raynaud phenomenon and global assessments. Simplified data were gathered during open-label follow up. Results Enrolled were 147 patients (109F/38M), mean age 48.8 years with SSc of mean duration 10.5 years. At week 20, mean net ulcer burden was reduced −0.43 ulcers on treprostinil (1.80 vs. 1.37) and −0.10 ulcers on placebo (1.61 vs. 1.51; p = 0.20). There were no effects on ulcer healing or prevention, and small, inconsistent effects on Raynaud phenomenon, global assessment, hand function and quality-of-life measures. In open-label follow-up, there was a continued, small reduction in net ulcer burden (-0.52 month 3, n = 104; −0.64 month 12, n = 36). Common adverse effects were headache, nausea, diarrhea, jaw pain, flushing and other gastrointestinal symptoms. Conclusions Administration of oral treprostinil twice daily over 20 weeks was associated with small and statistically insignificant reduction in net ulcer burden in comparison to placebo.
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A Randomized Controlled Trial of Acupressure for the Treatment of Raynaud's Phenomenon: The difficulty of conducting a trial in Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016; 1:226-233. [PMID: 27840853 DOI: 10.5301/jsrd.5000206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of acupressure on Raynaud's phenomenon (RP) in a randomized controlled clinical trial (RCT) and to evaluate the difficulties of conducting a RP RCT. METHODS A pilot single center RCT of acupressure vs. targeted patient education was conducted for the treatment of RP. Patients with either primary (N = 15) or secondary (N = 8) RP were randomized in an 8-week study. The primary endpoints included a decrease in the frequency and duration of RP. Secondary endpoints included several serum biomarkers including endothelial dysfunction, Raynaud's attack symptoms, Raynaud's Condition Score, and patient and physician global assessments of RP. Primary data analysis was conducted using the last observation carried forward and t-tests or a Wilcoxon rank test was used to compare the two groups. RESULTS 23 patients were randomized and 7 discontinued prematurely. 78% of patients were female, 96% were Caucasian, and the mean age was 49.8 (SD=16) years. No statistically significant differences were detected between the acupressure vs. education groups in primary and secondary outcomes (p> 0.05). Frequency of attacks decreased by 6.7 attacks (SD=8.8) in the acupressure group vs. 7.2 (SD=12.8) in the education group (p=0.96), and the duration of attacks decreased by 11.4 (SD=19.9) minutes in the acupressure group vs. an increase of 0.8 minutes (SD=11.2) in the education group (p=0.14). There were no adverse events noted in the RCT. CONCLUSION This pilot study does not support efficacy of acupressure for RP.
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34
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Kowal-Bielecka O, Fransen J, Avouac J, Becker M, Kulak A, Allanore Y, Distler O, Clements P, Cutolo M, Czirjak L, Damjanov N, Del Galdo F, Denton CP, Distler JHW, Foeldvari I, Figelstone K, Frerix M, Furst DE, Guiducci S, Hunzelmann N, Khanna D, Matucci-Cerinic M, Herrick AL, van den Hoogen F, van Laar JM, Riemekasten G, Silver R, Smith V, Sulli A, Tarner I, Tyndall A, Welling J, Wigley F, Valentini G, Walker UA, Zulian F, Müller-Ladner U. Update of EULAR recommendations for the treatment of systemic sclerosis. Ann Rheum Dis 2016; 76:1327-1339. [PMID: 27941129 DOI: 10.1136/annrheumdis-2016-209909] [Citation(s) in RCA: 671] [Impact Index Per Article: 83.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/22/2016] [Accepted: 10/09/2016] [Indexed: 12/16/2022]
Abstract
The aim was to update the 2009 European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis (SSc), with attention to new therapeutic questions. Update of the previous treatment recommendations was performed according to EULAR standard operating procedures. The task force consisted of 32 SSc clinical experts from Europe and the USA, 2 patients nominated by the pan-European patient association for SSc (Federation of European Scleroderma Associations (FESCA)), a clinical epidemiologist and 2 research fellows. All centres from the EULAR Scleroderma Trials and Research group were invited to submit and select clinical questions concerning SSc treatment using a Delphi approach. Accordingly, 46 clinical questions addressing 26 different interventions were selected for systematic literature review. The new recommendations were based on the available evidence and developed in a consensus meeting with clinical experts and patients. The procedure resulted in 16 recommendations being developed (instead of 14 in 2009) that address treatment of several SSc-related organ complications: Raynaud's phenomenon (RP), digital ulcers (DUs), pulmonary arterial hypertension (PAH), skin and lung disease, scleroderma renal crisis and gastrointestinal involvement. Compared with the 2009 recommendations, the 2016 recommendations include phosphodiesterase type 5 (PDE-5) inhibitors for the treatment of SSc-related RP and DUs, riociguat, new aspects for endothelin receptor antagonists, prostacyclin analogues and PDE-5 inhibitors for SSc-related PAH. New recommendations regarding the use of fluoxetine for SSc-related RP and haematopoietic stem cell transplantation for selected patients with rapidly progressive SSc were also added. In addition, several comments regarding other treatments addressed in clinical questions and suggestions for the SSc research agenda were formulated. These updated data-derived and consensus-derived recommendations will help rheumatologists to manage patients with SSc in an evidence-based way. These recommendations also give directions for future clinical research in SSc.
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Affiliation(s)
- Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jaap Fransen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jerome Avouac
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Mike Becker
- University Hospital Charité, Berlin, Germany.,University Hospital Zurich, Zurich, Switzerland
| | - Agnieszka Kulak
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | | | - Philip Clements
- University of California at Los Angeles, Los Angeles, California, USA
| | - Maurizio Cutolo
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
| | - Laszlo Czirjak
- Department of Rheumatology and Immunology, Medical Center, University of Pecs, Pecs, Hungary
| | | | | | | | | | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | | | | | - Daniel E Furst
- University of California at Los Angeles, Los Angeles, California, USA
| | | | | | - Dinesh Khanna
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester, UK
| | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Richard Silver
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vanessa Smith
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
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Affiliation(s)
- Fredrick M Wigley
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
| | - Nicholas A Flavahan
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
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Hunzelmann N, Riemekasten G, Becker M, Moinzadeh P, Kreuter A, Melchers I, Mueller‐Ladner U, Meier F, Worm M, Lee H, Herrgott I, Pfeiffer C, Fierlbeck G, Henes J, Juche A, Zeidler G, Mensing H, Günther C, Sárdy M, Burkhardt H, Koehm M, Kuhr K, Krieg T, Sunderkötter C. The Predict Study: low risk for digital ulcer development in patients with systemic sclerosis with increasing disease duration and lack of topoisomerase‐1 antibodies. Br J Dermatol 2016; 174:1384-7. [DOI: 10.1111/bjd.14367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- N. Hunzelmann
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - G. Riemekasten
- Department of Rheumatology and Clinical Immunology University of Berlin, Charité Berlin Germany
| | - M.O. Becker
- Department of Rheumatology and Clinical Immunology University of Berlin, Charité Berlin Germany
| | - P. Moinzadeh
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - A. Kreuter
- Helios St Elisabeth Clinic Dermatology and Venereology Oberhausen Germany
| | - I. Melchers
- University Medical Center Freiburg Clinical Research Unit for Rheumatology Freiburg Germany
| | - U. Mueller‐Ladner
- Justus Liebig University Giessen Kerckhoff Clinic Rheumatology and Clinical Immunology Bad Nauheim Germany
| | - F. Meier
- Justus Liebig University Giessen Kerckhoff Clinic Rheumatology and Clinical Immunology Bad Nauheim Germany
| | - M. Worm
- Department of Dermatology and Venereology University of Berlin, Charité Berlin Germany
| | - H. Lee
- Department of Dermatology and Venereology University of Berlin, Charité Berlin Germany
| | - I. Herrgott
- Department of Dermatology and Department of Translational Dermatoinfectiology University of Muenster Muenster Germany
| | - C. Pfeiffer
- University Hospital Ulm Dermatology Ulm Germany
| | - G. Fierlbeck
- Department of Dermatology University of Tübingen Tübingen Germany
| | - J. Henes
- Department of Rheumatology University of Tübingen Tübingen Germany
| | - A. Juche
- Johanniter Hospital Treuenbrietzen Rheumatology Treuenbrietzen Germany
| | - G. Zeidler
- Johanniter Hospital Treuenbrietzen Rheumatology Treuenbrietzen Germany
| | - H. Mensing
- Hamburg Alstertal Clinic for Dermatology Hamburg Germany
| | - C. Günther
- University Hospital Carl Gustav Carus Dermatology Dresden Germany
| | - M. Sárdy
- Ludwig Maximilian University Dermatology and Allergology Munich Germany
| | - H. Burkhardt
- Goethe‐University Frankfurt & Clinical Research Fraunhofer IME Translational Medicine and Pharmacology (TMP), RheumatologyFrankfurt/Main Germany
| | - M. Koehm
- Goethe‐University Frankfurt & Clinical Research Fraunhofer IME Translational Medicine and Pharmacology (TMP), RheumatologyFrankfurt/Main Germany
| | - K. Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology University Hospital of Cologne Kerpener Straße 62 50937 Köln Germany
| | - T. Krieg
- Department of Dermatology and Venereology University Hospital of Cologne Kerpener Straße 62 Köln 50937 Germany
| | - C. Sunderkötter
- Department of Dermatology and Department of Translational Dermatoinfectiology University of Muenster Muenster Germany
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Asaki T, Kuwano K, Morrison K, Gatfield J, Hamamoto T, Clozel M. Selexipag: An Oral and Selective IP Prostacyclin Receptor Agonist for the Treatment of Pulmonary Arterial Hypertension. J Med Chem 2015; 58:7128-37. [DOI: 10.1021/acs.jmedchem.5b00698] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tetsuo Asaki
- Discovery Research
Laboratories, Nippon Shinyaku Co., Ltd., 14 Nishinosho-Monguchi-Cho, Kisshoin, Minami-ku, Kyoto 601-8550, Japan
| | - Keiichi Kuwano
- Discovery Research
Laboratories, Nippon Shinyaku Co., Ltd., 14 Nishinosho-Monguchi-Cho, Kisshoin, Minami-ku, Kyoto 601-8550, Japan
| | - Keith Morrison
- Drug Discovery Department, Actelion Pharmaceuticals Ltd., Gewerbestrasse 16, Allschwil CH4123, Switzerland
| | - John Gatfield
- Drug Discovery Department, Actelion Pharmaceuticals Ltd., Gewerbestrasse 16, Allschwil CH4123, Switzerland
| | - Taisuke Hamamoto
- Discovery Research
Laboratories, Nippon Shinyaku Co., Ltd., 14 Nishinosho-Monguchi-Cho, Kisshoin, Minami-ku, Kyoto 601-8550, Japan
| | - Martine Clozel
- Drug Discovery Department, Actelion Pharmaceuticals Ltd., Gewerbestrasse 16, Allschwil CH4123, Switzerland
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Abstract
Raynaud’s phenomenon and digital ulcerations are two common clinical features seen in patients with systemic sclerosis. They are painful and lead to significant morbidity and altered hand function within this patient population. While currently there are no US Food and Drug Administration (FDA)-approved medications for the treatment of digital ulcerations in the United States, clinical trials have supported the use of pharmacologic and nonpharmacologic modalities in facilitating healing of existing digital ulcers and preventing formation of new ulcers. This article reviews the published data on these therapeutic options.
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Affiliation(s)
- Shawn Abraham
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Virginia Steen
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
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Pauling JD, Shipley JA, Hart DJ, McGrogan A, McHugh NJ. Use of Laser Speckle Contrast Imaging to Assess Digital Microvascular Function in Primary Raynaud Phenomenon and Systemic Sclerosis: A Comparison Using the Raynaud Condition Score Diary. J Rheumatol 2015; 42:1163-8. [PMID: 26034146 DOI: 10.3899/jrheum.141437] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Evaluate objective assessment of digital microvascular function using laser speckle contrast imaging (LSCI) in a cross-sectional study of patients with primary Raynaud phenomenon (RP) and systemic sclerosis (SSc), comparing LSCI with both infrared thermography (IRT) and subjective assessment using the Raynaud Condition Score (RCS) diary. METHODS Patients with SSc (n = 25) and primary RP (n = 18) underwent simultaneous assessment of digital perfusion using LSCI and IRT with a cold challenge on 2 occasions, 2 weeks apart. The RCS diary was completed between assessments. The relationship between objective and subjective assessments of RP was evaluated. Reproducibility of LSCI/IRT was assessed, along with differences between primary RP and SSc, and the effect of sex. RESULTS There was moderate-to-good correlation between LSCI and IRT (Spearman rho 0.58-0.84, p < 0.01), but poor correlation between objective assessments and the RCS diary (p > 0.05 for all analyses). Reproducibility of IRT and LSCI was moderate at baseline (ICC 0.51-0.63) and immediately following cold challenge (ICC 0.56-0.86), but lower during reperfusion (ICC 0.3-0.7). Neither subjective nor objective assessments differentiated between primary RP and SSc. Men reported lower median daily frequency of RP attacks (0.82 vs 1.93, p = 0.03). Perfusion using LSCI/IRT was higher in men for the majority of assessments. CONCLUSION Objective and subjective methods provide differing information on microvascular function in RP. There is good convergent validity of LSCI with IRT and acceptable reproducibility of both modalities. Neither subjective nor objective assessments could differentiate between primary RP and SSc. Influence of sex on subjective and objective assessment of RP warrants further evaluation.
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Affiliation(s)
- John D Pauling
- From the Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; and the Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.J.D. Pauling, BMedSci, BMBS, MRCP, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath; J.A. Shipley, BSc, PhD; D.J. Hart, BSc, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; A. McGrogan, PhD, Department of Pharmacy and Pharmacology, University of Bath; N.J. McHugh, BMBS, FRCP, FRCPath, MD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath.
| | - Jacqueline A Shipley
- From the Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; and the Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.J.D. Pauling, BMedSci, BMBS, MRCP, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath; J.A. Shipley, BSc, PhD; D.J. Hart, BSc, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; A. McGrogan, PhD, Department of Pharmacy and Pharmacology, University of Bath; N.J. McHugh, BMBS, FRCP, FRCPath, MD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath
| | - Darren J Hart
- From the Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; and the Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.J.D. Pauling, BMedSci, BMBS, MRCP, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath; J.A. Shipley, BSc, PhD; D.J. Hart, BSc, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; A. McGrogan, PhD, Department of Pharmacy and Pharmacology, University of Bath; N.J. McHugh, BMBS, FRCP, FRCPath, MD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath
| | - Anita McGrogan
- From the Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; and the Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.J.D. Pauling, BMedSci, BMBS, MRCP, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath; J.A. Shipley, BSc, PhD; D.J. Hart, BSc, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; A. McGrogan, PhD, Department of Pharmacy and Pharmacology, University of Bath; N.J. McHugh, BMBS, FRCP, FRCPath, MD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath
| | - Neil J McHugh
- From the Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; and the Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.J.D. Pauling, BMedSci, BMBS, MRCP, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath; J.A. Shipley, BSc, PhD; D.J. Hart, BSc, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases; A. McGrogan, PhD, Department of Pharmacy and Pharmacology, University of Bath; N.J. McHugh, BMBS, FRCP, FRCPath, MD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, and Department of Pharmacy and Pharmacology, University of Bath
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Volkmann ER, Furst DE. Management of Systemic Sclerosis-Related Skin Disease: A Review of Existing and Experimental Therapeutic Approaches. Rheum Dis Clin North Am 2015. [PMID: 26210126 DOI: 10.1016/j.rdc.2015.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The skin is the most common organ system involved in patients with systemic sclerosis (SSc). Nearly all patients experience cutaneous symptoms, including sclerosis, Raynaud's phenomenon, digital ulcers, telangiectasias, and calcinosis. In addition to posing functional challenges, cutaneous symptoms are often a major cause of pain, psychological distress, and body image dissatisfaction. The present article reviews the main features of SSc-related cutaneous manifestations and highlights an evidence-based treatment approach for treating each manifestation. This article also describes novel treatment approaches and opportunities for further research in managing this important clinical dimension of SSc.
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Affiliation(s)
- Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA.
| | - Daniel E Furst
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA
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García de la Peña Lefebvre P, Nishishinya MB, Pereda CA, Loza E, Sifuentes Giraldo WA, Román Ivorra JA, Carreira P, Rúa-Figueroa I, Pego-Reigosa JM, Muñoz-Fernández S. Efficacy of Raynaud's phenomenon and digital ulcer pharmacological treatment in systemic sclerosis patients: a systematic literature review. Rheumatol Int 2015; 35:1447-59. [PMID: 25824427 DOI: 10.1007/s00296-015-3241-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 03/02/2015] [Indexed: 11/29/2022]
Abstract
To evaluate the efficacy of current treatments for the Raynaud phenomenon (RP) in patients with systemic sclerosis (SSc), a systematic literature search was performed using Medline, EMBASE, and Cochrane Central Register of Controlled Trials (from 1961 to October 2011). We included meta-analyses, systematic reviews, clinical trials, and high-quality cohort studies published in English or Spanish. Patient populations had to include adults diagnosed with limited cutaneous or diffuse SSc who had associated RP and/or digital ulcers under pharmacological treatment. Efficacy of treatments was evaluated based on: number of RP episodes, RP severity, episode-free time, ulcer improvement/healing, and appearance of new ulcers. We used the Jadad scale of methodological quality to evaluate the quality of randomized clinical trials, and the 2009 Oxford Centre for Evidence-Based Medicine classification for other studies. Of a total of 1617 studies identified, only 27 fulfilled inclusion criteria. Drugs received the following grade recommendations: Grade A for nifedipine, nicardipine, quinapril, IV iloprost, bosentan, tadalafil, and MQx-503; Grade B for beraprost, cicaprost, DMSO, cyclofenil, and atorvastatin; and Grade C for misoprostol, prazosin, OPC-2826, enalapril, sildenafil, antioxidant, and stanazolol. Calcium channel blockers, prostanoids, tadalafil, and bosentan received the highest recommendation level for their effectiveness. However, most systematic reviews reviewed just a handful of studies with small sample sizes and short follow-ups. Our review shows that the existing evidence on the efficacy of RP treatment in SSc patients is inconclusive which calls for further research, especially in the form of prospective studies of high quality with long-term follow-ups.
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Affiliation(s)
- Paloma García de la Peña Lefebvre
- Servicio de Reumatología, Hospitales Universitarios Grupo Madrid (Madrid, Montepríncipe, Sanchinarro y Torrelodones), c/Oña nº10, 28050, Madrid, Spain,
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Lustig N, Rada G. Is iloprost effective in secondary Raynaud’s phenomenon? Medwave 2015; 15:e6082. [DOI: 10.5867/medwave.2015.02.6082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Raynaud syndrome (RS) was first described by the French physician Maurice Raynaud in 1862 with the characteristic tricolor change featuring pallor (ischemic phase), cyanosis (deoxygenation phase), and erythema (reperfusion phase) induced by cold or stress. Although the underlying pathophysiological mechanism is unclear, alterations in activity of the peripheral adrenoceptor have been implicated, specifically an enhanced smooth muscle contraction due to overexpression or hyperactivity of postsynaptic alpha 2 receptors. There are 2 ways that RS can appear clinically; isolated, formerly referred as Raynaud disease or now primary RS and in association with other conditions, usually connective tissue disorders (eg, Sjögren syndrome, systemic lupus erythematosus, scleroderma, and rheumatoid arthritis), frequently called Raynaud phenomenon or secondary RS. The estimated prevalence in the general population is 3%-5%, with a higher prevalence in women than in men. The diagnosis is mainly clinical, based on patient descriptions of skin changes. Upper extremity pulse-volume recording is used to rule out proximal arterial obstruction. The differentiation between a vasospastic vs and obstructive mechanism is made using digital pressures and photoplethysmography, where an obstructive mechanism has decreased pressures and blunted waveforms. Cold challenge testing, such as ice water immersion with temperature recovery, is highly sensitive but lack specificity. Serologic screening (antinuclear antibody and rheumatoid factor) is advocated to rule out associated connective tissue disorders. Most patients with RS can be managed conservatively, with avoidance of cold exposure or hand warming. For those in whom conservative management is inadequate, a number of pharmacologic and surgical therapies have been used. Owing to lack of complete understanding of the underlying pathophysiology, targeted therapy has not been possible; rather, therapy has been focused on the use of general vasodilation strategies. In this review, the diagnosis, natural history, and current medical and invasive therapy are summarized.
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Affiliation(s)
| | - Gregory J Landry
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR.
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N‐acetilcisteína oral no tratamento do fenômeno de Raynaud secundário à esclerose sistêmica: ensaio clínico randomizado, placebo‐controlado e duplo‐cego. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 54:452-8. [DOI: 10.1016/j.rbr.2014.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/21/2014] [Accepted: 07/18/2014] [Indexed: 11/22/2022] Open
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Roustit M, Khouri C, Blaise S, Villier C, Carpentier P, Cracowski JL. Pharmacologie du phénomène de Raynaud. Therapie 2014; 69:115-28. [DOI: 10.2515/therapie/2013068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/19/2013] [Indexed: 11/20/2022]
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46
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Hughes M, Herrick AL. Treatment options in Raynaud's phenomenon. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.883314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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47
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Mouthon L. L’atteinte de la main dans la sclérodermie systémique. Presse Med 2013; 42:1616-26. [DOI: 10.1016/j.lpm.2013.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 12/01/2022] Open
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48
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Bellando-Randone S, Cappelli S, Guiducci S, Cometi L, Matucci-Cerinic M. Treatment options in systemic sclerosis. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.849195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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49
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Viswanath V, Phiske MM, Gopalani VV. Systemic sclerosis: current concepts in pathogenesis and therapeutic aspects of dermatological manifestations. Indian J Dermatol 2013; 58:255-68. [PMID: 23918994 PMCID: PMC3726870 DOI: 10.4103/0019-5154.113930] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem connective tissue disease with protean clinical manifestations. Recent advances in understanding the pathogenic mechanisms have led to development of target-oriented and vasomodulatory drugs which play a pivotal role in treating various dermatological manifestations. An exhaustive literature search was done using Medline, Embase, and Cochrane library to review the recent concepts regarding pathogenesis and evidence-based treatment of salient dermatological manifestations. The concept of shared genetic risk factors for the development of autoimmune diseases is seen in SSc. It is divided into fibroproliferative and inflammatory groups based on genome-wide molecular profiling. Genetic, infectious, and environmental factors play a key role; vascular injury, fibrosis, and immune activation are the chief pathogenic factors. Vitamin D deficiency has been documented in SSc and correlates with the severity of skin involvement. Skin sclerosis, Raynaud's phenomenon (RP) with digital vasculopathies, pigmentation, calcinosis, and leg ulcers affect the patient's quality of life. Immunosuppressives, biologicals, and hematopoietic stem cell transplantation are efficacious in skin sclerosis. Endothelin A receptor antagonists, calcium-channel blockers, angiotensin receptor inhibitors, prostacyclin analogs, and phosphodiesterase type 5 (PDE-5) inhibitors are the mainstay in RP and digital vasculopathies. Pigmentation in SSc has been attributed to melanogenic potential of endothelin-1 (ET-1); the role of ET 1 antagonists and vitamin D analogs needs to be investigated. Sexual dysfunction in both male and female patients has been attributed to vasculopathy and fibrosis, wherein PDE-5 inhibitors are found to be useful. The future concepts of treating SSc may be based on the gene expression signature.
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Affiliation(s)
- Vishalakshi Viswanath
- Department of Dermatology, Rajiv Gandhi Medical College and CSM Hospital, Kalwa, Thane Municipal Corporation, India
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50
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Kotzki S, Roustit M, Arnaud C, Boutonnat J, Blaise S, Godin-Ribuot D, Cracowski JL. Anodal Iontophoresis of a Soluble Guanylate Cyclase Stimulator Induces a Sustained Increase in Skin Blood Flow in Rats. J Pharmacol Exp Ther 2013; 346:424-31. [DOI: 10.1124/jpet.113.205484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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