Systemic sclerosis disease modification clinical trials design: quo vadis?

The adoption of nintedanib in systemic sclerosis: the SENSCIS study

We live in an era of respiratory medicine in which there is increasing awareness of interstitial lung diseases (ILDs). This is probably due to the publication of evidence-based guidelines [1, 2] and the discovery of newer drugs [3, 4]. These advances are particularly evident for idiopathic pulmonary fibrosis (IPF), which is to date the only fibrotic disease with specific pharmacologic-approved treatments. The burgeoning interest in pulmonary fibrosis has recently shifted its focus to the possibility of using therapeutic interventions available for IPF on other non-IPF ILDs, including pulmonary fibrosis secondary to systemic sclerosis (SSc). ILD represents one of the most relevant complications of SSc [5], but a standard treatment has yet to be achieved. Currently, the therapeutic management of SSc-ILD includes a “wait and see” approach in patients with a slow functional decay, and an immunosuppressive strategy (cyclophosphamide or mycophenolate) in patients with progressive ILD [6]. The Safety and Efficacy of Nintedanib in Systemic Sclerosis (SENSCIS) trial[7] explored the use of nintedanib, an intracellular inhibitor of tyrosine kinases currently approved for IPF, in scleroderma patients.

Nintedanib shows a statistically significant effect on lung function decay in patients with ILD secondary to systemic sclerosis, but no effect on skin fibrosis and on health-related quality of lifehttp://bit.ly/2vfJRj7

Rituximab in early systemic sclerosis

OBJECTIVES

(1) Hypothesis testing of the potency of rituximab (RTX) in preventing fibrotic complications and (2) assessing acceptability and feasibility of RTX in early systemic sclerosis (SSc).

METHODS

A small, 24-month, randomised, double-blind, placebo-controlled, single-centre trial in patients with SSc diagnosed <2 years was conducted. Patients received RTX or placebo infusions at t=0, t=15 days and t=6 months. Patients were clinically evaluated every 3 months, with lung function tests and high-resolution CT every other visit. Skin biopsies were taken at baseline and month 3. Immunophenotyping of peripheral blood mononuclear cells was performed at every visit, except at months 9 and 18. Adverse events, course of skin and pulmonary involvement and B cell populations in skin and peripheral blood were evaluated.

RESULTS

In total 16, patients (rituximab n=8, placebo n=8) were included. Twelve patients had diffuse cutaneous SSc. Eighty-eight adverse events (RTX n=53, placebo n=35, p=0.22) and 11 serious adverse events (RTX n=7, placebo n=4, p=0.36) occurred. No unexpected RTX-related events were observed. Mean skin score over time did not differ between the groups. Over time, forced vital capacity and extent of lung involvement slightly improved with RTX, but this difference was insignificant. In peripheral blood B cells depletion was demonstrated.

CONCLUSIONS

No unexpected safety issues were observed with RTX in early SSc. Although this small trial could not confirm or reject potential efficacy of RTX in these patients, future placebo-controlled trials are warranted, specifically in the subgroup of patients with pulmonary involvement.

TRIAL REGISTRATION NUMBER

EudraCT 2008-07180-16; Results.

Treatment of Rapidly Progressive Systemic Sclerosis: Current and Futures Perspectives

INTRODUCTION

Systemic Sclerosis (SSc) is a systemic autoimmune disease characterized by severe and often progressive cutaneous, pulmonary, cardiac and gastrointestinal tract fibrosis, cellular and humoral immunologic alterations, and pronounced fibroproliferative vasculopathy. There is no effective SSc disease modifying therapy. Patients with rapidly progressive SSc have poor prognosis with frequent disability and very high mortality.

AREAS COVERED

This paper reviews currently available therapeutic approaches for rapidly progressive SSc and discuss novel drugs under study for SSc disease modification.

EXPERT OPINION

The extent, severity, and rate of progression of SSc skin and internal organ involvement determines the optimal therapeutic interventions for SSc. Cyclophosphamide for progressive SSc-associated interstitial lung disease and mycophenolate for rapidly progressive cutaneous involvement have shown effectiveness. Methotrexate has been used for less severe skin progression and for patients unable to tolerate mycophenolate. Rituximab was shown to induce improvement in SSc-cutaneous and lung involvement. Autologous bone marrow transplantation is reserved for selected cases in whom poor survival risk outweighs the high mortality rate of the procedure. Novel agents capable of modulating fibrotic and inflammatory pathways involved in SSc pathogenesis, including tocilizumab, pirfenidone, tyrosine kinase inhibitors, lipid lysophosphatidic acid 1, and NOX4 inhibitors are currently under development for the treatment of rapidly progressive SSc.