1
|
Szűcs G, Szekanecz Z, Szamosi S. Can we define difficult-to-treat systemic sclerosis? Expert Rev Clin Immunol 2024:1-17. [PMID: 38711393 DOI: 10.1080/1744666x.2024.2352450] [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: 01/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by microvascular alterations, immunopathology, and widespread fibrosis involving various organs. It is considered difficult to treat due to several reasons: complex pathogenesis, heterogeneity, late diagnosis, limited treatment options for certain organ manifestations, lack of personalized medicine. AREAS COVERED This review presents the heterogeneity, survival and organ manifestations with their risk factors of systemic sclerosis and their current treatment options, while drawing attention to difficult-to-treat forms of the disease, based on literature indexed in PubMed. EXPERT OPINION Despite recent advances in the management of SSc over the last decades, the disease presents significant morbidity and mortality. Although available treatment protocols brought significant advancements in terms of survival in SSc-associated interstitial lung disease and pulmonary arterial hypertension, less success has been achieved in the treatment of Raynaud's phenomenon and digital ulcers and the results are modest in case of heart, gastrointestinal, and renal manifestations. There are patients who do not respond to treatment and deteriorate even with adequate therapy. They can be considered difficult-to treat (D2T) cases. We have created a possible score system based on the individual organ manifestations and highlighted treatment options for the D2T SSc category.
Collapse
Affiliation(s)
- Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| |
Collapse
|
2
|
De Lorenzis E, Kakkar V, Di Donato S, Wilson M, Barnes T, Denton C, Derrett-Smith E, Douglas K, Helliwell P, Herrick AL, Saleem B, Nisar M, Morley C, Green L, Alcacer-Pitarch B, Del Galdo F. Clinical trajectories of hand function impairment in systemic sclerosis: an unmet clinical need across disease subsets. RMD Open 2024; 10:e003216. [PMID: 38216288 PMCID: PMC10806527 DOI: 10.1136/rmdopen-2023-003216] [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: 04/09/2023] [Accepted: 07/15/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Hand involvement is an early manifestation of systemic sclerosis (SSc), culprit of diagnosis and classification, and recognised major driver of disability. Impairment of hand function burdens both limited and diffuse cutaneous subsets and therefore could be targeted as 'basket' endpoint in SSc. Nevertheless, its natural history in current standard of care is not well characterised, limiting the design of targeted trials. The aim of this study is to describe prevalence, natural history and clinical factors associated with hand function deterioration in a longitudinal, multicentre, observational SSc cohort. METHODS Hand function was captured through the validated Cochin Hand Function Scale in patients consecutively enrolled in a multicentre observational study and observed over 24 months. Minimal clinically important differences and patient acceptable symptom state were analysed as previously described. RESULTS Three hundred and ninety-six consecutive patients were enrolled from 10 centres; 201 with complete follow-up data were included in the analysis. Median (IQR) disease duration was 5 (2-11) years. One hundred and five (52.2%) patients reported clinically significant worsening. Accordingly, the proportion of patients reporting unacceptable hand function increased over 2 years from 27.8% to 35.8% (p<0.001). Least absolute shrinkage and selection operator analysis identified male gender, disease subset, Raynaud's Condition Score, tenosynovitis and pain, as some of the key factors associated with worsening hand involvement. CONCLUSIONS Hand function deteriorates over time in more than 50% of SSc patients despite available therapies. The analysis of factors associated with hand function worsening supports the involvement of both inflammation, vascular and fibrotic processes in hand involvement, making it a hallmark clinical manifestation of SSc. Our data are poised to inform the design of intervention studies to target this major driver of disability in SSc.
Collapse
Affiliation(s)
- Enrico De Lorenzis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Vishal Kakkar
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Stefano Di Donato
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Michelle Wilson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Theresa Barnes
- Department of Rheumatology, Countess of Chester Hospital NHS Foundation Trust, Liverpool, UK
| | - Chris Denton
- Department of Rheumatology, Royal Free London NHS Foundation Trust, London, UK
| | - Emma Derrett-Smith
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karen Douglas
- Department of Rheumatology, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Philip Helliwell
- Department of Rheumatology, St. Luke's Hospital, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust,Manchester Academic Health Science Centre, Manchester, UK
| | - Benazir Saleem
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Department of Rheumatology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Muhammad Nisar
- Department of Rheumatology, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Catherine Morley
- Department of Rheumatology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lorraine Green
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Begonya Alcacer-Pitarch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
3
|
Çevik R, Em S, Nas K, Toprak M, Cengiz G, Çalış M, Sezer İ, Ünal Enginar A, Bora Karslı P, Sağ S, Sargın B, Alkan Melikoğlu M, Aydın Y, Tuncay Duruöz M, Hande Gezer H, Ecesoy H. Association of pain and clinical factors on disability and quality of life in systemic sclerosis: A cross-sectional study from Turkish League Against Rheumatism Network. Arch Rheumatol 2023; 38:9-21. [DOI: 10.46497/archrheumatol.2023.9243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/21/2021] [Indexed: 03/18/2023] Open
Abstract
Objectives: In this study, we aimed to evaluate the factors associated with disability and quality of life (QoL) in Turkish patients with systemic sclerosis (SSc).
Patients and methods: Between January 2018 and January 2019, a total of 256 SSc patients (20 males, 236 females; mean age: 50.9±12.4 years; range, 19 to 87 years) who were diagnosed with SSc were included in the study. Disability and health-related QoL (HRQoL) were evaluated by the Health Assessment Questionnaire (HAQ), scleroderma HAQ (SHAQ), Duruöz Hand Index (DHI), and Short Form-36 (SF-36). Linear regression analysis methods were used to describe factors associated with disability and QoL of the patients.
Results: All disability scores were higher and HRQoL scores were lower in diffuse cutaneous SSc patients compared limited cutaneous SSc, and differentiations were significant (p=0.001 and p=0.007). In multiple regression, pain (VAS) was the strongest predictor for high disability and low QoL scores (p<0.001) as HAQ (β=0.397, 0.386, 0.452), SHAQ (β=0.397, 0.448, 0.372), DHI (β=0.446, 0.536, 0.389), PCS (β=-0.417,-0.499, -0.408) and MCS (β=-0.478, -0.441, -0.370) in combined, lcSSc and dcSSc patients respectively. The factors associated with high disability and low QoL scores were forced vital capacity for HAQ (β=-0.172, p=0.002) and SF-36 PCS (β=0.187, p=0.001); disease duration for HAQ (β=0.208, p<0.001), DHI (β=0.147, p=0.006), and SF-36 PCS (β=-0.134, p=0.014); 6-minute walk test for HAQ (β=-0.161, p=0.005) and SF-36 PCS (β=0.153, p=0.009); and modified Rodnan skin score for SHAQ (β=0.250, p<0.001) and DHI (β=0.233, p<0.001) in SSc patients. Diffusing capacity of the lungs for carbon monoxide for HAQ (β=-0.189, p=0.010) and SHAQ (β=-0.247, p=0.002); erythrocyte sedimentation rate for DHI (β=0.322, p<0.001); age for SF-36 PCS (β=-0.221, p=0.003) and body mass index for SF-36 PCS (β=-0.200, p=0.008) and MCS (β=-0.175, p=0.034) were the other variables associated with high disability or low QoL scores in SSc subsets.
Conclusion: Clinicians should consider the management of the pain and its sources as a key to improve better functional state and quality of daily life in SSc.
Collapse
|
4
|
Poole JL, Forno K, Prokopiak A, Skipper B. Importance and difficulty with valued life activities for people with systemic sclerosis. Disabil Rehabil 2023; 45:220-225. [PMID: 35104183 DOI: 10.1080/09638288.2022.2028910] [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] [Indexed: 01/12/2023]
Abstract
PURPOSE To identify the importance of and difficulty with valued activities in persons with systemic sclerosis (SSc) and to examine relationships between disease symptoms and difficulty with valued activities using the Valued Activities Scale (VLA). A secondary purpose was to examine the internal consistency of the Short-VLA Scale (S-VLA). METHODS A cross-sectional convenience sample of 99 people with SSc completed questionnaires regarding demographics, symptom severity, Health Assessment Questionnaire (HAQ), Center for Epidemiologic Studies Depression Scale (CES-D), and the VLA. RESULTS Obligatory activities were rated as most important; committed activities were significantly more difficult than obligatory and discretionary. Less fatigue (p < 0.01) and lower HAQ (p < 0.001) and CES-D (p < 0.01) scores were associated with higher total VLA scores. Internal consistency of the S-VLA was excellent (Cronbach's alpha = 0.92; p < 0.0001). The correlation between the S-VLA and the VLA was excellent (r = 0.96; p < 0.001). There were moderate correlations between the S-VLA and the HAQ (r = 0.73; p < 0.0001); the correlation with the CES-D was only fair (r = 0.35; p < 0.001). CONCLUSIONS Committed and discretionary activities were more difficult for people with SSc to perform. Results are similar to findings with people with rheumatoid arthritis and systemic lupus erythematosus.IMPLICATIONS FOR REHABILITATIONHome management/caregiving (committed) and leisure and social participation (discretionary) activities are more difficult to perform by people with SSc compared to self-care (obligatory) activities.Our findings that difficulty scores on the VLA were associated with more fatigue and depression suggest the need for rehabilitation to reduce disability in people with SSc.The S-VLA may be a useful screening and monitoring tool for SSc and other chronic conditions.
Collapse
Affiliation(s)
- Janet L Poole
- Occupational Therapy Graduate Program, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Betty Skipper
- Department of Family and Community Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW The aim of this review is to give an update on advances in evaluation and management of systemic sclerosis (SSc)-related Raynaud's phenomenon and digital ulceration, focusing on reports from the last 18 months. The increasing recognition of the huge impact of Raynaud's phenomenon and of digital ulceration on the everyday lives of patients with SSc has sparked enthusiasm internationally to develop better outcome measures and better treatments, and so a review is timely. RECENT FINDINGS There have been recent advances in the development of patient reported outcome instruments [e.g. the Hand Disability in Systemic Sclerosis-Digital Ulcers (HDISS-DU) instrument] and also in noninvasive imaging techniques, including thermography and laser Doppler methods. Improved outcome measures will facilitate future clinical trials, both early phase proof-of-concept and later phase trials. New insights have been gained into mechanisms of action and methods of administration of 'conventional' therapies, for example phosphodiesterase inhibitors and intravenous prostanoids. New treatment approaches are being investigated, including topical and procedural therapies. SUMMARY Clinicians can look forward to seeing these advances translating into clinical benefit over the next 5 years. To help ensure this, they should strive whenever possible to recruit patients with SSc-related digital vasculopathy into observational studies and clinical trials.
Collapse
|
6
|
Xiang L, Kua SM, Low AH. Work Productivity and Economic Burden of Systemic Sclerosis in a Multi-Ethnic Asian Population. Arthritis Care Res (Hoboken) 2020; 74:818-827. [PMID: 33253494 PMCID: PMC9314801 DOI: 10.1002/acr.24521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/28/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess work productivity, identify associated factors and evaluate the economic burden of systemic sclerosis (SSc) in a multi-ethnic Asian population. METHODS Data on employment status and work productivity loss were collected. Associations between demographic and disease characteristics and unemployment status, work productivity loss and activity impairment were examined using logistic and linear regression analyses, as appropriate. Costs of unemployment and work productivity loss were estimated using the human capital approach. RESULTS Of 111 patients with a mean disease duration of 9.1 years, 33 (29.7%) were unemployed. Their mean age at unemployment was 44.2 years, equating to 22.8 years of lost employment. No demographic and disease characteristics were significantly associated with unemployment status in multivariable analysis. Of 73 employed patients, 39 (53.4%) reported work productivity loss, accounting for 45.9% of the working week. Presence of hyperlipidemia (coefficient= -19.01, p=0.03) was associated with work productivity loss in multivariable analysis. Of 78 employed and 33 unemployed patients, 37 (47.4%) and 19 (57.6%) reported activity impairment, accounting for 42.2% and 50.0% of the preceding week, respectively. Presence of hyperlipidemia (coefficient= -18.56, p<0.01) was associated with activity impairment in multivariable analysis. Annual cost of unemployment and work productivity loss were estimated to be SGD$53,244 and SGD$13,045 per patient, respectively. CONCLUSION SSc imposes significant unemployment and work productivity loss and causes substantial economic burden to both affected individuals and society. Modifying the identified factors associated with unemployment and work productivity loss may reduce the burden of SSc.
Collapse
Affiliation(s)
- Ling Xiang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sandra My Kua
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Andrea Hl Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
7
|
Hughes M, Alcacer-Pitarch B, Allanore Y, Baron M, Boin F, Bruni C, Chung L, Del Galdo F, Denton CP, Matucci-Cerinic M. Digital ulcers: should debridement be a standard of care in systemic sclerosis? THE LANCET. RHEUMATOLOGY 2020; 2:e302-e307. [PMID: 38273475 DOI: 10.1016/s2665-9913(19)30164-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 01/02/2023]
Abstract
Digital ulcers are a serious, recurrent complication in patients with systemic sclerosis. They are often slow to heal and exquisitely painful. Local wound care, such as debridement of the wound bed, is an essential component in the management of digital ulcers in systemic sclerosis. However, digital ulcer debridement is not a standard of care, and there is substantial international variation in the use of this approach. In this Viewpoint, we discuss the assessment of the wound bed and different methods of debridement using the model of tissue management, infection and inflammation, moisture control, and wound edge or epidermal advancement, known as TIME. We highlight the challenges in standard practice and the need for research into local wound care for this type of ulceration, before suggesting a potential roadmap to develop a standardised approach to support ulcer debridement in systemic sclerosis. Debridement might be the missing component in optimising the management of digital ulcers and we propose that the approach should be rigorously investigated as a standard of care in this common complication of systemic sclerosis.
Collapse
Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Begonya Alcacer-Pitarch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Murray Baron
- Division of Rheumatology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Biomedical Research Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Christopher P Denton
- Department of Rheumatology, Royal Free Hospital, University College London, London, UK
| | - Marco Matucci-Cerinic
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|