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Campochiaro C, Allanore Y, Braun-Moscovici Y, Matucci-Cerinic M, Balbir-Gurman A. Is cyclophosphamide still the gold standard in early severe rapidly progressive systemic sclerosis? Autoimmun Rev 2024; 23:103439. [PMID: 37690478 DOI: 10.1016/j.autrev.2023.103439] [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: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
Cyclophosphamide (CYC) has been a gold standard of treatment for severe progressive Systemic Sclerosis (SSc), especially in patients with concomitant interstitial lung disease (ILD). This approach was based on results of several interventional studies, including randomized control trials, which mainly addressed SSc-ILD as a primary end point and skin involvement as a second one. The use of CYC is time-limited due to significant adverse events. More recently, other immunosuppressive and biological agents showed efficacy but better safety profile in patients with SSc and SSc-ILD. With regards to other end-points, post-hoc analyses, systematic reviews and metalysis showed that CYC had limited influence on patients' quality of life, event-free survival and mortality. Comprehensive patient's stratification according to a molecular, cellular and phenotypic pattern may help in choosing of personalized medicine with more ambitious treatment effect and should be the future direction. According to the above available data and even if scientific evidence may be missing, experts' opinion has changed the attitude to CYC as an anchor drug in the management of severe SSc. Indeed, CYC has been pushed to the second and even third treatment option after mycophenolate mofetil, tocilizumab or rituximab. This position became obvious during debate on this topic at CORA meeting 2023.
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Affiliation(s)
- Corrado Campochiaro
- IRCCS San Raffaele Hospital, Unit of Immunology, Rheumatology, Allergy and Rare Diseases; Vita-Salute San Raffaele University, Milan, Italy
| | - Yannick Allanore
- Service de Rhumatologie, Hôpital Cochin, Université de Paris, Paris, France
| | - Yolanda Braun-Moscovici
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Rheumatology, Univercity of Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases; Vita-Salute San Raffaele Univercity, Milan, Italy
| | - Alexandra Balbir-Gurman
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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2
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Patnaik E, Lyons M, Tran K, Pattanaik D. Endothelial Dysfunction in Systemic Sclerosis. Int J Mol Sci 2023; 24:14385. [PMID: 37762689 PMCID: PMC10531630 DOI: 10.3390/ijms241814385] [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: 08/28/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Systemic sclerosis, commonly known as scleroderma, is an autoimmune disorder characterized by vascular abnormalities, autoimmunity, and multiorgan fibrosis. The exact etiology is not known but believed to be triggered by environmental agents in a genetically susceptible host. Vascular symptoms such as the Raynaud phenomenon often precede other fibrotic manifestations such as skin thickening indicating that vascular dysfunction is the primary event. Endothelial damage and activation occur early, possibly triggered by various infectious agents and autoantibodies. Endothelial dysfunction, along with defects in endothelial progenitor cells, leads to defective angiogenesis and vasculogenesis. Endothelial to mesenchymal cell transformation is another seminal event during pathogenesis that progresses to tissue fibrosis. The goal of the review is to discuss the molecular aspect of the endothelial dysfunction that leads to the development of systemic sclerosis.
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Affiliation(s)
- Eshaan Patnaik
- Department of Biology, Memphis University School, Memphis, TN 38119, USA;
| | - Matthew Lyons
- Division of Rheumatology, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA; (M.L.); (K.T.)
| | - Kimberly Tran
- Division of Rheumatology, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA; (M.L.); (K.T.)
| | - Debendra Pattanaik
- Division of Rheumatology, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA; (M.L.); (K.T.)
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3
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Zanin-Silva DC, Santana-Gonçalves M, Kawashima-Vasconcelos MY, Oliveira MC. Management of Endothelial Dysfunction in Systemic Sclerosis: Current and Developing Strategies. Front Med (Lausanne) 2021; 8:788250. [PMID: 35004754 PMCID: PMC8727451 DOI: 10.3389/fmed.2021.788250] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022] Open
Abstract
Systemic Sclerosis (SSc) is an autoimmune disease marked by dysregulation of the immune system, tissue fibrosis and dysfunction of the vasculature. Vascular damage, remodeling and inadequate endothelial repair are hallmarks of the disease. Since early stages of SSc, damage and apoptosis of endothelial cells (ECs) can lead to perivascular inflammation, oxidative stress and tissue hypoxia, resulting in multiple clinical manifestations. Raynaud's phenomenon, edematous puffy hands, digital ulcers, pulmonary artery hypertension, erectile dysfunction, scleroderma renal crisis and heart involvement severely affect quality of life and survival. Understanding pathogenic aspects and biomarkers that reflect endothelial damage in SSc is essential to guide therapeutic interventions. Treatment approaches described for SSc-associated vasculopathy include pharmacological options to improve blood flow and tissue perfusion and, more recently, cellular therapy to enhance endothelial repair, promote angiogenesis and heal injuries. This mini-review examines the current knowledge on cellular and molecular aspects of SSc vasculopathy, as well as established and developing therapeutic approaches for improving the vascular compartment.
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Affiliation(s)
- Djúlio César Zanin-Silva
- Center for Cell-Based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Basic and Applied Immunology Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maynara Santana-Gonçalves
- Center for Cell-Based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Oncology, Stem Cell and Cell-Therapy Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marianna Yumi Kawashima-Vasconcelos
- Center for Cell-Based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Internal Medicine Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Suga K, Yamashita H, Takahashi Y, Katagiri D, Hinoshita F, Kaneko H. Therapeutic efficacy of combined glucocorticoid, intravenous cyclophosphamide, and double-filtration plasmapheresis for skin sclerosis in diffuse systemic sclerosis. Medicine (Baltimore) 2020; 99:e19301. [PMID: 32150064 PMCID: PMC7478820 DOI: 10.1097/md.0000000000019301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We treated skin sclerosis with triple therapy consisting of a glucocorticoid, intravenous cyclophosphamide, and double-filtration plasmapheresis. The objective of this study was to analyze its effectiveness in a case series of patients who received triple therapy.We enrolled 8 patients with diffuse cutaneous systemic sclerosis (dcSSc) who received triple therapy at our hospital from 2008 to 2016. We analyzed the mean change in the modified Rodnan skin score (mRSS), percentage of the predicted forced vital capacity (%FVC), percentage of the predicted carbon monoxide diffusing capacity (%DLCO), and serum KL-6 levels from baseline to follow-up.All patients were treated with an intermediate dose of oral prednisolone (30.6 ± 2.1 mg/day) initially. The mean cumulative dose of intravenous cyclophosphamide was 1.4 ± 0.2 g. The mean mRSS decreased significantly at follow-up compared with that at baseline (27.0 ± 3.3 vs 15.8 ± 3.5; P = .03). At the end of the treatment, the mean %FVC and %DLCO were improved moderately, although the differences were not significant. The serum KL-6 levels decreased from 578.9 ± 146.5 to 205.3 ± 43.1 U/ml (P = .02). No significant correlation was found between the change in mRSS or disease duration and the initial skin score severity.Triple therapy may improve skin sclerosis, with effectiveness equal or superior to other reported treatments. This preliminary case series demonstrates the potential of triple therapy for treating dcSSc. However, prospective studies with long-term follow-up should be performed to assess its role.
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Affiliation(s)
| | | | | | - Daisuke Katagiri
- Division of Nephrology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Fumihiko Hinoshita
- Division of Nephrology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
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Blank RB, Nwawka OK, Yusov AA, Gordon JK. Inflammatory arthritis in systemic sclerosis: What to do? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:3-16. [PMID: 35382152 PMCID: PMC8922577 DOI: 10.1177/2397198318779532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/08/2018] [Indexed: 08/26/2024]
Abstract
Musculoskeletal involvement, including arthritis and tendinopathy, is a common and important determinant of disability and impaired quality of life in systemic sclerosis. However, the treatment of arthritis in systemic sclerosis has not been studied as a primary outcome in randomized controlled trials, and arthritis-specific outcome measures for systemic sclerosis have not been sufficiently validated to date. Rheumatologists caring for patients with systemic sclerosis must address these complaints regularly despite the fact that the level of evidence for the treatment of systemic sclerosis-related inflammatory arthritis is limited. Consensus statements, based on treatments for related musculoskeletal aspects of rheumatoid arthritis, systemic lupus erythematosus, and other autoimmune diseases, support the use of methotrexate and hydroxychloroquine. Newer biologics, which have efficacy in the treatment of other autoimmune conditions, may show promise in the treatment of arthritis in systemic sclerosis. In this article, we review the current literature on the assessment and treatment of systemic sclerosis arthritis in order to address management considerations.
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Affiliation(s)
- Rebecca B Blank
- NewYork-Presbyterian/Weill Cornell Medicine Center, New York, NY, USA
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Iqubal A, Iqubal MK, Sharma S, Ansari MA, Najmi AK, Ali SM, Ali J, Haque SE. Molecular mechanism involved in cyclophosphamide-induced cardiotoxicity: Old drug with a new vision. Life Sci 2018; 218:112-131. [PMID: 30552952 DOI: 10.1016/j.lfs.2018.12.018] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/08/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022]
Abstract
Cyclophosphamide (CP) is an important anticancer drug which belongs to the class of alkylating agent. Cyclophosphamide is mostly used in bone marrow transplantation, rheumatoid arthritis, lupus erythematosus, multiple sclerosis, neuroblastoma and other types of cancer. Dose-related cardiotoxicity is a limiting factor for its use. CP-induced cardiotoxicity ranges from 7 to 28% and mortality ranges from 11 to 43% at the therapeutic dose of 170-180 mg/kg, i.v. CP undergoes hepatic metabolism that results in the production of aldophosphamide. Aldophosphamide decomposes into phosphoramide mustard & acrolein. Phosphoramide is an active neoplastic agent, and acrolein is a toxic metabolite which acts on the myocardium and endothelial cells. This is the first review article that talks about cyclophosphamide-induced cardiotoxicity and the different signaling pathways involved in its pathogenicity. Based on the available literature, CP is accountable for cardiomyocytes energy pool alteration by affecting the heart fatty acid binding proteins (H-FABP). CP has been found associated with cardiomyocytes apoptosis, inflammation, endothelial dysfunction, calcium dysregulation, endoplasmic reticulum damage, and mitochondrial damage. Molecular mechanism of cardiotoxicity has been discussed in detail through crosstalk of Nrf2/ARE, Akt/GSK-3β/NFAT/calcineurin, p53/p38MAPK, NF-kB/TLR-4, and Phospholamban/SERCA-2a signaling pathway. Based on the available literature we support the fact that metabolites of CP are responsible for cardiotoxicity due to depletion of antioxidants/ATP level, altered contractility, damaged endothelium and enhanced pro-inflammatory/pro-apoptotic activities resulting into cardiomyopathy, myocardial infarction, and heart failure. Dose adjustment, elimination/excretion of acrolein and maintenance of endogenous antioxidant pool could be the therapeutic approach to mitigate the toxicities.
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Affiliation(s)
- Ashif Iqubal
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Mohammad Kashif Iqubal
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Sumit Sharma
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Mohd Asif Ansari
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Abul Kalam Najmi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Syed Mansoor Ali
- Department of Biosciences, Jamia Millia Islamia,110025 New Delhi, India
| | - Javed Ali
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Syed Ehtaishamul Haque
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India.
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Thakkar V, Patterson KA, Stevens W, Wilson M, Roddy J, Sahhar J, Proudman S, Hissaria P, Nikpour M. Increased serum levels of adhesion molecules ICAM-1 and VCAM-1 in systemic sclerosis are not specific for pulmonary manifestations. Clin Rheumatol 2018; 37:1563-1571. [PMID: 29687288 DOI: 10.1007/s10067-018-4081-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/15/2018] [Accepted: 03/23/2018] [Indexed: 01/15/2023]
Abstract
Studies suggest elevated serum intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) levels may be markers of pulmonary arterial hypertension in systemic sclerosis (SSc-PAH). We sought to evaluate whether ICAM-1 and VCAM-1 levels are useful screening biomarkers for incident SSc-PAH. In this cross-sectional study, four groups were selected from the Australian Scleroderma Cohort Study: group 1 (n = 15) had definite PAH; group 2 (n = 19) had interstitial lung disease (ILD); group 3 (n = 30) were SSc-controls; and group 4 (n = 34) were healthy controls. Serum ICAM-1 and VCAM-1 levels were measured using the Millipore Milliplex MAP Human 2-Plex Panel. There were no differences in ICAM-1 levels in the PAH versus ILD group (263.0 ± 85.4 vs 380.4 ± 168.3 ng/mL, p = 0.136), SSc-controls (263.0 ± 85.4 vs 253.1 ± 98.0 ng/mL, p = 1.00), or healthy controls (263.0 ± 85.4 vs 201.8 ± 57.2 ng/mL, p = 0.093). Similarly, there were no differences in VCAM-1 level in PAH versus ILD groups (1476.2 ± 434.9 vs 1424.8 ± 527.6 ng/mL, p = 1.00) and SSc-controls (1476.2 ± 434.9 vs 1409.5 ± 341.1 ng/mL, p = 1.00). SSc subjects had significantly higher levels of ICAM-1 (297.4 ± 134.0 vs 201.8 ± 57.2 ng/mL, p < 0.0001) and VCAM-1 compared to healthy controls (1432.7 ± 427.4 vs 1125.6 ± 273.4 ng/mL, p < 0.0001). Neither ICAM-1 nor VCAM-1 is a specific screening biomarker of SSc-PAH. Instead, increased levels of these adhesion molecules in SSc, irrespective of pulmonary complications, suggest that they may play a role in SSc pathogenesis.
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Affiliation(s)
- Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Liverpool BC, NSW, 2170, Australia.,School of Medicine, Western Sydney University, Campbelltown, NSW, Australia.,South Western Clinical School, University of New South Wales, Liverpool, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Parade, Fitzroy, VIC, 3065, Australia.,Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Parade, Fitzroy, VIC, 3065, Australia
| | - Karen A Patterson
- Flinders University, Bedford Park, South Australia, Australia.,Commonwealth Scientific and Industrial Research Organisation CSIRO, Adelaide, South Australia, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Parade, Fitzroy, VIC, 3065, Australia
| | - Michelle Wilson
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Parade, Fitzroy, VIC, 3065, Australia
| | - Janet Roddy
- Department of Rheumatology, Royal Perth Hospital, GPO Box X2213, Perth, WA, 6001, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health & Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Medicine, Monash Health & Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Pravin Hissaria
- Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia.,Department of Clinical Immunology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Parade, Fitzroy, VIC, 3065, Australia. .,Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Parade, Fitzroy, VIC, 3065, Australia.
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8
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Iudici M. What should clinicians know about the use of glucocorticoids in systemic sclerosis? Mod Rheumatol 2017; 27:919-923. [DOI: 10.1080/14397595.2016.1270796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michele Iudici
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
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9
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Bruce IN. The influence of other drugs on coronary heart disease (CHD) risk in systemic lupus erythematosus. Lupus 2016. [DOI: 10.1177/0961203306071674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Systemic lupus erythematosus (SLE) patients currently are exposed to a number of agents to control various manifestations of their disease. In particular the degree of immunosuppression employed is strongly related to the underlying disease severity. This causes problems when evaluating the longterm associations between drugs and outcomes such as cardiovascular disease. Nevertheless, most studies do suggest that increased and prolonged exposure to steroids is harmful to the vasculature and that antimalarial drugs may have several potential beneficial effects in reducing CHD risk in SLE. Further work is now needed to assess if there are doses or regimes of steroid therapy that can optimize their anti-inflammatory effects and minimise their adverse metabolic effects. With regard to other drugs used, it should not be assumed that all immunosuppressive drugs are equal with regard to the cardiovascular system. There is some emerging data that azathioprine may have an association with atherosclerosis development. Whether this is independent of the clinical phenotype remains an open question. Studies of MTX in RA are controversial and in SLE the specific cardiovascular effects of MTX requires direct study. With several novel agents currently in development, their potential effects on the vasculature need specific study to unravel the relative effects of the inflammatory burden, specific organ involvement and therapy on vascular risk.
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Affiliation(s)
- IN Bruce
- Rheumatism Research Centre and ARC Epidemiology Unit, The University of Manchester, Manchester, UK
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10
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Kim J, Chan JJ. Cyclophosphamide in dermatology. Australas J Dermatol 2016; 58:5-17. [PMID: 26806212 DOI: 10.1111/ajd.12406] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 09/02/2015] [Indexed: 01/19/2023]
Abstract
Cyclophosphamide is a chemotherapeutic agent which was first discovered in experimental tumours in rats, and it has since been widely used to treat malignancies and severe manifestations of various auto-immune diseases. High-dose chemotherapy and continuous daily oral regimens are associated with significant toxicity profiles, but i.v. pulsed regimens have lowered the rates of adverse effects in rheumatological studies. Cyclophosphamide has been shown to be useful in the treatment of severe autoimmune conditions due to its powerful immunosuppressive ability; however, it remains a relatively underused modality in dermatology. This article reviews the current literature on cyclophosphamide and its clinical applications in dermatology.
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Affiliation(s)
- Janet Kim
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan J Chan
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Kudo H, Wang Z, Jinnin M, Nakayama W, Inoue K, Honda N, Nakashima T, Kajihara I, Makino K, Makino T, Fukushima S, Ihn H. EBI3 Downregulation Contributes to Type I Collagen Overexpression in Scleroderma Skin. THE JOURNAL OF IMMUNOLOGY 2015; 195:3565-73. [DOI: 10.4049/jimmunol.1402362] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 08/05/2015] [Indexed: 01/30/2023]
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Abstract
Systemic sclerosis (SSc) is a multisystem connective tissue disorder featured by vascular injury and fibrosis of the skin and various internal organs with autoimmune background. Although the pathogenesis of SSc still remains elusive, it is generally accepted that initial vascular injury due to autoimmunity and/or environmental factors causes structural and functional abnormalities of vasculature which eventually result in the constitutive activation of fibroblasts in various organs. Structural alterations consist of destructive vasculopathy (loss of small vessels) and proliferative obliterative vasculopathy (occlusion of arterioles and small arteries with fibro-proliferative change) caused by impaired compensatory vasculogenesis and angiogenesis. Impaired function of SSc vasculature includes the altered expression of cell adhesion molecules predominantly inducing Th2 and Th17 cell infiltration, endothelial dysfunction primarily due to the low availability of nitric oxide, the activated endothelial-to-mesenchymal transition leading to fibro-proliferative vascular change and tissue fibrosis, and the impaired coagulation/fibrinolysis system promoting the formation of intravascular fibrin deposits. Recent new insights into the therapeutic mechanisms of intravenous cyclophosphamide pulse and bosentan and the establishment of a new SSc animal model (Klf5 (+/-);Fli1 (+/-) mice) provide us useful clues to further understand the development of vascular alterations characteristic of SSc. This article overviewed the present understanding of the pathogenesis of SSc vasculopathy.
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13
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Kudo H, Jinnin M, Asano Y, Trojanowska M, Nakayama W, Inoue K, Honda N, Kajihara I, Makino K, Fukushima S, Ihn H. Decreased interleukin-20 expression in scleroderma skin contributes to cutaneous fibrosis. Arthritis Rheumatol 2014; 66:1636-47. [PMID: 24470401 DOI: 10.1002/art.38380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 01/21/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To clarify the role of interleukin-20 (IL-20) in the regulatory mechanism of extracellular matrix expression and to determine the contribution of IL-20 to the phenotype of systemic sclerosis (SSc). METHODS Protein and messenger RNA (mRNA) levels of collagen, Fli-1, IL-20, and IL-20 receptor (IL-20R) were analyzed using polymerase chain reaction (PCR) array, immunoblotting, immunohistochemical staining, enzyme-linked immunosorbent assay, and real-time PCR. RESULTS PCR array revealed that IL-20 decreased gene expression of α2(I) collagen (0.03-fold), Smad3 (0.02-fold), and endoglin (0.05-fold) in cultured normal dermal fibroblasts. Fli-1 protein expression was induced by IL-20 (~2-fold). The inhibition of collagen by IL-20, the induction of Fli-1 by IL-20, and the reduction of Smad3 and endoglin by IL-20 were also observed in SSc fibroblasts. Serum IL-20 levels were reduced only slightly in SSc patients but were significantly decreased in patients with scleroderma spectrum disorders (the prodromal stage of SSc) compared with those in normal subjects (111.3 pg/ml versus 180.4 pg/ml; P < 0.05). On the other hand, IL-20 mRNA expression in SSc skin was decreased compared with that in normal skin (P < 0.05), which may result in the induction of collagen synthesis in SSc dermal fibroblasts. IL-20R was expressed in normal and SSc fibroblasts. Moreover, IL-20 supplementation by injection into the skin reversed skin fibrosis induced by bleomycin in mice (~0.5-fold). CONCLUSION IL-20 reduces basal collagen transcription via Fli-1 induction, while down-regulation of Smad3 and endoglin may cancel the effect of transforming growth factor β in SSc fibroblasts. To confirm the therapeutic value of IL-20 and IL-20R, their function and expression in vivo should be further studied.
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Iudici M, Fasano S, Iacono D, Russo B, Cuomo G, Valentini G. Prevalence and factors associated with glucocorticoids (GC) use in systemic sclerosis (SSc): a systematic review and meta-analysis of cohort studies and registries. Clin Rheumatol 2013; 33:153-64. [DOI: 10.1007/s10067-013-2422-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 10/18/2013] [Indexed: 11/30/2022]
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Takahashi T, Asano Y, Amiya E, Hatano M, Tamaki Z, Takata M, Ozeki A, Watanabe A, Kawarasaki S, Taniguchi T, Ichimura Y, Toyama T, Watanabe M, Hirata Y, Nagai R, Komuro I, Sato S. Clinical correlation of brachial artery flow-mediated dilation in patients with systemic sclerosis. Mod Rheumatol 2013. [PMID: 23543079 DOI: 10.1007/s10165-013-0867-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/07/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVE: To investigate the clinical significance of flow-mediated dilation (FMD) in systemic sclerosis (SSc). METHODS: Thirty-three SSc patients and 12 healthy controls were studied. Ultrasound assessment of the brachial artery FMD was performed on all subjects. The results were expressed as the percentage of increase in brachial artery diameter following hyperemia. RESULTS: Limited cutaneous SSc (lcSSc) patients had significantly lower FMD values than healthy controls (5.3 ± 2.7 versus 7.7 ± 2.0 %, p < 0.05), while the values in diffuse cutaneous SSc (dcSSc) patients (6.7 ± 4.0 %) were comparable to those in lcSSc patients and healthy controls. Although FMD values did not correlate with any clinical features in dcSSc patients, there was an inverse correlation between FMD values and disease duration in lcSSc patients (r = -0.64, p < 0.05). Furthermore, lcSSc patients with decreased FMD values showed significantly higher prevalence of digital ulcers and elevated right ventricular systolic pressure than those with normal values (for each; 75 versus 10 %, p < 0.05). CONCLUSION: The FMD values represent the severity of vascular damages, which progress along with disease duration and lead to digital ulcers and pulmonary arterial hypertension, in lcSSc patients.
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Affiliation(s)
- Takehiro Takahashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Takahashi T, Asano Y, Akamata K, Aozasa N, Taniguchi T, Noda S, Masui Y, Ichimura Y, Toyama T, Tamaki Z, Tada Y, Sugaya M, Kadono T, Sato S. Dynamics of serum angiopoietin-2 levels correlate with efficacy of intravenous pulse cyclophosphamide therapy for interstitial lung disease associated with systemic sclerosis. Mod Rheumatol 2012; 23:884-90. [PMID: 22972016 DOI: 10.1007/s10165-012-0755-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 08/22/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Angiopoietin-2 (Ang2) regulates the transition between vascular quiescence and angiogenesis in a context-dependent manner. In systemic sclerosis (SSc), serum Ang2 levels correlate with its disease activity. Therefore, we investigated the clinical significance of monitoring serum Ang2 levels during intravenous pulse cyclophosphamide (IVCY) therapy in SSc patients with interstitial lung disease (ILD). METHODS Serum Ang2 levels were determined by a specific enzyme-linked immunosorbent assay in seven SSc patients treated with IVCY and 20 healthy controls. In the patient group, serum samples were drawn the day before each IVCY therapy. RESULTS Serum Ang2 levels tended to be higher in SSc patients before IVCY than in healthy controls and significantly correlated with KL-6, surfactant protein D, erythrocyte sedimentation rate, and C-reactive protein in SSc patients with ILD. In sera drawn before the last IVCY, Ang2 levels were significantly decreased compared with initial levels. Notably, Δ serum Ang2 levels between baseline and after the first IVCY significantly correlated with Δ ILD score between before and after the entire IVCY therapy (r = 0.90, p < 0.01). CONCLUSION Monitoring Ang2 levels during IVCY treatment may be useful to evaluate and predict the efficacy of this treatment for SSc-ILD.
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Affiliation(s)
- Takehiro Takahashi
- Department of Dermatology, Faculty of Medicine, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Foocharoen C, Siriphannon Y, Mahakkanukrauh A, Suwannaroj S, Nanagara R. Incidence rate and causes of infection in Thai systemic sclerosis patients. Int J Rheum Dis 2012; 15:277-83. [PMID: 22709489 DOI: 10.1111/j.1756-185x.2012.01728.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Infection is a common cause of death in systemic sclerosis (SSc) but despite immunosuppressant therapy, there are few reports of opportunistic infection. OBJECTIVES To estimate the incidence of infection, to determine the etiologic organism, and to assess the risk factors for infection among Thai SSc patients. METHODS A historical cohort analysis was conducted on patients over 15 years of age, diagnosed with SSc, who attended the Scleroderma Clinic at Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 2005 and December 31, 2006. RESULTS The medical records of 117 SSc patients were reviewed. The female-to-male ratio was 1.5 : 1.0. Of the total 310 person-years under observation, 63 events of infection occurred. The incidence rate of infection was 20.3 per 100 person-years (95% CI 15.6-26.0) and the incidence rate of major infection was 11.0 per 100 person-years (95% CI 8.4-16.5). The mean age and mean duration of SSc at the time of infection was 50.1 ± 11.1 years (range, 25.2-76.6) and 12.9 ± 10.4 months (range, 0.5-34.6), respectively. Urinary tract infection was the most common infection (23.8%). Opportunistic infection was found in one case (esophageal candidiasis). Esophageal dysmotility was significantly related to major infection (odds ratio [OR] 3.22). There was a clinical association between aspiration pneumonia and esophageal dysmotility (OR 1.23), as well as non-strongyloidiasis diarrhea and gastrointestinal involvement (OR 2.28). One person died due to severe bacterial aspiration pneumonia. CONCLUSIONS Infection is not uncommon among SSc patients; however, opportunistic infection is rare, despite immunosuppressant therapy. Esophageal dysmotility increases the risk of major infection, particularly of aspiration pneumonia.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
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Baraut J, Farge D, Jean-Louis F, Kesmandt H, Durant C, Verrecchia F, Michel L. Les cytokines dans la sclérodermie systémique. ACTA ACUST UNITED AC 2012; 60:127-39. [DOI: 10.1016/j.patbio.2009.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 11/17/2009] [Indexed: 12/20/2022]
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Kajihara I, Jinnin M, Makino T, Toihata Yonemitsu A, Sakai K, Masuguchi S, Fukushima S, Ihn H. Clinical significance of cobblestone appearance on the skin of patients with systemic sclerosis. J Eur Acad Dermatol Venereol 2011; 26:123-5. [PMID: 22168777 DOI: 10.1111/j.1468-3083.2011.04007.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Takahashi T, Asano Y, Amiya E, Hatano M, Tamaki Z, Ozeki A, Watanabe A, Kawarasaki S, Nakao T, Taniguchi T, Ichimura Y, Toyama T, Watanabe M, Hirata Y, Nagai R, Sato S. Improvement of endothelial function in parallel with the amelioration of dry cough and dyspnea due to interstitial pneumonia by intravenous cyclophosphamide pulse therapy in patients with systemic sclerosis: a preliminary report of two cases. Mod Rheumatol 2011; 22:598-601. [PMID: 22015621 DOI: 10.1007/s10165-011-0545-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/26/2011] [Indexed: 11/30/2022]
Abstract
Intravenous cyclophosphamide pulse therapy (IVCY) exerts its efficacy against interstitial lung disease (ILD) associated with systemic sclerosis (SSc) by restoring vascular injuries as well as aberrant immune activation. We recently experienced two patients with SSc-ILD in whom the values of brachial flow-mediated dilation (FMD) reflected the efficacy of IVCY. We herein report the details of these cases and discuss the potential of FMD to predict and evaluate the effect of IVCY on SSc-ILD.
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Affiliation(s)
- Takehiro Takahashi
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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21
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Acquisition of expanded indications for intravenous cyclophosphamide in the management of childhood rheumatic disease in general. Mod Rheumatol 2011; 21:449-57. [DOI: 10.1007/s10165-011-0451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 03/18/2011] [Indexed: 10/18/2022]
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Abstract
Pulmonary involvement is second in frequency only to esophageal involvement as a visceral complication of systemic sclerosis (SSc) and has surpassed renal involvement as the most common cause of death. Interstitial lung disease and pulmonary vascular disease, particularly pulmonary arterial hypertension, are the most commonly encountered types of lung involvement. Chronic aspiration, airway disease, neuromuscular weakness, extrinsic pulmonary restrictive pathology, pleural effusions, pneumothorax, and lung cancer cause clinically significant disease and occur commonly enough to be routinely considered in the assessment of the SSc patient with respiratory symptoms. Affected patients have a significantly worse prognosis than patients with SSc who are free of pulmonary involvement.
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MESH Headings
- Familial Primary Pulmonary Hypertension
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/pathology
- Hypertension, Pulmonary/therapy
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/epidemiology
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/pathology
- Lung Diseases, Interstitial/therapy
- Lung Neoplasms/etiology
- Lung Neoplasms/pathology
- Prevalence
- Prognosis
- Respiratory Aspiration/etiology
- Respiratory Aspiration/pathology
- Risk Factors
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/epidemiology
- Scleroderma, Systemic/pathology
- Scleroderma, Systemic/therapy
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Affiliation(s)
- Jérôme Le Pavec
- Université Paris-Sud, Centre National de Référence de l'Hypertension Artérielle Pulmonaire, Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine-Béclère, Assistance Publique, Hôpitaux de Paris, Clamart, France.
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Cyclophosphamide for scleroderma lung disease: a systematic review and meta-analysis. Rheumatol Int 2011; 32:2431-44. [PMID: 21691743 DOI: 10.1007/s00296-011-1967-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 05/22/2011] [Indexed: 10/18/2022]
Abstract
To assess the effectiveness of cyclophosphamide in the management of scleroderma-related interstitial lung disease (ILD). In this systematic review study, the primary outcome measures were change in forced vital capacity (FVC) and diffusing capacity of the lung for carbon monoxide (D(L)CO) of the patients after 6 and 12 months. To assess the effect of cyclophosphamide on early stage of ILD, alveolitis, in SSc patients, we selected the studies that used the BAL findings or HRCT or recent deterioration of PFT with minimal chest X-ray finding in early stage of disease as diagnosis of alveolitis. A sensitive systematic search strategy was used to find all relevant studies. Finally, 17 trials were included in the analysis that was performed using STATA. (Version 8) and Review Manager (version 4.1; MetaView version 4.1) softwares. Results from 10 studies were pooled for the outcome variable of FVC after 12 months. The summary WMD (random effects) was 2.45 (95% CI, 0.760-4.149 P = 0.005), which means that cyclophosphamide was able to prevent deterioration of FVC after 12 months. In pooled data of 13 studies, about DLCO after 12 months WMD (random effects) was 2.003 2.96 (95% CI, -0.228 to 6.159 P = 0.069), which means that cyclophosphamide was not able to prevent deterioration of D(L)CO after 12 months. If we considered clinically sensible improvement as absolute value ≥10% in DLCO and VC, then result of treatment with cyclophosphamide treatment in scleroderma patients with ILD was not significant.
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Foocharoen C, Mahakkanukrauh A, Suwannaroj S, Nanagara R. Spontaneous skin regression and predictors of skin regression in Thai scleroderma patients. Clin Rheumatol 2011; 30:1235-40. [DOI: 10.1007/s10067-011-1744-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 03/21/2011] [Accepted: 03/24/2011] [Indexed: 11/25/2022]
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25
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Lung involvement in systemic sclerosis. Presse Med 2010; 40:e3-e17. [PMID: 21195581 DOI: 10.1016/j.lpm.2010.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 08/25/2010] [Accepted: 08/27/2010] [Indexed: 01/22/2023] Open
Abstract
Scleroderma is a multisystem disease characterized by a severe inflammatory process and exuberant fibrosis. Lung involvement is a frequent complication and a leading cause of morbidity and mortality in this syndrome. Two major pulmonary syndromes are associated with scleroderma; a pulmonary vascular disorder evolving over time into relatively isolated pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD). Each syndrome, when present, is a cause of morbidity and significantly reduces survival of scleroderma patients when compared to patients free of lung complication. When pulmonary hypertension and ILD are combined, survival is further reduced. Current therapy appears to have no meaningful effect on either condition and, thus, there is a need for better understanding of underlying pathogenic mechanisms. This review focuses on clinical, diagnostic, and therapeutic features of PAH and ILD as well as other frequent but less debilitating lung complications of scleroderma.
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Corticosteroids and the risk of scleroderma renal crisis: a systematic review. Rheumatol Int 2010; 32:645-53. [DOI: 10.1007/s00296-010-1697-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 11/21/2010] [Indexed: 11/26/2022]
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Domiciano DS, Bonfá E, Borges CTL, Kairalla RA, Capelozzi VL, Parra E, Christmann RB. A long-term prospective randomized controlled study of non-specific interstitial pneumonia (NSIP) treatment in scleroderma. Clin Rheumatol 2010; 30:223-9. [PMID: 20544245 DOI: 10.1007/s10067-010-1493-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 03/17/2010] [Accepted: 05/12/2010] [Indexed: 11/27/2022]
Abstract
UNLABELLED The association of cyclophosphamide (CYC) and prednisone (PRED) for the treatment of lung fibrosis in systemic sclerosis (SSc) was only evaluated in uncontrolled studies, although in idiopathic interstitial lung disease (ILD) this association seems to be beneficial in patients with non-specific interstitial pneumonia (NSIP). OBJECTIVES To treat SSc-ILD in a prospective open-label controlled study based on lung pattern during 12 months of treatment. METHODS A 3-year analysis was also performed. Twenty-four consecutive patients with SSc and ILD were submitted to an open lung biopsy. Eighteen patients (NSIP) were randomized in two groups: CYC versus CYC + PRED during 12 months. Lung function tests (diffusion lung capacity of monoxide carbone corrected for hemoglobin concentration (DLCO-Hb), forced vital capacity (FVC), total lung capacity) and Modified Rodnan Skin Score (MRSS) were performed before, after one of treatment and after 3 years from the end of the treatment. RESULTS Pulmonary function tests were similar in both groups on baseline. After 1 year of treatment, FVC% was comparable between CYC groups (p = 0.72) and in CYC + PRED (p = 0.40). Three years after the end of treatment, FVC% values (p = 0.39 in group CYC and p = 0.61 in CYC + PRED and p = 0.22 in CYC + PRED) and DLCO-Hb (p = 0.54 in CYC and p = 0.28 in CYC + PRED) were similar compared to 1 year of treatment. We observed a reduction of the MRSS in the CYC + PRED group after 1 year of treatment (p = 0.02); although after 3 years, MRSS values remained stable in both groups. CONCLUSIONS CYC was effective to stabilize lung function parameters in NSIP lung pattern of SSc disease for 3 years after the end of a 1-year therapy.
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Affiliation(s)
- Diogo S Domiciano
- Division of Rheumatology, University of São Paulo, São Paulo, Brazil
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Mouthon L, Mestre C, Bérezné A, Poiraudeau S, Marchand C, Guilpain P, Guillevin L, Launay O. Low influenza vaccination rate among patients with systemic sclerosis. Rheumatology (Oxford) 2009; 49:600-6. [PMID: 20040532 DOI: 10.1093/rheumatology/kep440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the influenza vaccination rate and factors influencing it in patients with SSc. METHODS A total of 177 SSc patients fulfilling the ACR and/or LeRoy and Medsger criteria were evaluated during annual meetings of the French patient association in 2006 (n = 71) and 2007 (n = 70) or during hospitalization in the Internal Medicine Department of Cochin Hospital in 2007 (n = 36). Information on influenza vaccination was collected by a standardized form. RESULTS Mean (s.d.) age and disease duration were 58.7 (12.6) and 10.5 (9.5) years, respectively. Overall, 69 (39%) patients received an influenza vaccination during the previous year. Among the 108 patients who were not vaccinated, 78 (72.2%) presented at least one indication for vaccination. The most frequent reasons for non-vaccination were absence of physician recommendation and fear of side effects. Patients who were and were not vaccinated did not differ in anxiety, depression, global disability or quality of life. Vaccination rate was significantly higher (59%) for patients who remembered receiving a letter from the French National Health Insurance Agency encouraging vaccination than among those who did not (26%, P = 0.0001). Multivariate analysis revealed the year of the last vaccination and age as two independent parameters associated with vaccination. CONCLUSIONS Influenza vaccination coverage is low in SSc patients. Lack of information and fear of adverse effects are the most common reasons for non-vaccination. Efforts are needed to increase the influenza vaccination coverage in this population.
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Affiliation(s)
- Luc Mouthon
- Department of Internal Medicine, Cochin Hospital, Paris Cedex 14, France.
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Derk CT, Grace E, Shenin M, Naik M, Schulz S, Xiong W. A prospective open-label study of mycophenolate mofetil for the treatment of diffuse systemic sclerosis. Rheumatology (Oxford) 2009; 48:1595-9. [PMID: 19846575 DOI: 10.1093/rheumatology/kep295] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of mycophenolate mofetil for the treatment of SSc. METHODS We recruited 15 patients with dcSSc to take part in an open-label study using mycophenolate mofetil to treat their disease over a 12-month period. The primary outcome measure was the modified Rodnan skin score (mRSS), whereas secondary outcomes included the Medsger severity score, pulmonary function studies, 2D echocardiograms and the Short Form Health Survey (SF)-36 questionnaire. RESULTS The mRSS significantly improved in those patients who tolerated the medication for >3 months (P < 0.0001), and there was a statistically significant improvement in the Medsger severity scores of the general (P = 0.05), peripheral vascular involvement (P = 0.05) and skin (P = 0.0003) scores. The SF-36 scores improved (P = 0.05) and the pulmonary function studies showed a trend towards improvement, though not of statistical significance. The mean pulmonary artery pressure by 2D echocardiography did not change. CONCLUSIONS In this prospective open-label study of mycophenolate mofetil for the treatment of dcSSc, we observed significant improvements in skin scores, peripheral vascular involvement and patient-perceived health status. Pulmonary function studies did not worsen as expected, but instead showed a trend towards improvement. Controlled trials are needed to further investigate this trend for improved pulmonary function studies.
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Affiliation(s)
- Chris T Derk
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Matucci-Cerinic M, Steen V, Nash P, Hachulla E. The complexity of managing systemic sclerosis: screening and diagnosis. Rheumatology (Oxford) 2009; 48 Suppl 3:iii8-13. [PMID: 19487228 DOI: 10.1093/rheumatology/ken482] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The difficulties inherent in diagnosing, screening and treating SSc are reflected by the complex pathology of the disease, which involves the development of severe organ-based complications that reduce both quality of life and overall survival. Early detection and prompt treatment of such complications depend upon a successful and timely screening strategy, which, in turn, requires cooperation between disciplines and good collaborative links at all stages of the disease. Establishment of a disease registry for SSc may also be of benefit, as such registries facilitate longitudinal observation of trends in disease presentation, management and outcome. They may also help to determine potential risk factors and identify those patient subgroups that face the highest risk of developing disease. In patients with known or suspected SSc, a panel of disease-specific markers--such as autoantibodies, cell activation markers and markers of organ involvement--may help to establish the diagnosis and assess prognosis; however, changes in serum levels of such markers throughout the course of SSc should be interpreted with caution, as they may not always correlate with disease activity. Nail-fold capillaroscopy is a promising tool for SSc assessment and may provide useful diagnostic and prognostic information, although further research is required to clarify its role in evaluating disease evolution.
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Affiliation(s)
- M Matucci-Cerinic
- Department of Biomedicine, Division of Rheumatology, Centre DenoThe, AOUC University of Florence, Florence, Italy.
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Rabquer BJ, Hou Y, Del Galdo F, Kenneth Haines G, Gerber ML, Jimenez SA, Seibold JR, Koch AE. The proadhesive phenotype of systemic sclerosis skin promotes myeloid cell adhesion via ICAM-1 and VCAM-1. Rheumatology (Oxford) 2009; 48:734-40. [PMID: 19439502 DOI: 10.1093/rheumatology/kep091] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE SSc is characterized by microvascular abnormalities and leucocyte infiltration. Previous studies have suggested a proadhesive phenotype in SSc skin, but the functional consequences of this phenotype are not fully understood. Molecules known to mediate leucocyte adhesion include those present at intracellular junctions, such as junctional adhesion molecule-B (JAM-B), JAM-C and CD99, as well as intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1). The aim of this study was to examine adhesive interactions in SSc skin. METHODS The expression of JAM-B, JAM-C, CD99, ICAM-1 and VCAM-1 in SSc skin was determined by immunohistology and cell surface ELISA. Myeloid U937 cell-SSc dermal fibroblast adhesion assays or in situ adhesion assays to SSc skin were performed. RESULTS JAM-C and CD99 expression on endothelial cells (ECs) in SSc skin was decreased compared with expression on normal ECs. CD99 was overexpressed on mononuclear cells in SSc skin and on SSc dermal fibroblasts. Neutralizing ICAM-1 inhibited the binding of U937 cells to SSc dermal fibroblasts. In addition, blocking both ICAM-1 and VCAM-1 inhibited U937 cell adhesion to either proximal (less involved) or distal (more involved) SSc skin. CONCLUSIONS These studies show that JAM-C and CD99 are aberrantly expressed in SSc skin. However, these adhesion molecules do not mediate myeloid cell-SSc skin adhesion. In contrast, we demonstrate an important role for ICAM-1 and VCAM-1 in the retention of myeloid cells in SSc skin, suggesting that targeting these molecules may be useful SSc therapies.
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Affiliation(s)
- Bradley J Rabquer
- Department of Internal Medicine, University of Michigan Medical School, AnnArbor, MI, USA.
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Valentini G, Cerinic MM. Anti-inflammatory New trends in the treatment of the patient with systemic sclerosis. Expert Opin Emerg Drugs 2008; 13:227-36. [DOI: 10.1517/14728214.13.2.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ohtsuka T. Relation between elevated high-sensitivity C-reactive protein and anti-mitochondria antibody in patients with systemic sclerosis. J Dermatol 2008; 35:70-5. [PMID: 18271801 DOI: 10.1111/j.1346-8138.2008.00418.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Systemic sclerosis (SSc) is a systemic connective tissue disease of unknown etiology which presents immunological, vascular and connective tissue abnormalities. C-reactive protein (CRP) has been used for the evaluation of inflammation in patients with infection and inflammatory diseases. Recently, high-sensitivity CRP has been shown to reflect mild and/or moderate inflammation for the prognosis of ischemic heart disease. High-sensitivity CRP was measured for the evaluation of mild and/or moderate inflammation in SSc. Forty SSc patients (male : female, 7:33; age, 16-78 years; mean, 61.9 years) were studied. High-sensitivity CRP was measured with a nephelometric assay. The detection limit was 0.0036 mg/dL, linearity from 0.015-1.5 mg/dL. The distribution of high-sensitivity CRP showed 26 cases (65.0%) low, three cases (7.5%) mild, four cases (10.0%) moderate, four cases (10.0%) high and three cases (7.5%) highest. The occurrence rate of anti-mitochondria antibody in high-sensitivity CRP elevated SSc patients (8/14, 57.1%) was significantly elevated compared with that of high-sensitivity CRP low SSc patients (3/26, 11.5%) (P < 0.01). These results led us to the conclusion that elevated high-sensitivity CRP shows relation to the occurrence of anti-mitochondria antibody.
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Affiliation(s)
- Tsutomu Ohtsuka
- Department of Dermatology, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan.
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Scorza R, Santaniello A, Salazar G, Lenna S, Della Bella S, Antonioli R, Toussoun K, Beretta L. Effects of aminaftone 75 mg TID on soluble adhesion molecules: A 12-week, randomized, open-label pilot study in patients with systemic sclerosis. Clin Ther 2008; 30:924-9. [DOI: 10.1016/j.clinthera.2008.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2008] [Indexed: 12/29/2022]
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Hachulla E. Traitement de la sclérodermie systémique (en dehors de l’hypertension artérielle pulmonaire). Rev Med Interne 2007; 28 Suppl 4:S277-84. [DOI: 10.1016/j.revmed.2007.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Sfikakis PP, Papamichael C, Stamatelopoulos KS, Tousoulis D, Fragiadaki KG, Katsichti P, Stefanadis C, Mavrikakis M. Improvement of vascular endothelial function using the oral endothelin receptor antagonist bosentan in patients with systemic sclerosis. ACTA ACUST UNITED AC 2007; 56:1985-93. [PMID: 17530638 DOI: 10.1002/art.22634] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Increased endothelin activity may play a role in the pathogenesis of vascular injury, a primary feature of systemic sclerosis (SSc; scleroderma). Our goal was to test the hypothesis that treatment with the oral endothelin receptor antagonist bosentan might improve vascular endothelial function in SSc patients. METHODS A 4-week, prospective, parallel-group study compared 12 SSc patients who did not receive bosentan treatment with 12 patients who did receive treatment (125 mg/day) for pulmonary hypertension and/or digital ulcers. There were no differences in demographic and clinical characteristics or medications between the 2 groups. Baseline endothelial dysfunction was documented by decreased brachial artery ultrasound-derived flow-mediated dilation (FMD%; <5.5). Pulse wave analysis, venous occlusion plethysmography, and measurement of serum vascular markers were performed in parallel. RESULTS FMD%, the main end point, increased significantly from a mean +/- SD of 3.1 +/- 1.3% to 8.4 +/- 2.6% after 4 weeks of bosentan treatment (P < 0.001, compared with a change from 2.4 +/- 1.6% to 2.4 +/- 2.2% in control patients). Arterial blood pressure, endothelium-independent vascular function, augmentation index, peripheral flow reserve, as well as circulating intercellular adhesion molecule 1, E-selectin, vascular endothelial growth factor, and endothelin 1 were not significantly affected by bosentan treatment. In patients continuously treated for 4 months, during which the dosage of bosentan remained at 125 mg/day (n = 5) or increased to 250 mg/day (n = 5), the 4-week results remained unchanged. CONCLUSION Small doses of bosentan improve endothelial function without affecting hemodynamic parameters or endothelial activation-related processes, thus supporting a direct, reversible effect of endothelin in SSc-associated vascular injury. A long-term, controlled trial to examine the potentially global clinical benefit of endothelin receptor blockade in patients with early SSc may be warranted.
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Affiliation(s)
- P P Sfikakis
- First Department of Propedeutic and Internal Medicine, Laikon Hospital, Athens University Medical School, Athens, Greece.
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Denton CP, Black CM, Abraham DJ. Mechanisms and consequences of fibrosis in systemic sclerosis. ACTA ACUST UNITED AC 2006; 2:134-44. [PMID: 16932673 DOI: 10.1038/ncprheum0115] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 11/28/2005] [Indexed: 12/22/2022]
Abstract
Systemic sclerosis (SSc), also known as scleroderma, is a complex connective tissue disease that is associated with a high mortality and is challenging to treat because of its clinical heterogeneity and a lack of effective antifibrotic therapies. SSc has vascular, immunologic and fibrotic components that are pathologically interconnected. A growing understanding of the molecular and cellular mechanisms that underlie SSc pathogenesis provides logical and novel approaches to treatment. At present most therapies are organ-based. Vascular and inflammatory components of the disease can also be treated, but effective antifibrotic therapies are lacking. A number of key molecular mediators have the potential to alter immune-cell, vascular and fibrotic processes and these mediators, which include transforming growth factor-beta isoforms, endothelin-1, connective-tissue growth factor, chemokines and members of the interleukin family, are attractive targets for therapeutic modulation. Key mediators can be blocked using antibodies, soluble receptors, endogenous inhibitors or small-molecule antagonists of ligands, receptors or signaling intermediates. Overall, this is an exciting time for new therapies in SSc and advances are being made in synchrony with an improved understanding of the molecular and biochemical basis of the disease.
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Affiliation(s)
- Christopher P Denton
- Centre for Rheumatology, Royal Free and University College Medical School, London, and Royal Free Hospital, UK.
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Valentini G, Paone C, La Montagna G, Chiarolanza I, Menegozzo M, Colutta E, Ruocco L. Low-dose intravenous cyclophosphamide in systemic sclerosis: an open prospective efficacy study in patients with early diffuse disease. Scand J Rheumatol 2006; 35:35-8. [PMID: 16467039 DOI: 10.1080/03009740510026896] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate the efficacy of a treatment with low-dose intravenous cyclophosphamide (CYC) and low-dose prednisone in early diffuse cutaneous systemic sclerosis (dcSSc). METHODS Patients with dcSSc and a disease duration <24 months consecutively admitted to a tertiary centre underwent a prospective 1-year study. They were treated with i.v. CYC 500 mg/pulses, 10 mg prednisone equivalent, and supportive therapy. Modified Rodnan skin score (mRss), Health Assessment Questionnaire-Disability Index (HAQ-DI), forced vital capacity (FVC), and diffusing lung capacity for CO (DLCO) were assessed as outcome measures. In addition, the nine Medsger severity scale scores were evaluated. RESULTS mRss and DLCO significantly improved at both 6 (p = 0.002 and 0.012, respectively) and 12 months (p = 0.002 and 0.003, respectively). HAQ-DI showed a nearly significant reduction at 12 months (p = 0.06). Medsger's severity scores also improved for general condition (p = 0.001), peripheral vascular (p = 0.05), skin (p = 0.02), joint/tendon (p = 0.001), muscle (p = 0.05), and lung (p = 0.02). No treatment interruption was needed. CONCLUSIONS This preliminary study suggests a role for low-dose i.v. CYC in the treatment of early dcSSc. Controlled studies are warranted.
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Affiliation(s)
- G Valentini
- The Rheumatology Health Unit, Second University of Naples, Italy.
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Liossis SNC, Bounas A, Andonopoulos AP. Mycophenolate mofetil as first-line treatment improves clinically evident early scleroderma lung disease. Rheumatology (Oxford) 2006; 45:1005-8. [PMID: 16490756 DOI: 10.1093/rheumatology/kei211] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To find an effective, safe immunosuppressive regimen as an alternative to cyclophosphamide (Cy) for the treatment of clinically evident diffuse scleroderma (dSSc)-associated alveolitis of recent onset. METHODS Five consecutive patients with dSSc and recent-onset alveolitis were enrolled and treated with mycophenolate mofetil (MMF) and small (< or =10 mg/day) doses of predinisolone in this open-label trial. One patient with long-standing fibrosing alveolitis was later added to our cohort. Pulmonary function tests [carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC)], pulmonary high-resolution computed tomography (HRCT) scans and clinical assessment were performed before and at specified time-points after enrolment. Cases of significant infections, leucopenia and abdominal pain were recorded. RESULTS After 4-6 months of MMF therapy, DLCO improved significantly compared with pre-treatment (mean DLCO 75.4% vs 64.2% of predicted value, respectively, P = 0.033). Values of FVC also improved, with the difference almost reaching levels of statistical significance (mean FVC 76.2% vs 65.6% of predicted value, P = 0.057). Ground glass opacities cleared in three of four patients with recent-onset alveolitis and were reduced in one patient after 6-8 months of treatment. Breathlessness and cough improved by 3 months. A possible treatment failure was seen in one patient. However, in five patients functional and clinical improvement was sustained during the study period. No adverse events were recorded in this ongoing clinical trial. CONCLUSION Our preliminary data suggest that in patients with dSSc and recent, clinically apparent alveolitis, early treatment with MMF and small doses of corticosteroids (CS) may represent an effective, well-tolerated and safe alternative therapy.
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Affiliation(s)
- S N C Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, 26504 Rion, Patras, Greece.
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Abstract
PURPOSE OF REVIEW To review the recent medical literature pertaining to interstitial lung disease found in association with systemic sclerosis remains a major contributor to morbidity and mortality. Significant progress is being made in terms of understanding the pathogenesis, the best approaches to clinical evaluation, and various options for therapy of systemic sclerosis patients whose disease course is complicated by interstitial lung disease. RECENT FINDINGS Recent studies highlight the importance of microvascular disease, autoimmunity, and fibroblast differentiation/activation in the pathogenesis of systemic sclerosis-interstitial lung disease, particularly in the early phase of disease. It appears as if the balance between various pro-fibrotic/pro-inflammatory and anti-fibrotic/anti-inflammatory mediators may be central to interstitial lung disease pathogenesis, which presents potential opportunities for therapeutic intervention. The clinical approach to staging of disease activity remains controversial. High resolution computed tomography scans, bronchoalveolar lavage and various serum markers (e.g., surfactant protein D and KL-6) each may provide useful information about the degree of activity of the systemic sclerosis-interstitial lung disease. Currently, treatment recommendations are limited by a scarcity of well designed clinical trials, but the recently completed Scleroderma Lung Study is a model for future studies and is providing useful information about this important complication of systemic sclerosis. SUMMARY Basic and clinical studies of systemic sclerosis patients with interstitial lung disease are yielding promising data that ultimately will be translated in to more effective diagnostic and therapeutic strategies.
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Affiliation(s)
- Kristin B Highland
- Division of Pulmonary, Critical Care, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC 29425, USA.
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Highland KB, Silver RM. Clinical aspects of lung involvement: lessons from idiopathic pulmonary fibrosis and the scleroderma lung study. Curr Rheumatol Rep 2005; 7:135-41. [PMID: 15760593 DOI: 10.1007/s11926-005-0066-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Interstitial lung disease (ILD) occurs frequently among patients with systemic slcerosis (SSc) and accounts for significant morbidity and mortality. SSc-ILD resembles idiopathic pulmonary fibrosis (IPF) in many respects; each is characterized by a restrictive ventilatory defect that results from an active fibrosing process in the lung interstitium, and each is characterized by ground glass opacification on high resolution computed tomography (HRCT) and inflammatory cells in bronchoalveolar lavage fluid (BALF). Differences in the classification of lung histo-pathology are noted frequently and may account for some of the difference in outcome for patients with SSc-ILD and IPF. Optimal treatment of SSc-ILD remains to be determined, but cyclophosphamide has been reported to be effective in a number of case series. A randomized controlled trial, the Scleroderma Lung Study (SLS), will be completed in 2005; the outcome of the SLS should define the efficacy of daily oral cyclophosphamide for SSc-ILD patients with alveolitis defined by BALF and HRCT.
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Affiliation(s)
- Kristin B Highland
- Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 912 CSB, Charleston, SC 29425, USA
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Abstract
The endothelium is a highly metabolically active organ that is involved in many physiological processes, including the control of vasomotor tone, barrier function, leukocyte adhesion and trafficking, inflammation, and hemostasis. Endothelial cell phenotypes are differentially regulated in space and time. Endothelial cell heterogeneity has important implications for developing strategies in basic research, diagnostics and therapeutics. The goals of this review are to: (i) consider mechanisms of endothelial cell heterogeneity; (ii) discuss the bench-to-bedside gap in endothelial biomedicine; (iii) revisit definitions for endothelial cell activation and dysfunction; and (iv) propose new goals in diagnosis and therapy. Finally, these themes will be applied to an understanding of vascular bed-specific hemostasis.
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Affiliation(s)
- W C Aird
- Division of Molecular and Vascular Medicine, Department of Medicine, and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Jinnin M, Ihn H, Mimura Y, Asano Y, Yamane K, Tamaki K. Matrix metalloproteinase-1 up-regulation by hepatocyte growth factor in human dermal fibroblasts via ERK signaling pathway involves Ets1 and Fli1. Nucleic Acids Res 2005; 33:3540-9. [PMID: 15972796 PMCID: PMC1156961 DOI: 10.1093/nar/gki648] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In this study, we clarified the molecular mechanism(s) underlying the regulation of matrix metalloproteinase (MMP)-1 gene by hepatocyte growth factor (HGF) in cultured human dermal fibroblasts. HGF induced MMP-1 protein as well as mRNA at a transcriptional level via extracellular signal-regulated kinase (ERK) signaling pathway. The region in the MMP-1 promoter mediating the inducible responsiveness to HGF, defined by the transient transfection analysis of the serial 5′ deletion constructs, contained an Ets binding site. Mutation of this Ets binding site abrogated the HGF-inducible promoter activity. Ets1 up-regulated the expression of MMP-1 promoter activity, whereas Fli1 had antagonistic effects on them. After HGF treatment, the protein level and the binding activity of Ets1 was increased and those of Fli1 was decreased, which were canceled by PD98059. These results suggest that HGF up-regulates MMP-1 expression via ERK signaling pathway through the balance of Ets1 and Fli1, which may be a novel mechanism of regulating MMP-1 gene expression.
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Affiliation(s)
| | - Hironobu Ihn
- To whom correspondence should be addressed. Tel: +81 3 3815 5411; Fax: +81 3 3814 1503;
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Hwa C, Sebastian A, Aird WC. Endothelial biomedicine: its status as an interdisciplinary field, its progress as a basic science, and its translational bench-to-bedside gap. ENDOTHELIUM : JOURNAL OF ENDOTHELIAL CELL RESEARCH 2005; 12:139-51. [PMID: 16291517 DOI: 10.1080/10623320500192016] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The endothelium, a layer of endothelial cells lining the luminal surface of all blood vessels, functions as a highly metabolically active organ spatially distributed throughout the body. Despite enormous advances in our understanding of endothelial cell biology, little awareness of this organ reaches clinical practice. The present study aims to document the extent and scope of the bench-to-bedside gap in endothelial biomedicine, and to offer hypotheses to explain the gaping chasm. A PubMed search using keywords "endothelial cells" and "endothelium" yielded over 90,000 publications, increasing exponentially over the past decade. A Scirus search without date restriction returned journal results for the endothelium not greatly fewer than for the epithelium. A survey of representative vascular biology meetings revealed a high percentage of talks related to the endothelium. The number of grants awarded by the National Institutes of Health for studies in endothelial cell biology continues to steadily increase. At the bedside, however, few clinicians give consideration to the health of the endothelium. A survey of the major medical textbooks revealed a paucity of index entries for "endothelial cells" or "endothelium." The endothelium does not offer itself for inspection, palpation, percussion, and/or auscultation. No convenient blood tests measure endothelial function. The authors propose to explain the bench-to-bedside gap in endothelial biomedicine as a function of (1) historical constraints, (2) the unseen and diffuse nature of the cell layer, (3) the complexity of the system, and (4) its adaptability. Until the bench-to-bedside gap closes, the enormous potential of the endothelium as a diagnostic, preventive, and therapeutic target will remain largely untapped.
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Affiliation(s)
- Charlotte Hwa
- Division of Molecular and Vascular Medicine, Department of Medicine, and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 023215, USA
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Crofford LJ. Immunomodulatory therapy for SSc: Will high-intensity immunosuppression with stem cell rescue improve outcome? Curr Rheumatol Rep 2005; 7:142-9. [PMID: 15760594 DOI: 10.1007/s11926-005-0067-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Effective treatments for severe systemic sclerosis (SSc) have not been identified. SSc is associated with high levels of morbidity and mortality related to functional impairment and organ dysfunction. The pathogenesis of SSc, as with all autoimmune disorders, is thought to involve the interplay between genetic background and environmental exposures. Abundant evidence exists for activation of humoral and cellular immunity in SSc. These immune and inflammatory mechanisms almost certainly play a role in vascular damage and activation of pathways that lead to fibrosis. However, the types and intensities of immunomodulatory therapies employed in other connective tissue diseases have not proved as useful in patients with SSc. The question remains if increasing the intensity of immunosuppression will prove a more successful strategy. Preliminary studies of intensification of therapy to immunoablative and myeloablative levels with hematopoietic stem cell rescue have been performed and appear promising. New studies to compare these approaches with conventional immunomodulatory therapy are underway.
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Affiliation(s)
- Leslie J Crofford
- Women's Health Program, Chief Division of Rheumatology, Room J-503, Kentucky Clinic, 740 S. Limestone St., Lexington, KY 40536, USA.
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Jinnin M, Ihn H, Mimura Y, Asano Y, Yamane K, Tamaki K. Effects of hepatocyte growth factor on the expression of type I collagen and matrix metalloproteinase-1 in normal and scleroderma dermal fibroblasts. J Invest Dermatol 2005; 124:324-30. [PMID: 15675950 DOI: 10.1111/j.0022-202x.2004.23601.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We investigated the direct effect of hepatocyte growth factor (HGF) on the expression of type I collagen in normal and scleroderma dermal fibroblasts, and analyzed the mechanisms underlying the effect in vitro. HGF did not change the protein expression of type I procollagen in the medium of normal human fibroblasts, whereas it reduced the expression in scleroderma fibroblasts. But mRNA levels and the promoter activity of alpha2(I) collagen gene were not significantly affected by HGF in either of the cells. On the other hand, matrix metalloproteinase-1 expression or activity was increased by HGF in both cells, but HGF had stronger effects in scleroderma fibroblasts than normal fibroblasts. Scleroderma fibroblasts overexpressed c-met protein, the receptor for HGF. The overexpression in scleroderma fibroblasts was abolished by the addition of antisense transforming growth factor (TGF)-beta1 oligonucleotide. Our study indicated that HGF may reduce type I collagen accumulation only in scleroderma fibroblasts by enhancing collagenolysis activity, probably because of the overexpression of c-met because of autocrine TGF-beta signaling. Thus, further investigation of the effects of HGF on collagen metabolism may contribute to the treatment of fibrosis in scleroderma.
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Affiliation(s)
- Masatoshi Jinnin
- Department of Dermatology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Riemekasten G, Schulze-Koops H. Medikament�se vasoaktive Therapien von Mikrozirkulationsst�rungen bei rheumatischen Erkrankungen. Z Rheumatol 2005; 64:123-36. [PMID: 15793678 DOI: 10.1007/s00393-005-0691-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- G Riemekasten
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité, Zentrum C6 im Deutschen Netzwerk für Sklerodermie, EUSTAR-Zentrum, Schumannstrasse 20/21, 10117 Berlin.
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Abstract
PURPOSE OF REVIEW Raynaud phenomenon is the earliest and most common clinical manifestations of scleroderma (systemic sclerosis). Therefore, Raynaud phenomenon offers the best window into the investigation of the early steps in the pathogenesis of systemic sclerosis. This review focuses on the differential diagnosis of Raynaud phenomenon, the transition of Raynaud phenomenon to systemic sclerosis, mechanisms and consequences of vascular injury and dysfunction in systemic sclerosis, and therapeutic options. RECENT FINDINGS Careful clinical evaluation using a simple definition of Raynaud phenomenon is the most reliable and reproducible method in the diagnosis. Although the assessment of vascular function by noninvasive methods is still not sensitive enough for the evaluation and follow-up of individual patients, it helps in the differential diagnosis and in population studies. Progressive deficiency in vasodilatory capacity of the vessels is proposed as a mechanism of Raynaud phenomenon, particularly in systemic sclerosis. In addition, decreased fibrinolysis and enhanced coagulation pathways undoubtedly contribute to vascular dysfunction. The mechanism of endothelial injury is still elusive, yet endothelial apoptosis mediated by antiendothelial antibodies is the most attractive hypothesis now. Therapies directed at the vascular disease continue to focus on the alleviation of vascular spasm. However, immunosuppressive therapy may influence the levels of vascular injury markers and thus may have an effect on the vascular disease itself. SUMMARY Continued progress in the investigation of the vascular aspects of scleroderma is described in this review. Immune involvement in the early stages of the disease and mechanism of vascular repair in advance cases are some of the highlights of last year's progress.
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Affiliation(s)
- M Bashar Kahaleh
- Division of Rheumatology, Department of Medicine, Medical College of Ohio, 1321 Glendale Avenue, Toledo, OH 43617, USA.
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Trad S, Amoura Z, Beigelman C, Haroche J, Costedoat N, Boutin LTHD, Cacoub P, Frances C, Wechsler B, Grenier P, Piette JC. Pulmonary arterial hypertension is a major mortality factor in diffuse systemic sclerosis, independent of interstitial lung disease. ACTA ACUST UNITED AC 2005; 54:184-91. [PMID: 16385514 DOI: 10.1002/art.21538] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine whether pulmonary arterial hypertension (PAH) is a prognostic factor for mortality in diffuse cutaneous systemic sclerosis (dcSSc), independent of interstitial lung disease (ILD). METHODS ILD was diagnosed by high-resolution computed tomography and PAH (pulmonary arterial systolic pressure [PASP] > or =45 mm Hg) by echocardiography. All patients with ILD underwent testing for total lung capacity (TLC), forced vital capacity (FVC), and diffusing capacity for carbon monoxide. RESULTS Eighty-six patients with dcSSc (mean age at diagnosis 44.5 years) were followed up for a median of 72.5 months. ILD was found in 52 patients (60%) and PAH in 18 (21%). ILD was associated with PAH in 15 patients. Seventeen patients died (19.8%), 9 of whom had PAH (P = 0.001) and 10 of whom had ILD (P = 0.99). By multivariate analysis, age at SSc diagnosis and PAH were the only independent predictors of death (hazard ratio [HR] 1.057, 95% confidence interval [95% CI] 1.009-1.109, P = 0.020 and HR 4.09, 95% CI 1.47-11.5, P = 0.007, respectively). Mean TLC and mean FVC were similar in ILD patients with and those without PAH (P = 0.71 and P = 0.40, respectively). Among ILD patients, age at SSc diagnosis and PAH were again the sole predictors of death (HR 1.073, 95% CI 1.003-1.149, P = 0.042 and HR 5.07, 95% CI 1.09-23.8, P = 0.038, respectively). Twenty ILD patients received at least 6 monthly pulses of intravenous cyclophosphamide (CYC). In CYC-treated patients with PAH (n = 8), PASP increased significantly during the CYC regimen (mean +/- SD 55 +/- 14.5 mm Hg; P = 0.015 versus baseline), while TLC remained stable during the same period. CONCLUSION These results indicate that, independent of ILD, PAH is a major prognostic factor for survival in dcSSc.
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Affiliation(s)
- Salim Trad
- Internal Medicine, Centre Hospitalier Universitaire Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
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