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Batko B, Jeka S, Wiland P, Zielińska A, Stopińska-Polaszewska M, Stajszczyk M, Kosydar-Piechna M, Cadatal MJ, Rivas JL. Geographical Differences in the Safety and Efficacy of Tofacitinib Versus TNFi: A Post Hoc Analysis of ORAL Surveillance. Rheumatol Ther 2024:10.1007/s40744-024-00693-y. [PMID: 39060905 DOI: 10.1007/s40744-024-00693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/14/2024] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION In ORAL Surveillance, incidence rates (IRs) of major adverse cardiovascular events (MACE) and malignancies (excluding non-melanoma skin cancer [NMSC]) in cardiovascular (CV)-risk-enriched patients with rheumatoid arthritis (RA) were numerically greater with tofacitinib in North America versus the rest of the world, due to underlying risk factors. Here, we evaluated the safety and efficacy of tofacitinib versus tumor necrosis factor inhibitors (TNFi) among patients with RA across geographical regions. METHODS Patients with RA in ORAL Surveillance (NCT02092467), who were aged ≥ 50 years with ≥ 1 additional CV risk factor, received tofacitinib 5 or 10 mg twice daily or TNFi; 45.9% were from either Poland or North America. This post hoc analysis stratified patients by region (Poland, North America, Other countries). Efficacy endpoints included Clinical Disease Activity Index, Disease Activity Score in 28 joints, with C-reactive protein (DAS28-4[CRP]), and Health Assessment Questionnaire-Disability Index (HAQ-DI). IRs and hazard ratios for adverse events were reported. RESULTS Of 4362 patients (Poland, N = 759; North America, N = 1243; Other countries, N = 2360), more patients from North America versus Poland/Other countries had CV risk factors such as body mass index ≥ 30 kg/m2 and history of diabetes/hypertension; however, more patients from Poland versus other regions were ever smokers and more patients from Poland/North America versus Other countries had history of coronary artery disease. MACE IRs were similar in North America and Poland, and numerically higher versus Other countries. IRs for malignancies (excluding NMSC) were numerically higher in North America versus Poland/Other countries with tofacitinib. Serious infections IRs were numerically higher in North America versus Poland across treatments. Venous thromboembolism/all-cause mortality IRs were generally comparable across regions. DAS28-4(CRP)/HAQ-DI improvements were generally lowest in North America. CONCLUSIONS Differences in safety outcomes were driven by the presence of baseline risk factors; North America and Poland demonstrated a higher proportion of patients with some baseline CV risk factors/comorbidities versus Other countries. TRIAL REGISTRATION NCT02092467 (ClinicalTrials.gov).
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Affiliation(s)
- Bogdan Batko
- Department of Rheumatology and Immunology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudzińskiego 1, 30-705, Kraków, Poland.
| | - Slawomir Jeka
- Clinic and Department of Rheumatology and Connective Tissue Diseases, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | | | - Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Disease, Silesian Center for Rheumatology, Orthopedics and Rehabilitation, Ustroń, Poland
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Godbole S, Solomon JL, Johnson M, Srivastava A, Carsons SE, Belilos E, De Leon J, Reiss AB. Treating Cardiovascular Disease in the Inflammatory Setting of Rheumatoid Arthritis: An Ongoing Challenge. Biomedicines 2024; 12:1608. [PMID: 39062180 PMCID: PMC11275112 DOI: 10.3390/biomedicines12071608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/30/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Despite progress in treating rheumatoid arthritis, this autoimmune disorder confers an increased risk of developing cardiovascular disease (CVD). Widely used screening protocols and current clinical guidelines are inadequate for the early detection of CVD in persons with rheumatoid arthritis. Traditional CVD risk factors alone cannot be applied because they underestimate CVD risk in rheumatoid arthritis, missing the window of opportunity for prompt intervention to decrease morbidity and mortality. The lipid profile is insufficient to assess CVD risk. This review delves into the connection between systemic inflammation in rheumatoid arthritis and the premature onset of CVD. The shared inflammatory and immunologic pathways between the two diseases that result in subclinical atherosclerosis and disrupted cholesterol homeostasis are examined. The treatment armamentarium for rheumatoid arthritis is summarized, with a particular focus on each medication's cardiovascular effect, as well as the mechanism of action, risk-benefit profile, safety, and cost. A clinical approach to CVD screening and treatment for rheumatoid arthritis patients is proposed based on the available evidence. The mortality gap between rheumatoid arthritis and non-rheumatoid arthritis populations due to premature CVD represents an urgent research need in the fields of cardiology and rheumatology. Future research areas, including risk assessment tools and novel immunotherapeutic targets, are highlighted.
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Affiliation(s)
| | | | | | | | | | | | | | - Allison B. Reiss
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (S.G.); (J.L.S.); (M.J.); (A.S.); (S.E.C.); (E.B.); (J.D.L.)
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Ma XN, Shi MF, Wang SI, Feng W, Chen SL, Zhong XQ, Liu QP, Cheng-Chung Wei J, Lin CS, Xu Q. Risk of dyslipidemia and major adverse cardiac events with tofacitinib versus adalimumab in rheumatoid arthritis: a real-world cohort study from 7580 patients. Front Pharmacol 2024; 15:1370661. [PMID: 38881871 PMCID: PMC11177090 DOI: 10.3389/fphar.2024.1370661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/13/2024] [Indexed: 06/18/2024] Open
Abstract
Objective To compare the effects of tofacitinib and adalimumab on the risk of adverse lipidaemia outcomes in patients with newly diagnosed rheumatoid arthritis (RA). Methods Data of adult patients newly diagnosed with RA who were treated with tofacitinib or adalimumab at least twice during a 3-year period from 1 January 2018 to 31 December 2020, were enrolled in the TriNetX US Collaborative Network. Patient demographics, comorbidities, medications, and laboratory data were matched by propensity score at baseline. Outcome measurements include incidental risk of dyslipidemia, major adverse cardiac events (MACE) and all-cause mortality. Results A total of 7,580 newly diagnosed patients with RA (1998 receiving tofacitinib, 5,582 receiving adalimumab) were screened. After propensity score matching, the risk of dyslipidaemia outcomes were higher in the tofacitinib cohort, compared with adalimumab cohort (hazard ratio [HR] with 95% confidence interval [CI], 1.250 [1.076-1.453]). However, there is no statistically significant differences between two cohorts on MACE (HR, 0.995 [0.760-1.303]) and all-cause mortality (HR, 1.402 [0.887-2.215]). Conclusion Tofacitinib use in patients with RA may increase the risk of dyslipidaemia to some extent compared to adalimumab. However, there is no differences on MACE and all-cause mortality.
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Affiliation(s)
- Xiao-Na Ma
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mei-Feng Shi
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shiow-Ing Wang
- Center for Health Data Science, Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wei Feng
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shu-Lin Chen
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiao-Qin Zhong
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qing-Ping Liu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Nursing, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
- Office of Research and Development, Asia University, Taichung, Taiwan
| | - Chang-Song Lin
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang Xu
- State Key Laboratory of Traditional Chinese Medicine Syndrome, The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Muñoz-Barrera L, Perez-Sanchez C, Ortega-Castro R, Corrales S, Luque-Tevar M, Cerdó T, Sanchez-Pareja I, Font P, Lopez-Mejías R, Calvo J, Abalos-Aguilera MC, Ruiz-Vilchez D, Segui P, Merlo C, Perez-Venegas J, Ruiz Montesino MD, Rodriguez-Escalera C, Barco CR, Fernandez-Nebro A, Vazque NM, Marenco JL, Montañes JU, Godoy-Navarrete J, Cabezas-Lucena AM, Estevez EC, Aguirre MA, González-Gay MA, Barbarroja N, Escudero-Contreras A, Lopez-Pedrera C. Personalized cardiovascular risk assessment in Rheumatoid Arthritis patients using circulating molecular profiles and their modulation by TNFi, IL6Ri, and JAKinibs. Biomed Pharmacother 2024; 173:116357. [PMID: 38479179 DOI: 10.1016/j.biopha.2024.116357] [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: 10/15/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND & OBJECTIVES This study aimed to: 1) analyze the inflammatory profile of Rheumatoid Arthritis (RA) patients, identifying clinical phenotypes associated with cardiovascular (CV) risk; 2) evaluate biologic and targeted-synthetic disease-modifying antirheumatic drugs (b-DMARDs and ts-DMARDs': TNFi, IL6Ri, JAKinibs) effects; and 3) characterize molecular mechanisms in immune-cell activation and endothelial dysfunction. PATIENTS & METHODS A total of 387 RA patients and 45 healthy donors were recruited, forming three cohorts: i) 208 RA patients with established disease but without previous CV events; ii) RA-CVD: 96 RA patients with CV events, and iii) 83 RA patients treated with b-DMARDs/ts-DMARDs for 6 months. Serum inflammatory profiles (cytokines/chemokines/growth factors) and NETosis/oxidative stress-linked biomolecules were evaluated. Mechanistic in vitro studies were performed on monocytes, neutrophils and endothelial cells (EC). RESULTS In the first RA-cohort, unsupervised clustering unveiled three distinct groups: cluster 3 (C3) displayed the highest inflammatory profile, significant CV-risk score, and greater atheroma plaques prevalence. In contrast, cluster 1 (C1) exhibited the lowest inflammatory profile and CV risk score, while cluster 2 (C2) displayed an intermediate phenotype. Notably, 2nd cohort RA-CVD patients mirrored C3's inflammation. Treatment with b-DMARDs or ts-DMARDs effectively reduced disease-activity scores (DAS28) and restored normal biomolecules levels, controlling CV risk. In vitro, serum from C3-RA or RA-CVD patients increased neutrophils activity and CV-related protein levels in cultured monocytes and EC, which were partially prevented by pre-incubation with TNFi, IL6Ri, and JAKinibs. CONCLUSIONS Overall, analyzing circulating molecular profiles in RA patients holds potential for personalized clinical management, addressing CV risk and assisting healthcare professionals in tailoring treatment, ultimately improving outcomes.
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Affiliation(s)
- Laura Muñoz-Barrera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Carlos Perez-Sanchez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Rafaela Ortega-Castro
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Sagrario Corrales
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Maria Luque-Tevar
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Tomás Cerdó
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Ismael Sanchez-Pareja
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Pilar Font
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Raquel Lopez-Mejías
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, IDIVAL, Santander, Spain
| | - Jerusalem Calvo
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - M Carmen Abalos-Aguilera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Desiree Ruiz-Vilchez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Pedro Segui
- Radiology Service, Reina Sofia Hospital/Maimonides Institute for Research in Biomedicine of Cordoba/University of Cordoba, Spain
| | - Christian Merlo
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | | | | | | | | | | | | | | | | | | | | | - Eduardo Collantes Estevez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Ma Angeles Aguirre
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | | | - Nuria Barbarroja
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Alejandro Escudero-Contreras
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Chary Lopez-Pedrera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain.
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Sanghavi N, Ingrassia JP, Korem S, Ash J, Pan S, Wasserman A. Cardiovascular Manifestations in Rheumatoid Arthritis. Cardiol Rev 2024; 32:146-152. [PMID: 36729119 DOI: 10.1097/crd.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disorder that characteristically affects the joints. RA has extra-articular manifestations that can impact multiple organ systems including the heart, lungs, eyes, skin, and brain. Cardiovascular involvement is a leading cause of mortality in RA. Cardiovascular manifestations of RA include accelerated atherosclerosis, heart failure, pericarditis, myocarditis, endocarditis, rheumatoid nodules, and amyloidosis. Inflammation is an important mediator of endothelial dysfunction and is a key driver of cardiovascular risk and complications in patients with RA. Prompt identification of cardiac pathologies in patients with RA is essential for appropriate management and treatment. Choosing the most appropriate treatment regimen is based on individual patient factors. In this article, we provide a comprehensive review of the epidemiology, pathophysiology, clinical manifestations, diagnosis, and medical management of cardiovascular manifestations of RA. We also discuss the relationship between anti-rheumatic medications, specifically non-steroidal anti-inflammatory drugs, corticosteroids, methotrexate, statins, tumor necrosis factor inhibitors, interleukin-6 inhibitors, Janus kinase inhibitors, and cardiovascular disease.
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Affiliation(s)
- Nirali Sanghavi
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | | | - Sindhuja Korem
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Julia Ash
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Amy Wasserman
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
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Szekanecz Z, Buch MH, Charles-Schoeman C, Galloway J, Karpouzas GA, Kristensen LE, Ytterberg SR, Hamar A, Fleischmann R. Efficacy and safety of JAK inhibitors in rheumatoid arthritis: update for the practising clinician. Nat Rev Rheumatol 2024; 20:101-115. [PMID: 38216757 DOI: 10.1038/s41584-023-01062-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/14/2024]
Abstract
Janus kinase (JAK) inhibitors, including tofacitinib, baricitinib, upadacitinib and filgotinib, are increasingly used in the treatment of rheumatoid arthritis (RA). There has been debate about their safety, particularly following the issuance of guidance by regulatory agencies advising caution in their use in certain patients. The registrational clinical trials and registry data of JAK inhibitors did not identify a difference in the risk of major adverse cardiovascular events (MACEs), venous thromboembolism, malignancies or infections (other than herpes zoster) with a JAK inhibitor versus a biologic DMARD. In the ORAL Surveillance trial, which enrolled patients >50 years of age with ≥1 cardiovascular risk factor, tofacitinib was statistically inferior to TNF inhibitors for the occurrence of MACEs and malignancy. Further post hoc analysis of the data revealed that an age of ≥65 years, a high baseline cardiovascular risk, a history of smoking, sustained inflammation, disease activity and suboptimal treatment of cardiovascular comorbidities all increase the risk of these outcomes. The guidance issued by regulatory agencies should be carefully considered to ensure appropriate and safe treatment of patients with RA without undertreatment of patients who might benefit from JAK inhibitor, as well as biologic, treatment. As always, the risks associated with the use of these agents, treatment goals, costs and patient preferences should be discussed with the patient.
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Affiliation(s)
- Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Christina Charles-Schoeman
- Division of Rheumatology, Department of Medicine, Harbour-University of California Los Angeles Medical Centre, Los Angeles, CA, USA
| | - James Galloway
- Department of Inflammation Biology and Centre for Rheumatic Diseases, King's College London, London, UK
| | - George A Karpouzas
- Division of Rheumatology, Department of Medicine, Harbour-University of California Los Angeles Medical Centre, Los Angeles, CA, USA
| | - Lars Erik Kristensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Attila Hamar
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roy Fleischmann
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, TX, USA
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7
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Alduraibi FK, Singh JA. How to Use Janus Kinase Inhibitors in the Treatment of Rheumatoid Arthritis? A Clinical Assessment of Risks and Benefits. Curr Rheumatol Rep 2023; 25:295-306. [PMID: 38102522 DOI: 10.1007/s11926-023-01122-9] [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] [Accepted: 11/04/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE OF REVIEW To provide an updated understanding of risks and benefits of Janus kinase inhibitors (JAKi) versus biologic disease-modifying antirheumatic drugs (bDMARDs) in the management of rheumatoid arthritis (RA). RECENT FINDINGS Shared decision-making is needed in choosing between JAKi and bDMARDs. Cardiovascular disease, malignancy, and thromboembolic events guide this choice. In patients with active RA despite methotrexate use, tumor necrosis factor inhibitor is conditionally favored over JAKi for low-cardiovascular-risk patients and strongly favored in those with pre-existing cardiovascular disease or multiple cardiovascular risk factors. Suboptimal treatment of treatment-refractory RA patients may pose a greater absolute cardiovascular risk than with JAKi use. Use of aspirin and statin may be considered to reduce cardiovascular risk. New safety data on JAKi has redefined the treatment approach in RA. JAKi remains an important oral medication option in active RA despite treatment with bDMARDs, especially in those with low cardiovascular risk.
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Affiliation(s)
- Fatima K Alduraibi
- Division of Clinical Immunology and Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Clinical Immunology and Rheumatology, Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, Department of Medicine, Musculoskeletal Outcomes Research, University of Alabama at Birmingham, Birmingham, AL, USA.
- Birmingham Veterans Affairs Medical, Birmingham, AL, USA.
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Yang V, Kragstrup TW, McMaster C, Reid P, Singh N, Haysen SR, Robinson PC, Liew DFL. Managing Cardiovascular and Cancer Risk Associated with JAK Inhibitors. Drug Saf 2023; 46:1049-1071. [PMID: 37490213 PMCID: PMC10632271 DOI: 10.1007/s40264-023-01333-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/26/2023]
Abstract
Janus kinase inhibitors (JAKi) have enormous appeal as immune-modulating therapies across many chronic inflammatory diseases, but recently this promise has been overshadowed by questions regarding associated cardiovascular and cancer risk emerging from the ORAL Surveillance phase 3b/4 post-marketing requirement randomized controlled trial. In that study of patients with rheumatoid arthritis with existing cardiovascular risk, tofacitinib, the first JAKi registered for chronic inflammatory disease, failed to meet non-inferiority thresholds when compared with tumor necrosis factor inhibitors for both incident major adverse cardiovascular events and incident cancer. While this result was unexpected by many, subsequently published observational data have also supported this finding. Notably, however, such a risk has largely not yet been demonstrated in patients outside the specific clinical situation examined in the trial, even in the face of many studies examining this. Nevertheless, this signal has practically re-aligned approaches to both tofacitinib and other JAKi to varying extents, in other patient populations and contexts: within rheumatoid arthritis, but also in psoriatic arthritis, axial spondyloarthritis, inflammatory bowel disease, atopic dermatitis, and beyond. Application to individual patients can be more challenging but remains important to harness the substantive potential of JAKi to the maximum extent safely possible. This review not only explores the evolution of the regulatory response to the signal, its informing data, biological plausibility, and its impact on guidelines, but also the many factors that clinicians must consider in navigating cardiovascular and cancer risk for their patients considering JAKi as immune-modulating therapy.
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Affiliation(s)
- Victor Yang
- Department of Rheumatology, Level 1, North Wing, Heidelberg Repatriation Hospital, Austin Health, 300 Waterdale Road, PO Box 5444, Heidelberg West, VIC, 3081, Australia
| | - Tue W Kragstrup
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Sector for Rheumatology, Diagnostic Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Christopher McMaster
- Department of Rheumatology, Level 1, North Wing, Heidelberg Repatriation Hospital, Austin Health, 300 Waterdale Road, PO Box 5444, Heidelberg West, VIC, 3081, Australia
- Department of Clinical Pharmacology and Therapeutics, Austin Health, Melbourne, VIC, Australia
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, VIC, Australia
| | - Pankti Reid
- Division of Rheumatology and Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago Biological Sciences Division, Chicago, IL, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Stine R Haysen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Philip C Robinson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, QLD, Australia
| | - David F L Liew
- Department of Rheumatology, Level 1, North Wing, Heidelberg Repatriation Hospital, Austin Health, 300 Waterdale Road, PO Box 5444, Heidelberg West, VIC, 3081, Australia.
- Department of Clinical Pharmacology and Therapeutics, Austin Health, Melbourne, VIC, Australia.
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
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9
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Gerganov G, Georgiev T, Dimova M, Shivacheva T. Vascular effects of biologic and targeted synthetic antirheumatic drugs approved for rheumatoid arthritis: a systematic review. Clin Rheumatol 2023; 42:2651-2676. [PMID: 36991244 DOI: 10.1007/s10067-023-06587-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) increases the risk of cardiovascular disease (CVD), with inflammation playing a key role. Biologic and targeted synthetic drugs used to treat RA can induce systemic immunomodulation and may have pleiotropic effects on vascular function, making it crucial to investigate their impact on CVD risk in RA patients. METHODS A systematic review of the literature was conducted to investigate the impact of biologic and targeted synthetic treatments approved for RA on various cardiovascular markers, including endothelial function, arterial stiffness, and subclinical atherosclerosis. Our analysis included a search of the MedLine (via PubMed) and Web of Science databases using a pre-determined search strategy. We conducted a narrative synthesis of the included studies due to heterogeneity in study design and outcome measures. RESULTS From an initial pool of 647 records, we excluded 327 studies based on their titles and abstracts, and we selected 182 studies for final examination. Ultimately, 58 articles met our inclusion criteria and were included in our systematic review. Our analysis of these studies revealed a positive effect of biologic and targeted synthetic therapies on vascular dysfunction associated with RA. However, the impact of these treatments on subclinical atherosclerosis was inconsistent. CONCLUSION Overall, our systematic review provides important insights into the potential cardiovascular benefits of biologic and targeted synthetic treatments for RA by a still unknown mechanism. These findings can inform clinical practice and contribute to our understanding of their possible effects on early vascular pathology. Key Points • Great heterogeneity of methods are used to evaluate the endothelial function and arterial stiffness in patients with RA on biologic and targeted synthetic antirheumatic drugs. • Most studies have shown a considerable improvement in endothelial function and arterial stiffness with TNFi, despite some studies reporting only transient or no improvement. • Anakinra and tocilizumab may have a beneficial effect on vascular function and endothelial injury, as indicated by increased FMD, coronary flow reserve, and reduced levels of biomarkers of endothelial function, while the overall impact of JAKi and rituximab remains inconclusive based on the reviewed studies. • To fully comprehend the distinctions between biologic therapies, more long-term, well-designed clinical trials are necessary using a homogeneous methodology.
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Affiliation(s)
- Georgi Gerganov
- Department of Propedeutics of Internal Medicine, Faculty of Medicine, Medical University - Varna, 9002, Varna, Bulgaria
- Clinic of Rheumatology, University Hospital St. Marina - Varna, 9010, Varna, Bulgaria
| | - Tsvetoslav Georgiev
- Clinic of Rheumatology, University Hospital St. Marina - Varna, 9010, Varna, Bulgaria.
- First Department of Internal Medicine, Faculty of Medicine, Medical University - Varna, 9002, Varna, Bulgaria.
| | - Maria Dimova
- Department of Propedeutics of Internal Medicine, Faculty of Medicine, Medical University - Varna, 9002, Varna, Bulgaria
- Clinic of Internal Medicine, University Hospital St. Marina - Varna, 9010, Varna, Bulgaria
| | - Tanya Shivacheva
- Clinic of Rheumatology, University Hospital St. Marina - Varna, 9010, Varna, Bulgaria
- First Department of Internal Medicine, Faculty of Medicine, Medical University - Varna, 9002, Varna, Bulgaria
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10
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Tong X, Shen CY, Jeon HL, Li Y, Shin JY, Chan SC, Yiu KH, Pratt NL, Ward M, Lau CS, Wong IC, Li X, Lai ECC. Cardiovascular risk in rheumatoid arthritis patients treated with targeted synthetic and biological disease-modifying antirheumatic drugs: A multi-centre cohort study. J Intern Med 2023; 294:314-325. [PMID: 37282790 DOI: 10.1111/joim.13681] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND This study aimed to compare the cardiovascular safety of interleukin-6 inhibitors (IL-6i) and Janus Kinase inhibitors (JAKi) to tumour necrosis factor inhibitors (TNFi). METHODS We conducted a retrospective cohort study using population-based electronic databases from Hong Kong, Taiwan and Korea. We identified newly diagnosed patients with rheumatoid arthritis (RA) who received b/tsDMARDs first time. We followed patients from b/tsDMARD initiation to the earliest outcome (acute coronary heart disease, stroke, heart failure, venous thromboembolism and systemic embolism) or censoring events (death, transformation of b/tsDMARDs on different targets, discontinuation and study end). Using TNFi as reference, we applied generalized linear regression for the incidence rate ratio estimation adjusted by age, sex, disease duration and comorbidities. Random effects meta-analysis was used for pooled analysis. RESULTS We identified 8689 participants for this study. Median (interquartile range) follow-up years were 1.45 (2.77) in Hong Kong, 1.72 (2.39) in Taiwan and 1.45 (2.46) in Korea. Compared to TNFi, the adjusted incidence rate ratios (aIRRs) (95% confidence interval [CI]) of IL-6i in Hong Kong, Taiwan and Korea are 0.99 (0.25, 3.95), 1.06 (0.57, 1.98) and 1.05 (0.59, 1.86) and corresponding aIRR of JAKi are 1.50 (0.42, 5.41), 0.60 (0.26, 1.41), and 0.81 (0.38, 1.74), respectively. Pooled aIRRs showed no significant risk of cardiovascular events (CVEs) associated with IL-6i (1.05 [0.70, 1.57]) nor JAKi (0.80 [0.48, 1.35]) compared to TNFi. CONCLUSION There was no difference in the risk of CVE among RA patients initiated with IL-6i, or JAKi compared to TNFi. The finding is consistent in Hong Kong, Taiwan and Korea.
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Affiliation(s)
- Xinning Tong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Orthopaedics, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Chin-Yao Shen
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ha-Lim Jeon
- School of Pharmacy, Jeonbuk National University, Jeonju, South Korea
| | - Yihua Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Seoul, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Seoul, South Korea
| | - Shirley Cw Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kai Hang Yiu
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Michael Ward
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Chak Sing Lau
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Ck Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Aston School of Pharmacy, Aston University, Birmingham, UK
| | - Xue Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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11
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Adorni MP, Papotti B, Borghi MO, Raschi E, Zimetti F, Bernini F, Meroni PL, Ronda N. Effect of the JAK/STAT Inhibitor Tofacitinib on Macrophage Cholesterol Metabolism. Int J Mol Sci 2023; 24:12571. [PMID: 37628747 PMCID: PMC10454555 DOI: 10.3390/ijms241612571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
The impact of JAK/STAT inhibitors, which are used in various inflammatory diseases, on cardiovascular risk is controversial and has recently raised safety concerns. Our study investigates the direct effects of tofacitinib on macrophage cholesterol metabolism, which is crucial for atherosclerosis plaque development and stability. Cultured human macrophages THP-1 were used to assess the impact of tofacitinib on cell cholesterol efflux and synthesis via radioisotopic methods, and on cholesterol uptake by measuring the cell cholesterol content with a fluorometric assay. The cholesterol acceptors and donors were either standard lipoproteins or sera from patients with juvenile idiopathic arthritis (JIA) and from control subjects. Tofacitinib significantly increased the macrophage cholesterol efflux to all acceptors; it reduced cholesterol uptake from both the normal and hypercholesterolemic sera; and it reduced cholesterol synthesis. The treatment of macrophages with tofacitinib was able to increase the cholesterol efflux and decrease cholesterol uptake when using sera from untreated JIA patients with active disease as cholesterol acceptors and donors, respectively. In conclusion, our in vitro data support the concept that tofacitinib has a favorable impact on macrophage cholesterol metabolism, even in the presence of sera from rheumatologic patients, and suggest that other mechanisms may be responsible for the cardiovascular risk associated with tofacitinib use in selected patient populations.
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Affiliation(s)
- Maria Pia Adorni
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, Via Volturno 39/F, 43125 Parma, Italy;
| | - Bianca Papotti
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy; (B.P.); (F.Z.); (F.B.)
| | - Maria Orietta Borghi
- Experimental Laboratory of Immuno-Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Via Zucchi 18, 20095 Milan, Italy; (M.O.B.); (E.R.); (P.L.M.)
| | - Elena Raschi
- Experimental Laboratory of Immuno-Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Via Zucchi 18, 20095 Milan, Italy; (M.O.B.); (E.R.); (P.L.M.)
| | - Francesca Zimetti
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy; (B.P.); (F.Z.); (F.B.)
| | - Franco Bernini
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy; (B.P.); (F.Z.); (F.B.)
| | - Pier Luigi Meroni
- Experimental Laboratory of Immuno-Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Via Zucchi 18, 20095 Milan, Italy; (M.O.B.); (E.R.); (P.L.M.)
| | - Nicoletta Ronda
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy; (B.P.); (F.Z.); (F.B.)
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12
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Faquetti ML, Vallejo-Yagüe E, Cordtz R, Dreyer L, Burden AM. JAK-inhibitors and risk on serious viral infection, venous thromboembolism and cardiac events in patients with rheumatoid arthritis: A protocol for a prevalent new-user cohort study using the Danish nationwide DANBIO register. PLoS One 2023; 18:e0288757. [PMID: 37498856 PMCID: PMC10374052 DOI: 10.1371/journal.pone.0288757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
Janus Kinase inhibitors (JAKis) are targeted synthetic disease-modifying antirheumatic drugs and represent an important alternative to treat patients with moderate to high rheumatoid arthritis (RA) disease activity. Safety concerns associated with increased risk for venous thromboembolism (VTE), serious viral infection, and, more recently, major adverse cardiovascular events (MACE) in JAKi users have emerged worldwide. However, as the exact mechanisms to explain these safety concerns remain unclear, the increased risk of VTE, MACE, and serious viral infection in JAKi users is heavily debated. In light of the need to enrich the safety profile of JAKis in real-world data, we aim to quantify the incidence and risk of MACE, VTE, and serious viral infections in RA patients registered in the Danish DANBIO registry, a nationwide registry of biological therapies used in rheumatology. Therefore, we will conduct a population-based cohort study using a prevalent new-user design. We will identify all RA patients in the DANBIO, ≥ 18 years old, receiving a JAKi or a tumor necrosis factor α inhibitor (TNF-αi) from January 2017 to December 2022. Prevalent and new users of JAKis will be matched to TNF-αi comparators with similar exposure history using time-conditional propensity scores (TCPS). We will describe the cumulative incidence of the outcomes (VTE, MACE, serious viral infection) in each exposure group (JAKi users; TNF-αi users), stratified by outcome type. Additionally, the Aalen-Johansen method will be used to estimate the time-to-event survival function stratified by outcome type. We will also estimate the hazard ratio (HR) with 95% confidence interval (CI) of each outcome in both exposure groups using the time-dependent Cox proportional hazards model. Results will enrich the safety profile of JAKis in real-world data.
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Affiliation(s)
| | - Enriqueta Vallejo-Yagüe
- Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - René Cordtz
- Center of Rheumatic Research Aalborg, (CERRA), Aalborg University Hospital, Aalborg, Denmark
- DANBIO Register, Aalborg, Denmark
| | - Lene Dreyer
- Center of Rheumatic Research Aalborg, (CERRA), Aalborg University Hospital, Aalborg, Denmark
- DANBIO Register, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Andrea M Burden
- Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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13
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Weber BN, Giles JT, Liao KP. Shared inflammatory pathways of rheumatoid arthritis and atherosclerotic cardiovascular disease. Nat Rev Rheumatol 2023; 19:417-428. [PMID: 37231248 PMCID: PMC10330911 DOI: 10.1038/s41584-023-00969-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/27/2023]
Abstract
The association between chronic inflammation and increased risk of cardiovascular disease in rheumatoid arthritis (RA) is well established. In the general population, inflammation is an established independent risk factor for cardiovascular disease, and much interest is placed on controlling inflammation to reduce cardiovascular events. As inflammation encompasses numerous pathways, the development of targeted therapies in RA provides an opportunity to understand the downstream effect of inhibiting specific pathways on cardiovascular risk. Data from these studies can inform cardiovascular risk management in patients with RA, and in the general population. This Review focuses on pro-inflammatory pathways targeted by existing therapies in RA and with mechanistic data from the general population on cardiovascular risk. Specifically, the discussions include the IL-1, IL-6 and TNF pathways, as well as the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signalling pathway, and the role of these pathways in RA pathogenesis in the joint alongside the development of atherosclerotic cardiovascular disease. Overall, some robust data support inhibition of IL-1 and IL-6 in decreasing the risk of cardiovascular disease, with growing data supporting IL-6 inhibition in both patients with RA and the general population to reduce the risk of cardiovascular disease.
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Affiliation(s)
- Brittany N Weber
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jon T Giles
- Columbia University, Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Katherine P Liao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
- Rheumatology Section, VA Boston Medical Center, Boston, MA, USA.
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14
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Vosko I, Zirlik A, Bugger H. Impact of COVID-19 on Cardiovascular Disease. Viruses 2023; 15:508. [PMID: 36851722 PMCID: PMC9962056 DOI: 10.3390/v15020508] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral infection with the novel severe acute respiratory distress syndrome corona virus 2 (SARS-CoV-2). Until now, more than 670 million people have suffered from COVID-19 worldwide, and roughly 7 million death cases were attributed to COVID-19. Recent evidence suggests an interplay between COVID-19 and cardiovascular disease (CVD). COVID-19 may serve as a yet underappreciated CVD risk modifier, including risk factors such as diabetes mellitus or arterial hypertension. In addition, recent data suggest that previous COVID-19 may increase the risk for many entities of CVD to an extent similarly observed for traditional cardiovascular (CV) risk factors. Furthermore, increased CVD incidence and worse clinical outcomes in individuals with preexisting CVD have been observed for myocarditis, acute coronary syndrome, heart failure (HF), thromboembolic complications, and arrhythmias. Direct and indirect mechanisms have been proposed by which COVID-19 may impact CVD and CV risk, including viral entry into CV tissue or by the induction of a massive systemic inflammatory response. In the current review, we provide an overview of the literature reporting an interaction between COVID-19 and CVD, review potential mechanisms underlying this interaction, and discuss preventive and treatment strategies and their interference with CVD that were evaluated since the onset of the COVID-19 pandemic.
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Affiliation(s)
| | | | - Heiko Bugger
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria
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15
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Misra DP, Pande G, Agarwal V. Cardiovascular risks associated with Janus kinase inhibitors: peering outside the black box. Clin Rheumatol 2023; 42:621-632. [PMID: 36264400 DOI: 10.1007/s10067-022-06415-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 01/29/2023]
Abstract
Considerable controversy related to the cardiovascular safety of Janus kinase inhibitors (JAKinibs) has arisen following the results of the ORAL Surveillance trial. In this trial of rheumatoid arthritis (RA) ≥ 50 years with at least one prevalent cardiovascular disease (CVD) risk factor, tofacitinib was not found to be non-inferior to tumour necrosis factor-alpha inhibitors (TNFi) with regards to the risk for major adverse cardiovascular events (MACE), venous thromboembolism (VTE) or malignancy. Following the results of ORAL Surveillance, the United States Food and Drug Administration (US FDA) issued a boxed warning regarding increased risks of MACE, VTE and malignancy with tofacitinib, baricitinib or upadacitinib in inflammatory arthritis or ulcerative colitis. Analysis of data from other trials (including long-term follow-up studies) of tofacitinib in RA, psoriasis, psoriatic arthritis, spondyloarthritis and inflammatory bowel diseases suggests an overall similar risk of MACE or VTE with tofacitinib when compared with TNFi. In specific patient populations with risk factors for or prior history of MACE or VTE, the risk of subsequent MACE or VTE with tofacitinib use is considerably heightened. Post-hoc analyses from ORAL Surveillance presented at the recent EULAR meeting further help to delineate patients with RA at increased risk of MACE/VTE with tofacitinib. Based on the available literature from trials and long-term follow-up studies of baricitinib and upadacitinib, there exists insufficient evidence to extend the warning of MACE/VTE with tofacitinib to these drugs. Ongoing post-marketing surveillance studies of JAKinibs in immune-mediated inflammatory diseases should help clarify CVD risk with JAKinibs.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India.
| | - Gaurav Pande
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, India
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Soós B, Hamar A, Pusztai A, Czókolyová M, Végh E, Szamosi S, Pethő Z, Gulyás K, Kerekes G, Szántó S, Szűcs G, Christians U, Klawitter J, Seres T, Szekanecz Z. Effects of tofacitinib therapy on arginine and methionine metabolites in association with vascular pathophysiology in rheumatoid arthritis: A metabolomic approach. Front Med (Lausanne) 2022; 9:1011734. [PMID: 36438060 PMCID: PMC9684209 DOI: 10.3389/fmed.2022.1011734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Rheumatoid arthritis (RA) has been associated with changes in lipid, arginine and NO metabolism with increased cardiovascular (CV) risk. The aim of this study is to evaluate the effect of tofacitinib, a Janus kinase (JAK) inhibitor, on arginine and methionine metabolism in correlation with inflammation, functional and pathological vascular changes during one-year treatment of patients with RA. Materials and methods Thirty RA patients with active disease were treated with either 5 mg bid or 10 mg bid tofacitinib for 12 months. We determined DAS28, CRP, IgM rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) levels. We assessed brachial artery flow-mediated vasodilation (FMD), carotid intima-media thickness (IMT) and pulse-wave velocity (PWV) by ultrasound at baseline and after 6 and 12 months. We also determined plasma L-arginine, L-citrulline, L-ornithine, inducible nitric oxide synthase (iNOS), asymmetric (ADMA) and symmetric dimethylarginine (SDMA), L-N-monomethyl-arginine (L-NMMA), cysteine, homocysteine, and methionine levels at these time points. Results Twenty-six patients (13 on each arm) completed the study. CRP, ESR and DAS28 decreased significantly during one-year treatment with tofacitinib. Arginine and ADMA showed a negative univariate correlation with CRP but not with FMD, PWV or IMT. Tofacitinib at 10 mg bid significantly increased L-arginine, L-ornithine, iNOS and methionine levels after 12 months. ADMA and SDMA levels did not change in our study. Methionine showed negative correlation with FMD at baseline and positive correlation with PWV after 12 months. No change was observed in FMD and PWV but a significant increase was measured in IMT at 6 and 12 months. Multivariate analysis indicated variable correlations of L-arginine, L-citrulline, ADMA, L-NMMA, homocysteine and methionine with DAS28, CRP, ESR and RF but not with anti-CCP after one-year treatment. With respect to vascular pathophysiology, only PWV and methionine correlated with each other. Conclusion One-year tofacitinib treatment suppressed systemic inflammation and improved functional status in RA. FMD, PWV have not been affected by one-year tofacitinib treatment., while IMT increased further despite treatment. Increased arginine and methionine might contribute to the anti-inflammatory effects of tofacitinib. Increased arginine availability with no changing ADMA may protect FMD and PWV from deterioration. The increase of IMT in the anti-inflammatory environment cannot be explained by arginine or methionine metabolism in this study.
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Affiliation(s)
- Boglárka Soós
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Attila Hamar
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anita Pusztai
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Monika Czókolyová
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Edit Végh
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsófia Pethő
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Gulyás
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - György Kerekes
- Intensive Care Unit, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Sándor Szántó
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Sports Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tamás Seres
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- *Correspondence: Zoltán Szekanecz,
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Effects of One-Year Tofacitinib Therapy on Lipids and Adipokines in Association with Vascular Pathophysiology in Rheumatoid Arthritis. Biomolecules 2022; 12:biom12101483. [PMID: 36291691 PMCID: PMC9599623 DOI: 10.3390/biom12101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Cardiovascular (CV) morbidity, mortality and metabolic syndrome are associated with rheumatoid arthritis (RA). A recent trial has suggested increased risk of major CV events (MACE) upon the Janus kinase (JAK) inhibitor tofacitinib compared with anti-tumor necrosis factor α (TNF-α) therapy. In our study, we evaluated lipids and other metabolic markers in relation to vascular function and clinical markers in RA patients undergoing one-year tofacitinib therapy. Patients and methods: Thirty RA patients treated with either 5 mg or 10 mg bid tofacitinib were included in a 12-month follow-up study. Various lipids, paraoxonase (PON1), myeloperoxidase (MPO), thrombospondin-1 (TSP-1) and adipokine levels, such as adiponectin, leptin, resistin, adipsin and chemerin were determined. In order to assess flow-mediated vasodilation (FMD), common carotid intima-media thickness (IMT) and arterial pulse-wave velocity (PWV) ultrasonography were performed. Assessments were carried out at baseline, and 6 and 12 months after initiating treatment. Results: One-year tofacitinib therapy significantly increased TC, HDL, LDL, APOA, APOB, leptin, adipsin and TSP-1, while significantly decreasing Lp(a), chemerin, PON1 and MPO levels. TG, lipid indices (TC/HDL and LDL/HDL), adiponectin and resistin showed no significant changes. Numerous associations were found between lipids, adipokines, clinical markers and IMT, FMD and PWV (p < 0.05). Regression analysis suggested, among others, association of BMI with CRP and PWV (p < 0.05). Adipokines variably correlated with age, BMI, CRP, CCP, FMD, IMT and PWV, while MPO, PON1 and TSP-1 variably correlated with age, disease duration, BMI, RF and PWV (p < 0.05). Conclusions: JAK inhibition by tofacitinib exerts balanced effects on lipids and other metabolic markers in RA. Various correlations may exist between metabolic, clinical parameters and vascular pathophysiology during tofacitinib treatment. Complex assessment of lipids, metabolic factors together with clinical parameters and vascular pathophysiology may be utilized in clinical practice to determine and monitor the CV status of patients in relation with clinical response to JAK inhibition.
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Wen P, Luo P, Zhang B, Wang Y, Hao L, Wang J, Guo J, Liu R, Zhang Y, Chen J. Hotspots and future directions in rheumatoid arthritis-related cardiovascular disease: A scientometric and visualization study from 2001 to 2021 based on Web of Science. Front Med (Lausanne) 2022; 9:931626. [PMID: 35966862 PMCID: PMC9372309 DOI: 10.3389/fmed.2022.931626] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/14/2022] [Indexed: 12/19/2022] Open
Abstract
Background The morbidity and mortality of cardiovascular diseases (CVD) in patients with rheumatoid arthritis (RA) is significantly higher than those in the general population, leading to RA-related CVD has attracted broad attention and numerous articles have been published. However, no study has systematically examined this area from a scientometric perspective. This study aimed to visualize the knowledge structure and identify emerging research trends and potential hotspots in this field. Materials and methods Articles and reviews on RA-CVD published from 2001 to 2021 were extracted from the Web of Science Core Collection database. CiteSpace and VOSviewer software were used to visualize the knowledge network of countries, institutions, authors, references and keywords in this field. SPSS and Microsoft Excel software were used for curve fitting and correlation analysis. Results A total of 2,618 articles and reviews were included. The number of publications about RA-related CVD significantly increased yearly. Publications were mainly concentrated in North America, Europe and East Asia. The United States contributed most with 699 publications, followed by the United Kingdom and Italy. Gross Domestic Product was an important factor affecting scientific output. University of Manchester and Professor Kitas George D. were the most prolific institutions and influential authors, respectively. Journal of Rheumatology was the most productive journal for RA-related CVD research. The research hotspots switched in the order of clinical features (cardiovascular events), mechanism exploration, anti-tumor necrosis factor therapy, risk factors, and antirheumatic drug safety, which can be observed from the keyword analysis and co-cited reference cluster analysis. Conclusions This study found that research on RA-related CVD is flourishing. The safety and cardiovascular pharmacological mechanisms of anti-rheumatoid drugs, especially targeted synthetic DMARDs, would be the focus of current research and developmental trends in future research.
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Affiliation(s)
- Pengfei Wen
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Pan Luo
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Binfei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Yakang Wang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Linjie Hao
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Jun Wang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Jianbin Guo
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Rui Liu
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Yumin Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Juan Chen
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
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Merzel Šabović EK, Starbek Zorko M, Janić M. Killing Two Birds with One Stone: Potential Therapies Targeting Psoriasis and Atherosclerosis at the Same Time. Int J Mol Sci 2022; 23:ijms23126648. [PMID: 35743091 PMCID: PMC9224172 DOI: 10.3390/ijms23126648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 01/27/2023] Open
Abstract
Psoriasis is a chronic systemic inflammatory disease. Due to systemic inflammation, it is associated with many comorbidities. Among them, cardiovascular diseases represent the most common causes of morbidity and mortality in this population. Therefore, physicians treating patients with psoriasis should keep in mind that, as important as the treatment of psoriasis, awareness of cardiovascular risk deserves additional attention. Thus, in parallel with psoriasis treatment, a cardiovascular risk assessment must also be performed and addressed accordingly. In addition to encouraging non-pharmacologic strategies for a healthy lifestyle, physicians should be familiar with different pharmacologic options that can target psoriasis and reduce cardiovascular risk. In the present article, we present the pathophysiological mechanisms of the psoriasis and cardiometabolic interplay, our view on the interaction of psoriasis and cardiovascular disease, review the atherosclerotic effect of therapeutic options used in psoriasis, and vice versa, i.e., what the effect of medications used in the prevention of atherosclerosis could be on psoriasis.
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Affiliation(s)
- Eva Klara Merzel Šabović
- Department of Dermatovenerology, University Medical Centre Ljubljana, Gradiškova Ulica 10, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
- Correspondence:
| | - Mateja Starbek Zorko
- Department of Dermatovenerology, University Medical Centre Ljubljana, Gradiškova Ulica 10, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
| | - Miodrag Janić
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Zaloška Cesta 7, SI-1000 Ljubljana, Slovenia
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20
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Khosrow-Khavar F, Kim SC, Lee H, Lee SB, Desai RJ. Tofacitinib and risk of cardiovascular outcomes: results from the Safety of TofAcitinib in Routine care patients with Rheumatoid Arthritis (STAR-RA) study. Ann Rheum Dis 2022; 81:798-804. [PMID: 35027405 PMCID: PMC9117457 DOI: 10.1136/annrheumdis-2021-221915] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/30/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Recent results from 'ORAL Surveillance' trial have raised concerns regarding the cardiovascular safety of tofacitinib in patients with rheumatoid arthritis (RA). We further examined this safety concern in the real-world setting. METHODS We created two cohorts of patients with RA initiating treatment with tofacitinib or tumour necrosis factor inhibitors (TNFI) using deidentified data from Optum Clinformatics (2012-2020), IBM MarketScan (2012-2018) and Medicare (parts A, B and D, 2012-2017) claims databases: (1) A 'real-world evidence (RWE) cohort' consisting of routine care patients and (2) A 'randomised controlled trial (RCT)-duplicate cohort' mimicking inclusion and exclusion criteria of the ORAL surveillance trial to calibrate results against the trial findings. Cox proportional hazards models with propensity score fine stratification weighting were used to estimate HR and 95% CIs for composite outcome of myocardial infarction and stroke and accounting for 76 potential confounders. Database-specific effect estimates were pooled using fixed effects models with inverse-variance weighting. RESULTS In the RWE cohort, 102 263 patients were identified of whom 12 852 (12.6%) initiated tofacitinib. The pooled weighted HR (95% CI) comparing tofacitinib with TNFI was 1.01 (0.83 to 1.23) in RWE cohort and 1.24 (0.90 to 1.69) in RCT-duplicate cohort which aligned closely with ORAL-surveillance results (HR: 1.33, 95% CI 0.91 to 1.94). CONCLUSIONS We did not find evidence for an increased risk of cardiovascular outcomes with tofacitinib in patients with RA treated in the real-world setting; however, tofacitinib was associated with an increased risk of cardiovascular outcomes, although statistically non-significant, in patients with RA with cardiovascular risk factors. TRIAL REGISTRATION NUMBER NCT04772248.
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Affiliation(s)
- Farzin Khosrow-Khavar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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A Review of Safety Outcomes from Clinical Trials of Baricitinib in Rheumatology, Dermatology and COVID-19. Adv Ther 2022; 39:4910-4960. [PMID: 36063279 PMCID: PMC9443639 DOI: 10.1007/s12325-022-02281-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 01/30/2023]
Abstract
Baricitinib is an oral, selective inhibitor of Janus kinase (JAK)1/JAK2 that transiently and reversibly inhibits many proinflammatory cytokines. This mechanism is a key mediator in a number of chronic inflammatory diseases; accordingly, baricitinib has been studied and approved for the treatment of several rheumatological and dermatological disorders, as well as COVID-19. This narrative review summarises and discusses the safety profile of baricitinib across these diseases, with special focus on adverse events of special interest (AESI) for JAK inhibitors, using integrated safety data sets of clinical trial data, and puts findings into context with the underlying risk in the respective disease populations, using supporting literature. We show that rates of infection with baricitinib generally reflected the inherent risk of the disease populations being treated, with serious infections and herpes zoster being more frequent in rheumatic diseases than in dermatological disorders, and herpes simplex being reported particularly in atopic dermatitis. Similarly, rates of major adverse cardiovascular events (MACE), venous thromboembolism (VTE) and malignancies were generally within or below the ranges reported for the respective disease populations, thereby reflecting the underlying risk; these events were therefore more frequent in patients with rheumatic diseases than in those with dermatological disorders, the latter of whom generally had low absolute risk. AESI were usually more common in patients with risk factors specific for each event. When a population similar to that of ORAL Surveillance was considered, the incidence rate of MACE with baricitinib was numerically lower than that reported with tofacitinib and similar to that of tumour necrosis factor inhibitors. No safety concerns were observed in hospitalised patients with COVID-19 who received baricitinib for up to 14 days. Identifying the patterns and likelihoods of AEs that occur during treatment in large groups of patients with different diseases can help the physician and patient better contextualise the benefit-to-risk ratio for the individual patient.
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22
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Rojas-Giménez M, López-Medina C, Calvo-Gutiérrez J, Puche-Larrubia MÁ, Gómez-García I, Seguí-Azpilcueta P, Ábalos-Aguilera MDC, Ruíz D, Collantes-Estévez E, Escudero-Contreras A. Association between Carotid Intima-Media Thickness and the Use of Biological or Small Molecule Therapies in Patients with Rheumatoid Arthritis. Diagnostics (Basel) 2021; 12:diagnostics12010064. [PMID: 35054229 PMCID: PMC8775122 DOI: 10.3390/diagnostics12010064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The objective of this study was to assess the association of carotid intima-media thickness (CIMT), and also the presence of atheromatous plaque, with biological and targeted synthetic disease-modifying antirheumatic drugs, in an established cohort of patients with rheumatoid arthritis (RA). Patients and Methods: We conducted a cross-sectional observational study based on a cohort of patients with RA and a registry of healthy controls, in whom the CIMT and presence of atheromatous plaque were assessed by ultrasound. Data were collected on disease activity, lab results and treatments. Descriptive and bivariate analyses were performed and two multivariate linear regression models (with CIMT as the dependent variable) were constructed to identify variables independently associated with CIMT in our sample of patients with RA. Results: A total of 176 individuals (146 patients with RA and 30 controls) were included. A higher percentage of patients than controls had atheromatous plaque (33.8% vs. 12.5%, p = 0.036), but no differences were found in terms of CIMT (0.64 vs. 0.61, p = 0.444). Compared to values in patients on other therapies, the CIMT was smaller among patients on tumour necrosis factor alpha (TNFα) inhibitors (mean [SD]: 0.58 [0.10] vs. 0.65 [0.19]; p = 0.013) and among those on Janus kinase inhibitors (mean [SD]: 0.52 [0.02] vs. 0.64 [0.18]; p < 0.001), while no differences were found as a function of the use of the other therapies considered. The multivariate linear regression analysis to identify factors associated with CIMT in our patients, adjusting for traditional cardiovascular risk factors such as hypertension, high levels of low-density lipoproteins, diabetes mellitus and smoking, showed that male sex, older age and having a greater cumulative erythrocyte sedimentation rate were independently associated with a larger CIMT, while patients on TNFα inhibitors had a CIMT 0.075 mm smaller than those on other treatments. Conclusions: The use of TNFα inhibitors may protect against subclinical atherosclerosis in patients with RA, patients on this biologic having smaller CIMTs than patients on other disease-modifying antirheumatic drugs. Nonetheless, these results should be confirmed in prospective studies with larger sample sizes.
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Affiliation(s)
- Marta Rojas-Giménez
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Clementina López-Medina
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
- Correspondence:
| | - Jerusalem Calvo-Gutiérrez
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - María Ángeles Puche-Larrubia
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Ignacio Gómez-García
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Pedro Seguí-Azpilcueta
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - María del Carmen Ábalos-Aguilera
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - Desirée Ruíz
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Eduardo Collantes-Estévez
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - Alejandro Escudero-Contreras
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
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Hamar A, Hascsi Z, Pusztai A, Czókolyová M, Végh E, Pethő Z, Gulyás K, Soós B, Kerekes G, Szekanecz É, Hodosi K, Szántó S, Szűcs G, Seres T, Szekanecz Z, Szamosi S. Prospective, simultaneous assessment of joint and vascular inflammation by PET/CT in tofacitinib-treated patients with rheumatoid arthritis: associations with vascular and bone status. RMD Open 2021; 7:e001804. [PMID: 34740980 PMCID: PMC8573670 DOI: 10.1136/rmdopen-2021-001804] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/27/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Attila Hamar
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | | | - Anita Pusztai
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Monika Czókolyová
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Edit Végh
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Zsófia Pethő
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Katalin Gulyás
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Boglárka Soós
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - György Kerekes
- Intensive Care Unit, Department of Medicine, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Éva Szekanecz
- Department of Oncology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Katalin Hodosi
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Sándor Szántó
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
- Department of Sports Medicine, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Gabriella Szűcs
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Tamás Seres
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Zoltán Szekanecz
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Szilvia Szamosi
- Division of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
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Totoson P, Peyronnel C, Quirié A, Pédard M, Cefis M, Bermont L, Prigent-Tessier A, Prati C, Tournier M, Wendling D, Marie C, Demougeot C. Tofacitinib improved peripheral endothelial dysfunction and brain-derived neurotrophic factor levels in the rat adjuvant-induced arthritis model. Fundam Clin Pharmacol 2021; 36:363-374. [PMID: 34661311 DOI: 10.1111/fcp.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/12/2021] [Indexed: 01/10/2023]
Abstract
This study aimed to explore the effect of Tofacitinib on endothelial dysfunction and cerebral levels of brain-derived neurotrophic factor (BDNF) in the adjuvant-induced arthritis (AIA) rat model. Tofacitinib (10 mg/kg twice a day) or vehicle was administered from the first signs of inflammation. Arthritis scores were daily monitored while other parameters including endothelial function assessed from aortic rings, radiographic scores, blood pressure, heart rate, circulating levels of triglycerides, cholesterol, and interleukin (IL)-1β, tumor necrosis factor-α (TNF-α), IL-17A, and cerebral BDNF levels were determined after 3 weeks of treatment. A group of non-AIA rats served as controls. In AIA rats, as compared with vehicle, Tofacitinib significantly reduced arthritis and radiographic scores, decreased total cholesterol and low-density lipoprotein cholesterol (LDL-C), but changed neither blood pressure nor heart rate and proinflammatory cytokines levels. It also fully restored acetylcholine (Ach)-induced relaxation (p < 0.05) through increased nitric oxide (NO) synthase activity, reduced BH4 deficiency and O2 -° production, decreased cyclo-oxygenase-2 (COX-2)/arginase activities, and enhanced endothelium-derived hyperpolarizing factor (EDHF) production. These effects translated into a decrease in atherogenic index and an elevation of BDNF levels in the prefrontal cortex (p < 0.05) and hippocampus (p < 0.001). The present study identified Tofacitinib as an efficient therapeutic option to reduce cardiovascular risk and improve BDNF-dependent cognition in arthritis.
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Affiliation(s)
- Perle Totoson
- PEPITE EA4267, FHU INCREASE, Université Bourgogne Franche-Comté, Besançon, France
| | - Célian Peyronnel
- PEPITE EA4267, FHU INCREASE, Université Bourgogne Franche-Comté, Besançon, France
| | - Aurore Quirié
- INSERM UMR1093-CAPS, Université Bourgogne Franche-Comté, UFR Sciences de Santé, Dijon, France
| | - Martin Pédard
- INSERM UMR1093-CAPS, Université Bourgogne Franche-Comté, UFR Sciences de Santé, Dijon, France
| | - Marina Cefis
- INSERM UMR1093-CAPS, Université Bourgogne Franche-Comté, UFR Sciences de Santé, Dijon, France
| | - Laurent Bermont
- Service de Biochimie médicale, CHRU Besançon, Besançon, France
| | - Anne Prigent-Tessier
- INSERM UMR1093-CAPS, Université Bourgogne Franche-Comté, UFR Sciences de Santé, Dijon, France
| | - Clément Prati
- PEPITE EA4267, FHU INCREASE, Université Bourgogne Franche-Comté, Besançon, France.,Service de Rhumatologie, CHRU Besançon, Besançon, France
| | - Maude Tournier
- PEPITE EA4267, FHU INCREASE, Université Bourgogne Franche-Comté, Besançon, France
| | - Daniel Wendling
- Service de Rhumatologie, CHRU Besançon, Besançon, France.,EA 4266 "Agents Pathogènes et Inflammation", EPILAB, Université Bourgogne Franche-Comté, Besançon, France
| | - Christine Marie
- INSERM UMR1093-CAPS, Université Bourgogne Franche-Comté, UFR Sciences de Santé, Dijon, France
| | - Céline Demougeot
- PEPITE EA4267, FHU INCREASE, Université Bourgogne Franche-Comté, Besançon, France
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Psoriasis and Cardiovascular Disease: Novel Mechanisms and Evolving Therapeutics. Curr Atheroscler Rep 2021; 23:67. [PMID: 34468875 PMCID: PMC9744099 DOI: 10.1007/s11883-021-00963-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Psoriasis is a chronic inflammatory skin condition that is associated with increased cardiovascular risk compared to those without psoriasis. This review will cover emerging mechanisms of cardiovascular risk, key pathways targeted with biologic therapies, and the current evidence on therapies to modulate this risk in patients with psoriasis. RECENT FINDINGS Recent scientific work has highlighted mechanisms that contribute to this enhanced risk, including the role of vascular endothelial dysfunction, platelet activation, dyslipidemia, and increased cardiometabolic comorbidities. Newer biologic and targeted synthetic therapies have transformed psoriasis treatment with high rates of clinical remission and durable skin disease control now possible. Epidemiological evidence suggests that many of these therapies may lower cardiovascular risk in psoriasis, although prospective interventional data is lacking (or mixed). Recently, caution has also been raised that some treatments may negatively affect cardiovascular risk. Overall, the current data suggests a positive or neutral ability to reduce cardiovascular risk for TNF, IL-17A, and IL-12/23p40 inhibitors, but current evidence remains conflicting for anti-IL-23/p19 and JAK inhibitors. More studies that include prospective cohorts, larger number of patients, treatment duration, and validated surrogate outcomes are needed to better evaluate the role of biologic therapies on cardiovascular risk in psoriasis.
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Santos-Moreno P, Burgos-Angulo G, Martinez-Ceballos MA, Pizano A, Echeverri D, Bautista-Niño PK, Roks AJM, Rojas-Villarraga A. Inflammaging as a link between autoimmunity and cardiovascular disease: the case of rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2020-001470. [PMID: 33468563 PMCID: PMC7817822 DOI: 10.1136/rmdopen-2020-001470] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/27/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Currently, traditional and non-traditional risk factors for cardiovascular disease have been established. The first group includes age, which constitutes one of the most important factors in the development of chronic diseases. The second group includes inflammation, the pathophysiology of which contributes to an accelerated process of vascular remodelling and atherogenesis in autoimmune diseases. Indeed, the term inflammaging has been used to refer to the inflammatory origin of ageing, explicitly due to the chronic inflammatory process associated with age (in healthy individuals). Taking this into account, it can be inferred that people with autoimmune diseases are likely to have an early acceleration of vascular ageing (vascular stiffness) as evidenced in the alteration of non-invasive cardiovascular tests such as pulse wave velocity. Thus, an association is created between autoimmunity and high morbidity and mortality rates caused by cardiovascular disease in this population group. The beneficial impact of the treatments for rheumatoid arthritis at the cardiovascular level has been reported, opening new opportunities for pharmacotherapy.
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Affiliation(s)
| | - Gabriel Burgos-Angulo
- Internal Medicine Department, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogota, Cundinamarca, Colombia
| | | | - Alejandro Pizano
- Vascular Function Research Laboratory and Department of Interventional Cardiology, Fundación Cardioinfantil Instituto de Cardiología, Bogota, Cundinamarca, Colombia
| | - Dario Echeverri
- Vascular Function Research Laboratory and Department of Interventional Cardiology, Fundación Cardioinfantil Instituto de Cardiología, Bogota, Cundinamarca, Colombia
| | - Paula K Bautista-Niño
- Research Center, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Anton J M Roks
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus Medical Center Department of Internal Medicine, Rotterdam, South Holland, The Netherlands
| | - Adriana Rojas-Villarraga
- Research Division, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Cundinamarca, Colombia
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Baldini C, Moriconi FR, Galimberti S, Libby P, De Caterina R. The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms. Eur Heart J 2021; 42:4389-4400. [PMID: 34343257 DOI: 10.1093/eurheartj/ehab447] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/21/2021] [Accepted: 07/31/2021] [Indexed: 01/07/2023] Open
Abstract
Inflammation contributes centrally to cardiovascular diseases, and anti-inflammatory treatments can reduce cardiovascular events. The JAK-STAT pathway is an emerging target in inflammation, mainly in rheumatoid arthritis (RA) and chronic myeloproliferative neoplasms (MPNs), disorders that heighten cardiovascular risk. The aim of this study was to review the international literature on the relationship between dysregulation of the JAK-STAT pathway in RA/MPNs and cardiovascular risk and on the potential cardiovascular effects of JAK-STAT inhibitors. The JAK-STAT pathway sustains inflammatory and thrombotic events in autoimmune disorders such as RA and MPNs. Here, an imbalance exists between pro- and anti-inflammatory cytokines [increased levels of interleukin (IL)-6, IL-1-β, tumour necrosis factor-α, decreased levels of IL-10] and the over-expression of some prothrombotic proteins, such as protein kinase Cε, on the surface of activated platelets. This pathway also operates in atherosclerotic cardiovascular disease. JAK-STAT inhibitors may reduce cardiovascular events and related deaths in such conditions, but the potential of these agents requires more studies, especially with regard to cardiovascular safety, and particularly for potential prothrombotic effects. JAK-STAT inhibitors merit consideration to curb heightened cardiovascular risk in patients with RA and MPNs, with rigorous assessment of the potential benefits and risks.
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Affiliation(s)
- Chiara Baldini
- Division of Rheumatology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Francesca Romana Moriconi
- Division of Rheumatology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy.,Division of Cardiology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Sara Galimberti
- Division of Hematology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital-Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Raffaele De Caterina
- Division of Cardiology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
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Atzeni F, Rodríguez-Carrio J, Popa CD, Nurmohamed MT, Szűcs G, Szekanecz Z. Cardiovascular effects of approved drugs for rheumatoid arthritis. Nat Rev Rheumatol 2021; 17:270-290. [PMID: 33833437 DOI: 10.1038/s41584-021-00593-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
The risk of cardiovascular disease is increased in patients with rheumatoid arthritis compared with the general population owing to the influence of traditional and non-traditional risk factors. Inflammation has a pivotal contribution and can accelerate the atherosclerotic process. Although dampening inflammation with DMARDs should theoretically abrogate this process, evidence suggests that these drugs can also promote atherosclerosis directly and indirectly, hence adding to an increased cardiovascular burden. However, the extent and direction of the effects largely differ across drugs. Understanding how these drugs influence endothelial damage and vascular repair mechanisms is key to understanding these outcomes. NSAIDs and glucocorticoids can increase the cardiovascular risk. Conversely, conventional, biologic and targeted DMARDs control inflammation and reduce this risk, although some of these drugs can also aggravate traditional factors or thrombotic events. Given these data, the fundamental objective for clinicians should be disease control, in an individualized approach that considers the most appropriate drug for each patient, taking into account joint and cardiovascular outcomes. This Review provides a comprehensive analysis of the effects of DMARDs and other approved drugs on cardiovascular involvement in rheumatoid arthritis, from a clinical and mechanistic perspective, with a roadmap to inform the research agenda.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
| | - Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Călin D Popa
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, Nijmegen, The Netherlands
| | - Michael T Nurmohamed
- Deptartment of Rheumatology, Amsterdam University Medical Center & Reade, Amsterdam, The Netherlands
| | - Gabriella Szűcs
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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29
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Liberale L, Ministrini S, Carbone F, Camici GG, Montecucco F. Cytokines as therapeutic targets for cardio- and cerebrovascular diseases. Basic Res Cardiol 2021; 116:23. [PMID: 33770265 PMCID: PMC7997823 DOI: 10.1007/s00395-021-00863-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/16/2021] [Indexed: 02/07/2023]
Abstract
Despite major advances in prevention and treatment, cardiac and cerebral atherothrombotic complications still account for substantial morbidity and mortality worldwide. In this context, inflammation is involved in the chronic process leading atherosclerotic plaque formation and its complications, as well as in the maladaptive response to acute ischemic events. For this reason, modulation of inflammation is nowadays seen as a promising therapeutic strategy to counteract the burden of cardio- and cerebrovascular disease. Being produced and recognized by both inflammatory and vascular cells, the complex network of cytokines holds key functions in the crosstalk of these two systems and orchestrates the progression of atherothrombosis. By binding to membrane receptors, these soluble mediators trigger specific intracellular signaling pathways eventually leading to the activation of transcription factors and a deep modulation of cell function. Both stimulatory and inhibitory cytokines have been described and progressively reported as markers of disease or interesting therapeutic targets in the cardiovascular field. Nevertheless, cytokine inhibition is burdened by harmful side effects that will most likely prevent its chronic use in favor of acute administrations in well-selected subjects at high risk. Here, we summarize the current state of knowledge regarding the modulatory role of cytokines on atherosclerosis, myocardial infarction, and stroke. Then, we discuss evidence from clinical trials specifically targeting cytokines and the potential implication of these advances into daily clinical practice.
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Affiliation(s)
- Luca Liberale
- Center for Molecular Cardiology, University of Zürich, Wagistrasse 12, 8952, Schlieren, Switzerland. .,First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Stefano Ministrini
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Internal Medicine, Angiology and Atherosclerosis, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Wagistrasse 12, 8952, Schlieren, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.,Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy.,First Clinic of Internal Medicine, Department of Internal Medicine and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
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30
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Gadina M, Chisolm DA, Philips RL, McInness IB, Changelian PS, O'Shea JJ. Translating JAKs to Jakinibs. THE JOURNAL OF IMMUNOLOGY 2020; 204:2011-2020. [PMID: 32253269 DOI: 10.4049/jimmunol.1901477] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/11/2020] [Indexed: 12/21/2022]
Abstract
The discovery of JAKs and STATs and their roles in cytokine and IFN action represented a significant basic advance and a new paradigm in cell signaling. This was quickly followed by discoveries pointing to their essential functions, including identification of JAK3 mutations as a cause of SCID. This and other findings predicted the use of therapeutically targeting JAKs as a new strategy for treating immune and inflammatory diseases. This now is a reality with seven approved jakinibs being used to treat multiple forms of arthritis, inflammatory bowel disease and myeloproliferative neoplasms, and numerous ongoing clinical trials in other settings. This story provides interesting insights into the process of translating basic discoveries and also reveals the need to return to basic work to fill gaps that now become apparent.
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Affiliation(s)
- Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Danielle A Chisolm
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Rachael L Philips
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Iain B McInness
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, United Kingdom; and
| | | | - John J O'Shea
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892;
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31
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Fragoulis GE, Panayotidis I, Nikiphorou E. Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment. Curr Vasc Pharmacol 2020; 18:431-446. [PMID: 31258091 DOI: 10.2174/1570161117666190619143842] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Ismini Panayotidis
- Faculty of Medical Sciences, Medical School, University College London, London, United Kingdom
| | - Elena Nikiphorou
- Department of Inflammation Biology, King's College London, London, UK and Department of Rheumatology, King's College Hospital, London, United Kingdom
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32
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Kamperidis N, Kamperidis V, Zegkos T, Kostourou I, Nikolaidou O, Arebi N, Karvounis H. Atherosclerosis and Inflammatory Bowel Disease-Shared Pathogenesis and Implications for Treatment. Angiology 2020; 72:303-314. [PMID: 33601945 DOI: 10.1177/0003319720974552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Atherosclerosis and inflammatory bowel disease (IBD) are often regarded as 2 distinct entities. The commonest manifestation of atherosclerosis is ischemic heart disease (IHD), and an association between IHD and IBD has been reported. Atherosclerosis and IBD share common pathophysiological mechanisms in terms of their genetics, immunology, and contributing environmental factors. Factors associated with atherosclerosis are implicated in the development of IBD and vice versa. Therefore, treatments targeting the common pathophysiology pathways may be effective in both conditions. The current review considers the pathophysiological pathways that are shared between the 2 conditions and discusses the implications for treatment and research.
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Affiliation(s)
- Nikolaos Kamperidis
- 3749St Mark's Hospital, Harrow, London, United Kingdom.,* Nikolaos Kamperidis and Vasileios Kamperidis are sharing first authorship
| | - Vasileios Kamperidis
- 1st Cardiology Department, 37788AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.,* Nikolaos Kamperidis and Vasileios Kamperidis are sharing first authorship
| | - Thomas Zegkos
- 1st Cardiology Department, 37788AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Olga Nikolaidou
- Radiology Department, Pananikolaou General Hospital, Thessaloniki, Greece
| | - Naila Arebi
- 3749St Mark's Hospital, Harrow, London, United Kingdom
| | - Haralambos Karvounis
- 1st Cardiology Department, 37788AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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33
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Update on the Safety Profile of Tofacitinib in Rheumatoid Arthritis from Clinical Trials to Real-World Studies: A Narrative Review. Rheumatol Ther 2020; 8:17-40. [PMID: 33245555 PMCID: PMC7991042 DOI: 10.1007/s40744-020-00258-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Tofacitinib is approved for the treatment of moderate to severe active rheumatoid arthritis (RA) in adult patients who do not respond adequately or are intolerant to one or more disease-modifying anti-rheumatic drugs. The tofacitinib RA clinical development program included randomized controlled trials of 6–24-month duration and long-term extension studies with > 7061 patients and 22,875 patient-years of exposure. To date, there are no data from other randomized studies in patients with cardiovascular risk factors comparing the long-term safety of a JAK inhibitor versus an anti-TNF. Real-world studies are necessary to complete the body of evidence supporting the effectiveness and safety of a therapeutic agent. In the case of tofacitinib, real-world data derive from health insurance claims databases, registries (US Corrona Registry, Swiss Registry, and others), national pharmacovigilance programs, and hospital databases (case series). The present article provides complete and up-to-date information on the safety profile of tofacitinib in RA, from clinical trials to real-world studies. Tofacitinib has demonstrated a consistent safety profile during up to 9.5 years of experience in randomized controlled trials and long-term extension studies. Real-world evidence has not added new safety issues with respect to those found in the clinical program. In general, the safety profile of tofacitinib is consistent with that of biologic disease-modifying anti-rheumatic drugs, with an increased risk of herpes zoster that seems to be a class effect of Janus kinase inhibitors. The continuous follow-up of therapeutic agents to treat rheumatoid arthritis is needed to adequately establish the safety profile for new mechanisms of action and potential risks associated with their longer term use.
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34
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Carbone F, Bonaventura A, Liberale L, Paolino S, Torre F, Dallegri F, Montecucco F, Cutolo M. Atherosclerosis in Rheumatoid Arthritis: Promoters and Opponents. Clin Rev Allergy Immunol 2020; 58:1-14. [PMID: 30259381 DOI: 10.1007/s12016-018-8714-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Substantial epidemiological data identified cardiovascular (CV) diseases as a main cause of mortality in patients with rheumatoid arthritis (RA). In light of this, RA patients may benefit from additional CV risk screening and more intensive prevention strategies. Nevertheless, current algorithms for CV risk stratification still remain tailored on general population and are burdened by a significant underestimation of CV risk in RA patients. Acute CV events in patients with RA are largely related to an accelerated atherosclerosis. As pathophysiological features of atherosclerosis overlap those occurring in the inflamed RA synovium, the understanding of those common pathways represents an urgent need and a leading challenge for CV prevention in patients with RA. Genetic background, metabolic status, gut microbiome, and systemic inflammation have been also suggested as additional key pro-atherosclerotic factors. The aim of this narrative review is to update the current knowledge about pathophysiology of atherogenesis in RA patients and potential anti-atherosclerotic effects of disease-modifying anti-rheumatic drugs.
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Affiliation(s)
- Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Center for Molecular Cardiology, University of Zürich, 12 Wagistrasse, 8952, Schlieren, Switzerland
| | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, San Martino Polyclinic Hospital, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino Genoa, 10 Largo Benzi, 16132, Genoa, Italy
| | - Francesco Torre
- IRCCS Ospedale Policlinico San Martino Genoa, 10 Largo Benzi, 16132, Genoa, Italy.,Clinic of Emergency Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Franco Dallegri
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, 10 Largo Benzi, 16132, Genoa, Italy
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, 10 Largo Benzi, 16132, Genoa, Italy.,First Clinic of Internal Medicine, Department of Internal Medicine and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - Maurizio Cutolo
- IRCCS Ospedale Policlinico San Martino Genoa, 10 Largo Benzi, 16132, Genoa, Italy. .,Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, San Martino Polyclinic Hospital, Genoa, Italy.
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35
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Massalska M, Maslinski W, Ciechomska M. Small Molecule Inhibitors in the Treatment of Rheumatoid Arthritis and Beyond: Latest Updates and Potential Strategy for Fighting COVID-19. Cells 2020; 9:E1876. [PMID: 32796683 PMCID: PMC7464410 DOI: 10.3390/cells9081876] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023] Open
Abstract
The development of biological disease-modifying antirheumatic drugs (bDMARDs) and target synthetic DMARDs (tsDMARDs), also known as small molecule inhibitors, represent a breakthrough in rheumatoid arthritis (RA) treatment. The tsDMARDs are a large family of small molecules targeting mostly the several types of kinases, which are essential in downstream signaling of pro-inflammatory molecules. This review highlights current challenges associated with the treatment of RA using small molecule inhibitors targeting intracellular JAKs/MAPKs/NF-κB/SYK-BTK signaling pathways. Indeed, we have provided the latest update on development of small molecule inhibitors, their clinical efficacy and safety as a strategy for RA treatment. On the other hand, we have highlighted the risk and adverse effects of tsDMARDs administration including, among others, infections and thromboembolism. Therefore, performance of blood tests or viral infection screening should be recommended before the tsDMARDs administration. Interestingly, recent events of SARS-CoV-2 outbreak have demonstrated the potential use of small molecule inhibitors not only in RA treatment, but also in fighting COVID-19 via blocking the viral entry, preventing of hyperimmune activation and reducing cytokine storm. Thus, small molecule inhibitors, targeting wide range of pro-inflammatory singling pathways, may find wider implications not only for the management of RA but also in the controlling of COVID-19.
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Affiliation(s)
| | | | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland; (M.M.); (W.M.)
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36
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Xie W, Zhang Z. Tofacitinib in cardiovascular outcomes: friend or foe? Rheumatology (Oxford) 2020; 59:1797-1798. [PMID: 32163579 DOI: 10.1093/rheumatology/keaa090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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37
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Nasonov EL, Avdeeva AS, Lila AM. Efficacy and safety of tofacitinib for immune-mediated inflammatory rheumatic diseases (Part I). RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.14412/1995-4484-2020-62-79] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia
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38
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Xie W, Xiao S, Huang Y, Sun X, Zhang Z. Effect of tofacitinib on cardiovascular events and all-cause mortality in patients with immune-mediated inflammatory diseases: a systematic review and meta-analysis of randomized controlled trials. Ther Adv Musculoskelet Dis 2019; 11:1759720X19895492. [PMID: 31897092 PMCID: PMC6918042 DOI: 10.1177/1759720x19895492] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background We aimed to systematically assess a possible association of tofacitinib therapy with cardiovascular events (CVEs) and all-cause mortality. Methods Systematic searches of PubMed, Embase, and Cochrane Library were conducted from inception through March 2019. Randomized controlled trials in patients with immune-mediated inflammatory diseases (IMIDs) reporting safety data were included. Included studies compared tofacitinib with placebo or 5 mg tofacitinib with 10 mg tofacitinib. The primary and secondary outcome measures were all CVEs [major adverse cardiovascular events (MACEs)/venous thromboembolism events (VTEs)] and all-cause mortality. Results 29 studies randomizing 13,611 patients were included. Compared with placebo, there was no significant increased risk of all CVEs (OR = 1.07, 95% CI 0.49-2.34), MACEs (OR 1.54, 95% CI 0.42-5.59), or all-cause mortality (OR = 1.13, 95% CI 0.26-4.95), but a decreased rate of VTEs (OR 0.03, 95% CI 0.00-0.21) in patients with IMIDs initiating tofacitinib. Meanwhile, paired comparison showed 10 mg tofacitinib twice daily was associated with a significantly lower incidence of all CVEs (OR = 0.56, 95% CI 0.33-0.96), MACEs (OR = 0.48, 95% CI 0.22-1.05), or all-cause mortality (OR = 0.47, 95% CI 0.19-1.17), but a trend toward an increase in VTEs risk (OR = 1.47, 95% CI 0.25-8.50), compared with the 5 mg regimen. Conclusion Compared with placebo, there was no augmented risk of CVEs and all-cause mortality in patients with IMIDs following tofacitinib treatment in a short-term perspective, whereas 10 mg twice daily tofacitinib appeared to be associated with reduction in cardiovascular and all-cause mortality risks, except VTEs, relative to the 5 mg twice daily dose. Long-term studies and postmarketing risk monitoring are increasingly needed to develop a better understanding.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, West District, Beijing, China
| | - Shiyu Xiao
- Department of Gastroenterology, Peking University Third Hospital, Haidian District, Beijing, China
| | - Yanrong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, West District, Beijing, China
| | - Xiaoying Sun
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, West District, Beijing, China
| | - Zhuoli Zhang
- Director of Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street, West District, Beijing 100034, China
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39
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Tran V, Limketkai BN, Sauk JS. IBD in the Elderly: Management Challenges and Therapeutic Considerations. Curr Gastroenterol Rep 2019; 21:60. [PMID: 31776797 DOI: 10.1007/s11894-019-0720-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Elderly patients with inflammatory bowel disease (IBD) are increasing in prevalence as our population ages and the incidence of IBD increases. The purpose of this review is to describe the management challenges in elderly IBD patients, including comorbid conditions and therapeutic considerations unique to the elderly population. RECENT FINDINGS The elderly experience coexisting comorbidities that complicate IBD management. The disease course and potential side effects of treatments can impact the elderly IBD patient differently than younger IBD patients. The duration for colorectal cancer surveillance (CRC) also remains controversial and should be individualized to determine when discontinuation is appropriate. Given greater safety considerations in the elderly IBD population, treatment targets and management goals require a more personalized approach in the elderly, taking into account coexisting comorbidities, inflammatory burden, and functional limitations.
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Affiliation(s)
- Vivy Tran
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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40
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Richez C, Morel J, Cornec D, Daïen C, Goupille P, Lazaro E, Lequerré T, Nocturne G, de Lédinghen V, Le Goff B, Pourcher V, Prati C, Seror R, Tournadre A, Truchetet ME, Sibilia J, Pham T. Practical management of patients on Janus kinase inhibitor (JAKi) therapy: Practical fact sheets drawn up by the Rheumatism and Inflammation Club (CRI), a group endorsed by the French Society for Rheumatology (SFR). Joint Bone Spine 2019; 86 Suppl 1:eS2-eS103. [PMID: 31791545 DOI: 10.1016/s1297-319x(19)30154-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | | | | | - Claire Daïen
- Service de Rhumatologie, CHU Montpellier, Montpellier
| | | | | | | | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac
| | | | - Valérie Pourcher
- Service de Maladies Infectieuses et Tropicales, CHU Pitié-Salpétrière, Paris
| | | | - Raphaèle Seror
- Service de Rhumatologie, CHU Bicêtre, Le Kremlin-Bicêtre
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand
| | | | - Jean Sibilia
- Service de Rhumatologie, CHU Hautepierre, Strasbourg
| | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille
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Abstract
BACKGROUND The treatment of ulcerative colitis (UC) is based on conventional therapies (aminosalicylates, corticosteroids, and immunosuppressants) and when these are ineffective, biologic drugs. However, in a substantial portion of patients undergoing treatment with biologic agents there is primary or secondary loss of response. Thus, new therapeutic options are been actively explored; among these, there is interest in the Janus kinase (JAK) inhibitors, small molecules that can be administered orally. METHODS We carried out an extensive literature search concerning the effects of JAK inhibitors for the treatment of patients with UC. RESULTS Tofacitinib is the drug more extensively studied in this setting, and it was recently approved in Europe for the treatment of moderate to severe UC. The available data suggest that this drug can be effective in obtaining clinical and endoscopic remission in UC patients unresponsive to other treatments, even in those previously treated with biologic drugs. In addition, the drug was able to improve significantly the quality of life of these patients. There are still few data available for the treatment of UC with other JAK inhibitors. CONCLUSIONS The JAK inhibitors, in particular tofacitinib, are a new class of orally administered drugs effective for the treatment of UC. However, more studies are needed to ascertain the safety of tofacitinib in the long term and whether other compounds of this class may be equally effective.
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Hollan I, Ronda N, Dessein P, Agewall S, Karpouzas G, Tamargo J, Niessner A, Savarese G, Rosano G, Kaski JC, Wassmann S, Meroni PL. Lipid management in rheumatoid arthritis: a position paper of the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:104-114. [DOI: 10.1093/ehjcvp/pvz033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity, partly due to alterations in lipoprotein quantity, quality and cell cholesterol trafficking. Although cardiovascular disease significantly contributes to mortality excess in RA, cardiovascular prevention has been largely insufficient. Because of limited evidence, optimal strategies for lipid management (LM) in RA have not been determined yet, and recommendations are largely based on expert opinions. In this position paper, we describe abnormalities in lipid metabolism and introduce a new algorithm for estimation of cardiovascular risk (CVR) and LM in RA. The algorithm stratifies patients according to RA-related factors impacting CVR (such as RA activity and severity and medication). We propose strategies for monitoring of lipid parameters and treatment of dyslipidaemia in RA (including lifestyle, statins and other lipid-modifying therapies, and disease modifying antirheumatic drugs). These opinion-based recommendations are meant to facilitate LM in RA until more evidence is available.
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Affiliation(s)
- Ivana Hollan
- Lillehammer Hospital for Rheumatic Diseases, M. Grundtvigs veg 6, 2609 Lillehammer, Norway
- Department of Medicine, Division of Cardiovascular Medicine, 75 Francis Street, Boston, MA, 02115, USA
| | | | - Patrick Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
- Department of Rheumatology, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Jubilee Road, Parktown, Johannesburg 2196, South Africa
- Rheumatology Unit, Free University Hospital, Faculty of Medicine and Pharmacy, Free University, Laarbeeklaan 103, Jette, Brussels 1090, Belgium
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - George Karpouzas
- Department of Medicine, Division of Rheumatology, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, 1124 W Carson Street, Building E4-R17A,Torrance, CA 90502, USA
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Plaza de Ramón y Cajal s/n, 28040, Madrid, Spain
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gianluigi Savarese
- Norrbacka, S1:02, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Roma, Via della Pisana 249, 00163 Roma, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 ORE, UK
| | - Sven Wassmann
- Cardiology Pasing, Institutstr. 14, 81241 Munich, Germany
- Department of Cardiology, University of the Saarland, Kirrbergerstr. 100, 66421 Homburg/Saar, Germany
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Via Ariosto, 14, 20145 Milan, Italy
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Xie W, Huang Y, Xiao S, Sun X, Fan Y, Zhang Z. Impact of Janus kinase inhibitors on risk of cardiovascular events in patients with rheumatoid arthritis: systematic review and meta-analysis of randomised controlled trials. Ann Rheum Dis 2019; 78:1048-1054. [DOI: 10.1136/annrheumdis-2018-214846] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 02/07/2023]
Abstract
ObjectivesTo investigate the effect of Janus kinase inhibitors (Jakinibs) on cardiovascular risk in adult patients with rheumatoid arthritis (RA) via a meta-analysis of randomised controlled trials (RCTs).MethodsPubMed, Embase and Cochrane library were thoroughly searched for RCTs reporting safety issues in patients with RA receiving Jakinibs, from inception to October 2018. The primary and secondary outcomes were all cardiovascular events (CVEs) and major adverse cardiovascular events (MACEs)/venous thromboembolism events (VTEs). OR and 95% CI were calculated using the Mantel-Haenszel fixed-effect method.Results26 RCTs randomising 11 799 patients were included. No significant difference was observed regarding all CVEs risk following Jakinibs usage in general (OR 1.04 (0.61 to 1.76), p = 0.89), tofacitinib (OR 0.63 (0.26 to 1.54), p = 0.31), baricitinib (OR 1.21 (0.51 to 2.83), p = 0.66), upadacitinib (OR 3.29 (0.59 to 18.44), p = 0.18), peficitinib (OR 0.43 (0.07 to 2.54), p = 0.35) or decernotinib (OR 1.12 (0.13 to 10.11), p = 0.92). Likewise, there was no significant difference for Jakinibs treatment overall regarding occurrence of MACEs (OR 0.80 (0.36 to 1.75), p = 0.57) or VTEs (OR 1.16 (0.48 to 2.81), p = 0.74). Dose-dependent impact of Jakinibs on the risks of all CVEs, MACEs and VTEs was not observed in tofacitinib (5 mg vs 10 mg), upadacitinib (15 mg vs 30 mg), whereas baricitinib at 2 mg was found to be safer than 4 mg in all CVEs incidence (OR 0.19 (0.04 to 0.88), p = 0.03).ConclusionThe existing evidence from RCTs indicated no significant change in cardiovascular risk for Jakinib-treated patients with RA in a short-term perspective, but postmarketing data are sorely needed to ascertain their cardiovascular safety, especially at the higher dose, due to increased risk of thromboembolism events for both tofacitinib and baricitinib at higher dosage.
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Novikova DS, Udachkina HV, Markelova EI, Kirillova IG, Misiyuk AS, Demidova NV, Popkova TV. Dynamics of body mass index and visceral adiposity index in patients with rheumatoid arthritis treated with tofacitinib. Rheumatol Int 2019; 39:1181-1189. [DOI: 10.1007/s00296-019-04303-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/09/2019] [Indexed: 12/31/2022]
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Tran V, Shammas RM, Sauk JS, Padua D. Evaluating tofacitinib citrate in the treatment of moderate-to-severe active ulcerative colitis: design, development and positioning of therapy. Clin Exp Gastroenterol 2019; 12:179-191. [PMID: 31118734 PMCID: PMC6507103 DOI: 10.2147/ceg.s150908] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/06/2019] [Indexed: 12/14/2022] Open
Abstract
The etiology of ulcerative colitis (UC) is complex and involves a host of genetic, epigenetic and environmental factors. Over the last thirty years, signaling pathways like the Janus kinase (JAK) signaling pathway have been implicated in its pathogenesis. Pharmacologic blockade of this pathway is available through several small molecule inhibitors, including tofacitinib. Tofacitinib is an orally administered pan-JAK inhibitor that was first approved by the Food and Drug Administration (FDA) for use in rheumatologic disorders such as rheumatoid arthritis and psoriatic arthritis. The FDA approved its use in moderate-to-severe active ulcerative colitis in 2018. The aim of this review will be to discuss the role of tofacitinib in ulcerative colitis. We will discuss the role of JAK-STAT signaling, clinical data available for tofacitinib, and the safety profile for this therapy. Tofacitinib's place in the UC management algorithm is currently being debated. This effective oral therapy is poised to be a mainstay of UC therapeutics. This review will highlight the key clinical features and detail the UC experience to date.
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Affiliation(s)
- Vivy Tran
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rania M Shammas
- Department of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Tamar and Vatche Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - David Padua
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Tamar and Vatche Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Gadina M, Le MT, Schwartz DM, Silvennoinen O, Nakayamada S, Yamaoka K, O’Shea JJ. Janus kinases to jakinibs: from basic insights to clinical practice. Rheumatology (Oxford) 2019; 58:i4-i16. [PMID: 30806710 PMCID: PMC6657570 DOI: 10.1093/rheumatology/key432] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/15/2018] [Indexed: 12/30/2022] Open
Abstract
Cytokines are critical mediators of diverse immune and inflammatory diseases. Targeting cytokines and cytokine receptors with biologics has revolutionized the treatment of many of these diseases, but targeting intracellular signalling with Janus kinase (JAK) inhibitors (jakinibs) now represents a major new therapeutic advance. We are still in the first decade since these drugs were approved and there is still much to be learned about the mechanisms of action of these drugs and the practical use of these agents. Herein we will review cytokines that do, and just as importantly, do not signal by JAKs, as well as explain how this relates to both efficacy and side effects in various diseases. We will review new, next-generation selective jakinibs, as well as the prospects and challenges ahead in targeting JAKs.
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Affiliation(s)
- Massimo Gadina
- Translational Immunology Section, National Institutes of Health, Bethesda, MD, USA
| | - Mimi T Le
- Translational Immunology Section, National Institutes of Health, Bethesda, MD, USA
| | - Daniella M Schwartz
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis, and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Olli Silvennoinen
- Institute of Biotechnology, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Life Sciences, Fimlab Laboratories University of Tampere, Tampere, Finland
| | - Shingo Nakayamada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Disease, Kitasato University, School of Medicine, Sagamihara, Kanagawa, Japan
| | - John J O’Shea
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis, and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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Abstract
Inflammatory bowel disease (IBD) is a chronic heterogeneous group of diseases that has undergone major advances in the understanding of its etiology and pathogenesis in recent years. The development of biologics had resulted in better overall management of the disease, including lower rates of surgery and better long-term clinical and patient-reported outcomes. Treatment modalities have either been newly developed or extrapolated from their approved use for a different indication. Modes of action and treatment targets have varied as well. Treatments such as vedolizumab and ustekinumab, as well as second-generation corticosteroids have been approved by the US Food and Drug Administration (FDA) for the treatment of IBD. Other agents are currently being developed at various stages of clinical trials including anti-adhesion agents such as etrolizumab and abrilumab, JAK inhibitors such as tofacitinib, and anti-trafficking molecules. Toll-like receptors and phosphatidylcholine are also new promising emerging targets that are being investigated in phase 3 clinical trials. It is projected that many therapies will become available in the coming years if supported by the results of current clinical trials. This will provide IBD patients with a wide array of options and allow physicians to choose the best therapies for each individual patient.
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Affiliation(s)
- Roni Weisshof
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Katia El Jurdi
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Nada Zmeter
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA.
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Weisshof R, Golan MA, Yvellez OV, Rubin DT. The use of tofacitinib in the treatment of inflammatory bowel disease. Immunotherapy 2018; 10:837-849. [DOI: 10.2217/imt-2018-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Janus kinases (JAK) play a major role in the immunologic pathways and specifically in signal transduction in inflammatory bowel disease. Thus, they can serve as a target for new therapeutic options. Tofacitinib is a novel, first-in-class, pan-Janus kinase inhibitor. It has been found to be effective and safe in the treatment of moderate-to-severe ulcerative colitis. In this review, we will describe the drug's mechanism of action as well as the clinical evidence for its effectiveness in treating patients with inflammatory bowel disease.
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Affiliation(s)
- Roni Weisshof
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Maya Aharoni Golan
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Olivia V Yvellez
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL 60637, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL 60637, USA
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Gadina M, Johnson C, Schwartz D, Bonelli M, Hasni S, Kanno Y, Changelian P, Laurence A, O'Shea JJ. Translational and clinical advances in JAK-STAT biology: The present and future of jakinibs. J Leukoc Biol 2018; 104:499-514. [PMID: 29999544 DOI: 10.1002/jlb.5ri0218-084r] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 02/06/2023] Open
Abstract
In this era, it is axiomatic that cytokines have critical roles in cellular development and differentiation, immune homeostasis, and host defense. Equally, dysregulation of cytokines is known to contribute to diverse inflammatory and immune-mediated disorders. In fact, the past 20 years have witnessed the rapid translation of basic discoveries in cytokine biology to multiple successful biological agents (mAbs and recombinant fusion proteins) that target cytokines. These targeted therapies have not only fundamentally changed the face of multiple immune-mediated diseases but have also unequivocally established the role of specific cytokines in human disease; cytokine biologists have many times over provided remarkable basic advances with direct clinical benefit. Numerous cytokines rely on the JAK-STAT pathway for signaling, and new, safe, and effective small molecule inhibitors have been developed for a range of disorders. In this review, we will briefly summarize basic discoveries in cytokine signaling and briefly comment on some major unresolved issues. We will review clinical data pertaining to the first generation of JAK inhibitors and their clinical indications, discuss additional opportunities for targeting this pathway, and lay out some of the challenges that lie ahead.
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Affiliation(s)
- Massimo Gadina
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Catrina Johnson
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniella Schwartz
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael Bonelli
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarfaraz Hasni
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Yuka Kanno
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Paul Changelian
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Arian Laurence
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - John J O'Shea
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, Molecular Immunology and Inflammation Branch, National Institutes of Health, Bethesda, Maryland, USA
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50
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Cardiovascular Safety of Biologics and JAK Inhibitors in Patients with Rheumatoid Arthritis. Curr Rheumatol Rep 2018; 20:42. [DOI: 10.1007/s11926-018-0752-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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