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David M, Dieude P, Debray MP, Le Guen P, Crestani B, Borie R. [Low-dose methotrexate: Indications and side effects, particularly in cases of diffuse interstitial pneumonia]. Rev Mal Respir 2024:S0761-8425(24)00234-1. [PMID: 39025770 DOI: 10.1016/j.rmr.2024.06.008] [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: 11/25/2023] [Accepted: 06/09/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Methotrexate (MTX) is a folate antagonist used as an immunosuppressant in a number of conditions, including rheumatoid arthritis (RA). Low-dose MTX (MTX-LD) is associated with a risk of haematological, hepatic, gastrointestinal and pulmonary toxicity, which may up until now have limited its use. STATE OF THE ART In RA, data from retrospective cohorts have reported a possible excess risk of methotrexate toxicity in cases of underlying interstitial lung disease (ILD). However, recent prospective and retrospective multicentre studies have found no such increased risk, and have reassuringly concluded that MTX-LD can be prescribed in cases of RA-associated ILD (RA-ILD). PERSPECTIVES AND CONCLUSIONS Current recommendations are not to delay the introduction of MTX in patients with RA at risk of developing ILD or in the presence of RA-ILD with mild to moderate respiratory impairment.
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Affiliation(s)
- M David
- Service de pneumologie A, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Cité, Inserm, PHERE, 75018 Paris, France.
| | - P Dieude
- Université Paris Cité, Inserm, PHERE, 75018 Paris, France; Service de rhumatologie A, hôpital Bichat, AP-HP, Paris, France
| | - M P Debray
- Service de radiologie, hôpital Bichat, AP-HP, Paris, France
| | - P Le Guen
- Service de pneumologie A, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Cité, Inserm, PHERE, 75018 Paris, France
| | - B Crestani
- Service de pneumologie A, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Cité, Inserm, PHERE, 75018 Paris, France
| | - R Borie
- Service de pneumologie A, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Cité, Inserm, PHERE, 75018 Paris, France
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2
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Pugashetti JV, Lee JS. Overview of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Its Treatment. Semin Respir Crit Care Med 2024; 45:329-341. [PMID: 38484788 DOI: 10.1055/s-0044-1782218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Interstitial lung disease (ILD) is a common pulmonary complication of rheumatoid arthritis (RA), causing significant morbidity and mortality. Optimal treatment for RA-ILD is not yet well defined. Reliable prognostic indicators are largely byproducts of prior ILD progression, including low or decreasing forced vital capacity and extensive or worsening fibrosis on imaging. In the absence of validated tools to predict treatment response, decisions about whether to initiate or augment treatment are instead based on clinical judgment. In general, treatment should be initiated in patients who are symptomatic, progressing, or at high risk of poor outcomes. Retrospective data suggest that mycophenolate mofetil, azathioprine, and rituximab are likely effective therapies for RA-ILD. Abatacept is also emerging as a potential first-line treatment option for patients with RA-ILD. Further, recent data demonstrate that immunosuppression may be beneficial even in patients with a usual interstitial pneumonia (UIP) pattern on imaging, suggesting that immunosuppression should be considered irrespective of imaging pattern. Recent randomized controlled trials have shown that antifibrotic medications, such as nintedanib and likely pirfenidone, slow forced vital capacity decline in RA-ILD. Consideration can be given to antifibrotic initiation in patients progressing despite immunosuppression, particularly in patients with a UIP pattern. Future research directions include developing tools to predict which patients will remain stable from patients who will progress, discriminating patients who will respond to treatment from nonresponders, and developing algorithms for starting immunosuppression, antifibrotics, or both as first-line therapies.
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Affiliation(s)
- Janelle Vu Pugashetti
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Joyce S Lee
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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3
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Xie M, Zhu C, Ye Y. Incidence, risk factors, and prognosis of acute exacerbation of rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis. BMC Pulm Med 2023; 23:255. [PMID: 37434169 DOI: 10.1186/s12890-023-02532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Acute exacerbation (AE) is a devastating complication of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and leads to high mortality. This study aimed to investigate the incidence, risk factors, and prognosis of acute exacerbation of rheumatoid arthritis-associated interstitial lung disease (AE-RA-ILD). METHODS PubMed, EMBASE, Web of Science, and Medline were searched through 8 February 2023. Two independent researchers selected eligible articles and extracted available data. The Newcastle Ottawa Scale was used to assess the methodological quality of studies used for meta-analysis. The incidence and prognosis of AE-RA-ILD were investigated. Weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) and pooled odds ratios (ORs) with 95% CIs were calculated to explore the risk factors of AE in RA-ILD. RESULTS Twenty-one of 1,589 articles were eligible. A total of 385 patients with AE-RA-ILD, of whom 53.5% were male, were included. The frequency of AE in patients with RA-ILD ranged from 6.3 to 55.6%. The 1-year and 5-year AE incidences were 2.6-11.1% and 11-29.4%, respectively. The all-cause mortality rate of AE-RA-ILD was 12.6-27.9% at 30 days and 16.7-48.3% at 90 days. Age at RA diagnosis (WMD: 3.61, 95% CI: 0.22-7.01), male sex (OR: 1.60, 95% CI:1.16-2.21), smoking (OR: 1.50, 95% CI: 1.08-2.08), lower forced vital capacity predicted (FVC%; WMD: -8.63, 95% CI: -14.68 to - 2.58), and definite usual interstitial pneumonia (UIP) pattern (OR: 1.92, 95% CI: 1.15-3.22) were the risk factors of AE-RA-ILD. Moreover, the use of corticosteroids, methotrexate, and biological disease-modifying anti-rheumatic drugs, was not associated with AE-RA-ILD. CONCLUSION AE-RA-ILD was not rare and had a poor prognosis. Age at RA diagnosis, male sex, smoking, lower FVC%, and definite UIP pattern increased the risk of AE-RA-ILD. The use of medications, especially methotrexate and biological disease-modifying anti-rheumatic drugs, may not be related to AE-RA-ILD. REGISTRATION CRD42023396772.
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Affiliation(s)
- Maosheng Xie
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chao Zhu
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yujin Ye
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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4
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Andronache IT, Şuţa VC, Şuţa M, Ciocodei SL, Vladareanu L, Nicoara AD, Arghir OC. Better Safe than Sorry: Rheumatoid Arthritis, Interstitial Lung Disease, and Medication-A Narrative Review. Biomedicines 2023; 11:1755. [PMID: 37371850 DOI: 10.3390/biomedicines11061755] [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: 05/15/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
It is well known that rheumatoid arthritis (RA) patients are at an increased risk of developing non-infectious pulmonary complications, especially interstitial lung disease (ILD); however, the clinician must keep in mind that lung disease could not only be a manifestation of the underlying condition, but also a consequence of using disease-modifying therapies. New-onset ILD or ILD worsening has also been reported as a possible consequence of both conventional disease-modifying antirheumatic drugs (DMARDs) and biologic agents. This study is a narrative review of the current literature regarding the potential risk of developing interstitial lung disease along with the administration of specific drugs used in controlling rheumatoid arthritis. Its purpose is to fill knowledge gaps related to this challenging patient cohort by addressing various aspects of the disease, including prevalence, disease features, treatment strategies, and patient outcomes.
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Affiliation(s)
- Iulia-Tania Andronache
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
- Department of Rheumatology, Internal Medicine Clinic, "Dr. Alexandru Gafencu" Military Emergency Hospital Constanta, 900527 Constanta, Romania
| | - Victoria-Cristina Şuţa
- 3rd Department-1st Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Maria Şuţa
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Sabina-Livia Ciocodei
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Liliana Vladareanu
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Alina Doina Nicoara
- 3rd Department-1st Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Oana Cristina Arghir
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
- 4th Department-2nd Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
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5
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Damiani G, Amerio P, Bardazzi F, Carrera CG, Conti A, Cusano F, Dapavo P, DeSimone C, El Hachem M, Fabbrocini G, Gisondi P, Loconsole F, Micali G, Neri I, Parodi A, Piaserico S, Romanelli M, Stingeni L, Pigatto PDM. Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00930-2. [PMID: 37210684 DOI: 10.1007/s13555-023-00930-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/17/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND After decades of use, methotrexate displays an established safety and efficacy profile in both in-hospital and outpatient settings. Despite its widespread use, there is surprisingly little clinical evidence to guide daily practice with methotrexate in dermatology. OBJECTIVES To provide guidance for clinicians in daily practice for areas in which there is limited guidance. METHODS A Delphi consensus exercise on 23 statements was carried out on the use of methotrexate in dermatological routine settings. RESULTS Consensus was reached on statements that cover six main areas: (1) pre-screening exams and monitoring of therapy; (2) dosing and administration in patients naïve to methotrexate; (3) optimal strategy for patients in remission; (4) use of folic acid; (5) safety; and (6) predictors of toxicity and efficacy. Specific recommendations are provided for all 23 statements. CONCLUSIONS In order to optimize methotrexate efficacy, it is essential to optimize treatment using appropriate dosages, carrying out a rapid drug-based step-up on a treat-to-target strategy and preferably using the subcutaneous formulation. To manage safety aspects appropriately, it is essential to evaluate patients' risk factors and carry out proper monitoring during the course of treatment.
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Affiliation(s)
- Giovanni Damiani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy.
- Italian Center of Precisione Medicine and Chronic Inflammation, University of Milan, Milan, Italy.
- UOC Dermatology, Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161, Milan, Italy.
| | - Paolo Amerio
- Dermatologic Clinic, Department of Medicine and Aging Science, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Federico Bardazzi
- Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo G Carrera
- Fondazione Cà Granda IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Andrea Conti
- Dermatology Unit, Ospedale Infermi di Rimini, AUSL Romagna, Rimini, Italy
| | | | - Paolo Dapavo
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Clara DeSimone
- DermatologiaDipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - May El Hachem
- Dermatology Unit and Genodermatosis Research Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Francesco Loconsole
- Department of Biomedical Sciences and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | | | - Iria Neri
- Dermatology, Sant'Orsola-Malpighi Polyclinic University Hospital-IRCCS, University of Bologna, Bologna, Italy
| | - Aurora Parodi
- Dermatology Clinic, DISSAL, Polyclinic Hospital San Martino-IRCCS, University of Genoa, Genoa, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Luca Stingeni
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Paolo D M Pigatto
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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6
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Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
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Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
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7
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Wang Y, Chen T, Yang C, Li Q, Ma M, Xu H, Shi Q, Wang Y, Wang Y, Liang Q. Huangqi Guizhi Wuwu Decoction Improves Arthritis and Pathological Damage of Heart and Lung in TNF-Tg Mice. Front Pharmacol 2022; 13:871481. [PMID: 35600883 PMCID: PMC9114745 DOI: 10.3389/fphar.2022.871481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Huangqi Guizhi Wuwu Decoction (HGWD) is a traditional and effective Chinese medicine compound decoction for the treatment of rheumatoid arthritis (RA). However, there is few research on the treatment of rheumatoid cardiopulmonary complications. The present study was to study whether HGWD can alleviate the pathological changes caused by rheumatoid arthritis and cardiopulmonary complications. Methods: Five 3-month-old TNF-Tg mice were treated with HGWD (9.1 g/kg) once a day or the same dose of normal saline lasted for 8 weeks, and wild-type littermates of the same age were used as a negative control, and methotrexate (MTX) was intraperitoneally administered as a positive control. After the treatment, pathological staining was performed on the mouse ankle joints, heart, and lungs. Result: It was found that HGWD reduced the inflammation of the ankle joint synovium in TNF-Tg mice, and reduced myocardial hypertrophy, inflammatory infiltration and fibrosis of heart, as well as lung inflammation and fibrosis. Immunohistochemical staining with anti-TNF-α antibody showed that HGWD reduced the expression of TNF-α in the heart of TNF-Tg mice. Conclusion: In conclusion, HGWD alleviates joint inflammation in TNF-Tg mice and reduces the pathological changes of the heart and lungs.
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Affiliation(s)
- Yi Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Cardiovascular Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Tao Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Central Hospital of Jing'an District, Fudan University, Shanghai, China
| | - Can Yang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qiang Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengjiao Ma
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Cardiovascular Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hao Xu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qi Shi
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yongjun Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Youhua Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Cardiovascular Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qianqian Liang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Spine Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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8
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AlAmeel T, Al Sulais E, Raine T. Methotrexate in inflammatory bowel disease: A primer for gastroenterologists. Saudi J Gastroenterol 2022; 28:250-260. [PMID: 35042318 PMCID: PMC9408741 DOI: 10.4103/sjg.sjg_496_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Methotrexate is an antineoplastic agent that is also used at lower doses for anti-inflammatory properties. Along with thiopurines (azathioprine and 6-mercaptopurine), it has historically been an important part of pharmacological treatment for patients with inflammatory bowel disease. Despite an increase in therapeutic options, these immunomodulators continue to play important roles in the management of inflammatory bowel disease, used either as a monotherapy in mild to moderate cases or in combination with monoclonal antibodies to prevent immunogenicity and maintain efficacy. In light of data linking the use of thiopurines with the risk of malignancies, methotrexate has regained attention as a potential alternative. In this article, we review data on the pharmacology, safety, and efficacy of methotrexate and discuss options for the positioning of methotrexate alone, or in combination, in therapeutic algorithms for Crohn's disease and ulcerative colitis.
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Affiliation(s)
- Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Eman Al Sulais
- Division of Gastroenterology, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK,Address for correspondence: Dr. Eman Al Sulais, Division of Gastroenterology, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK. E-mail:
| | - Tim Raine
- Division of Gastroenterology, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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9
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van den Bosch L, Luppi F, Ferrara G, Mura M. Immunomodulatory treatment of interstitial lung disease. Ther Adv Respir Dis 2022; 16:17534666221117002. [PMID: 35938712 PMCID: PMC9364223 DOI: 10.1177/17534666221117002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) have an array of immunomodulatory treatment options compared with IPF, due to their inflammatory component. However, there is a relative paucity of guidance on the management of this heterogeneous group of diseases. In ILDs other than IPF, immunosuppression is the cornerstone of therapy, with varying levels of evidence for different immunomodulatory agents and for each specific ILD. Classification of ILDs is important for guiding treatment decisions. Immunomodulatory agents mainly include corticosteroids, mycophenolate mofetil (MMF), azathioprine, methotrexate, cyclophosphamide and rituximab. In this review, the available evidence for single agents in the most common ILDs is first discussed. We then reviewed practical therapeutic approaches in connective tissue disease-related ILD and interstitial pneumonia with autoimmune features, scleroderma-related ILD, vasculitis and dermatomyositis with hypoxemic respiratory failure, idiopathic non-specific interstitial pneumonia, hypersensitivity pneumonitis sarcoidosis, fibrosing organizing pneumonia and eosinophilic pneumonia. The treatment of acute exacerbations of ILD is also discussed. Therapy augmentation in ILD is dictated by the recognition of progression of disease. Criteria for the evaluation of progression of disease are then discussed. Finally, specific protocol and measures to increase patients' safety are reviewed as well, including general monitoring and serologic surveillance, Pneumocystis jirovecii prophylaxis, patients' education, genetic testing for azathioprine, MMF serum levels and cyclophosphamide administration protocols. Immunomodulatory therapies are largely successful in the management of ILDs and can be safely managed with the application of specific protocols, precautions and monitoring.
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Affiliation(s)
| | - Fabrizio Luppi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marco Mura
- London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Room E6-203, London, ON N6A 5W9, Canada
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10
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Vinicki JP, Papagno MJ, Estevez AJ. Methotrexate-Induced Pneumonitis in Rheumatoid Arthritis: Long-term Treatment With Tofacitinib Therapy. J Clin Rheumatol 2021; 27:S426-S427. [PMID: 32053543 DOI: 10.1097/rhu.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Inokuma S. Search of official nationwide database in Japan for adverse events associated with disease-modifying antirheumatic drug therapies: focus on therapies in combination with methotrexate. Expert Opin Drug Saf 2021; 21:573-580. [PMID: 34762577 DOI: 10.1080/14740338.2022.2006180] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND Disease-modifying antirheumatic drugs (DMARDs) are essential for rheumatoid arthritis (RA) therapy. The adverse events (AEs) evaluation should focus on that methotrexate (MTX) is frequently prescribed in combination with others (combination MTX). METHODS A search of the website of the official Japanese Agency for AEs, including lymphoproliferative disease (LPD), cytopenia, interstitial pneumonia, infectious pneumonia other than Pneumocystis jirovecii pneumonia (PCP) (i-Pn), and PCP, associated with MTX, tacrolimus, adalimumab, tocilizumab, and abatacept therapies reported from 2014 to 2016 was performed. Number of each AE cases and its ratio to total number of AEs cases were examined. Combination MTX was checked for RA cases. RESULTS A total of 8874 cases were listed. In 3955 MTX cases, LPD was most frequent (36.4%). In any of the other four DMARDs cases, i-Pn was most frequent (4.2~15.3%); PCP cases showed most frequent combination MTX (94.4%). In total, including cases reported for MTX therapy, 98.2% of LPD and 97.6% of PCP cases had MTX, and less than 90% of the other AEs cases had MTX. CONCLUSION LPD was by far the most frequent AE associated with MTX therapy. PCP was strongly associated with combination MTX. For any of the other four DMARDs, i-Pn was most frequent.
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Affiliation(s)
- Shigeko Inokuma
- Chiba Central Medical Center; National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
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12
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Furukawa H, Oka S, Higuchi T, Shimada K, Hashimoto A, Matsui T, Tohma S. Biomarkers for interstitial lung disease and acute-onset diffuse interstitial lung disease in rheumatoid arthritis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211022506. [PMID: 34211592 PMCID: PMC8216360 DOI: 10.1177/1759720x211022506] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/11/2021] [Indexed: 12/31/2022] Open
Abstract
Interstitial lung disease (ILD) is frequently a complication of rheumatoid arthritis (RA) as an extra-articular manifestation which has a poor prognosis. Acute-onset diffuse ILD (AoDILD) occasionally occurs in RA and includes acute exacerbation of ILD, drug-induced ILD, and Pneumocystis pneumonia. AoDILD also confers a poor prognosis in RA. Previously-established biomarkers for ILD include Krebs von den lungen-6 and surfactant protein-D originally defined in patients with idiopathic pulmonary fibrosis; the sensitivity of these markers for RA-associated ILD (RA-ILD) is low. Although many studies on ILD markers have been performed in idiopathic pulmonary fibrosis, only a few validation studies in RA-ILD or AoDILD have been reported. Biomarkers for RA-ILD and AoDILD are thus still required. Recently, genomic, cytokine, antibody, and metabolomic profiles of RA-ILD or AoDILD have been investigated with the aim of improving biomarkers. In this review, we summarize current preliminary data on these potential biomarkers for RA-ILD or AoDILD. The development of biomarkers on RA-ILD has only just begun. When validated, such candidate biomarkers will provide valuable information on pathogenesis, prognosis, and drug responses in RA-ILD in future.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Rheumatology, National Hospital Organization Tokyo National Hospital, 3-1-1 Takeoka, Kiyose 204-8585, Japan
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
| | - Shomi Oka
- Department of Rheumatology, National Hospital Organization Tokyo National Hospital, Kiyose, Japan
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
| | - Takashi Higuchi
- Department of Rheumatology, National Hospital Organization Tokyo National Hospital, Kiyose, Japan
- Department of Nephrology, Ushiku Aiwa General Hospital, Ushiku, Japan
| | - Kota Shimada
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Atsushi Hashimoto
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
- Department of Internal Medicine, Sagami Seikyou Hospital, Minami-ku, Sagamihara, Japan
| | - Toshihiro Matsui
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
| | - Shigeto Tohma
- Department of Rheumatology, National Hospital Organization Tokyo National Hospital, Kiyose, Japan
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Minami-ku, Sagamihara, Japan
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13
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Cano-Jiménez E, Vázquez Rodríguez T, Martín-Robles I, Castillo Villegas D, Juan García J, Bollo de Miguel E, Robles-Pérez A, Ferrer Galván M, Mouronte Roibas C, Herrera Lara S, Bermudo G, García Moyano M, Rodríguez Portal JA, Sellarés Torres J, Narváez J, Molina-Molina M. Diagnostic delay of associated interstitial lung disease increases mortality in rheumatoid arthritis. Sci Rep 2021; 11:9184. [PMID: 33911185 PMCID: PMC8080671 DOI: 10.1038/s41598-021-88734-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/15/2021] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease whose main extra-articular organ affected is the lung, sometimes in the form of diffuse interstitial lung disease (ILD) and conditions the prognosis. A multicenter, observational, descriptive and cross-sectional study of consecutive patients diagnosed with RA-ILD. Demographic, analytical, respiratory functional and evolution characteristics were analyzed to evaluate the predictors of progression and mortality. 106 patients were included. The multivariate analysis showed that the diagnostic delay was an independent predictor of mortality (HR 1.11, CI 1.01-1.23, p = 0.035). Also, age (HR 1.33, 95% CI 1.09-1.62, p = 0.0045), DLCO (%) (HR 0.85, 95% CI 0.73-0.98, p = 0.0246), and final SatO2 (%) in the 6MWT (HR 0.62, 95% CI 0.39-0.99, p = 0.0465) were independent predictor variables of mortality, as well as GAP index (HR 4.65, 95% CI 1.59-13.54, p = 0.0051) and CPI index (HR 1.12, 95% CI 1.03-1.22, p = 0.0092). The withdrawal of MTX or LFN after ILD diagnosis was associated with disease progression in the COX analysis (HR 2.18, 95% CI 1.14-4.18, p = 0.019). This is the first study that highlights the diagnostic delay in RA-ILD is associated with an increased mortality just like happens in IPF.
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Affiliation(s)
- Esteban Cano-Jiménez
- Hospital Universitario Lucus Augusti, Rúa Dr. Ulises Romero, 1, 27003, Lugo, Spain.
| | | | - Irene Martín-Robles
- Hospital Universitario Lucus Augusti, Rúa Dr. Ulises Romero, 1, 27003, Lugo, Spain
| | | | | | | | - Alejandro Robles-Pérez
- Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet del Llobregat, Barcelona, Spain
| | | | | | | | - Guadalupe Bermudo
- Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet del Llobregat, Barcelona, Spain
| | | | | | | | - Javier Narváez
- Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet del Llobregat, Barcelona, Spain
| | - María Molina-Molina
- Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet del Llobregat, Barcelona, Spain
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14
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Venetsanopoulou AI, Markatseli TE, Iliou C, Tziortzioti Z, Argyropoulou MI, Drosos AA, Voulgari PV. Pleural effusion in psoriatic arthritis patients: a case series and review of the literature. Clin Rheumatol 2021; 40:4741-4748. [PMID: 33782750 DOI: 10.1007/s10067-021-05712-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/02/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Abstract
Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis. Pulmonary involvement is a rare extra-articular manifestation of the disease characterized by rigidity of the chest wall and apical pulmonary fibrosis. Pleural effusion is uncommon in PsA. We present four cases of patients with PsA who developed pleural effusions. We report for the first time a PsA patient who was drug-naïve and developed unilateral pleuritis. We also describe one PsA case with pleuritis while he was on methotrexate (MTX) and two PsA cases on tumor necrosis factor (TNF) inhibitors. The literature review revealed six cases with pleural effusion, which were drug-induced. These patients presented pleural effusions while they were treated with MTX (2 patients) and TNF inhibitors (4 patients). In PsA patients with pleuritis, a detailed investigation to rule out infections is necessary. In addition, increased pharmacovigilance will detect cases of drug-induced serositis.
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Affiliation(s)
- Aliki I Venetsanopoulou
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - Theodora E Markatseli
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - Chrisoula Iliou
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - Zoi Tziortzioti
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - Maria I Argyropoulou
- Department of Clinical Radiology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece
| | - Paraskevi V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, 45110, Ioannina, Greece.
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15
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Cottin V, Bendstrup E, Bonniaud P, Nasser M, Spagnolo P, Valenzuela C, Kolb M. The case of methotrexate and the lung: Dr Jekyll and Mr Hyde. Eur Respir J 2021; 57:57/2/2100079. [PMID: 33574052 DOI: 10.1183/13993003.00079-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Vincent Cottin
- Dept of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,University of Lyon, INRAE, IVPC, Lyon, France
| | - Elizabeth Bendstrup
- Center for Rare Lung Diseases, Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Philippe Bonniaud
- Constitutive Reference Center for Rare Pulmonary Diseases, Dept of Pulmonary Medicine and Intensive Care Unit, University Hospital, Bourgogne-Franche-Comté, Burgundy University, Inserm 1231, Dijon, France
| | - Mouhamad Nasser
- Dept of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,University of Lyon, INRAE, IVPC, Lyon, France
| | - Paolo Spagnolo
- Respiratory Disease Unit, Dept of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Claudia Valenzuela
- Pulmonology Dept, Hospital Universitario de la Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Martin Kolb
- Dept of Respiratory Medicine, Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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16
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Juge PA, Lee JS, Lau J, Kawano-Dourado L, Rojas Serrano J, Sebastiani M, Koduri G, Matteson E, Bonfiglioli K, Sawamura M, Kairalla R, Cavagna L, Bozzalla Cassione E, Manfredi A, Mejia M, Rodríguez-Henriquez P, González-Pérez MI, Falfán-Valencia R, Buendia-Roldán I, Pérez-Rubio G, Ebstein E, Gazal S, Borie R, Ottaviani S, Kannengiesser C, Wallaert B, Uzunhan Y, Nunes H, Valeyre D, Saidenberg-Kermanac'h N, Boissier MC, Wemeau-Stervinou L, Flipo RM, Marchand-Adam S, Richette P, Allanore Y, Dromer C, Truchetet ME, Richez C, Schaeverbeke T, Lioté H, Thabut G, Deane KD, Solomon JJ, Doyle T, Ryu JH, Rosas I, Holers VM, Boileau C, Debray MP, Porcher R, Schwartz DA, Vassallo R, Crestani B, Dieudé P. Methotrexate and rheumatoid arthritis associated interstitial lung disease. Eur Respir J 2021; 57:13993003.00337-2020. [PMID: 32646919 PMCID: PMC8212188 DOI: 10.1183/13993003.00337-2020] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/13/2020] [Indexed: 01/25/2023]
Abstract
QUESTION ADDRESSED BY THE STUDY Methotrexate (MTX) is a key anchor drug for rheumatoid arthritis (RA) management. Fibrotic interstitial lung disease (ILD) is a common complication of RA. Whether MTX exposure increases the risk of ILD in patients with RA is disputed. We aimed to evaluate the association of prior MTX use with development of RA-ILD. METHODS Through a case-control study design with discovery and international replication samples, we examined the association of MTX exposure with ILD in 410 patients with chronic fibrotic ILD associated with RA (RA-ILD) and 673 patients with RA without ILD. Estimates were pooled over the different samples using meta-analysis techniques. RESULTS Analysis of the discovery sample revealed an inverse relationship between MTX exposure and RA-ILD (adjusted OR 0.46, 95% CI 0.24-0.90; p=0.022), which was confirmed in the replication samples (pooled adjusted OR 0.39, 95% CI 0.19-0.79; p=0.009). The combined estimate using both the derivation and validation samples revealed an adjusted OR of 0.43 (95% CI 0.26-0.69; p=0.0006). MTX ever-users were less frequent among patients with RA-ILD compared to those without ILD, irrespective of chest high-resolution computed tomography pattern. In patients with RA-ILD, ILD detection was significantly delayed in MTX ever-users compared to never-users (11.4±10.4 years and 4.0±7.4 years, respectively; p<0.001). ANSWER TO THE QUESTION Our results suggest that MTX use is not associated with an increased risk of RA-ILD in patients with RA, and that ILD was detected later in MTX-treated patients.
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Affiliation(s)
- Pierre-Antoine Juge
- Dept of Rheumatology, DMU Locomotion, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France.,These authors contributed equally
| | - Joyce S Lee
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,These authors contributed equally
| | - Jessica Lau
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,These authors contributed equally
| | - Leticia Kawano-Dourado
- Pulmonary Division, Heart Institute (InCor) Medical School of the University of São Paulo, São Paulo, Brazil
| | - Jorge Rojas Serrano
- Unidad de Enfermedades del Intersticio Pulmonar y Reumatología, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosió Villegas, Ciudad de México, México
| | - Marco Sebastiani
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Gouri Koduri
- Rheumatology Dept, Southend University Hospital NHSFT, Southend-on-Sea, UK
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Dept of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Karina Bonfiglioli
- Division of Rheumatology, Medical School of the University of São Paulo, São Paulo, Brazil
| | - Marcio Sawamura
- Division of Radiology, Medical School of the University of São Paulo, São Paulo, Brazil
| | - Ronaldo Kairalla
- Pulmonary Division, Heart Institute (InCor) Medical School of the University of São Paulo, São Paulo, Brazil
| | - Lorenzo Cavagna
- University and IRCCS Policlinico S. Matteo Foundation of Pavia, Pavia, Italy
| | | | - Andreina Manfredi
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mayra Mejia
- Unidad de Enfermedades del Intersticio Pulmonar y Reumatología, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosió Villegas, Ciudad de México, México
| | | | - Montserrat I González-Pérez
- Unidad de Enfermedades del Intersticio Pulmonar y Reumatología, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosió Villegas, Ciudad de México, México
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Ciudad de México, México
| | - Ivette Buendia-Roldán
- Research Direction, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Ciudad de México, México
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Ciudad de México, México
| | - Esther Ebstein
- Dept of Rheumatology, DMU Locomotion, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Steven Gazal
- Dept of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Raphaël Borie
- Dept of Pulmonology, Centre de Référence des Maladies Pulmonaires Rares, INSERM UMR1152, DHU APOLLO, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Sébastien Ottaviani
- Dept of Rheumatology, DMU Locomotion, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Caroline Kannengiesser
- Dept of Genetics, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Benoît Wallaert
- CHRU de Lille, Service de Pneumologie et Immuno-Allergologie, Centre de compétence des maladies pulmonaires rares, FHU IMMINENT, Lille, France
| | - Yurdagul Uzunhan
- Dept of Pulmonology, Centre de Référence des Maladies Pulmonaires Rares, Inserm 1272, Hôpital Avicenne, APHP, Université Paris 13, Bobigny, France
| | - Hilario Nunes
- Dept of Pulmonology, Centre de Référence des Maladies Pulmonaires Rares, Inserm 1272, Hôpital Avicenne, APHP, Université Paris 13, Bobigny, France
| | - Dominique Valeyre
- Dept of Pulmonology, Centre de Référence des Maladies Pulmonaires Rares, Inserm 1272, Hôpital Avicenne, APHP, Université Paris 13, Bobigny, France
| | | | | | - Lidwine Wemeau-Stervinou
- CHRU de Lille, Service de Pneumologie et Immuno-Allergologie, Centre de compétence des maladies pulmonaires rares, FHU IMMINENT, Lille, France
| | | | | | - Pascal Richette
- AP-HP, Hôpital Lariboisière, Service de Rhumatologie, DMU Locomotion, Université de Paris, Paris, France.,INSERM, UMR_1132, Paris, France
| | - Yannick Allanore
- APHP, Hôpital Cochin, Service de Rhumatologie A, Université de Paris, Paris, France.,INSERM, U1016, UMR_8104, Paris, France
| | - Claire Dromer
- Service de Pneumologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | | | | | - Huguette Lioté
- APHP, Hôpital Tenon, Service de Pneumologie, Paris, France
| | - Gabriel Thabut
- APHP, Hôpital Bichat, INSERM 1152, Service de Pneumologie B, DHU FIRE, Université de Paris, Paris, France
| | - Kevin D Deane
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Tracy Doyle
- Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ivan Rosas
- Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - V Michael Holers
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine Boileau
- Dept of Genetics, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Marie-Pierre Debray
- Dept of Radiology, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France
| | - Raphaël Porcher
- Université de Paris, CRESS, INSERM, INRA, Paris, France.,Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel-Dieu, Paris, France
| | - David A Schwartz
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Bruno Crestani
- Dept of Genetics, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France.,These authors contributed equally
| | - Philippe Dieudé
- Dept of Rheumatology, DMU Locomotion, INSERM UMR1152, Hôpital Bichat-Claude Bernard, APHP, Université de Paris, Paris, France.,These authors contributed equally
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17
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Does methotrexate cause progressive fibrotic interstitial lung disease? A systematic review. Rheumatol Int 2021; 41:1055-1064. [PMID: 33515067 PMCID: PMC8079289 DOI: 10.1007/s00296-020-04773-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023]
Abstract
The aim is to evaluate the published evidence on whether methotrexate (MTX) use causes progressive fibrotic interstitial lung disease (fILD). This PRISMA-compliant systematic review has been registered electronically with PROSPERO 2018 ID CRD42018087838, Centre of review and dissemination at the University of York. A total of 29 articles met the inclusion criteria. Thirteen articles were found to support the claim that MTX causes fILD. They all had a low Downs and Black quality score (< 6/27). Their ‘risk of bias’ assessment scores indicated serious to critical risk of bias. The 16 articles rejecting the claim that MTX causes fILD were of higher quality as indicated by their Downs and Black score. Their ‘risk of bias’ assessment scores suggested only a low to moderate risk of bias. This systematic literature review supports the finding that MTX does not cause fILD in humans. Three studies suggest that MTX treatment may actually improve outcomes in patients with rheumatoid arthritis (RA) associated fILD by slowing down ILD progression.
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18
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Seeliger B, Prasse A. Immunomodulation in Autoimmune Interstitial Lung Disease. Respiration 2020; 99:819-829. [PMID: 33271551 DOI: 10.1159/000511200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/28/2020] [Indexed: 11/19/2022] Open
Abstract
Interstitial lung diseases (ILDs) associated with autoimmune or systemic disease are increasingly recognized and our pathophysiological understanding rapidly expanding. Treatment modalities, however, are still mainly driven by established disease-modifying antirheumatic drugs (DMARDs) where, despite decades of experience of their use in the underlying diseases such as rheumatoid arthritis, mostly ret-rospective data exist informing their effect on the course of interstitial lung disease (ILD). In recent years, randomized trials investigating the effects of biological DMARDs (bDMARDs) have been completed or are currently running, generating new treatment options for often relentlessly progressive diseases. Herein, we summarize the evidence and current use of both synthetic DMARDs and bDMARDs in the context of ILDs associated with autoimmune/systemic disease.
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Affiliation(s)
- Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School and Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany,
| | - Antje Prasse
- Department of Respiratory Medicine, Hannover Medical School and Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany.,Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
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19
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Sparks JA, Dellaripa PF, Glynn RJ, Paynter NP, Xu C, Ridker PM, Solomon DH. Pulmonary Adverse Events in Patients Receiving Low-Dose Methotrexate in the Randomized, Double-Blind, Placebo-Controlled Cardiovascular Inflammation Reduction Trial. Arthritis Rheumatol 2020; 72:2065-2071. [PMID: 32741143 DOI: 10.1002/art.41452] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/12/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We previously reported that low-dose methotrexate (MTX) was associated with an increased risk of pulmonary adverse events (AEs) in a large randomized, placebo-controlled trial. Herein, we report details on the predictors and severity of pulmonary AEs. METHODS We conducted a prespecified analysis of pulmonary AEs in the Cardiovascular Inflammation Reduction Trial. Adults with known cardiovascular disease and diabetes/metabolic syndrome were randomly allocated to receive low-dose MTX (target dose 15-20 mg/week) or placebo after a 6-8-week open-label run-in phase in which all patients received low-dose MTX. Individuals with systemic inflammatory diseases were excluded. Pulmonary AEs were adjudicated in a blinded manner. We described severe pulmonary AEs and examined associations of baseline characteristics with pulmonary AEs in patients receiving low-dose MTX. RESULTS A total of 2,391 subjects were randomized to receive low-dose MTX and 2,395 to receive placebo. There were 13 severe pulmonary AEs (0.5%) and 7 cases of possible pneumonitis (0.3%) in the low-dose MTX group, compared to 8 (0.3%) and 1 (<0.1%), respectively, in the placebo group. Among those randomized to receive low-dose MTX, risk factors for any pulmonary AE included female sex (hazard ratio [HR] 1.69 versus male sex [95% confidence interval (95% CI) 1.16-2.45]), white race (HR 2.35 versus other race [95% CI 1.03-5.36]), and insulin use (HR 1.60 versus non-use [95% CI 1.11-2.30]). The only risk factor for severe pulmonary AEs was older age at baseline (HR 1.09 per year increase [95% CI 1.02-1.16]). CONCLUSION In this large placebo-controlled trial, pulmonary AEs, including possible pneumonitis, were uncommon but were more likely to occur in those randomized to receive low-dose MTX. White race, older age, male sex, and insulin use were associated with an increased risk of pulmonary AEs in those receiving low-dose MTX.
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Affiliation(s)
- Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul F Dellaripa
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert J Glynn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nina P Paynter
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chang Xu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul M Ridker
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel H Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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20
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Dejcman D, Skowasch D, Pizarro C, Krause A, Thomas D, Schäfer VS. Pulmonary Manifestations of Rheumatoid Arthritis, Psoriatic Arthritis and Peripheral Spondyloarthritis: Prevalence, Diagnostic Approach and Treatment Options. Curr Rheumatol Rev 2020; 17:17-28. [PMID: 32888273 DOI: 10.2174/1573397116666200905122757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022]
Abstract
Interstitial lung disease (ILD) is the most common form of pulmonary impairment in patients with rheumatoid arthritis (RA). However, patients with RA or other arthritic diseases such as psoriatic arthritis (PsA) or peripheral spondyloarthritis (pSpA) are at a higher risk of developing several other pulmonary diseases, such as chronic obstructive lung disease (COPD), compared to patients without arthritis. This review aims at summarizing the current knowledge on the prevalence of pulmonary diseases in the above-mentioned forms of arthritis, the challenges faced by prevalence studies in detecting pulmonary diseases in patients with arthritis, as well as possible treatment options. Dyspnea, cough or other pulmonary symptoms in arthritis patients should prompt gradual diagnostic procedures considering pulmonary manifestations as a major cluster of differential diagnosis. However, treatment options often lack solid evidence-based guidelines and referrals to specialized centers are often necessary.
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Affiliation(s)
- Daniel Dejcman
- Department of Internal Medicine III - Oncology, Hematology, Immunology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Dirk Skowasch
- Department of Internal Medicine II - Cardiology, Angiology and Pulmonology, University Hospital Bonn, Bonn, Germany
| | - Carmen Pizarro
- Department of Internal Medicine II - Cardiology, Angiology and Pulmonology, University Hospital Bonn, Bonn, Germany
| | - Andreas Krause
- Rheumatology and Clinical Immunology, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Daniel Thomas
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Valentin Sebastian Schäfer
- Department of Internal Medicine III - Oncology, Hematology, Immunology and Rheumatology, University Hospital Bonn, Bonn, Germany
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Distefano G, Fanzone L, Palermo M, Tiralongo F, Cosentino S, Inì C, Galioto F, Vancheri A, Torrisi SE, Mauro LA, Foti PV, Vancheri C, Palmucci S, Basile A. HRCT Patterns of Drug-Induced Interstitial Lung Diseases: A Review. Diagnostics (Basel) 2020; 10:diagnostics10040244. [PMID: 32331402 PMCID: PMC7236658 DOI: 10.3390/diagnostics10040244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 12/11/2022] Open
Abstract
Interstitial Lung Diseases (ILDs) represent a heterogeneous group of pathologies, which may be related to different causes. A low percentage of these lung diseases may be secondary to the administration of drugs or substances. Through the PubMed database, an extensive search was performed in the fields of drug toxicity and interstitial lung disease. We have evaluated the different classes of drugs associated with pulmonary toxicity. Several different high resolution computed tomography (HRCT) patterns related to pulmonary drug toxicity have been reported in literature, and the most frequent ILDs patterns reported include Nonspecific Interstitial Pneumonia (NSIP), Usual Interstitial Pneumonia (UIP), Hypersensitivity Pneumonitis (HP), Organizing Pneumonia (OP), Acute Respiratory Distress Syndrome (ARDS), and Diffuse Alveolar Damage (DAD). Finally, from the electronic database of our Institute we have selected and commented on some cases of drug-induced lung diseases related to the administration of common drugs. As the imaging patterns are rarely specific, an accurate evaluation of the clinical history is required and a multidisciplinary approach—involving pneumologists, cardiologists, radiologists, pathologists, and rheumatologists—is recommended.
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Affiliation(s)
- Giulio Distefano
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
- Correspondence: ; Tel.: +39-338-5020-778
| | - Luigi Fanzone
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Monica Palermo
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Francesco Tiralongo
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Salvatore Cosentino
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Corrado Inì
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Federica Galioto
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Ada Vancheri
- Department of Clinical and Experimental Medicine, University of Catania, Regional Referral Centre for Rare Lung Disease, 95123 Catania, Italy; (A.V.); (S.E.T.)
| | - Sebastiano E. Torrisi
- Department of Clinical and Experimental Medicine, University of Catania, Regional Referral Centre for Rare Lung Disease, 95123 Catania, Italy; (A.V.); (S.E.T.)
| | - Letizia A. Mauro
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Pietro V. Foti
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Carlo Vancheri
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Stefano Palmucci
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
| | - Antonio Basile
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”-University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy; (L.F.); (M.P.); (F.T.); (S.C.); (C.I.); (F.G.); (L.A.M.); (P.V.F.); (C.V.); (S.P.); (A.B.)
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Solomon DH, Glynn RJ, Karlson EW, Lu F, Corrigan C, Colls J, Xu C, MacFadyen J, Barbhaiya M, Berliner N, Dellaripa PF, Everett BM, Pradhan AD, Hammond SP, Murray M, Rao DA, Ritter SY, Rutherford A, Sparks JA, Stratton J, Suh DH, Tedeschi SK, Vanni KMM, Paynter NP, Ridker PM. Adverse Effects of Low-Dose Methotrexate: A Randomized Trial. Ann Intern Med 2020; 172:369-380. [PMID: 32066146 PMCID: PMC7229518 DOI: 10.7326/m19-3369] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Low-dose methotrexate (LD-MTX) is the most commonly used drug for systemic rheumatic diseases worldwide and is the recommended first-line agent for rheumatoid arthritis. Despite extensive clinical use for more than 30 years, few data on adverse event (AE) rates derive from randomized, placebo-controlled trials, where both causality and magnitude of risk can be inferred. OBJECTIVE To investigate AE rates, risk, and risk differences comparing LD-MTX versus placebo. DESIGN Prespecified secondary analyses of a double-blind, placebo-controlled, randomized trial. (ClinicalTrials.gov: NCT01594333). SETTING North America. PARTICIPANTS Adults with known cardiovascular disease and diabetes or metabolic syndrome. INTERVENTION Random allocation to LD-MTX (≤20 mg/wk) or placebo. All participants received folic acid, 1 mg/d, 6 days per week. MEASUREMENTS Risks for specific AEs of interest, as well as for all AEs, were compared across treatment groups after blinded adjudication. RESULTS After an active run-in period, 6158 patients were enrolled and 4786 randomly assigned to a group; median follow-up was 23 months and median dosage 15 mg/wk. Among the randomly assigned participants, 81.2% were male, median age was 65.7 years, and median body mass index was 31.5 kg/m2. Of 2391 participants assigned to LD-MTX, 2080 (87.0%) had an AE of interest, compared with 1951 of 2395 (81.5%) assigned to placebo (hazard ratio [HR], 1.17 [95% CI, 1.10 to 1.25]). The relative hazards of gastrointestinal (HR, 1.91 [CI, 1.75 to 2.10]), pulmonary (HR, 1.52 [CI, 1.16 to 1.98]), infectious (HR, 1.15 [CI, 1.01 to 1.30]), and hematologic (HR, 1.15 [CI, 1.07 to 1.23]) AEs were elevated for LD-MTX versus placebo. With the exception of increased risk for skin cancer (HR, 2.05 [CI, 1.28 to 3.28]), the treatment groups did not differ in risk for other cancer or mucocutaneous, neuropsychiatric, or musculoskeletal AEs. Renal AEs were reduced in the LD-MTX group (HR, 0.85 [CI, 0.78 to 0.93]). LIMITATION The trial was done in patients without rheumatic disease who tolerated LD-MTX during an active run-in period. CONCLUSION Use of LD-MTX was associated with small to moderate elevations in risks for skin cancer and gastrointestinal, infectious, pulmonary, and hematologic AEs, whereas renal AEs were decreased. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Daniel H Solomon
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Robert J Glynn
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Elizabeth W Karlson
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Fengxin Lu
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Cassandra Corrigan
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Josh Colls
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Chang Xu
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Jean MacFadyen
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | | | - Nancy Berliner
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Paul F Dellaripa
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Brendan M Everett
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Aruna D Pradhan
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Sarah P Hammond
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Meredith Murray
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Deepak A Rao
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Susan Y Ritter
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Anna Rutherford
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Jeffrey A Sparks
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Jackie Stratton
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Dong H Suh
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Sara K Tedeschi
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Kathleen M M Vanni
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Nina P Paynter
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
| | - Paul M Ridker
- Brigham and Women's Hospital, Boston, Massachusetts (D.H.S., R.J.G., E.W.K., F.L., C.C., J.C., C.X., J.M., N.B., P.F.D., B.M.E., A.D.P., S.P.H., M.M., D.A.R., S.Y.R., A.R., J.A.S., J.S., D.H.S., S.K.T., K.M.V., N.P.P., P.M.R.)
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Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med 2019; 40:545-560. [PMID: 31376890 DOI: 10.1016/j.ccm.2019.05.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.
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Affiliation(s)
- Anthony J Esposito
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sarah G Chu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Rachna Madan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Tracy J Doyle
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Paul F Dellaripa
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review. Eur J Med Chem 2018; 158:502-516. [PMID: 30243154 DOI: 10.1016/j.ejmech.2018.09.027] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022]
Abstract
Methotrexate (MTX) is used as an anchor disease-modifying anti-rheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA) because of its potent efficacy and tolerability. MTX benefits a large number of RA patients but partially suffered from side effects. A variety of side effects can be associated with MTX when treating RA patients, from mild to severe or discontinuation of the treatment. In this report, we reviewed the possible side effects that MTX might cause from the most common gastrointestinal toxicity effects to less frequent malignant diseases. In order to achieve regimen with less side effects, the administration of MTX with appropriate dose and a careful pretreatment inspection is necessary. Further investigations are required when combining MTX with other drugs so as to enhance the efficacy and reduce side effects at the same time. The management of MTX treatment is also discussed to provide strategies for occurred side effects. Thus, this review will provide scholars with a comprehensive understanding the side effects of MTX administration by RA patients.
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Spagnolo P, Lee JS, Sverzellati N, Rossi G, Cottin V. The Lung in Rheumatoid Arthritis. Arthritis Rheumatol 2018; 70:1544-1554. [DOI: 10.1002/art.40574] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 05/22/2018] [Indexed: 12/21/2022]
Affiliation(s)
| | | | | | - Giulio Rossi
- Azienda USL Valle d'Aosta, Regional Hospital; Aosta Italy
| | - Vincent Cottin
- Hospices Civils de Lyon; Louis Pradel Hospital; National Reference Center for Rare Pulmonary Diseases; Lyon France
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Abstract
The treatment of rheumatoid arthritis (RA) has undergone considerable changes over the last 15–20 years. With an expansion in the armamentarium of therapies available for RA comes a wider choice in selecting the best treatment in terms of comparative safety in the presence of comorbidities. Clinicians frequently encounter patients with RA-associated interstitial lung disease with uncontrolled joint disease and have to make decisions about the safest treatments in this context with the eventual goal of joint remission. In this chapter, available evidence is reviewed on the comparative pulmonary safety of non-biologic disease-modifying antirheumatic drugs (nbDMARDs), biologic DMARDs, biosimilars and targeted synthetic DMARDs in RA-ILD. In addition, the potential role for additional immunosuppression in RA-ILD is reviewed as well as overarching recommendations proposed for patient assessment to guide treatment decisions and management.
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Clinical, Epidemiological, and Histopathological Features of Respiratory Involvement in Rheumatoid Arthritis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7915340. [PMID: 29238722 PMCID: PMC5697381 DOI: 10.1155/2017/7915340] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/22/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022]
Abstract
Although by definition rheumatoid arthritis (RA) is an articular disorder, it is a systemic disease, and 18–40% of patients experience extra-articular manifestations (EAMs). The involvement of the respiratory system occurs in about 30–40% of RA patients, and in about 10–20% of them it represents the first manifestation of RA. A wide range of pulmonary manifestations are detectable in RA patients, including pulmonary parenchymal disease, pleural involvement, and airway and pulmonary inflammation. The clinical, radiological, and histological spectra of respiratory manifestations in RA reflect chronic immune activation, increased susceptibility to infection (often related to immunosuppressive medications), or direct drug. The type and severity of pulmonary involvement influence the prognosis, ranging from mild self-limiting conditions to severe life-threatening complications. Herein, we reviewed the various manifestations of respiratory involvement in RA, providing an overview on epidemiological, histological, clinical, and radiological data.
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HLA-A 31:01 is not associated with the development of methotrexate pneumonitis in the UK population: results from a genome-wide association study. Ann Rheum Dis 2017; 76:e51. [DOI: 10.1136/annrheumdis-2017-211512] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist 2016; 21:1471-1482. [PMID: 27496039 PMCID: PMC5153332 DOI: 10.1634/theoncologist.2015-0164] [Citation(s) in RCA: 469] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/20/2016] [Indexed: 12/29/2022] Open
Abstract
: High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used to treat a range of adult and childhood cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI) in 2%-12% of patients. Nephrotoxicity results from crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. AKI and other toxicities of high-dose methotrexate can lead to significant morbidity, treatment delays, and diminished renal function. Risk factors for methotrexate-associated toxicity include a history of renal dysfunction, volume depletion, acidic urine, and drug interactions. Renal toxicity leads to impaired methotrexate clearance and prolonged exposure to toxic concentrations, which further worsen renal function and exacerbate nonrenal adverse events, including myelosuppression, mucositis, dermatologic toxicity, and hepatotoxicity. Serum creatinine, urine output, and serum methotrexate concentration are monitored to assess renal clearance, with concurrent hydration, urinary alkalinization, and leucovorin rescue to prevent and mitigate AKI and subsequent toxicity. When delayed methotrexate excretion or AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase are usually sufficient to allow renal recovery without the need for dialysis. Prompt recognition and effective treatment of AKI and associated toxicities mitigate further toxicity, facilitate renal recovery, and permit patients to receive other chemotherapy or resume HDMTX therapy when additional courses are indicated. IMPLICATIONS FOR PRACTICE High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used for a range of cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI), attributable to crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. When AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase allow renal recovery without the need for dialysis. This article, based on a review of the current associated literature, provides comprehensive recommendations for prevention of toxicity and, when necessary, detailed treatment guidance to mitigate AKI and subsequent toxicity.
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Affiliation(s)
- Scott C Howard
- School of Health Studies, University of Memphis, Memphis, Tennessee, USA
| | - John McCormick
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, New York, New York, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, New York, New York, USA
| | | | - R Donald Harvey
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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Samad A, Khalil A, Ali I, Khan AU. Methotrexate-induced pneumonitis in a patient with rheumatoid arthritis: a case report. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Abdul Samad
- Department of Medicine and Allied; Northwest General Hospital and Research Centre; Peshawar Pakistan
| | - Abdul Khalil
- Department of Medicine and Allied; Northwest General Hospital and Research Centre; Peshawar Pakistan
| | - Iftikhar Ali
- Department Of Pharmacy Services; Northwest General Hospital and Research Centre; Peshawar Pakistan
- Department of Pharmacy; University of Swabi; Swabi Pakistan
| | - Aziz Ullah Khan
- Department Of Pharmacy Services; Northwest General Hospital and Research Centre; Peshawar Pakistan
- Department of Pharmacy; University of Swabi; Swabi Pakistan
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Abstract
The lung is a common site of complications of systemic connective tissue disease (CTD), and lung involvement can present in several ways. Interstitial lung disease (ILD) and pulmonary hypertension are the most common lung manifestations in CTD. Although it is generally thought that interstitial lung disease develops later on in CTD it is often the initial presentation ("lung dominant" CTD). ILD can be present in most types of CTD, including rheumatoid arthritis, scleroderma, systemic lupus erythematosus, polymyositis or dermatomyositis, Sjögren's syndrome, and mixed connective tissue disease. Despite similarities in clinical and pathologic presentation, the prognosis and treatment of CTD associated ILD (CTD-ILD) can differ greatly from that of other forms of ILD, such as idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) can present as a primary vasculopathy in pulmonary arterial hypertension or in association with ILD (PH-ILD). Therefore, detailed history, physical examination, targeted serologic testing, and, occasionally, lung biopsy are needed to diagnose CTD-ILD, whereas both non-invasive and invasive assessments of pulmonary hemodynamics are needed to diagnose pulmonary hypertension. Immunosuppression is the mainstay of treatment for ILD, although data from randomized controlled trials (RCTs) to support specific treatments are lacking. Furthermore, treatment strategies vary according to the clinical situation-for example, the treatment of a patient newly diagnosed as having CTD-ILD differs from that of someone with an acute exacerbation of the disease. Immunosuppression is indicated only in select cases of pulmonary arterial hypertension related to CTD; more commonly, selective pulmonary vasodilators are used. For both diseases, comorbidities such as sleep disordered breathing, symptoms of dyspnea, and cough should be evaluated and treated. Lung transplantation should be considered in patients with advanced disease but is not always feasible because of other manifestations of CTD and comorbidities. Clinical trials of novel therapies including immunosuppressive therapies are needed to inform best treatment strategies.
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Affiliation(s)
- Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sonye K Danoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Nair A, Walsh SLF, Desai SR. Imaging of pulmonary involvement in rheumatic disease. Rheum Dis Clin North Am 2015; 41:167-96. [PMID: 25836636 DOI: 10.1016/j.rdc.2014.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Lung disease commonly occurs in connective tissue diseases (CTD) and is an important cause of morbidity and mortality. Imaging is central to the evaluation of CTD-associated pulmonary complications. In this article, a general discussion of radiologic considerations is followed by a description of the pulmonary appearances in individual CTDs, and the imaging appearances of acute and nonacute pulmonary complications. The contribution of imaging to monitoring disease, evaluating treatment response, and prognostication is reviewed. Finally, we address the role of imaging in the challenging multidisciplinary evaluation of interstitial lung disease where there is an underlying suspicion of an undiagnosed CTD.
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Affiliation(s)
- Arjun Nair
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Simon L F Walsh
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sujal R Desai
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Iqbal K, Kelly C. Treatment of rheumatoid arthritis-associated interstitial lung disease: a perspective review. Ther Adv Musculoskelet Dis 2015; 7:247-67. [PMID: 26622326 PMCID: PMC4637848 DOI: 10.1177/1759720x15612250] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting 0.5-1% of the worldwide population. Whilst predominantly causing chronic pain and inflammation in synovial joints, it is also associated with significant extra-articular manifestations in a large proportion of patients. Among the various pulmonary manifestations, interstitial lung disease (ILD), a progressive fibrotic disease of the lung parenchyma, is the commonest and most important, contributing significantly to increased morbidity and mortality. The most frequent patterns of RA-associated ILD (RA-ILD) are usual interstitial pneumonia and nonspecific interstitial pneumonia. New insights during the past several years have highlighted the epidemiological impact of RA-ILD and have begun to identify factors contributing to its pathogenesis. Risk factors include smoking, male sex, human leukocyte antigen haplotype, rheumatoid factor and anticyclic citrullinated protein antibodies (ACPAs). Combined with clinical information, chest examination and pulmonary function testing, high-resolution computed tomography of the chest forms the basis of investigation and allows assessment of subtype and disease extent. The management of RA-ILD is a challenge. Several therapeutic agents have been suggested in the literature but as yet no large randomized controlled trials have been undertaken to guide clinical management. Therapy is further complicated by commonly prescribed drugs of proven articular benefit such as methotrexate, leflunomide (LEF) and anti-tumour necrosis factor α agents having been implicated in both ex novo occurrence and acceleration of existing ILD. Agents that offer promise include immunomodulators such as mycophenolate and rituximab as well as newly studied antifibrotic agents. In this review, we discuss the current literature to evaluate recommendations for the management of RA-ILD and discuss key gaps in our knowledge of this important disease.
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Affiliation(s)
- Kundan Iqbal
- Department of Medicine at Queen Elizabeth Hospital, Gateshead & University of Newcastle upon Tyne Medical School, Newcastle upon Tyne, Tyne and Wear, UK
| | - Clive Kelly
- Department of Medicine at Queen Elizabeth Hospital, Gateshead NE96SX, UK & University of Newcastle upon Tyne Medical School, Newcastle upon Tyne, Tyne and Wear, NE14LP, UK
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Olivas-Flores EM, Bonilla-Lara D, Gamez-Nava JI, Rocha-Muñoz AD, Gonzalez-Lopez L. Interstitial lung disease in rheumatoid arthritis: Current concepts in pathogenesis, diagnosis and therapeutics. World J Rheumatol 2015; 5:1-22. [DOI: 10.5499/wjr.v5.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/27/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is the most common chronic autoimmune inflammatory joint disease. RA-associated interstitial lung disease (RA-ILD) is a major extra-articular complication and causes symptoms that lead to a deterioration in the quality of life, high utilization of health resources, and an increased risk of earlier mortality. Early in the course of RA-ILD, symptoms are highly variable, making the diagnosis difficult. Therefore, a rational diagnostic strategy that combines an adequate clinical assessment with the appropriate use of clinical tests, including pulmonary function tests and high-resolution computed tomography, should be used. In special cases, lung biopsy or bronchioalveolar lavage should be performed to achieve an early diagnosis. Several distinct histopathological subtypes of RA-ILD are currently recognized. These subtypes also have different clinical presentations, which vary in therapeutic response and prognosis. This article reviews current evidence about the epidemiology of RA-ILD and discusses the varying prevalence rates observed in different studies. Additionally, aspects of RA-ILD pathogenesis, including the role of cytokines and other molecules such as autoantibodies, as well as the evidence linking several drugs used to treat RA with lung damage will be discussed. Some aspects of the clinical characteristics of RA-ILD are noted, and diagnostic strategies are reviewed. Finally, this article analyzes current treatments for RA-ILD, including immunosuppressive therapies and biologic agents, as well as other therapeutic modalities. The prognosis of this severe complication of RA is discussed. Additionally, this paper examines updated evidence from studies identifying an association between drugs used for the treatment of RA and the development of ILD.
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Life-threatening pneumonitis complicating low-dose methotrexate treatment for juvenile idiopathic arthritis in a child. Pediatr Emerg Care 2014; 30:415-7. [PMID: 24892681 DOI: 10.1097/pec.0000000000000151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Methotrexate, a drug commonly used to treat juvenile idiopathic arthritis (JIA), has been reported to cause interstitial pneumonitis as a rare complication in adults with rheumatoid arthritis. Only 1 suspicious case of methotrexate pneumonitis in a child with JIA has been reported in 1998, though with no histopathologic proof. Given its rarity and nonspecific presenting symptoms, diagnosis may be challenging, and a life-threatening illness can occur without a high index of suspicion, as illustrated by this report of a 13-year-old girl with JIA who developed fever, nonproductive cough, and dyspnea as presenting features of interstitial pneumonitis after 1 year of methotrexate therapy. Chest high-resolution computed tomography revealed patchy ground-glass opacities and interlobular septal thickening without pleural effusion. Lung biopsy showed interstitial pneumonitis with diffuse alveolar damage. The symptoms and radiographs improved dramatically after withdrawal of methotrexate and administration of corticosteroids. A restrictive ventilatory defect with decreased diffusion capacity on pulmonary function testing persisted until 20 months after methotrexate withdrawal. There is no single pathognomic feature for methotrexate pneumonitis; rather, diagnosis relies on a constellation of clinical, radiologic, and pathologic findings. This report highlights the necessity for pediatricians to be continuously vigilant for interstitial pneumonitis in children receiving methotrexate who develop new unexplained pulmonary symptoms.
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Conway R, Low C, Coughlan RJ, O'Donnell MJ, Carey JJ. Methotrexate and Lung Disease in Rheumatoid Arthritis: A Meta-Analysis of Randomized Controlled Trials. Arthritis Rheumatol 2014; 66:803-12. [DOI: 10.1002/art.38322] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/12/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Richard Conway
- Galway University Hospitals, Merlin Park; Galway Ireland
| | | | | | | | - John J. Carey
- Galway University Hospitals, Merlin Park; Galway Ireland
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Pneumonitis due to cytomegalovirus during chronic methotrexate treatment. ACTA ACUST UNITED AC 2014; 10:328-30. [PMID: 24646908 DOI: 10.1016/j.reuma.2013.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/19/2013] [Accepted: 07/24/2013] [Indexed: 11/20/2022]
Abstract
Although hypersensitivity pneumonitis is the most common pulmonary complication described during treatment with methotrexate, other complications like lymphoproliferative and infectious disease may be considered in the study of respiratory disease associated to methotrexate. The existence of an increased risk to developing infectious diseases may be similar to that observed during treatment with antagonists of tumor necrosis factor and corticosteroids, where Cytomegalovirus pneumonia is a serious complication; early diagnosis and treatment will prevent a potentially fatal outcome.
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Schwaiblmair M, Behr W, Haeckel T, Märkl B, Foerg W, Berghaus T. Drug induced interstitial lung disease. Open Respir Med J 2012; 6:63-74. [PMID: 22896776 PMCID: PMC3415629 DOI: 10.2174/1874306401206010063] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/06/2012] [Accepted: 07/06/2012] [Indexed: 01/15/2023] Open
Abstract
With an increasing number of therapeutic drugs, the list of drugs that is responsible for severe pulmonary disease also grows. Many drugs have been associated with pulmonary complications of various types, including interstitial inflammation and fibrosis, bronchospasm, pulmonary edema, and pleural effusions. Drug-induced interstitial lung disease (DILD) can be caused by chemotherapeutic agents, antibiotics, antiarrhythmic drugs, and immunosuppressive agents. There are no distinct physiologic, radiographic or pathologic patterns of DILD, and the diagnosis is usually made when a patient with interstitial lung disease (ILD) is exposed to a medication known to result in lung disease. Other causes of ILD must be excluded. Treatment is avoidance of further exposure and systemic corticosteroids in patients with progressive or disabling disease.
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Affiliation(s)
- Martin Schwaiblmair
- Department of Internal Medicine I, Klinikum Augsburg, Ludwig-Maximilians-University of Munich, Germany
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Malik S, Saravanan V, Kelly C. Interstitial lung disease in rheumatoid arthritis: an update on diagnosis and management. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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