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Kayser C, de Oliveira Delgado SM, Zimmermann AF, Horimoto AMC, Del Rio APT, de Souza Müller C, Camargo CZ, Lupo CM, de Moraes DA, Do Rosário E Souza EJ, Santos FPST, Sekiyama JY, Lonzetti LS, de Oliveira Martins LV, Bezerra MC, Bredemeier M, Oliveira MC, da Fonseca Salgado MC, Miossi R, de Araújo Fontenele SM, Hax V, Dantas AT, Sampaio-Barros PD. 2023 Brazilian Society of Rheumatology guidelines for the treatment of systemic sclerosis. Adv Rheumatol 2024; 64:52. [PMID: 38987832 DOI: 10.1186/s42358-024-00392-w] [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: 09/30/2023] [Accepted: 06/25/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a rare chronic autoimmune disease with heterogeneous manifestations. In the last decade, several clinical trials have been conducted to evaluate new treatment options for SSc. The purpose of this work is to update the recommendations of the Brazilian Society of Rheumatology in light of the new evidence available for the pharmacological management of SSc. METHODS A systematic review including randomized clinical trials (RCTs) for predefined questions that were elaborated according to the Patient/Population, Intervention, Comparison, and Outcomes (PICO) strategy was conducted. The rating of the available evidence was performed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. To become a recommendation, at least 75% agreement of the voting panel was needed. RESULTS Six recommendations were elaborated regarding the pharmacological treatment of Raynaud's phenomenon, the treatment (healing) and prevention of digital ulcers, skin involvement, interstitial lung disease (ILD) and gastrointestinal involvement in SSc patients based on results available from RCTs. New drugs, such as rituximab, were included as therapeutic options for skin involvement, and rituximab, tocilizumab and nintedanib were included as therapeutic options for ILD. Recommendations for the pharmacological treatment of scleroderma renal crisis and musculoskeletal involvement were elaborated based on the expert opinion of the voting panel, as no placebo-controlled RCTs were found. CONCLUSION These guidelines updated and incorporated new treatment options for the management of SSc based on evidence from the literature and expert opinion regarding SSc, providing support for decision-making in clinical practice.
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Affiliation(s)
- Cristiane Kayser
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo-UNIFESP, Rua dos Otonis 863, 2º andar, Vila Clementino, São Paulo, SP, 04025-002, Brazil.
| | - Sandra Maximiano de Oliveira Delgado
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo-UNIFESP, Rua dos Otonis 863, 2º andar, Vila Clementino, São Paulo, SP, 04025-002, Brazil
- Rheumatology Division, Hospital Sírio Libanês, Brasília, DF, Brazil
| | - Adriana Fontes Zimmermann
- Rheumatology Division, Professor Polydoro Ernani de São Tiago University Hospital, Universidade Federal de Santa Catarina-UFSC, Florianópolis, SC, Brazil
| | - Alex Magno Coelho Horimoto
- Rheumatology Division, Hospital Regional do Mato Grosso do Sul, Faculdade de Medicina, Universidade Federal de Mato Grosso do Sul-UFMS, Campo Grande, MS, Brazil
| | | | - Carolina de Souza Müller
- Rheumatology Division, Hospital de Clínicas, Universidade Federal do Paraná-UFPR, Curitiba, PR, Brazil
| | - Cintia Zumstein Camargo
- Internal Medicine Departament, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista-UNESP, Botucatu, SP, Brazil
| | - Cristiano Michelini Lupo
- Rheumatology Division, Faculdade de Medicina de São José do Rio Preto-FAMERP, São José do Rio Preto, SP, Brazil
| | | | | | | | - Juliana Yuri Sekiyama
- Internal Medicine Departament, Universidade Estadual de Maringá-UEM, Maringá, PR, Brazil
| | - Lilian Scussel Lonzetti
- Rheumatology Division, Universidade Federal de Ciências da Saúde de Porto Alegre-UFCSPA, Porto Alegre, RS, Brazil
| | - Lucas Victória de Oliveira Martins
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo-UNIFESP, Rua dos Otonis 863, 2º andar, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | | | - Markus Bredemeier
- Rheumatology Division, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil
| | - Maria Carolina Oliveira
- Clinical Immunology Division, Ribeirão Preto Medical School, Universidade de São Paulo-USP, Ribeirão Preto, SP, Brazil
| | | | - Renata Miossi
- Rheumatology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo-USP, São Paulo, SP, Brazil
| | | | - Vanessa Hax
- Rheumatology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, RS, Brazil
| | | | - Percival Degrava Sampaio-Barros
- Rheumatology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo-USP, São Paulo, SP, Brazil
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Costa E, Cunha-Santos F, Dourado E, Oliveira D, Falzon L, Romão V, Duarte AC, Cordeiro A, Santiago T, Sepriano A. Systematic literature review to inform the Portuguese recommendations for the management of Raynaud's phenomenon and digital ulcers in systemic sclerosis and other connective tissue diseases. ARP RHEUMATOLOGY 2024; 3:128-144. [PMID: 38306796 DOI: 10.63032/yhbl8967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
OBJECTIVE To perform a systematic literature review (SLR) aimed at evaluating the efficacy and safety of pharmacological and non-pharmacological treatments for Raynaud's phenomenon (RP) and digital ulcers (DU) in patients with systemic sclerosis (SSc) and other connective tissue diseases (CTD), in order to inform the Portuguese recommendations for managing RP and DU in these patients. METHODS A SLR was conducted until May 2022 to identify studies assessing the efficacy and safety of pharmacological and non-pharmacological interventions for RP and DU in SSc and other CTD. Eligible study designs included randomized controlled trials (RCTs), controlled clinical trials, and their extensions for assessing efficacy and safety of interventions. Observational studies with a comparator were included for evaluating the efficacy and safety of non-pharmacological interventions and safety of pharmacological interventions. The risk of bias of each study was assessed using standard tools. RESULTS Out of 71 publications meeting the inclusion criteria, 59 evaluated pharmacological and 12 non-pharmacological interventions. We found moderate quality evidence supporting the efficacy of calcium channel blockers, phosphodiesterase-5 inhibitors, and intravenous prostacyclin analogues in reducing RP frequency, severity, and duration. Intravenous iloprost had a small to moderate effect size in improving DU healing. Phosphodiesterase-5 inhibitors were effective in reducing total DU count, new DU occurrence, and enhancing DU healing. Bosentan effectively prevented new DU in SSc patients. No new safety concerns were associated with these treatments. The studies on non-pharmacological interventions were, in general, of low quality, and had a small sample size. Warming measures decreased frequency and duration of RP attacks; laser therapy improved RP-related outcomes; local oxygen-ozone therapy improved RP outcomes as an add-on therapy; bone marrow mononuclear cell implantation improved DU-associated pain; periarterial sympathectomy and vascular bypass reduced DU number and finger amputation risk. CONCLUSION The available evidence supports the efficacy and safety of pharmacological interventions, namely nifedipine, sildenafil, iloprost, and bosentan in treating RP and DU in patients with SSc and other CTD. Scarce and low-quality evidence does support the use of some non-pharmacological interventions but with only a modest effect size. This SLR underscores the limited availability of high-quality evidence for determining the optimal treatment.
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Affiliation(s)
| | | | | | | | | | - Vasco Romão
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | | | | | - Tânia Santiago
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Zhang MD, Huang WY, Luo JY, He RQ, Huang ZG, Li JD, Qin F, Chen G, Lei L. The 'whole landscape' of research on systemic sclerosis over the past 73 years. Autoimmun Rev 2024; 23:103538. [PMID: 38556034 DOI: 10.1016/j.autrev.2024.103538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE This study aimed to analyse existing research on systemic sclerosis (SSc) conducted over the past 73 years to develop an essential reference for a comprehensive and objective understanding of this field of inquiry. METHODS Using the Web of Science Core Collection, PubMed, and Scopus databases as data sources for the bibliometric analysis, we searched for published literature related to SSc over the past 73 years. The Bibliometrix package was used to analyse key bibliometric indicators, such as annual publication volume, countries, journals, author contributions, and research hotspots. RESULTS From 1970 to 2022, the number of SSc articles steadily increased, reaching its peak in 2020-2022, with approximately 1200 papers published in each of these three years. Matucci-Cerinic et al.'s team published the most articles (425). The United States (11,282), Italy (7027), and France (5226) were the most predominant contexts. The most influential scholars in the field were Denton, Leroy, Steen, and Khanna, with H-indices of 86, 84, and 83, respectively. Arthritis and Rheumatism was the most influential journal in this field (H-index 142). High-frequency keywords in the SSc field included fibrosis (738), inflammation (242), vasculopathy (145), fibroblasts (120), and autoantibodies (118) with respect to pathogenesis, and interstitial lung disease (ILD, 708), pulmonary arterial hypertension (PAH, 696), and Raynaud's phenomenon (326) with regards to clinical manifestations. CONCLUSION In the past three years, SSc research has entered a period of rapid development, mainly driven by research institutions in Europe and the United States. The most influential journal has been Arthritis and Rheumatism, and autoimmune aspects, vasculopathy, fibrogenesis, PAH, and ILD remain the focus of current research and indicate trends in future research.
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Affiliation(s)
- Meng-Di Zhang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Wan-Ying Huang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Jia-Yuan Luo
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Rong-Quan He
- Department of Medical Oncology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Zhi-Guang Huang
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Jian-Di Li
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Fang Qin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China
| | - Gang Chen
- Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China.
| | - Ling Lei
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Zhuang Autonomous Region, No. 6, Shuangyong Road, 530021 Nanning, PR China.
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Curtiss P, Svigos K, Schwager Z, Lo Sicco K, Franks AG. Part II: The treatment of primary and secondary Raynaud's phenomenon. J Am Acad Dermatol 2024; 90:237-248. [PMID: 35809802 DOI: 10.1016/j.jaad.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/15/2022] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
Raynaud phenomenon (RP) presents with either primary or secondary disease, and both have the potential to negatively impact patient quality of life. First-line management of RP should include lifestyle modifications in all patients. Some patients with primary RP and most with secondary RP require pharmacologic therapies, which may include calcium channel blockers, topical nitrates, phosphodiesterase 5 inhibitors, or endothelin antagonists. Additional approaches to treatment for those with signs of critical ischemia or those who fail pharmacologic therapy include botulinum toxin injection and digital sympathectomy. Herein, we describe in detail the treatment options for patients with RP as well as provide treatment algorithms for each RP subtype.
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Affiliation(s)
- Paul Curtiss
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Katerina Svigos
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Zachary Schwager
- Department of Dermatology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kristen Lo Sicco
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York.
| | - Anrdew G Franks
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; Division of Rheumatology, Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York
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Pușcașu C, Zanfirescu A, Negreș S, Șeremet OC. Exploring the Multifaceted Potential of Sildenafil in Medicine. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2190. [PMID: 38138293 PMCID: PMC10744870 DOI: 10.3390/medicina59122190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Phosphodiesterase type 5 (PDE5) is pivotal in cellular signalling, regulating cyclic guanosine monophosphate (cGMP) levels crucial for smooth muscle relaxation and vasodilation. By targeting cGMP for degradation, PDE5 inhibits sustained vasodilation. PDE5 operates in diverse anatomical regions, with its upregulation linked to various pathologies, including cancer and neurodegenerative diseases. Sildenafil, a selective PDE5 inhibitor, is prescribed for erectile dysfunction and pulmonary arterial hypertension. However, considering the extensive roles of PDE5, sildenafil might be useful in other pathologies. This review aims to comprehensively explore sildenafil's therapeutic potential across medicine, addressing a gap in the current literature. Recognising sildenafil's broader potential may unveil new treatment avenues, optimising existing approaches and broadening its clinical application.
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Affiliation(s)
| | - Anca Zanfirescu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, Traian Vuia 6, 020956 Bucharest, Romania; (C.P.); (S.N.); (O.C.Ș.)
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Maltez N, Maxwell LJ, Rirash F, Tanjong Ghogomu E, Harding SE, Tingey PC, Wells GA, Tugwell P, Pope J. Phosphodiesterase 5 inhibitors (PDE5i) for the treatment of Raynaud's phenomenon. Cochrane Database Syst Rev 2023; 11:CD014089. [PMID: 37929840 PMCID: PMC10626647 DOI: 10.1002/14651858.cd014089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Raynaud's phenomenon is a vasodilatory phenomenon characterised by digital pallor, cyanosis, and pain of the extremities. Primary Raynaud's phenomenon has no underlying disease associated with it, while secondary Raynaud's phenomenon is associated with connective tissue disorders such as systemic sclerosis. Systemic sclerosis causes fibrosis and commonly affects the skin and internal organs such as the gastrointestinal tract, lungs, kidney, and heart. Phosphodiesterase 5 inhibitors (PDE5i) are a class of drugs that increases blood flow to the extremities and may be beneficial in the treatment of Raynaud's phenomenon. OBJECTIVES To assess the benefits and harms of PDE5i compared to placebo for the treatment of Raynaud's phenomenon. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries up to June 2022. We did not apply any language restrictions. We searched the bibliographies of retrieved articles and contacted key experts in the field for additional and unpublished data. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing PDE5i to placebo in people with primary and secondary Raynaud's phenomenon. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS This review included nine RCTs which ranged in duration from four to eight weeks and included a total of 411 participants. The majority had Raynaud's phenomenon secondary to systemic sclerosis. Tadalafil was assessed in four studies, sildenafil in three studies, vardenafil in one study, and a new PDE5 inhibitor known as "PF-00489791" in one study. Three studies were parallel design and six studies were cross-over. The frequency of attacks per week was 24 with placebo and PDE5i reduced the frequency of attacks by an average of three attacks per week (mean difference (MD) -3.07, 95% confidence interval (CI) -5.15 to -1.00; 8 studies; low-certainty evidence). The duration of attacks per day was 55 minutes with placebo and PDE5i reduced the duration of attacks by an average of five minutes (MD -5.31, 95% CI -8.90 to -1.71; 8 studies; low-certainty evidence). Very low-certainty evidence from one study with eight participants showed severity of Raynaud's attacks (assessed on a 10 cm visual analogue scale with lower scores indicating less severity) was 20% lower with a PDE5i (3.7 with placebo compared to 1.6 with treatment; MD -2.1, 95% CI -2.7 to 1.4; very low-certainty evidence). Pain and patient global assessment were assessed on a 10 cm visual analogue scale with lower scores indicating improvement. Low-certainty evidence showed that the use of PDE5i may result in little to no difference compared to placebo in reducing the average pain of Raynaud's attacks (3 to 2.9; MD -0.10, 95% CI -0.78 to 0.57; 4 studies). Global scores were 36% lower with the use of a PDE5i compared to placebo (9.2 to 5.6; MD -3.59, 95% CI -4.45 to -2.73; 1 study, 24 participants; low-certainty evidence). The rate of withdrawals during treatment with PDE5i ranged from 4% to 20% compared with 2% in the placebo group in five studies. Four studies reported no withdrawals due to adverse events. Seven studies reported no serious adverse events. The rate of serious adverse events reported in two studies ranged from 2% during treatment to 4% with placebo. The majority of the studies were judged as low or unclear risk of bias for selection, performance, and detection bias. Almost half were judged at high risk of attrition bias and unclear risk for selective reporting bias. We downgraded frequency of attacks, duration of attacks, pain intensity, and patient global assessment for small sample sizes and concerns about inconsistency and graded each as low certainty of evidence. We downgraded severity of attacks to very low certainty due to serious concerns about imprecision and publication bias. We downgraded withdrawals due to adverse events and serious adverse events to moderate certainty of evidence due to a low number of reported events. AUTHORS' CONCLUSIONS Based on low-certainty evidence, PDE5i may reduce the frequency of attacks of Raynaud's phenomenon by a small amount per week, result in a small reduction in the duration of attack, improve patients' global assessment of their disease, and result in little to no difference in pain. PDE5i probably result in little or no difference in serious adverse events but slightly increase the likelihood of withdrawing from treatment due to an adverse event.
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Affiliation(s)
- Nancy Maltez
- Department of Rheumatology, The Ottawa Hospital, Ottawa, Canada
| | - Lara J Maxwell
- Cochrane Musculoskeletal, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Fadumo Rirash
- Department of Medicine, University of Western Ontario, London, Canada
| | | | - Sarah E Harding
- Pediatric Critical Care Medicine, SUNY Upstate Medical University, Syracuse, USA
| | - Paul C Tingey
- Department of Medicine, University of Western Ontario, London, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Janet Pope
- Department of Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Canada
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Maltez N, Hughes M, Brown E, Hickey V, Shea B, Herrick AL, Proudman S, Merkel PA, Pauling JD. Domain reporting in systemic sclerosis-related Raynaud's phenomenon: An OMERACT scoping review. Semin Arthritis Rheum 2023; 61:152208. [PMID: 37202251 DOI: 10.1016/j.semarthrit.2023.152208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Raynaud's phenomenon (RP) is a cardinal feature of SSc and is associated with significant disease-related morbidity that impacts on quality of life. The assessment of SSc-RP is challenging. The aim of this scoping review was to evaluate the outcome domains studied and outcome measures used in clinical studies of SSc-RP. METHODS Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify randomized control trials (RCTs), quasi-randomized studies, case-control studies, prospective and retrospective cohort studies, case series, and cross-sectional studies of adult participants with SSc-associated RP, written in English. A minimum of 25 participants for studies of imaging modalities and 40 participants for questionnaire-based studies was required for inclusion. Basic laboratory and genetic studies were excluded. No limitations were imposed based on intervention, comparator, or study setting. Study characteristics and primary and secondary target domains in each study were recorded. RESULTS 58 studies (24 randomized clinical trials) were included in the final analysis. The commonest domains captured were severity of attacks (n=35), frequency of attacks (n=28), and duration of attacks (n=19). Objective assessments of digital perfusion were also commonly used in studies of SSc-RP. CONCLUSION The outcome domains and the associated outcomes used to assess the impact of SSc-RP in research studies are broad and have varied across studies. The results of this study will inform the OMERACT Vascular Disease in Systemic Sclerosis Working Group to establish a core set of disease domains encompassing the impact of RP in SSc.
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Affiliation(s)
- Nancy Maltez
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Michael Hughes
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Beverley Shea
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susanna Proudman
- Discipline of Medicine, University of Adelaide and Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Pauling
- North Bristol NHS Trust, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
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Ramahi A, Hughes M, Khanna D. Practical management of Raynaud's phenomenon - a primer for practicing physicians. Curr Opin Rheumatol 2022; 34:235-244. [PMID: 35699336 PMCID: PMC9246963 DOI: 10.1097/bor.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Raynaud's phenomenon (RP) is a common vasospastic condition that results in digital hypoperfusion in response to cold and/or emotional stress and is associated with significant pain and disability. The aim of our review is to provide a practical approach for clinicians to inform assessment and management of patients with RP. RECENT FINDINGS Autoantibodies and nailfold capillaroscopy are key investigations to stratify the risk of progression to systemic sclerosis (SSc) in patients RP, which was recently confirmed in the multicenter, very early diagnosis of systemic sclerosis (VEDOSS) project. Research has explored the complex lived-patient experience of RP including digital vasculopathy in SSc and has highlighted the need for outcome measure development to facilitate research in the field. Pharmacological treatment strategies vary significantly internationally and there is continued interest in developing surgical approaches. SUMMARY We provide a practical and up-to-date approach to inform the assessment and management of patients with RP including guidance on drug initiation and escalation. Calcium channel blockers are first-line treatment and can be initiated by primary care physicians. We also highlight second-line drug therapies used for refractory RP and the potential role for surgical intervention.
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Affiliation(s)
- Ahmad Ramahi
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Michael Hughes
- Tameside Hospital, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, United Kingdom
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
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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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Alhendi FJ, Werth VP, Sollecito TP, Stoopler ET. Systemic sclerosis: Update for oral health care providers. SPECIAL CARE IN DENTISTRY 2021; 40:418-430. [PMID: 33448431 DOI: 10.1111/scd.12492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022]
Abstract
Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune disease of unknown origin characterized by an uncontrolled inflammatory process resulting in fibrosis of the skin, internal organs and vasculopathy. Manifestations of SSc are heterogenous and can include pulmonary, cardiac, neural, renal, muscular, cutaneous and orofacial complications. Recent scientific advances have led to a better understanding of disease etiopathogenesis and the development of a new classification system. Therapeutic management is often multidisciplinary and targeted toward the affected organs. Oral health care providers (OHCPs) should be familiar with SSc, particularly as it relates to its impact on the orofacial region and modifications to delivery of oral health care for patients with this condition.
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Affiliation(s)
- Fatmah J Alhendi
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Dermatology, Philadelphia V.A. Hospital, Hospital of the University of Pennsylvania and the Veteran's Administration Medical Center, Philadelphia, Pennsylvania
| | - Thomas P Sollecito
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Eric T Stoopler
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
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11
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The Phosphodiesterase Type 5 Inhibitor Sildenafil Improves DNA Stability and Redox Homeostasis in Systemic Sclerosis Fibroblasts Exposed to Reactive Oxygen Species. Antioxidants (Basel) 2020; 9:antiox9090786. [PMID: 32854347 PMCID: PMC7555932 DOI: 10.3390/antiox9090786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/11/2022] Open
Abstract
Systemic sclerosis (SSc) is a multi-system connective tissue disease characterized by the increased deposition of extracellular matrix proteins such as collagen and fibronectin. Although the pathogenesis is not completely understood, a number of studies suggest that free radicals could be the major contributors to the disease. Indeed, different studies demonstrated how oxidative stress could contribute to the fibrotic process activation at the level of the skin and visceral organs. Emerging evidences highlight the beneficial effects of sildenafil, a phosphodiesterase type 5 inhibitor (PDE5i), which protects different cell lines from the cell damage induced by reactive oxygen species (ROS). These data make sildenafil a good candidate for therapeutic treatment aimed to protect biological macromolecules against oxidative damage, thus preserving cell viability. The purpose of this study was to evaluate the sensitivity of SSc dermal fibroblasts to an oxidative insult and the ability for sildenafil to prevent/reduce the DNA damage due to ROS action. Additionally, we evaluated the capacity for sildenafil to influence redox homeostasis and cytotoxicity, as well as cell proliferation and cell cycle progression. We demonstrated that SSc fibroblasts have an increased sensitivity to a pro-oxidant environment in comparison to healthy controls. The sildenafil treatment reduced ROS-induced DNA damage, counteracted the negative effects of ROS on cell viability and proliferation, and promoted the activity of specific enzymes involved in redox homeostasis maintenance. To our knowledge, in this report, we demonstrate, for the first time, that sildenafil administration prevents ROS-induced instability in human dermal fibroblasts isolated by SSc patients. These results expand the use of PDE5i as therapeutic agents in SSc by indicating a protective role in tissue damage induced by oxidative insult.
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12
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Nagaraja V, Matucci-Cerinic M, Furst DE, Kuwana M, Allanore Y, Denton CP, Raghu G, Mclaughlin V, Rao PS, Seibold JR, Pauling JD, Whitfield ML, Khanna D. Current and Future Outlook on Disease Modification and Defining Low Disease Activity in Systemic Sclerosis. Arthritis Rheumatol 2020; 72:1049-1058. [PMID: 32134199 DOI: 10.1002/art.41246] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 02/27/2020] [Indexed: 01/15/2023]
Abstract
Systemic sclerosis (SSc) is an autoimmune rheumatic disease with heterogeneous clinical manifestations and a variable course in which the severity of the pathology dictates the disease prognosis and course. Among autoimmune rheumatic diseases, SSc has the highest mortality rate among all rheumatic diseases, though there are exciting new therapeutic targets that appear to halt the progression of SSc manifestations such as skin or lung fibrosis. In selected patients, high-intensity regimens with autologous stem cell transplantation can favorably modify the course. In what was once thought to be an untreatable disease, targeted therapies have now changed the outlook of SSc to a treatable disorder. Herein, we discuss the targeted therapies modifying the outlook on selected organ involvement and creating opportunities for future treatment. We also present a framework for defining low disease activity in SSc.
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Affiliation(s)
| | | | - Daniel E Furst
- University of California in Los Angeles, University of Washington, Seattle, and University of Florence, Florence, Italy
| | | | - Yannick Allanore
- Paris Descartes University, INSERM U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France
| | | | | | | | | | - James R Seibold
- Scleroderma Research Consultants, LLC, Aiken, South Carolina
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, Bath, UK
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13
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Fujimoto M, Asai J, Asano Y, Ishii T, Iwata Y, Kawakami T, Kodera M, Abe M, Amano M, Ikegami R, Isei T, Isogai Z, Ito T, Inoue Y, Irisawa R, Ohtsuka M, Omoto Y, Kato H, Kadono T, Kaneko S, Kanoh H, Kawaguchi M, Kukino R, Kono T, Koga M, Sakai K, Sakurai E, Sarayama Y, Shintani Y, Tanioka M, Tanizaki H, Tsujita J, Doi N, Nakanishi T, Hashimoto A, Hasegawa M, Hayashi M, Hirosaki K, Fujita H, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Motegi SI, Yatsushiro H, Yamasaki O, Yoshino Y, Pavoux AJLE, Tachibana T, Ihn H. Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers. J Dermatol 2020; 47:1071-1109. [PMID: 31960490 DOI: 10.1111/1346-8138.15186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 11/30/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
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Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Jun Asai
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yohei Iwata
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masanari Kodera
- Department of Dermatology, JCHO Chukyo Hospital, Nagoya, Japan
| | | | - Masahiro Amano
- Department of Dermatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuta Ikegami
- Department of Dermatology, JCHO Osaka Hospital, Osaka, Japan
| | - Taiki Isei
- Department of Dermatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Zenzo Isogai
- Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuji Inoue
- Suizenji Dermatology Clinic, Kumamoto, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoichi Omoto
- Department of Dermatology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Hiroshi Kato
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takafumi Kadono
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sakae Kaneko
- Department of Dermatology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Hiroyuki Kanoh
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Takeshi Kono
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzei, Japan
| | - Monji Koga
- Department of Dermatology, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Sakai
- Department of Dermatology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | | | | | | | | | - Hideaki Tanizaki
- Department of Dermatology, Osaka Medical College, Takatsuki, Japan
| | - Jun Tsujita
- Department of Dermatology, Social Insurance Inatsuki Hospital, Fukuoka Prefecture Social Insurance Hospital Association, Fukuoka, Japan
| | - Naotaka Doi
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Hideki Fujita
- Division of Dermatological Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate, School of Medical and Dental Sciences, Niigata, Japan.,Department of Dermatology, Uonuma Kikan Hospital, Minamiuonuma, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Shimotsuke, Japan
| | | | - Naoki Madokoro
- Department of Dermatology, MAZDA Hospital, Aki-gun, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Osamu Yamasaki
- Department of Dermatology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Khouri C, Lepelley M, Bailly S, Blaise S, Herrick AL, Matucci-Cerinic M, Allanore Y, Trinquart L, Cracowski JL, Roustit M. Comparative efficacy and safety of treatments for secondary Raynaud's phenomenon: a systematic review and network meta-analysis of randomised trials. THE LANCET. RHEUMATOLOGY 2019; 1:e237-e246. [PMID: 38229380 DOI: 10.1016/s2665-9913(19)30079-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several pharmacological treatments are available for secondary Raynaud's phenomenon, but there is uncertainty regarding the best options. We aimed to assess and compare the benefits and harms of treatments available for secondary Raynaud's phenomenon. METHOD We did a systematic review and network meta-analysis of randomised controlled trials (RCTs) of pharmacological treatments. We searched for systematic reviews published in MEDLINE and the Cochrane Database of Systematic Reviews up to Jan 31, 2017, and for RCTs published from inception to Sept 24, 2019 in MEDLINE, Embase, and ClinicalTrials.gov. We included double-blind RCTs (parallel or crossover) that compared two or more pharmacological treatments or placebo in patients with secondary Raynaud's phenomenon. Individual patient data were obtained for one unpublished RCT. Three researchers independently screened the texts and extracted the data. Efficacy outcomes included severity (on a ten-point scale), daily frequency, and mean duration of Raynaud's phenomenon attacks. We also examined tolerability and acceptability. Pairwise meta-analyses and Bayesian random-effects network meta-analyses were used to synthesise data. This study is registered with PROSPERO (CRD42017057518). FINDINGS We included 58 RCTs in the analysis, comprising 3867 patients (3540 [91·5%] with secondary Raynaud's phenomenon) and 15 classes of drugs. Phosphodiesterase 5 (PDE5) inhibitors were more effective than placebo for frequency (mean difference -0·36 [95% credibility interval -0·69 to -0·04]), severity (-0·34 [-0·66 to -0·03]), and duration (-3·42 [-6·62 to -0·29]) of attacks (low to moderate level of evidence). Calcium channel blockers (CCBs) were superior to placebo for frequency (-0·35 [-0·67 to -0·02]) and severity (-0·84 [-1·25 to -0·45]) of attacks (low level of evidence). For severity of attacks, selective serotonin-reuptake inhibitors (-1·54 [-2·68 to -0·41]; very low level of evidence) and oral prostacyclin receptor agonists (-0·48 [-0·80 to -0·16]; low level of evidence) were superior to placebo. No other drug classes were significantly superior to placebo with regard to efficacy outcomes. Compared with placebo, tolerability was lower for PDE5 inhibitors (incidence rate ratio for serious adverse events or early study exit due to adverse events 3·30 [95% CrI 1·49 to 7·55]) and CCBs (3·13 [1·33 to 7·04]). For all outcomes, global heterogeneity and between-study variance ranged from low (I2=0% and τ2=0·0 for attack severity and duration) to moderate (I2=41% and τ2=0·2 for tolerability). The overall risk of bias was judged to be low in 22 (38%), high in ten (17%), and unclear in 26 (45%) RCTs. INTERPRETATION PDE5 inhibitors and CCBs are the most effective pharmacological options, albeit with moderate efficacy and a low level of evidence. Current evidence does not support the use of any other drug in secondary Raynaud's phenomenon. FUNDING None.
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Affiliation(s)
- Charles Khouri
- Pharmacovigilance Unit, Grenoble Alpes University Hospital, Grenoble, France; Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Marion Lepelley
- Pharmacovigilance Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Sebastien Bailly
- EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Sophie Blaise
- Department of Vascular Medicine, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Careggi University Hospital, Florence, Italy
| | - Yannick Allanore
- INSERM U1016 UMR8104 Cochin Institute, Paris Descartes University, Paris, France; Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jean-Luc Cracowski
- Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France
| | - Matthieu Roustit
- Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France; HP2 Laboratory, U1042 INSERM, Grenoble Alpes University, Grenoble, France.
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15
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Pauling JD, Saketkoo LA, Matucci-Cerinic M, Ingegnoli F, Khanna D. The patient experience of Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2019. [PMID: 29538754 DOI: 10.1093/rheumatology/key026] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RP is the most common manifestation of SSc and a major cause of disease-related morbidity. This review provides a detailed appraisal of the patient experience of SSc-RP and potential implications for disease classification, patient-reported outcome instrument development and SSc-RP clinical trial design. The review explores the clinical features of SSc-RP, the severity and burden of SSc-RP symptoms and the impact of SSc-RP on function, work and social participation, body image dissatisfaction and health-related quality of life in SSc. Where management of SSc-RP is concerned, the review focuses on the 'patient experience' of interventions for SSc-RP, examining geographic variation in clinical practice and potential barriers to the adoption of treatment recommendations concerning best-practice management of SSc-RP. Knowledge gaps are highlighted that could form the focus of future research. A more thorough understanding of the patient experience could support the development of novel reported outcome instruments for assessing SSc-RP.
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Affiliation(s)
- John D Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.,Royal National Hospital for Rheumatic Diseases (part of Royal United Hospitals), Upper Borough Walls, Bath, UK
| | - Lesley Ann Saketkoo
- School of Medicine, University of Tulane Medical Center, New Orleans, LA, USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine, Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Ingegnoli
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Universita degli Studi di Milano, Milano, Italy
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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16
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Pauling JD, Reilly E, Smith T, Frech TM. Evolving Symptom Characteristics of Raynaud's Phenomenon in Systemic Sclerosis and Their Association With Physician and Patient-Reported Assessments of Disease Severity. Arthritis Care Res (Hoboken) 2019; 71:1119-1126. [PMID: 30133174 DOI: 10.1002/acr.23729] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/14/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assessment of Raynaud's phenomenon (RP) in systemic sclerosis (SSc) is reliant on self-report. The Raynaud's Condition Score (RCS) diary assumes discrete episodic RP attacks, although not all SSc patients identify with this paradigm. We investigated the clinical associations of SSc-RP symptom characteristics and the evolution of SSc-RP symptoms with disease progression. METHODS A cross-sectional study at UK and US sites captured digital color changes of SSc-RP and patients' ability to identify with diagrammatic representations (and descriptive stems) of 4 distinct theoretical SSc-RP patterns (progressing severity A through D) reflecting progressively severe SSc-RP experiences. SSc-RP self-management and symptom evolution were explored. Patient demographics, the clinical phenotype, the Scleroderma Health Assessment Questionnaire (SHAQ), the 2-week RCS diary, and patient and physician global assessments were collected. RESULTS We enrolled 107 patients with SSc (with questionnaires returned by 94). A higher number of self-reported digital color changes of SSc-RP were associated with increased SSc-RP symptom severity but not with the SSc clinical phenotype. Patients could identify with distinct patterns of SSc-RP. These patterns were associated with disease duration, global disease severity, and conceptually linked physician and patient assessments of peripheral vascular severity (e.g., SHAQ RP subscale and RCS diary parameters), but not with conceptually unrelated outcomes (e.g., SHAQ breathing subscale). SSc-RP characteristics and symptom severity evolve during the disease course. CONCLUSION Patients identify with distinct patterns of SSc-RP that may relate to progression of the obliterative microangiopathy of SSc. Difficulty distinguishing discrete SSc-RP attacks from persistent digital ischemia in patients with advanced SSc could influence diary-based approaches to assessing SSc-RP, with implications for future clinical trials.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, and University of Bath, Bath, UK
| | - Elizabeth Reilly
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, and University of Bath, Bath, UK
| | | | - Tracy M Frech
- Salt Lake Regional Veterans Affairs Medical Center and University of Utah, Salt Lake City
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17
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Herrick AL. Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:89-101. [PMID: 35382391 PMCID: PMC8922643 DOI: 10.1177/2397198319826467] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/27/2018] [Indexed: 09/05/2023]
Abstract
Raynaud's phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud's phenomenon is very common, affecting approximately 3%-5% of the general population. Although much rarer, systemic sclerosis-related Raynaud's phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud's phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis-related Raynaud's phenomenon (which is the most researched form of Raynaud's phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from 'isolated' to systemic sclerosis-related Raynaud's phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both 'uncomplicated' and 'complicated' Raynaud's phenomena (i.e. Raynaud's phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5-10 years are highlighted.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
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18
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Pauling JD, Reilly E, Smith T, Frech TM. Factors Influencing Raynaud Condition Score Diary Outcomes in Systemic Sclerosis. J Rheumatol 2019; 46:1326-1334. [PMID: 30824643 DOI: 10.3899/jrheum.180818] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Raynaud phenomenon (RP) in systemic sclerosis (SSc) could be influenced by clinical phenotype, environmental factors (e.g., season), and personal factors (e.g., coping strategies and ill-health perceptions). We studied the relative influence of a range of putative factors affecting patient-reported assessment of SSc-RP severity. METHODS SSc patients were enrolled at UK and US sites. Participants completed the 2-week Raynaud Condition Score (RCS) diary alongside collection of patient demographics, clinical phenotype, the Coping Strategies Questionnaire, Pain Catastrophizing Scale, Scleroderma Health Assessment Questionnaire (SHAQ), and both patient/physician visual analog scale (VAS) assessments for RP, digital ulcer disease, and global disease. Environmental temperature data were obtained at each site. A second RCS diary was completed 6 months after enrollment. RESULTS We enrolled 107 patients (baseline questionnaires returned by 94). There were significant associations between RCS diary variables and both catastrophizing and coping strategies. There were significant associations between RCS diary outcomes and both environmental temperature and season of enrollment. Age, disease duration, sex, disease subtype, smoking, and vasodilator use were not associated with RCS diary outcomes. The best-fitting multivariate model identified the patient RP VAS, SHAQ pain VAS, and SHAQ gastrointestinal VAS subscales as the strongest independent predictors of the RCS. CONCLUSION Patient-reported assessment of SSc-RP severity is associated with a number of factors including pain, catastrophizing, and coping strategies. The effects of seasonal variation in environmental temperature on SSc-RP burden has implications for clinical trial design. Treatments targeting SSc-RP pain and the development of behavioral interventions enhancing coping strategies may reduce the burden of SSc-RP.
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Affiliation(s)
- John D Pauling
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA. .,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center.
| | - Elizabeth Reilly
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
| | - Theresa Smith
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
| | - Tracy M Frech
- From the Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); Department of Pharmacy and Pharmacology, University of Bath; Department of Mathematical Sciences, University of Bath, Bath, UK; University of Utah, and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,J.D. Pauling, BMedSci, BMBS, PhD, FRCP, Senior Lecturer, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), and Department of Pharmacy and Pharmacology, University of Bath; E. Reilly, MBBCh, MRCP, Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals); T. Smith, BA, BSc, PhD, Department of Mathematical Sciences, University of Bath; T.M. Frech, MD, MS, University of Utah, and Salt Lake Regional Veterans Affairs Medical Center
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D'Andrea S, Barbonetti A, Martorella A, Necozione S, Francavilla F, Francavilla S. Effect of prolonged treatment with phosphodiesterase-5-inhibitors on endothelial dysfunction in vascular diseases and vascular risk conditions: A systematic review analysis and meta-analysis of randomized double-blind placebo-controlled trials. Int J Clin Pract 2019; 73:e13296. [PMID: 30471172 DOI: 10.1111/ijcp.13296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/15/2018] [Accepted: 11/18/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To challenge the argument that continuous use of phosphodiesterase-5-selective inhibitors may reduce endothelial cell dysfunction in patients with vascular diseases or vascular risk conditions. DESIGN This study included systematic reviews and meta-analysis of randomized double-blind placebo-controlled trials dealing with the prolonged use of phosphodiesterase-5-selective inhibitors. The risk of bias and quality of trials were assessed by the Cochrane algorithm. Fixed or random effect models, standardised mean differences and heterogeneity were estimated in the study. DATA SOURCES Systematic search for randomized double-blind placebo-controlled trials was done in PubMed, Scopus, CINAHL, Science direct and the Cochrane Library. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomized double-blind placebo-controlled trials reporting measures of endothelial cell dysfunction and/or endothelial cell activation were included. RESULTS On the whole, 469 subjects were allocated to the phosphodiesterase-5-selective inhibitor group, while 463 were assigned to the placebo group in 13 randomized double-blind placebo-controlled trials. Flow-mediated dilation of the brachial artery was found to improve after the administration of phosphodiesterase-5-selective inhibitors (P < 0.0001). The results were questioned by the elevated and uncorrectable heterogeneity (I2 = 92%) and the asymmetry of the funnel plot suggested a publication bias. Phosphodiesterase-5-selective inhibitors have no effect on endothelial cell dysfunction, as assessed in the resistance vessels by digital arterial tonometry. The blood level of endothelin-1 was observed to be decreased in phosphodiesterase-5-selective inhibitors arm (P = 0.03), although the effect disappeared once the publication bias and heterogeneity were corrected. The effect of phosphodiesterase-5-selective inhibitors on biomarkers of endothelial cell activation was found to be inconsistent. CONCLUSIONS The results on the benefits of a prolonged use of phosphodiesterase-5-selective inhibitors, with the objective of lowering endothelial cell dysfunction in patients with vascular diseases or vascular risk conditions are not convincing. This is because of the overall low quality of evidence, giving an unclear scientific support to this treatment. Systematic review registration: PROSPERO registration: CRD42017055399.
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Affiliation(s)
- Settimio D'Andrea
- Department of Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Arcangelo Barbonetti
- Department of Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Alessio Martorella
- Department of Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | | | - Felice Francavilla
- Department of Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Sandro Francavilla
- Department of Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
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Use of nitroglycerin ointment to treat primary and secondary Raynaud’s phenomenon: a systematic literature review. Rheumatol Int 2018; 38:2209-2216. [DOI: 10.1007/s00296-018-4119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
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Baron M, Kahaleh B, Bernstein EJ, Chung L, Clements PJ, Denton C, Domsic RT, Ferdowsi N, Foeldvari I, Frech T, Gordon JK, Hudson M, Johnson SR, Khanna D, McMahan Z, Merkel PA, Narain S, Nikpour M, Pauling JD, Ross L, Valenzuela Vergara AM, Vacca A. An Interim Report of the Scleroderma Clinical Trials Consortium Working Groups. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 4:17-27. [PMID: 30906878 DOI: 10.1177/2397198318783926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Scleroderma Clinical Trials Consortium (SCTC) represents many of the clinical researchers in the world who are interested in improving the efficiency of clinical trials in Systemic Sclerosis (SSc). The SCTC has established 11 working groups (WGs) to develop and validate better ways of measuring and recording multiple aspects of this heterogeneous disease. These include groups working on arthritis, disease damage, disease activity, cardiac disease, juvenile SSc, the gastrointestinal tract, vascular component, calcinosis, scleroderma renal crisis, interstitial lung disease, and skin measurement. Members of the SCTC may join any one or more of these groups. Some of the WGs have only recently started their work, some are nearing completion of their mandated tasks and others are in the midst of their projects. All these projects, which are described in this paper, will help to improve clinical trials and observational studies by improving or developing better, more sensitive ways of measuring various aspects of the disease. As Lord Kelvin stated, "To measure is to know. If you cannot measure it you cannot improve it." The SCTC is dedicated to improving the lives of patients with SSc and it is our hope that the contributions of the WGs will be one important step in this process.
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Affiliation(s)
- Murray Baron
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Bashar Kahaleh
- Faculty of Rheumatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Elana J Bernstein
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Philip J Clements
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; University College London, London, United Kingdom
| | - Christopher Denton
- Insitute of Immunity and Transplantation, University College London, London, United Kingdom
| | - Robyn T Domsic
- Arthritis and Autoimmunity Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nava Ferdowsi
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric Rheumatology, Hamburg, Germany
| | - Tracy Frech
- Department of Rheumatology, University of Utah, UT, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Sindhu R Johnson
- Department of Rheumatology, Toronto Western Hospital, Toronto, Canada
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, MI, USA
| | | | - Peter A Merkel
- Department of Medicine, University of Pennsylvania, PA, USA
| | - Sonali Narain
- Department of Rheumatology, Hosfra Northwell School of Medicine
| | - Mandana Nikpour
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - John D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases University of Bath
| | - Laura Ross
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
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Hinze AM, Wigley FM. Pharmacotherapy Options in the Management of Raynaud's Phenomenon. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018; 4:235-254. [PMID: 31538045 DOI: 10.1007/s40674-018-0102-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose of review Multiple classes of medications have been studied for the treatment of Raynaud's phenomenon (RP) with or without digital ischemia. The goal of this review is to discuss the outcomes of recent studies and to report on our approach to the management of RP in light of the available evidence. Recent findings Comparing treatments for RP remains a challenge as efficacy endpoint vary widely among trials. While calcium channel blockers are used first-line in the pharmacologic management of RP, phosphodiesterase 5 inhibitors have also been shown to be beneficial in reducing symptoms. In the setting of digital ischemia, administration of intravenous prostanoids is the standard of care. Bosentan has shown benefit in the prevention of future ulcers in patients with scleroderma. Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients. Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common. Summary Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP. Based on the available evidence, we start with CCBs and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist in cases of recurrent digital ulcers. A surgical sympathectomy may be used in refractory cases of digital ischemia. A digital block may also be a less invasive, but temporary, intervention allowing for titration of medical therapy.
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Affiliation(s)
- Alicia M Hinze
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
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Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
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Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
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Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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Pearson DR, Werth VP, Pappas-Taffer L. Systemic sclerosis: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:459-474. [PMID: 30047430 DOI: 10.1016/j.clindermatol.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.
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Affiliation(s)
- David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bellando-Randone S, Bruni C, Lepri G, Fiori G, Bartoli F, Conforti ML, Moggi-Pignone A, Guiducci S, Giuggioli D, Colaci M, Spinella A, Ferri C, Matucci-Cerinic M. The safety of iloprost in systemic sclerosis in a real-life experience. Clin Rheumatol 2018; 37:1249-1255. [DOI: 10.1007/s10067-018-4043-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/01/2018] [Accepted: 02/14/2018] [Indexed: 02/02/2023]
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Denton CP, Hachulla É, Riemekasten G, Schwarting A, Frenoux JM, Frey A, Le Brun FO, Herrick AL. Efficacy and Safety of Selexipag in Adults With Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Randomized, Placebo-Controlled, Phase II Study. Arthritis Rheumatol 2017; 69:2370-2379. [PMID: 29193819 PMCID: PMC6099416 DOI: 10.1002/art.40242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 08/22/2017] [Indexed: 01/03/2023]
Abstract
Objective To determine the effect of selexipag, an oral, selective IP prostacyclin receptor agonist, on the frequency of attacks of Raynaud's phenomenon (RP) in patients with systemic sclerosis (SSc). Methods Patients with SSc‐related RP were randomized 1:1 to placebo (n = 38) or selexipag (n = 36) in individualized doses (maximum of 1,600 μg twice daily) during a 3‐week titration period. The primary end point was the weekly average number of RP attacks during the study maintenance period, analyzed using a Bayesian approach with a negative binomial model adjusted for baseline number of RP attacks. Other outcome measures included Raynaud's Condition Score (RCS), RP attack duration, and treatment‐emergent adverse events (AEs). Results Baseline characteristics were comparable between treatment groups. For 83.3% of patients, the individualized maintenance dosage of selexipag was ≤800 μg twice daily. No significant difference was observed between placebo and selexipag in weekly average number of electronic diary (eDiary)–recorded RP attacks during the maintenance period (14.2 attacks during the maintenance period and 21.5 attacks during the baseline week in the placebo group [n = 32] versus 18.0 attacks during the maintenance period and 22.4 attacks during the baseline week in the selexipag group [n = 27]; adjusted mean treatment difference of 3.4 in favor of placebo). No significant treatment effect was observed on RCS or RP attack duration. In the double‐blind period, 86.8% of placebo‐treated patients and 100% of selexipag‐treated patients reported ≥1 AE; 55.3% and 91.7%, respectively, reported ≥1 prostacyclin‐associated AE. Conclusion Treatment with selexipag did not reduce the number of RP attacks compared with placebo. The safety profile of selexipag was similar to that previously reported. This study provides important information about the feasibility of eDiary reporting of RP attacks in clinical trials.
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Affiliation(s)
| | - Éric Hachulla
- National Referral Centre for Rare Systemic Auto-immune Diseases, Department of Internal Medicine, Hôpital Huriez, University of Lille, Lille, France
| | | | - Andreas Schwarting
- Johannes Gutenberg University, Mainz, and ACURA Rheumatology Centre RLP, Bad Kreuznach, Germany
| | | | - Aline Frey
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust and NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Herrick AL. Evidence-based management of Raynaud's phenomenon. Ther Adv Musculoskelet Dis 2017; 9:317-329. [PMID: 29201156 PMCID: PMC5700788 DOI: 10.1177/1759720x17740074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
Raynaud's phenomenon (RP) is relevant to the rheumatologist because it may signify an underlying connective tissue disease and also because it can be very challenging to treat, especially when it has progressed to digital ulceration or critical ischaemia. This review article discusses diagnosis (does this patient have an underlying connective tissue disease?), including the role for nailfold capillaroscopy, and treatment. Management of 'uncomplicated' RP is first described and then treatment of RP complicated by progression to digital ulceration or critical ischaemia, highlighting recent advances (including phosphodiesterase type 5 inhibition, and endothelin 1 receptor antagonism) and the evidence base underpinning these. Possible future therapies are briefly discussed.
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Affiliation(s)
- Ariane L. Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK, M13 9PT and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK
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Cutolo M, Smith V, Furst DE, Khanna D, Herrick AL. Points to consider-Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v45-v48. [PMID: 28992170 DOI: 10.1093/rheumatology/kex199] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 11/13/2022] Open
Abstract
RP is an exaggerated vasospastic response to cold or emotion. Randomized, double-blind, placebo-controlled trials with either parallel group or cross-over trials should be mainly considered. Cross-over design, which is good for early phase trials of immediate or very short-term outcomes, is important in a condition as heterogeneous as RP: a wash-out period between treatment arms should always be included to minimize the possibility of a period (carry-over) effect. Duration of RP trials is usually constrained by the need to complete these over a single season, usually winter when the weather is colder. For cross-over trials, each treatment arm tends to be 4 weeks or less. Frequency and duration of attacks, and the Raynaud's Condition Score are widely used outcome measures. There is increasing interest in physiological laboratory endpoints, for example laser Doppler imaging at least for early phase trials.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS, University of Genova, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital.,Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Daniel E Furst
- Department of Rheumatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine University of Michigan, University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust, Manchester and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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Abstract
Systemic sclerosis, also called scleroderma, is an immune-mediated rheumatic disease that is characterised by fibrosis of the skin and internal organs and vasculopathy. Although systemic sclerosis is uncommon, it has a high morbidity and mortality. Improved understanding of systemic sclerosis has allowed better management of the disease, including improved classification and more systematic assessment and follow-up. Additionally, treatments for specific complications have emerged and a growing evidence base supports the use of immune suppression for the treatment of skin and lung fibrosis. Some manifestations of the disease, such as scleroderma renal crisis, pulmonary arterial hypertension, digital ulceration, and gastro-oesophageal reflux, are now treatable. However, the burden of non-lethal complications associated with systemic sclerosis is substantial and is likely to become more of a challenge. Here, we review the clinical features of systemic sclerosis and describe the best practice approaches for its management. Furthermore, we identify future areas for development.
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Affiliation(s)
- Christopher P Denton
- UCL Division of Medicine, University College London, London, UK; UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK.
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32
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How I treat patients with systemic sclerosis in clinical practice. Autoimmun Rev 2017; 16:1024-1028. [DOI: 10.1016/j.autrev.2017.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/28/2017] [Indexed: 12/28/2022]
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Abstract
INTRODUCTION Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.
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Affiliation(s)
- Ariane L Herrick
- a Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,b NIHR Manchester Musculoskeletal Biomedical Research Unit , Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
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A Randomized Controlled Trial of Acupressure for the Treatment of Raynaud's Phenomenon: The difficulty of conducting a trial in Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016; 1:226-233. [PMID: 27840853 DOI: 10.5301/jsrd.5000206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of acupressure on Raynaud's phenomenon (RP) in a randomized controlled clinical trial (RCT) and to evaluate the difficulties of conducting a RP RCT. METHODS A pilot single center RCT of acupressure vs. targeted patient education was conducted for the treatment of RP. Patients with either primary (N = 15) or secondary (N = 8) RP were randomized in an 8-week study. The primary endpoints included a decrease in the frequency and duration of RP. Secondary endpoints included several serum biomarkers including endothelial dysfunction, Raynaud's attack symptoms, Raynaud's Condition Score, and patient and physician global assessments of RP. Primary data analysis was conducted using the last observation carried forward and t-tests or a Wilcoxon rank test was used to compare the two groups. RESULTS 23 patients were randomized and 7 discontinued prematurely. 78% of patients were female, 96% were Caucasian, and the mean age was 49.8 (SD=16) years. No statistically significant differences were detected between the acupressure vs. education groups in primary and secondary outcomes (p> 0.05). Frequency of attacks decreased by 6.7 attacks (SD=8.8) in the acupressure group vs. 7.2 (SD=12.8) in the education group (p=0.96), and the duration of attacks decreased by 11.4 (SD=19.9) minutes in the acupressure group vs. an increase of 0.8 minutes (SD=11.2) in the education group (p=0.14). There were no adverse events noted in the RCT. CONCLUSION This pilot study does not support efficacy of acupressure for RP.
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Kowal-Bielecka O, Fransen J, Avouac J, Becker M, Kulak A, Allanore Y, Distler O, Clements P, Cutolo M, Czirjak L, Damjanov N, Del Galdo F, Denton CP, Distler JHW, Foeldvari I, Figelstone K, Frerix M, Furst DE, Guiducci S, Hunzelmann N, Khanna D, Matucci-Cerinic M, Herrick AL, van den Hoogen F, van Laar JM, Riemekasten G, Silver R, Smith V, Sulli A, Tarner I, Tyndall A, Welling J, Wigley F, Valentini G, Walker UA, Zulian F, Müller-Ladner U. Update of EULAR recommendations for the treatment of systemic sclerosis. Ann Rheum Dis 2016; 76:1327-1339. [PMID: 27941129 DOI: 10.1136/annrheumdis-2016-209909] [Citation(s) in RCA: 671] [Impact Index Per Article: 83.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/22/2016] [Accepted: 10/09/2016] [Indexed: 12/16/2022]
Abstract
The aim was to update the 2009 European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis (SSc), with attention to new therapeutic questions. Update of the previous treatment recommendations was performed according to EULAR standard operating procedures. The task force consisted of 32 SSc clinical experts from Europe and the USA, 2 patients nominated by the pan-European patient association for SSc (Federation of European Scleroderma Associations (FESCA)), a clinical epidemiologist and 2 research fellows. All centres from the EULAR Scleroderma Trials and Research group were invited to submit and select clinical questions concerning SSc treatment using a Delphi approach. Accordingly, 46 clinical questions addressing 26 different interventions were selected for systematic literature review. The new recommendations were based on the available evidence and developed in a consensus meeting with clinical experts and patients. The procedure resulted in 16 recommendations being developed (instead of 14 in 2009) that address treatment of several SSc-related organ complications: Raynaud's phenomenon (RP), digital ulcers (DUs), pulmonary arterial hypertension (PAH), skin and lung disease, scleroderma renal crisis and gastrointestinal involvement. Compared with the 2009 recommendations, the 2016 recommendations include phosphodiesterase type 5 (PDE-5) inhibitors for the treatment of SSc-related RP and DUs, riociguat, new aspects for endothelin receptor antagonists, prostacyclin analogues and PDE-5 inhibitors for SSc-related PAH. New recommendations regarding the use of fluoxetine for SSc-related RP and haematopoietic stem cell transplantation for selected patients with rapidly progressive SSc were also added. In addition, several comments regarding other treatments addressed in clinical questions and suggestions for the SSc research agenda were formulated. These updated data-derived and consensus-derived recommendations will help rheumatologists to manage patients with SSc in an evidence-based way. These recommendations also give directions for future clinical research in SSc.
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Affiliation(s)
- Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Jaap Fransen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jerome Avouac
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Mike Becker
- University Hospital Charité, Berlin, Germany.,University Hospital Zurich, Zurich, Switzerland
| | - Agnieszka Kulak
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | | | - Philip Clements
- University of California at Los Angeles, Los Angeles, California, USA
| | - Maurizio Cutolo
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
| | - Laszlo Czirjak
- Department of Rheumatology and Immunology, Medical Center, University of Pecs, Pecs, Hungary
| | | | | | | | | | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | | | | | - Daniel E Furst
- University of California at Los Angeles, Los Angeles, California, USA
| | | | | | - Dinesh Khanna
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester, UK
| | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Richard Silver
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vanessa Smith
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratories and Clinical Division of Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino, Genova, Italy
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Recent advances in the pathogenesis and management of Raynaud's phenomenon and digital ulcers. Curr Opin Rheumatol 2016; 28:577-85. [DOI: 10.1097/bor.0000000000000332] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Treatment of skin manifestations in systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and dermatomyositis (DM) is based on the results of only few randomized controlled trials. The first-line treatment for disfiguring and widespread cutaneous involvement in SLE is antimalarials, but some patients are therapy resistant. Recently, the monoclonal antibody belimumab was approved for SLE as an adjunct therapy for patients with autoantibody-positive disease who despite standard therapy show high disease activity, intolerance of other treatments, or an unacceptably high need for corticosteroids. However, a validated skin score has not been used to confirm the efficacy of belimumab on mucocutaneous manifestations. In SSc, another multi-systemic progressive disease, involvement of the lung, kidney, and the heart is frequently treated with corticosteroids and immunosuppressives, but therapeutic modalities for cutaneous lesions, such as skin sclerosis and digital ulcers, are limited. In the past years, treatment with the endothelin-receptor antagonist bosentan has been proven to reduce the occurrence of new digital ulcers in SSc patients but has no or limited effect on healing of digital ulcers. DM is an idiopathic autoimmune disease characterized by inflammation of the muscles and skin, which is treated with immunosuppressives. Corticosteroids are the first-line treatment for muscle involvement in DM, but skin lesions often flare by reduction or discontinuation. In summary, there is a high unmet need for new therapeutic strategies focusing on skin involvement in systemic autoimmune diseases. Therefore, innovative designs of randomized controlled trials with validated skin scores are warranted to develop new therapeutic strategies for patients with cutaneous manifestations.
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Abstract
Raynaud's phenomenon (RP) is a major cause of pain and disability in patients with autoimmune connective tissue diseases (CTDs), particularly systemic sclerosis (SSc). The clinician must perform a comprehensive clinical assessment in patients with RP to differentiate between primary (idiopathic) and secondary RP, in particular (for rheumatologists), secondary to an autoimmune CTD, as both the prognosis and treatment may differ significantly. Key investigations are nailfold capillaroscopy and testing for autoantibodies (in particular, those associated with SSc). Patients with RP and either abnormal nailfold capillaroscopy or an SSc-specific antibody (and especially with both) have a high risk of transitioning to an autoimmune CTD. Both nailfold capillaroscopy and autoantibody specificity may help the clinician in predicting organ-based complications. The management of CTD-associated RP requires a multifaceted approach to treatment, including patient education and conservative ('non-drug') measures. Patients with CTD-associated RP often require pharmacological treatment, which in the first instance is usually a calcium channel blocker, although other agents can be used. There is an increasing tendency to use phosphodiesterase type 5 inhibitors early in the treatment of CTD-associated RP. Oral therapies are commonly associated with side effects (often due to systemic vasodilation) that may result in failure of dose escalation and/or permanent discontinuation. Intravenous prostanoid therapy and surgery (e.g., botulinum toxin injection and digital sympathectomy) can be considered in severe RP. Patients with CTD-associated RP can develop a number of ischaemic digital complications (primarily ulcers and critical ischaemia), which may be associated with significant tissue loss. Future research is required to increase the understanding of the pathogenesis and natural history of RP (to drive therapeutic advances), and to explore/develop drug therapies, including those that target the mechanisms mediating cold-induced vasoconstriction, and locally acting therapies free of systemic side effects.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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Brady SM, Shapiro L, Mousa SA. Current and future direction in the management of scleroderma. Arch Dermatol Res 2016; 308:461-71. [PMID: 27139430 DOI: 10.1007/s00403-016-1647-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/23/2016] [Accepted: 04/08/2016] [Indexed: 12/19/2022]
Abstract
Scleroderma is a heterogeneous disease with a complex etiology. As more information is gained about the underlying mechanisms and the improved classifications of scleroderma subtypes, treatments can be better personalized. Improving scleroderma patients' early diagnosis before end organ manifestations occur should improve clinical trial design and outcomes. Two recently FDA-approved antifibrotics for idiopathic pulmonary fibrosis may be effective treatments in patients with pulmonary fibrosis secondary to scleroderma after further investigation. The potential impact of Nanobiotechnology in improving the efficacy and safety of existing antifibrotics and immunomodulators might present an exciting new approach in the management of scleroderma.
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Affiliation(s)
- Sean M Brady
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive (Room 238), Rensselaer, NY, 12144, USA
| | - Lee Shapiro
- Division of Rheumatology, Steffens Scleroderma Center, Albany Medical College, Albany, NY, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive (Room 238), Rensselaer, NY, 12144, USA.
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Abstract
PURPOSE OF REVIEW To review pharmacologic and nonpharmacologic therapies in the treatment of systemic sclerosis (SSc) from 2011 to 2014 through a systematic review. RECENT FINDINGS Our systematic review identifies randomized controlled trials, meta-analyses, systematic reviews, case series, and observational studies which support organ-based therapy with known immunosuppressive agents, novel agents, and hematopoietic stem cell transplantation, and also includes nonpharmacologic therapies improving visceral and physical function. SUMMARY SSc is an orphan autoimmune disorder with significant morbidity and mortality. Although there has been significant progress over the years in therapeutic options for SSc, the mainstays of treatment are organ-based and primarily symptom management. Our systematic review of the last 4 years of treatment emphasizes known treatment strategies already in practice, but also identifies new therapeutic approaches with additional biologic agents and hematopoietic stem cell transplantation.
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Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by autoantibody production, small-vessel vasculopathy, and skin and other organ fibrosis. The disease is clinically heterogeneous with most patients having some degree of skin sclerosis with varying organ system involvement. Early disease can be difficult to diagnose, especially with minimal skin sclerosis and absence of anti-nuclear antibody (ANA) positivity; however, studies have demonstrated early diagnosis is important as early treatment could potentially lead to better outcomes. New classification criteria have recently been published that have higher sensitivity for detecting early disease thus allowing for a broader spectrum of patients to be represented in clinical trials. Treatment guidelines have been published based on a limited number of randomized-controlled clinical trials; however, there are ongoing phase II and III clinical trials with novel agents that are promising and will change the treatment landscape over the next decade.
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Affiliation(s)
- Courtney J McCray
- Division of Rheumatology and Clinical Immunogenetics, Department of Internal Medicine, University of Texas Health Science Center-Houston (UTHSC-H), 6431 Fannin St. MSB 5.278, Houston, TX, 77030, USA
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Valdeolivas-Casillas N, Medina-Montalvo MS, Polo-Rodríguez I, Ruiz-Gutiérrez L, Moruno-Cruz H, Izquierdo-Sancho C. Tratamiento con toxina botulínica del fenómeno de Raynaud severo. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.piel.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hughes M, Ong VH, Anderson ME, Hall F, Moinzadeh P, Griffiths B, Baildam E, Denton CP, Herrick AL. Consensus best practice pathway of the UK Scleroderma Study Group: digital vasculopathy in systemic sclerosis. Rheumatology (Oxford) 2015; 54:2015-24. [DOI: 10.1093/rheumatology/kev201] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 01/02/2023] Open
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Hachulla E, Hatron PY, Carpentier P, Agard C, Chatelus E, Jego P, Mouthon L, Queyrel V, Fauchais AL, Michon-Pasturel U, Jaussaud R, Mathian A, Granel B, Diot E, Farge-Bancel D, Mekinian A, Avouac J, Desmurs-Clavel H, Clerson P. Efficacy of sildenafil on ischaemic digital ulcer healing in systemic sclerosis: the placebo-controlled SEDUCE study. Ann Rheum Dis 2015; 75:1009-15. [PMID: 25995322 PMCID: PMC4893100 DOI: 10.1136/annrheumdis-2014-207001] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/23/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the effect of sildenafil, a phosphodiesterase type 5 inhibitor, on digital ulcer (DU) healing in systemic sclerosis (SSc). METHODS Randomised, placebo-controlled study in patients with SSc to assess the effect of sildenafil 20 mg or placebo, three times daily for 12 weeks, on ischaemic DU healing. The primary end point was the time to healing for each DU. Time to healing was compared between groups using Cox models for clustered data (two-sided tests, p=0.05). RESULTS Intention-to-treat analysis involved 83 patients with a total of 192 DUs (89 in the sildenafil group and 103 in the placebo group). The HR for DU healing was 1.33 (0.88 to 2.00) (p=0.18) and 1.27 (0.85 to 1.89) (p=0.25) when adjusted for the number of DUs at entry, in favour of sildenafil. In the per protocol population, the HRs were 1.49 (0.98 to 2.28) (p=0.06) and 1.43 (0.93 to 2.19) p=0.10. The mean number of DUs per patient was lower in the sildenafil group compared with the placebo group at week (W) 8 (1.23±1.61 vs 1.79±2.40 p=0.04) and W12 (0.86±1.62 vs 1.51±2.68, p=0.01) resulting from a greater healing rate (p=0.01 at W8 and p=0.03 at W12). CONCLUSIONS The primary end point was not reached in intention-to-treat, partly because of an unexpectedly high healing rate in the placebo group. We found a significant decrease in the number of DUs in favour of sildenafil compared with placebo at W8 and W12, confirming a sildenafil benefit. TRIAL REGISTRATION NUMBER NCT01295736.
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Affiliation(s)
- Eric Hachulla
- Médecine Interne, Hopital Huriez, Université de Lille, Lille, France
| | | | | | | | | | - Patrick Jego
- Médecine Interne, CHR Rennes Sud, Rennes, France
| | - Luc Mouthon
- Médecine Interne, AP-HP, Hôpital Cochin, Université Paris Descartes, Paris, France
| | | | | | | | | | - Alexis Mathian
- Médecine Interne 2, Hôpital Pitié-Salpêtrière, Paris, France
| | - Brigitte Granel
- Médecine Interne, Hôpital Nord, Aix Marseille Université, Marseille, France
| | | | | | - Arsène Mekinian
- Medicine interne and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), AP-HP, Hôpital Saint Antoine, Paris, France
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Volkmann ER, Furst DE. Management of Systemic Sclerosis-Related Skin Disease: A Review of Existing and Experimental Therapeutic Approaches. Rheum Dis Clin North Am 2015. [PMID: 26210126 DOI: 10.1016/j.rdc.2015.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The skin is the most common organ system involved in patients with systemic sclerosis (SSc). Nearly all patients experience cutaneous symptoms, including sclerosis, Raynaud's phenomenon, digital ulcers, telangiectasias, and calcinosis. In addition to posing functional challenges, cutaneous symptoms are often a major cause of pain, psychological distress, and body image dissatisfaction. The present article reviews the main features of SSc-related cutaneous manifestations and highlights an evidence-based treatment approach for treating each manifestation. This article also describes novel treatment approaches and opportunities for further research in managing this important clinical dimension of SSc.
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Affiliation(s)
- Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA.
| | - Daniel E Furst
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA
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47
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Abstract
Raynaud syndrome (RS) was first described by the French physician Maurice Raynaud in 1862 with the characteristic tricolor change featuring pallor (ischemic phase), cyanosis (deoxygenation phase), and erythema (reperfusion phase) induced by cold or stress. Although the underlying pathophysiological mechanism is unclear, alterations in activity of the peripheral adrenoceptor have been implicated, specifically an enhanced smooth muscle contraction due to overexpression or hyperactivity of postsynaptic alpha 2 receptors. There are 2 ways that RS can appear clinically; isolated, formerly referred as Raynaud disease or now primary RS and in association with other conditions, usually connective tissue disorders (eg, Sjögren syndrome, systemic lupus erythematosus, scleroderma, and rheumatoid arthritis), frequently called Raynaud phenomenon or secondary RS. The estimated prevalence in the general population is 3%-5%, with a higher prevalence in women than in men. The diagnosis is mainly clinical, based on patient descriptions of skin changes. Upper extremity pulse-volume recording is used to rule out proximal arterial obstruction. The differentiation between a vasospastic vs and obstructive mechanism is made using digital pressures and photoplethysmography, where an obstructive mechanism has decreased pressures and blunted waveforms. Cold challenge testing, such as ice water immersion with temperature recovery, is highly sensitive but lack specificity. Serologic screening (antinuclear antibody and rheumatoid factor) is advocated to rule out associated connective tissue disorders. Most patients with RS can be managed conservatively, with avoidance of cold exposure or hand warming. For those in whom conservative management is inadequate, a number of pharmacologic and surgical therapies have been used. Owing to lack of complete understanding of the underlying pathophysiology, targeted therapy has not been possible; rather, therapy has been focused on the use of general vasodilation strategies. In this review, the diagnosis, natural history, and current medical and invasive therapy are summarized.
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Affiliation(s)
| | - Gregory J Landry
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR.
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Nagaraja V, Denton CP, Khanna D. Old medications and new targeted therapies in systemic sclerosis. Rheumatology (Oxford) 2014; 54:1944-53. [PMID: 25065013 DOI: 10.1093/rheumatology/keu285] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
SSc is a multiorgan disease with significant morbidity that is associated with poor health-related quality of life. Treatment of this condition is often organ based and non-curative. However, there are newer, potentially disease-modifying therapies available to treat certain aspects of the disease. This review focuses on old and new therapies in the management of SSc in clinical practice.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA and
| | | | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA and
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Roustit M, Khouri C, Blaise S, Villier C, Carpentier P, Cracowski JL. Pharmacologie du phénomène de Raynaud. Therapie 2014; 69:115-28. [DOI: 10.2515/therapie/2013068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/19/2013] [Indexed: 11/20/2022]
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50
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Hughes M, Herrick AL. Treatment options in Raynaud's phenomenon. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.883314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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