1
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Kawazoe M, Nanki T. Comparison of efficacy of continuous mycophenolate mofetil with sequential cyclophosphamide and tacrolimus as maintenance therapy for lupus nephritis. Lupus 2024; 33:319-327. [PMID: 38232223 DOI: 10.1177/09612033241228177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To evaluate the renal response to mycophenolate mofetil (MMF) as maintenance therapy for lupus nephritis (LN) in Japanese patients, we compared the efficacy of MMF and the sequential use of monthly intravenous cyclophosphamide (IVCY) followed by tacrolimus (TAC). METHODS We examined 14 patients with LN who were treated with continuous MMF as induction and maintenance therapies (MMF group) and 10 patients with LN who received monthly IVCY as induction therapy followed by maintenance therapy with TAC (IVCY-TAC group). We assessed the therapeutic effects of each treatment regimen on renal manifestations and serological findings over a 36-month period after treatment initiation. RESULTS Mean urine protein-to-creatinine ratios in the MMF and IVCY-TAC groups significantly decreased from 2.75 to 0.11 g/gCr and from 3.26 to 0.22 g/gCr, respectively. Significant improvements in serum immunological variables (serum complement C3 or C4 levels and the anti-double-stranded DNA antibody titer) and reductions in the SLE disease activity index and daily prednisolone dosages were observed in both groups during induction therapy and were maintained during maintenance therapy. Efficacy was similar between the MMF and IVCY-TAC groups. CONCLUSION MMF has potential as an effective treatment for renal manifestations in Japanese patients throughout induction and maintenance therapies for LN, as an alternative to conventional IVCY-TAC therapy, and as a glucocorticoid-sparing agent.
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Affiliation(s)
- Mai Kawazoe
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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2
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Calatayud E, Montomoli M, Ávila A, Sancho Calabuig A, Alegre-Sancho JJ. Experience with abatacept in refractory lupus nephritis. Rheumatol Int 2023; 43:2319-2326. [PMID: 37650922 PMCID: PMC10587212 DOI: 10.1007/s00296-023-05389-0] [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: 02/27/2023] [Accepted: 06/29/2023] [Indexed: 09/01/2023]
Abstract
Lupus nephritis is a major cause of morbidity in patients with systemic lupus erythematosus. Responsiveness to treatment is crucial to avoid chronic kidney disease. New molecules have been developed in recent years to improve renal survival rates. Biological therapies as coadjutant to conventional induction treatment have been tested in randomized clinical trials with heterogeneous results. Like many others biologic therapies, Abatacept has not shown a clear benefit in the context of clinical trials. We present two cases of lupus nephritis patients in whom addition of abatacept resulted in complete remission of the renal disease. The first case described a 49-year-old male with class IV lupus nephritis with nephrotic range proteinuria and high immunological activity refractory to conventional treatment with cyclophosphamide and corticosteroids and multitarget therapy with tacrolimus, mycophenolate mofetil and prednisone. Several biological therapies (rituximab, belimumab and tocilizumab) were unsuccessfully tried, so that abatacept was added to his background multitarget therapy showing complete clinical response. The second case described a 52-year-old female with class IV lupus nephritis treated initially with conventional treatment with partial response. In successive renal flares with nephrotic proteinuria, she showed intolerance to rituximab and refractoriness to voclosporin. Finally, abatacept was added to her background therapy with MMF and PDN showing complete and maintained remission of the disease. In no case the use of abatacept was associated with serious adverse events. Based on our experience, abatacept should be considered as a safe rescue therapy in patients with refractory lupus nephritis and proteinuria with nephrotic range. In addition to this case, we reviewed the use of abatacept in lupus nephritis in the literature.
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Affiliation(s)
- Emma Calatayud
- Hospital Universitario Doctor Peset, Valencia, Spain
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
| | | | - Ana Ávila
- Hospital Universitario Doctor Peset, Valencia, Spain
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Asunción Sancho Calabuig
- Hospital Universitario Doctor Peset, Valencia, Spain
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Juan José Alegre-Sancho
- Hospital Universitario Doctor Peset, Valencia, Spain
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
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3
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Jiang N, Li M, Zhang H, Duan X, Li X, Fang Y, Li H, Yang P, Luo H, Wang Y, Peng L, Zhao J, Wu C, Wang Q, Tian X, Zhao Y, Zeng X. Sirolimus versus tacrolimus for systemic lupus erythematosus treatment: results from a real-world CSTAR cohort study. Lupus Sci Med 2022; 9:9/1/e000617. [PMID: 34980680 PMCID: PMC8724817 DOI: 10.1136/lupus-2021-000617] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The effectiveness and safety of sirolimus for SLE treatment have been shown in some uncontrolled studies. However, a comparison of sirolimus with other classic immunosuppressants has not been reported. We conducted the study to compare the effectiveness and safety of sirolimus versus tacrolimus for SLE treatment. METHODS A real-world cohort study was conducted. Patients with clinically active SLE who were prescribed sirolimus or tacrolimus were enrolled. Propensity score matching was used to ensure equivalent disease conditions and background medications. SLE disease activity indices, serological parameters, steroid doses, modification of other immunosuppressants, renal effectiveness and adverse events were compared between the two groups at 3-month, 6-month, 9-month and 12-month follow-up visits. RESULTS Data from 52 patients in each of the sirolimus and tacrolimus groups were analysed. Indices regarding the effectiveness of sirolimus, including Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores, physician's global assessment (PhGA) scores, and proportion of patients with SLEDAI-2K reduction of ≥4 and PhGA increase of <0.3, were equivalent to those of tacrolimus at all follow-up timepoints (all p≥0.05). Greater improvements in complement levels were observed in the sirolimus group at 3 and 6 months. Higher percentages of patients with prednisone doses ≤7.5 mg/day were observed in the sirolimus group at all timepoints. Seventeen adverse events in the sirolimus group were recorded. None was severe or led to drug discontinuation. CONCLUSIONS Overall, sirolimus was as effective as tacrolimus in the treatment of SLE. Sirolimus had better effects on serological improvement and glucocorticoid tapering. Sirolimus was well tolerated in patients with SLE.
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Affiliation(s)
- Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Hongfeng Zhang
- Department of Rheumatology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaofeng Li
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yongfei Fang
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Hongbin Li
- Department of Rheumatology, The Affiliated Hospital of Inner Mongolia Medical College, Hohhot, China
| | - Pingting Yang
- Department of Rheumatology and Immunology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Hui Luo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liying Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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4
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Ponticelli C, Reggiani F, Moroni G. Old and New Calcineurin Inhibitors in Lupus Nephritis. J Clin Med 2021; 10:jcm10214832. [PMID: 34768354 PMCID: PMC8584552 DOI: 10.3390/jcm10214832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/27/2022] Open
Abstract
Calcineurin inhibitors (CNIs) are drugs that inhibit calcineurin, a key phosphatase that dephosphorylates a transcription factor called the nuclear factor of activated T cells (NFAT), allowing its translocation into the nucleus of quiescent T cells. In the nucleus, NFAT activates interleukin 2, which stimulates the proliferation and differentiation of T-cells. CNIs can also stabilize the actin cytoskeleton of podocytes reducing proteinuria. Thanks to these characteristics, CNIs have been often used in the treatment of autoimmune diseases. However, the therapeutic index of CNIs is narrow, and their interactions with other drugs can increase toxicity or reduce efficacy. In lupus nephritis, cyclosporine and tacrolimus have been used both in induction and maintenance therapies. Observational studies and randomized controlled trials showed that both cyclosporine and tacrolimus can increase efficacy. Tolerance is satisfactory if low doses are used and the patient is carefully monitored. More recently, a new CNI, called voclosporin (VCS), has been approved by the Food and Drug Administration for use in lupus nephritis. VCS offers potential advantages over other CNIs. In two large multiethnic trials, VCS was not associated with adverse renal and metabolic events and obtained positive results despite a novel and rapid corticosteroid tapering regime.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology Division, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Francesco Reggiani
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
| | - Gabriella Moroni
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
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5
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Zheng P, Yu Z, Li L, Liu S, Lou Y, Hao X, Yu P, Lei M, Qi Q, Wang Z, Gao F, Zhang Y, Li Y. Predicting Blood Concentration of Tacrolimus in Patients With Autoimmune Diseases Using Machine Learning Techniques Based on Real-World Evidence. Front Pharmacol 2021; 12:727245. [PMID: 34630104 PMCID: PMC8497784 DOI: 10.3389/fphar.2021.727245] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/09/2021] [Indexed: 11/17/2022] Open
Abstract
Tacrolimus is a widely used immunosuppressive drug in patients with autoimmune diseases. It has a narrow therapeutic window, thus requiring therapeutic drug monitoring (TDM) to guide the clinical regimen. This study included 193 cases of tacrolimus TDM data in patients with autoimmune diseases at Southern Medical University Nanfang Hospital from June 7, 2018, to December 31, 2020. The study identified nine important variables for tacrolimus concentration using sequential forward selection, including height, tacrolimus daily dose, other immunosuppressants, low-density lipoprotein cholesterol, mean corpuscular volume, mean corpuscular hemoglobin, white blood cell count, direct bilirubin, and hematocrit. The prediction abilities of 14 models based on regression analysis or machine learning algorithms were compared. Ultimately, a prediction model of tacrolimus concentration was established through eXtreme Gradient Boosting (XGBoost) algorithm with the best predictive ability (R2 = 0.54, mean absolute error = 0.25, and root mean square error = 0.33). Then, SHapley Additive exPlanations was used to visually interpret the variable’s impacts on tacrolimus concentration. In conclusion, the XGBoost model for predicting blood concentration of tacrolimus on the basis of real-world evidence has good predictive performance, providing guidance for the adjustment of regimen in clinical practice.
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Affiliation(s)
- Ping Zheng
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Liren Li
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiting Liu
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Lou
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xin Hao
- Dalian Medicinovo Technology Co. Ltd., Dalian, China
| | - Peng Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Ming Lei
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiaona Qi
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Zeyuan Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Yuqing Zhang
- Zhongshan School of Medicine, SYSU, Guangzhou, China
| | - Yilei Li
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
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6
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Kim CS, Mathew AP, Vasukutty A, Uthaman S, Joo SY, Bae EH, Ma SK, Park IK, Kim SW. Glycol chitosan-based tacrolimus-loaded nanomicelle therapy ameliorates lupus nephritis. J Nanobiotechnology 2021; 19:109. [PMID: 33865397 PMCID: PMC8052756 DOI: 10.1186/s12951-021-00857-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/08/2021] [Indexed: 12/13/2022] Open
Abstract
Background Recently, we developed hydrophobically modified glycol chitosan (HGC) nanomicelles loaded with tacrolimus (TAC) (HGC-TAC) for the targeted renal delivery of TAC. Herein, we determined whether the administration of the HGC-TAC nanomicelles decreases kidney injury in a model of lupus nephritis. Lupus-prone female MRL/lpr mice were randomly assigned into three groups that received intravenous administration of either vehicle control, an equivalent dose of TAC, or HGC-TAC (0.5 mg/kg TAC) weekly for 8 weeks. Age-matched MRL/MpJ mice without Faslpr mutation were also treated with HGC vehicle and used as healthy controls. Results Weekly intravenous treatment with HGC-TAC significantly reduced genetically attributable lupus activity in lupus nephritis-positive mice. In addition, HGC-TAC treatment mitigated renal dysfunction, proteinuria, and histological injury, including glomerular proliferative lesions and tubulointerstitial infiltration. Furthermore, HGC-TAC treatment reduced renal inflammation and inflammatory gene expression and ameliorated increased apoptosis and glomerular fibrosis. Moreover, HGC-TAC administration regulated renal injury via the TGF-β1/MAPK/NF-κB signaling pathway. These renoprotective effects of HGC-TAC treatment were more potent in lupus mice compared to those of TAC treatment alone. Conclusion Our study indicates that weekly treatment with the HGC-TAC nanomicelles reduces kidney injury resulting from lupus nephritis by preventing inflammation, fibrosis, and apoptosis. This advantage of a new therapeutic modality using kidney-targeted HGC-TAC nanocarriers may improve drug adherence and provide treatment efficacy in lupus nephritis mice. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12951-021-00857-w.
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Affiliation(s)
- Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61496, Republic of Korea.,Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ansuja Pulickal Mathew
- Department of Biomedical Sciences, BioMedical Sciences Graduate Program (BMSGP), Chonnam National University, Hwasun, 58128, Republic of Korea
| | - Arathy Vasukutty
- Department of Biomedical Sciences, BioMedical Sciences Graduate Program (BMSGP), Chonnam National University, Hwasun, 58128, Republic of Korea
| | - Saji Uthaman
- Department of Polymer Science and Engineering, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Soo Yeon Joo
- Department of Internal Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61496, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61496, Republic of Korea.,Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61496, Republic of Korea.,Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - In-Kyu Park
- Department of Biomedical Sciences, BioMedical Sciences Graduate Program (BMSGP), Chonnam National University, Hwasun, 58128, Republic of Korea.
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61496, Republic of Korea. .,Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
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7
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Takada K, Katada Y, Ito S, Hayashi T, Kishi J, Itoh K, Yamashita H, Hirakata M, Kawahata K, Kawakami A, Watanabe N, Atsumi T, Takasaki Y, Miyasaka N. Impact of adding tacrolimus to initial treatment of interstitial pneumonitis in polymyositis/dermatomyositis: a single-arm clinical trial. Rheumatology (Oxford) 2020; 59:1084-1093. [PMID: 31539061 PMCID: PMC7850120 DOI: 10.1093/rheumatology/kez394] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/19/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Interstitial pneumonia is common and has high short-term mortality in patients with PM and DM despite glucocorticoid (GC) treatment. Retrospective studies suggested that the early use of immunosuppressive drugs with GCs might improve its short-term mortality. Methods A multicentre, single-arm, 52-week-long clinical trial was performed to test whether the initial combination treatment with tacrolimus (0.075 mg/kg/day, adjusted for the target whole-blood trough levels between 5 and 10 ng/ml) and GCs (0.6–1.0 mg/kg/day of prednisolone followed by a slow taper) improves short-term mortality of PM/DM-interstitial pneumonia patients. The primary outcome was overall survival. We originally intended to compare, by using propensity-score matching, the outcome data of clinical trial patients with that of historical control patients who were initially treated with GCs alone. Results The 52-week survival rate with the combination treatment (N = 26) was 88.0% (95% CI, 67.3, 96.0). Safety profiles of the combination treatment were consistent with those known for tacrolimus and high-dose GCs individually. Serious adverse events occurred in 11 patients (44.0%), which included four opportunistic infections. Only 16 patients, including only 1 deceased patient, were registered as historical controls, which precluded meaningful comparative analysis against the clinical trial patients. Conclusion Our study provided findings which suggest that initial treatment with tacrolimus and GCs may improve short-term mortality of PM/DM-interstitial pneumonia patients with manageable safety profiles. This was the first prospective clinical investigation conducted according to the Good Clinical Practice Guideline of the International Conference on Harmonization for the treatment of this potentially life-threatening disease. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT00504348.
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Affiliation(s)
- Kazuki Takada
- Department of Professional Development in Health Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Yoshinori Katada
- Department of Rheumatology and Clinical Immunology, Sakai City Medical Center, Osaka
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Niigata
| | - Taichi Hayashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Jun Kishi
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima
| | - Kenji Itoh
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Saitama
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo
| | - Michito Hirakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo
| | - Kimito Kawahata
- Division of Rheumatology and Allergology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki
| | - Norihiko Watanabe
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Hokkaido
| | - Yoshinari Takasaki
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Saitama
| | - Nobuyuki Miyasaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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8
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Chen X, Wang DD, Xu H, Li ZP. Population pharmacokinetics model and initial dose optimization of tacrolimus in children and adolescents with lupus nephritis based on real-world data. Exp Ther Med 2020; 20:1423-1430. [PMID: 32765671 PMCID: PMC7388563 DOI: 10.3892/etm.2020.8821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/01/2020] [Indexed: 12/31/2022] Open
Abstract
The present study aimed to establish a population pharmacokinetics model of tacrolimus and further optimize the initial dosing regimen of tacrolimus in pediatric and adolescent patients with lupus nephritis (LN). Pediatric and adolescent patients with LN were recruited between August 2014 and September 2019 at the Children's Hospital of Fudan University (Shanghai, China). Relevant information was used to set up a population pharmacokinetics model with a Nonlinear Mixed Effect Model and the initial dosage regimen was simulated with the Monte Carlo method. Body weight and co-administration of wuzhi capsule were indicated to influence tacrolimus clearance in pediatric and adolescent patients with LN, and at the same body weight, the rate of tacrolimus clearance in patients without vs. with co-administration of wuzhi capsule was 1:0.71. In addition, in patients who were not administered wuzhi capsule, an initial dosage regimen of 0.15 mg/kg/day was recommended for a body weight of 10-23 kg and 0.10 mg/kg/day for 23-60 kg; in patients who were administered wuzhi capsule, an initial dosage regimen of 0.10 mg/kg/day was recommended for a body weight of 10-23 kg and 0.05 mg/kg/day for 23-60 kg. To the best of our knowledge, the present study was the first to establish a population pharmacokinetics model of tacrolimus in order to determine the optimal initial dosage regimen of tacrolimus in pediatric and adolescent patients with LN.
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Affiliation(s)
- Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Dong-Dong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Zhi-Ping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
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9
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Takeuchi T, Wakasugi N, Uno S, Makino H. Long-term Safety and Effectiveness of Tacrolimus in Patients With Lupus Nephritis: 5-year Interim Postmarketing Surveillance Study in Japan (TRUST). J Rheumatol 2020; 48:74-81. [PMID: 32238515 DOI: 10.3899/jrheum.191008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the long-term safety and effectiveness of tacrolimus for treating lupus nephritis (LN) in the real-world clinical setting. METHODS This is an ongoing, open-label, noncomparative, observational, postmarketing surveillance study conducted across 275 sites in Japan. Registered patients with LN were followed for 10 years. Here we report data relating to 5 years of tacrolimus maintenance therapy at the interim data cutoff in August 2016. RESULTS Of 1395 registered patients, 1355 received tacrolimus maintenance therapy for LN and provided safety data. The most common serious adverse drug reactions (ADR) included pneumonia (1.1%), herpes zoster (1.0%), cellulitis (1.0%), and diabetes mellitus (1.0%). ADR occurred mainly within the first 28 weeks of tacrolimus treatment, and no marked increase was observed during the follow-up period. Subgroup analyses suggested that risk factors for commonly observed ADR associated with tacrolimus included inpatient management, LN disease severity, increasing age, abnormal renal or hepatic function, and comorbid or previous disease. The cumulative rate of progression to renal failure (based on the attending physician's assessment) was 0.8% at Year 1 and 6.6% at Year 5. Cumulative relapse rates were 7.8% and 30.6%, respectively. Urine protein:creatinine ratio, serum anti-dsDNA antibody levels, complement C3 levels, and steroid-sparing effects were all significantly improved from 4 weeks after tacrolimus treatment initiation (P < 0.001) and were sustained over 5 years. CONCLUSION Long-term tacrolimus maintenance treatment over 5 years in the real-world clinical setting was well tolerated and effective in a large population of patients with LN (www.ClinicalTrials.gov: NCT01410747).
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Affiliation(s)
- Tsutomu Takeuchi
- T. Takeuchi MD, PhD, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo
| | - Naoko Wakasugi
- N. Wakasugi, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Satoshi Uno
- N. Wakasugi, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
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10
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Drug repurposing to improve treatment of rheumatic autoimmune inflammatory diseases. Nat Rev Rheumatol 2019; 16:32-52. [PMID: 31831878 DOI: 10.1038/s41584-019-0337-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 02/08/2023]
Abstract
The past century has been characterized by intensive efforts, within both academia and the pharmaceutical industry, to introduce new treatments to individuals with rheumatic autoimmune inflammatory diseases (RAIDs), often by 'borrowing' treatments already employed in one RAID or previously used in an entirely different disease, a concept known as drug repurposing. However, despite sharing some clinical manifestations and immune dysregulation, disease pathogenesis and phenotype vary greatly among RAIDs, and limited understanding of their aetiology has made repurposing drugs for RAIDs challenging. Nevertheless, the past century has been characterized by different 'waves' of repurposing. Early drug repurposing occurred in academia and was based on serendipitous observations or perceived disease similarity, often driven by the availability and popularity of drug classes. Since the 1990s, most biologic therapies have been developed for one or several RAIDs and then tested among the others, with varying levels of success. The past two decades have seen data-driven repurposing characterized by signature-based approaches that rely on molecular biology and genomics. Additionally, many data-driven strategies employ computational modelling and machine learning to integrate multiple sources of data. Together, these repurposing periods have led to advances in the treatment for many RAIDs.
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11
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Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, Cervera R, Doria A, Gordon C, Govoni M, Houssiau F, Jayne D, Kouloumas M, Kuhn A, Larsen JL, Lerstrøm K, Moroni G, Mosca M, Schneider M, Smolen JS, Svenungsson E, Tesar V, Tincani A, Troldborg A, van Vollenhoven R, Wenzel J, Bertsias G, Boumpas DT. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78:736-745. [DOI: 10.1136/annrheumdis-2019-215089] [Citation(s) in RCA: 780] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.
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12
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Zhou T, Lin S, Yang S, Lin W. Efficacy and safety of tacrolimus in induction therapy of patients with lupus nephritis. Drug Des Devel Ther 2019; 13:857-869. [PMID: 30880918 PMCID: PMC6420100 DOI: 10.2147/dddt.s189156] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this study was to detect the efficacy and safety of tacrolimus (TAC) in induction therapy of patients with lupus nephritis. METHODS Associated studies were extracted from the PubMed and the Cochrane Library on July 10, 2018, and applicable investigations were pooled and analyzed by meta-analysis. Data on complete remission (CR), total remission (TR; complete plus partial remission), proteinuria levels, urine erythrocyte number, albumin, glomerular filtration rate, negative rate of ds-DNA, C3 levels, C4 levels, systemic lupus erythematosus disease activity index (SLE-DAI), etc, were extracted and pooled using RevMan 5.3. RESULTS In the therapeutic regimen of TAC + glucocorticoids (GC) vs cyclophosphamide (CYC) + GC, the results indicated that the TAC group had high values of CR, TR, albumin, and negative rate of ds-DNA, and low values of proteinuria levels and SLE-DAI when compared with those in CYC group (all P<0.05). In the therapeutic regimen comprising TAC + GC vs mycophenolate mofetil (MMF) + GC, the results indicated that the difference of CR, TR, proteinuria levels, and albumin between TAC group and MMF group were not significant (all P>0.05). In the therapeutic regimen comprising TAC + MMF + GC vs CYC + GC, multitarget therapy group showed higher values of CR, TR, urinary protein decline, and rise of serum albumin when compared with CYC group (all P<0.05). CONCLUSION TAC is an effective and safe agent in induction therapy of patients with lupus nephritis.
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Affiliation(s)
- Tianbiao Zhou
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou 515041, China,
| | - Shujun Lin
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou 515041, China,
| | - Shen Yang
- Department of Nephrology, Huadu District People's Hospital of Guangzhou, Southern Medical University, Guangzhou 510800, China
| | - Wenshan Lin
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou 515041, China,
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13
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Tani C, Elefante E, Martin-Cascón M, Belhocine M, Lavilla Olleros C, Vagelli R, Stagnaro C, Costedoat-Chalumeau N, Ruiz-Irastorza G, Mosca M. Tacrolimus in non-Asian patients with SLE: a real-life experience from three European centres. Lupus Sci Med 2018; 5:e000274. [PMID: 30538815 PMCID: PMC6257376 DOI: 10.1136/lupus-2018-000274] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/02/2018] [Accepted: 07/06/2018] [Indexed: 12/27/2022]
Abstract
Objectives To analyse the real-life practice on the use of Tacrolimus (TAC) in patients with systemic lupus erythematosus (SLE) from three European SLE referral centres. Methods Adult patients with SLE regularly followed at three European referral centres were included. Demographics, cumulative organ involvement, treatment history, Systemic Lupus Disease Activity Index (SLEDAI), laboratory features and physician's judgement were collected at baseline and at 3-6-12 months after starting TAC. Results 29 patients were included (89% female, mean age 38±9 years). Ethnicity was predominantly Caucasian (82%), Black African (11%), Hispanic (3.5%) and Caribbean (3.5%). The main indications for TAC prescription were renal involvement (82.7%), arthritis (10.3%), cutaneous manifestations (6.8%), haematological manifestations (6.8%), serositis (3.4%). At 3 months, there was a clinical improvement in 21 patients (72.4%) and 9 of these experienced a complete resolution of symptoms (31%). This corresponds to: (1) a significant decrease in the mean SLEDAI; (2) a significant decrease in the mean 24 hours proteinuria; a significant increase in C3 and stable creatinine values. At 6 months (n=25), the physician declared an improvement in 19 patients (76%) and a complete resolution of symptoms in 9 (36%). The same trend was observed at 12 months of follow-up. TAC was discontinued in nine pts (31%); reasons for discontinuation were inefficacy (13.8%), drug intolerance (10%) and disease remission (6.9%). Conclusions Despite the limitation due to the small number of patients and the uncontrolled nature of the study, these data show that TAC can be considered a valid therapeutic option in patients with SLE, especially for renal involvement.
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Affiliation(s)
- Chiara Tani
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Elena Elefante
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Miguel Martin-Cascón
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Meriem Belhocine
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Cristina Lavilla Olleros
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Roberta Vagelli
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Chiara Stagnaro
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Nathalie Costedoat-Chalumeau
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Guillermo Ruiz-Irastorza
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy.,Centre de référence maladies auto-immunes et systémiques rares de l'île de France, Service de médecine interne Pôle médecine, Hôpital Cochin, AP-HP, Paris, France.,Autoimmune Diseases Research Unit, BioCruces, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
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14
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Long-term effects of tacrolimus for maintenance therapy of lupus nephritis: a 5-year retrospective study at a single center. Rheumatol Int 2018; 38:2271-2277. [PMID: 30203113 DOI: 10.1007/s00296-018-4154-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
Previously, we reported the short-term effects of tacrolimus in treating lupus nephritis (LN); however, long-term data are lacking. We conducted a retrospective study of 26 adult patients with LN. Tacrolimus was initiated at a dose of 3 mg/day after induction therapy. We retrospectively collected data on renal response; modified lupus nephritis disease activity index (m-LNDAI), including hematuria, proteinuria, complement 3, anti-double-stranded DNA antibody, and estimated glomerular filtration rate (eGFR); and prednisolone (PSL) dose. Three patients discontinued tacrolimus treatment because of related complications, including acute myeloblastic leukemia, tremor, or a general personal choice or a desire to become pregnant. We analyzed data from 23 patients who were treated with tacrolimus over a 5-year period. The mean urinary protein/creatinine ratio decreased from a baseline of 0.24 (min 0.00-max 4.20) to 0.00 (0.00-7.05) at 5 years (p = 0.0134), while eGFR levels remained unchanged throughout the 5 years. The mean m-LNDAI decreased from a baseline of 3.00 (0.00-12.0) to 2.00 (0.00-4.00) at 5 years (p = 0.0074). The mean PSL dose decreased from a baseline of 0.33 (0.00-0.75) mg/kg/day to 0.15 (0.15-0.33) at 5 years (p = 0.001). Our results suggest that tacrolimus is potentially effective for treating LN and that the current dosage was generally well tolerated for long-term maintenance treatment in our patients with LN.
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15
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Abstract
Most of the attention paid to lupus nephritis, in the medical literature and in clinical trials, has primarily focused on proliferative forms of lupus nephritis (class III and IV lesions), but with lower thresholds to biopsy and rebiopsy patients with lupus, clinicians are encountering more cases with purely mesangial disease (class I and II) or membranous nephropathy patterns (class V). These lesions often will be associated with milder disease courses but still require dedicated follow-up by a nephrologist and focused therapeutic strategies that, at times, will include immunosuppression.
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Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 4-124, New York, NY 10032, USA.
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16
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Tunnicliffe DJ, Palmer SC, Henderson L, Masson P, Craig JC, Tong A, Singh‐Grewal D, Flanc RS, Roberts MA, Webster AC, Strippoli GFM. Immunosuppressive treatment for proliferative lupus nephritis. Cochrane Database Syst Rev 2018; 6:CD002922. [PMID: 29957821 PMCID: PMC6513226 DOI: 10.1002/14651858.cd002922.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids, has been first-line treatment for inducing disease remission for proliferative lupus nephritis, reducing death at five years from over 50% in the 1950s and 1960s to less than 10% in recent years. Several treatment strategies designed to improve remission rates and minimise toxicity have become available. Treatments, including mycophenolate mofetil (MMF) and calcineurin inhibitors, alone and in combination, may have equivalent or improved rates of remission, lower toxicity (less alopecia and ovarian failure) and uncertain effects on death, end-stage kidney disease (ESKD) and infection. This is an update of a Cochrane review first published in 2004 and updated in 2012. OBJECTIVES Our objective was to assess the evidence and evaluate the benefits and harms of different immunosuppressive treatments in people with biopsy-proven lupus nephritis. The following questions relating to management of proliferative lupus nephritis were addressed: 1) Are new immunosuppressive agents superior to or as effective as cyclophosphamide plus corticosteroids? 2) Which agents, dosages, routes of administration and duration of therapy should be used? 3) Which toxicities occur with the different treatment regimens? SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 2 March 2018 with support from the Cochrane Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any immunosuppressive treatment for biopsy-proven class III, IV, V+III and V+VI lupus nephritis in adult or paediatric patients were included. DATA COLLECTION AND ANALYSIS Data were abstracted and the risks of bias were assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) and measures on continuous scales calculated as mean differences (MD) with 95% confidence intervals (CI). The primary outcomes were death (all causes) and complete disease remission for induction therapy and disease relapse for maintenance therapy. Evidence certainty was determined using GRADE. MAIN RESULTS In this review update, 26 new studies were identified, to include 74 studies involving 5175 participants overall. Twenty-nine studies included children under the age of 18 years with lupus nephritis, however only two studies exclusively examined the treatment of lupus nephritis in patients less than 18 years of age.Induction therapy Sixty-seven studies (4791 participants; median 12 months duration (range 2.5 to 48 months)) reported induction therapy. The effects of all treatment strategies on death (all causes) and ESKD were uncertain (very low certainty evidence) as this outcome occurred very infrequently. Compared with intravenous (IV) cyclophosphamide, MMF may have increased complete disease remission (RR 1.17, 95% CI 0.97 to 1.42; low certainty evidence), although the range of effects includes the possibility of little or no difference.Compared to IV cyclophosphamide, MMF is probably associated with decreased alopecia (RR 0.29, 95% CI 0.19 to 0.46; 170 less (129 less to 194 less) per 1000 people) (moderate certainty evidence), increased diarrhoea (RR 2.42, 95% CI 1.64 to 3.58; 142 more (64 more to 257 more) per 1000 people) (moderate certainty evidence) and may have made little or no difference to major infection (RR 1.02, 95% CI 0.67 to 1.54; 2 less (38 less to 62 more) per 1000 people) (low certainty evidence). It is uncertain if MMF decreased ovarian failure compared to IV cyclophosphamide because the certainty of the evidence was very low (RR 0.36, 95% CI 0.06 to 2.18; 26 less (39 less to 49 more) per 1000 people). Studies were not generally designed to measure ESKD.MMF combined with tacrolimus may have increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 336 more (17 to 1048 more) per 1000 people (low certainty evidence) compared with IV cyclophosphamide, however the effects on alopecia, diarrhoea, ovarian failure, and major infection remain uncertain. Compared to standard of care, the effects of biologics on most outcomes were uncertain because of low to very low certainty of evidence.Maintenance therapyNine studies (767 participants; median 30 months duration (range 6 to 63 months)) reported maintenance therapy. In maintenance therapy, disease relapse is probably increased with azathioprine compared with MMF (RR 1.75, 95% CI 1.20 to 2.55; 114 more (30 to 236 more) per 1000 people (moderate certainty evidence). Multiple other interventions were compared as maintenance therapy, but patient-outcome data were sparse leading to imprecise estimates. AUTHORS' CONCLUSIONS In this review update, studies assessing treatment for proliferative lupus nephritis were not designed to assess death (all causes) or ESKD. MMF may lead to increased complete disease remission compared with IV cyclophosphamide, with an acceptable adverse event profile, although evidence certainty was low and included the possibility of no difference. Calcineurin combined with lower dose MMF may improve induction of disease remission compared with IV cyclophosphamide, but the comparative safety profile of these therapies is uncertain. Azathioprine may increase disease relapse as maintenance therapy compared with MMF.
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Affiliation(s)
- David J Tunnicliffe
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Lorna Henderson
- NHS LothianRenal DepartmentRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Philip Masson
- Royal Free London NHS Foundation TrustDepartment of Renal MedicineLondonUK
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Allison Tong
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Davinder Singh‐Grewal
- The Sydney Children's Hospitals NetworkDepartment Paediatric RheumatologyThe Children's Hospital at WestmeadCnr Hainsworth and Hawkesbury RoadsWestmeadNSWAustralia2145
| | - Robert S Flanc
- Monash Medical CentreDepartment of NephrologyClayton RdClaytonVICAustralia3168
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Efficacy of Cyclosporine in the Induction and Maintenance of Remission in a Systemic Lupus Erythematosus Patient Presenting with Macrophage-Activating Syndrome. Case Rep Rheumatol 2018; 2018:1961585. [PMID: 29552369 PMCID: PMC5821990 DOI: 10.1155/2018/1961585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/24/2017] [Accepted: 12/03/2017] [Indexed: 11/17/2022] Open
Abstract
Macrophage-activating syndrome (MAS) is a rare condition characterized by dysfunctional macrophage activation leading to overproduction of cytokines and phagocytosis of erythrocytes, leukocytes, and platelets. MAS is associated with infectious diseases, malignancies, and autoimmune rheumatic disorders. Herein, we present a 22-year-old Hispanic woman with SLE who was hospitalized because of a three-week history of fever, fatigue, polyarthralgia, nausea, and abdominal pain. Initial laboratories showed severe pancytopenia with marked elevation of liver enzymes and ferritin levels. Bone marrow biopsy revealed macrophages with engulfed erythrocytes consistent with MAS. The patient was treated with high-dose corticosteroids, intravenous immunoglobulins, and cyclosporine 3 mg/kg/day. She had a remarkable clinical response to this therapy. She was continued on cyclosporine, and prednisone dose was gradually decreased to 7.5 mg daily without experiencing recurrent disease. She remained in full clinical remission for 12 months. Our case, together with other reports, suggests that combination therapy with corticosteroids, immunoglobulins, and cyclosporine appears to be effective for patients with SLE-associated MAS. Furthermore, cyclosporine seems to be a good drug for maintenance of remission.
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Ikeda K, Nakajima S, Tanji K, Hirai T, Uomori K, Morimoto S, Tomita S, Fukunaga M, Tamura N, Sekigawa I. Intestinal perforation due to hemorrhagic Cytomegalovirus enteritis in a patient with severe uncontrolled lupus nephritis: a case and review of the literature. Rheumatol Int 2017; 37:1395-1399. [PMID: 28283734 DOI: 10.1007/s00296-017-3693-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/28/2017] [Indexed: 10/20/2022]
Abstract
A 31-year-old woman with systemic lupus erythematosus and lupus nephritis was treated with prednisone and immunosuppressants. After her lupus nephritis symptoms worsened, both high-dose steroid and cyclophosphamide pulse therapy were administered. The patient developed an intestinal perforation, and laparoscopic Hartmann's surgery was performed on the sigmoid colon. Serum Cytomegalovirus (CMV) antigen C7HRP was detected, and the patient was diagnosed with CMV colitis and underwent a colon resection. Severe hematochezia continued despite ganciclovir administration, and the patient underwent laparoscopic total colectomy and partial ileostomy. CMV enteritis should be considered in patients treated with prednisone and immunosuppressants and those who have abdominal pain and hematochezia. Immunocompromised patients with intestinal perforation due to CMV enteritis have a poor prognosis. We report a case with along with the results of a literature review.
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Affiliation(s)
- Keigo Ikeda
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan.
| | - Shihoko Nakajima
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kana Tanji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takuya Hirai
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan
| | - Kaori Uomori
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shinji Morimoto
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan
| | - Shigeki Tomita
- Department of Pathology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan
| | - Masaki Fukunaga
- Department of Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Iwao Sekigawa
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, 279-0021, Japan
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Efficacy and safety of tacrolimus treatment for neuromyelitis optica spectrum disorder. Sci Rep 2017; 7:831. [PMID: 28400553 PMCID: PMC5429791 DOI: 10.1038/s41598-017-00860-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/15/2017] [Indexed: 12/17/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a severe inflammatory autoimmune disease that mainly involves the optic nerves and spinal cord, causing blindness and paralysis. Although some immunosuppressants such as rituximab and azathioprine have proven to be effective in relapse prevention, the high costs or intolerable adverse events preclude their wide application. Thus, we have conducted a retrospective study in 25 NMOSD patients who were treated with tacrolimus, an immunosuppressant with high efficacy and good tolerance in other autoimmune diseases, to assess its efficacy and safety in NMOSD treatment during the last five years (2011-2016). The results revealed that tacrolimus could reduce the relapse rate by 86.2% and improve the Expanded Disability Status Scale (EDSS) scores (4.5 vs 2.3; P < 0.001) significantly. Relapses in tacrolimus treatment were associated with serum titers of aquaporin 4 antibody (AQP4-IgG) (P = 0.028). Further Cox proportional analysis demonstrated that patients with high titers of AQP4-IgG (≥1:64) had a significantly higher risk of relapse than those with low titers after tacrolimus therapy (HR:5.665; CI95: 1.012-31.705; P = 0.048). Tacrolimus tended to be superior to azathioprine (29 patients) in terms of efficacy and safety during the same period. Our study suggests that tacrolimus may be another promising immunosuppressant for NMOSD.
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Sex Differences in the Blood Concentration of Tacrolimus in Systemic Lupus Erythematosus and Rheumatoid Arthritis Patients with CYP3A5*3/*3. Biochem Genet 2017; 55:268-277. [PMID: 28324194 PMCID: PMC5438821 DOI: 10.1007/s10528-017-9795-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/13/2017] [Indexed: 01/19/2023]
Abstract
The purpose of this study was to describe the impact of sex and cytochrome P450 3A5 (CYP3A5) variant on the blood concentration of tacrolimus in patients with systemic lupus erythematosus or rheumatoid arthritis. The blood concentration of tacrolimus (ng/mL) divided by the daily dose of tacrolimus (mg/day) and the patient's weight (kg) (C/D) was obtained from 55 patients. The C/D value was analysed according to genetic variation in CYP3A5 or ATP binding cassette subfamily B member 1 (ABCB1), sex, and age. The C/D value in the CYP3A5*3/*3 group was significantly higher than in the CYP3A5*1/*1 and *1/*3 groups (p < 0.05, effect size: d = 1.40). In the CYP3A5*3/*3 group, the concentration of tacrolimus was significantly higher in men than in women (p < 0.05, effect size: d = 1.78). Furthermore, in the CYP3A5*3/*3 group, the concentration of tacrolimus was significantly higher in women aged over 50 years than in women aged under 50 years (p < 0.05, effect size: d = 1.18). In contrast, ABCB1 genetic variations did not show any significant effect on the C/D value. Since the blood concentration of tacrolimus in patients with CYP3A5*3/*3 varies depending on sex and age, these factors should be considered when studying the difference of sex in CYP3A.
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Fernandez Nieto M, Jayne DR. Con: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1567-71. [PMID: 27591328 DOI: 10.1093/ndt/gfw291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 01/30/2023] Open
Abstract
Lupus nephritis (LN) therapy has limited efficacy due to its toxicity, and LN patients suffer high risks of renal and cardiovascular morbidity and mortality. Calcineurin inhibitors (CNIs) have been used for over >30 years in LN treatment and are an established alternative therapy for Class V nephritis, but uncertainty remains about their role in proliferative disease or in the maintenance of remission. More recently, the combination of CNIs with mycophenolate mofetil (MMF) and glucocorticoid combination therapy, 'multitarget' therapy and the use of tacrolimus as opposed to ciclosporin has received attention. Is the evidence now sufficient to support the routine use of regimens including CNIs in LN? Although CNIs appear to have similar efficacy to MMF-based regimens as induction therapy, and are comparable with azathioprine as maintenance treatment, CNI toxicities, such as new-onset hypertension, hyperglycaemia and nephrotoxicity, have been problematic. Multitarget therapy improves the rate of complete remission in short-term studies, but whether this benefit is maintained over the longer term is uncertain. However, patient tolerability is lower and the frequency of serious events is higher in multitarget versus cyclophosphamide-based regimens, and there is a paucity of evidence from non-Asian ethnic groups. CNI-based therapy is also complicated by the absence of standardized dosing and the need for drug level monitoring, as well as by pharmacogenetic differences. Also, multitarget therapy increases the complexity and the cost of treatment. There is insufficient evidence to support the routine use of CNI-based or multitarget therapy for proliferative LN. Further data on long-term renal and cardiovascular outcomes and strategies to improve tolerability and safety are required.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Kansal A, Tripathi D, Rai MK, Agarwal V. Persistent expression and function of P-glycoprotein on peripheral blood lymphocytes identifies corticosteroid resistance in patients with systemic lupus erythematosus. Clin Rheumatol 2015; 35:341-9. [PMID: 26415739 DOI: 10.1007/s10067-015-3079-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/15/2015] [Accepted: 09/17/2015] [Indexed: 12/18/2022]
Abstract
Corticosteroids (CS) are the mainstay of treatment in systemic lupus erythematosus (SLE) patients. However, some patients have poor response to CS treatment. Among the multiple mechanisms of CS resistance, overexpression of P-glycoprotein (P-gp) on peripheral blood lymphocytes (PBL) may be one of them as this result in efflux of CS from lymphocytes. Thus, we evaluated the role of P-gp protein on PBLs in patients with SLE in its response to CS therapy. SLE patients (n = 42) (fulfilling ACR revised criteria) who were naïve to CS and immunosuppressive drugs were enrolled. Disease activity was assessed using SLE disease activity index (SLEDAI) and expression, and function of P-gp was evaluated by flow cytometry at baseline and after 3 months of therapy with CS. At 3 months, patients with SLEDAI >4 and SLEDAI ≤4 were grouped as nonresponders and responders, respectively. P-gp expression was significantly increased on PBLs of SLE patients as compared to healthy controls (p < 0.001). P-gp expression and function correlated with SLEDAI (r = 0.49, p = 0.005; and r = 0.49, p = 0.001, respectively). P-gp expression and function were not different in responders and nonresponders at baseline. However, at 3 months of CS therapy, P-gp expression and function decreased in responders (p < 0.001 and p < 0.005, respectively), whereas in nonresponders, it remained unchanged. Persistent overexpression and activity of P-gp are associated with poor response to CS in CS naïve patients of SLE.
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Affiliation(s)
- Amit Kansal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Deepak Tripathi
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Mohit K Rai
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India.
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Ishii S, Miwa Y, Otsuka K, Nishimi S, Nishimi A, Saito M, Miura Y, Oguro N, Tokunaga T, Takahashi R, Kasama T. Influence of renal complications on the efficacy and adverse events of tacrolimus combination therapy in patients with systemic lupus erythematosus (SLE) during a maintenance phase: a single-centre, prospective study. Lupus Sci Med 2015; 2:e000091. [PMID: 26056606 PMCID: PMC4453506 DOI: 10.1136/lupus-2015-000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/05/2015] [Accepted: 05/10/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The study investigated whether renal complications affected the efficacy and safety of tacrolimus combination therapy in patients with systemic lupus erythematosus (SLE) during a maintenance phase. METHODS Fifty-seven patients with SLE (A: 30 cases with renal complication, B: 27 cases without renal complications) were included. The presence of renal complications was defined as proteinuria ≥0.5 g/day and lupus nephritis on renal biopsy. Major outcome measures included SLE disease activity index (SLEDAI), steroid dose, serum anti-dsDNA Ab, C3 and creatinine (Cr) levels and estimated glomerular filtration rate (eGFR). The patient's background factors included age, gender, disease duration and ACE-I/angiotensin II receptor blocker and statin therapies. We compared these outcome measures pre treatment and after 1 year of treatment. RESULTS The SLEDAI and serum C3 levels improved in both groups from pretreatment period to post-treatment period: from 7.2±5.0 to 2.8±2.3 in A and 6.4±3.8 to 2.4±2.2 in B, p<0.001, and from 65.9±24.6 to 77.7±18.2 mg/dL in A and 81.8±23.0 to 90.6±19.4 mg/dL in B, p=0.002, respectively. The anti-dsDNA antibody level was reduced, and the serum Cr and eGFR levels were slightly elevated. No patients developed end-stage renal failure that required artificial dialysis. CONCLUSIONS Tacrolimus combination therapy had additive beneficial effects on reduced proteinuria and increased serum C3 levels in patients with SLE with renal complications during a maintenance phase.
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Affiliation(s)
- Sho Ishii
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Yusuke Miwa
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Kumiko Otsuka
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Shinichiro Nishimi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Airi Nishimi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Mayu Saito
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Nao Oguro
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Takahiro Tokunaga
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Ryo Takahashi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Tsuyoshi Kasama
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
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Tamura N. [Rheumatology: Progress in Diagnosis and Treatments Topics: IV. Collagen Diseases Except for Rheumatoid Arthritis and Hot Topics; 1. Systemic lupus erythematosus]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:2465-2472. [PMID: 27514195 DOI: 10.2169/naika.103.2465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Tian SY, Feldman BM, Beyene J, Brown PE, Uleryk EM, Silverman ED. Immunosuppressive therapies for the induction treatment of proliferative lupus nephritis: a systematic review and network metaanalysis. J Rheumatol 2014; 41:1998-2007. [PMID: 25225281 DOI: 10.3899/jrheum.140050] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate and determine the most effective immunosuppressive therapy for the induction treatment of proliferative lupus nephritis (PLN) based on renal remission. METHODS A systematic review of randomized controlled trials was conducted. The outcomes were renal remission at 6 months: (1) normalization of serum creatinine [(sCr), or within 15% of the normal range, i.e., sCr < 132 µmol/l - creatinine remission]; and (2) proteinuric remission (prU < 0.5 g/day/1.73m(2)). A Bayesian network metaanalysis was used. RESULTS The OR (95% credible interval) of inducing an sCr remission at 6 months was 1.70 (0.51, 6.87) for mycophenolate mofetil (MMF) versus cyclophosphamide (CYC); 2.16 (0.38, 13.36) for tacrolimus (Tac) versus CYC; and 1.25 (0.13, 10.51) for Tac versus MMF. For proteinuric remission the OR was 1.46 (0.81, 3.04) for MMF versus CYC; 1.96 (0.80, 5.11) for Tac versus CYC; and 1.34 (0.43, 3.90) for Tac versus MMF. The probability (95% credible interval) of inducing a creatinine remission at 6 months was Tac 56% (19%, 88%); MMF 51% (23%, 79%); and CYC 37% (28%, 47%). The probability of inducing a proteinuric remission was Tac 41% (23%, 63%); MMF 34% (23%, 50%); CYC 26% (20%, 32%); azathioprine 10% (1%, 55%); prednisone 11% (2%, 38%). None of the results were conclusive when examined in a sensitivity analysis. CONCLUSION There is currently insufficient evidence to determine which of these immunosuppressive agents is superior. The probability of renal remission is 50% or lower at 6 months.
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Affiliation(s)
- Simon Yu Tian
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Brian M Feldman
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Joseph Beyene
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Patrick E Brown
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Elizabeth M Uleryk
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Earl D Silverman
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
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Yagi N, Okada K, Sudo Y, Itoh H, Yoshida H, Kuroda T. Long-term post-marketing surveillance of mizoribine for the treatment of lupus nephritis: Safety and efficacy during a 3-year follow-up. SAGE Open Med 2014; 2:2050312114533960. [PMID: 26770729 PMCID: PMC4607187 DOI: 10.1177/2050312114533960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 03/28/2014] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the safety and efficacy of long-term use of mizoribine by undertaking a 3-year post-marketing surveillance study. METHODS Subjects were all lupus nephritis patients newly treated with mizoribine between 1 October 2003 and 30 September 2005 at contracted study sites. RESULTS Mizoribine was administered to 881 lupus nephritis patients in the safety analysis set consisting of 946 patients recruited from 281 contracted study sites after satisfying the eligibility criteria. There were 301 events of adverse drug reactions that were observed in 196 (20.7%) of the 946 subjects. There were 34 events of serious adverse drug reactions in 31 patients (3.2%). No deterioration in hematological and biochemical test values was observed, but immunological testing showed significant improvements in C3, CH50, and anti-DNA antibody titers. The negative rate of proteinuria also increased over time. The median steroid dosage was 15 mg/day at the commencement of treatment, but was reduced to 10 mg/day at 12 months and 8 mg/day at 36 months. CONCLUSION The findings of the 3-year long-term drug use surveillance study indicated that mizoribine can be used over the long term with relatively few adverse drug reactions, suggesting its suitability for use in maintenance drug therapy.
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Affiliation(s)
- Nobuyuki Yagi
- Scientific Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Kenya Okada
- Post-Marketing Surveillance Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Yohei Sudo
- Scientific Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Hiromichi Itoh
- Scientific Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Hisao Yoshida
- Post-Marketing Surveillance Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Tatsuhiko Kuroda
- Post-Marketing Surveillance Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
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Yang M, Li M, He W, Wang B, Gu Y. Calcineurin inhibitors may be a reasonable alternative to cyclophosphamide in the induction treatment of active lupus nephritis: A systematic review and meta-analysis. Exp Ther Med 2014; 7:1663-1670. [PMID: 24926363 PMCID: PMC4043578 DOI: 10.3892/etm.2014.1669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/21/2014] [Indexed: 12/13/2022] Open
Abstract
Although the accepted standard of care during the induction treatment of active lupus nephritis (LN) has been cyclophosphamide (CYC), recent trials suggest that calcineurin inhibitors (CNIs), which include cyclosporine A (CsA) and tacrolimus (TAC), may be just as, or even more, effective and less toxic than CYC. A systematic review and meta-analysis were performed to evaluate the clinical effects of CNIs on active LN compared with those of CYC. In the present study, clinical trials that compared CNIs with CYC in the induction therapy of active LN were searched in the Cochrane Library, Ovid and PubMed databases. The clinical data on renal remission and side-effects were collected and analyzed. The relative risk (RR) and 95% confidence intervals (CIs) were calculated. As a result, six controlled trials involving 265 patients were included in the meta-analysis, four of which compared TAC (treatment group) with CYC (control group), and the other two compared CsA (treatment group) with CYC (control group). CNIs were superior to CYC for higher complete remission (RR=1.56, 95% CI 1.14-2.15, Z=2.74, P=0.006) and better overall response/total remission (RR=1.23, 95% CI 1.07-1.42, Z=2.87, P=0.004) and had fewer side-effects. Among the CNIs, TAC demonstrated more favorable results than CsA. Therefore, it was concluded that CNIs may be a reasonable alternative to CYC in the induction treatment of active LN. However, large-scale, multicenter, well-designed clinical trials should be adopted to further confirm this conclusion.
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Affiliation(s)
- Min Yang
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Min Li
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Wei He
- Department of Gastroenterology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Bin Wang
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Yong Gu
- Division of Nephrology, Huashan Hospital and Institute of Nephrology, Fudan University, Shanghai 200040, P.R. China
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Nakane S, Fujita K, Shibuta Y, Matsui N, Harada M, Urushihara R, Nishida Y, Izumi Y, Kaji R. Successful treatment of stiff person syndrome with sequential use of tacrolimus. J Neurol Neurosurg Psychiatry 2013; 84:1177-80. [PMID: 23715915 DOI: 10.1136/jnnp-2013-305425] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sugiura K, Tanahashi K, Muro Y, Akiyama M. Cutaneous lupus mucinosis successfully treated with systemic corticosteroid and systemic tacrolimus combination therapy. J Am Acad Dermatol 2013; 69:e200-2. [PMID: 24034403 DOI: 10.1016/j.jaad.2013.04.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/10/2013] [Accepted: 04/13/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Kazumitsu Sugiura
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Tanaka H, Watanabe S, Aizawa-Yashiro T, Oki E, Kumagai N, Tsuruga K, Ito E. Long-term tacrolimus-based immunosuppressive treatment for young patients with lupus nephritis: a prospective study in daily clinical practice. NEPHRON. CLINICAL PRACTICE 2013; 121:c165-73. [PMID: 23327881 DOI: 10.1159/000346149] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 11/28/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal long-term treatment for lupus nephritis (LN) in pubertal patients remains to be determined. Tacrolimus (Tac) inhibits T cell activation, and is therefore expected to be effective in patients with LN. However, little has been published about the long-term efficacy and safety of Tac-based immunosuppressive treatment of young patients with LN in daily clinical practice. METHODS Nineteen consecutive patients with biopsy-proven LN were recruited for an open-label, prospective, long-term Tac-based treatment regimen. Tac was administered once daily at a dose of 3 mg as induction- or reinduction-maintenance treatment. Four patients (21%) with new-onset LN received mizoribine at a dose of 150 mg once daily in addition to Tac. Treatment outcomes were defined by the European Consensus Lupus Activity Measurement (ECLAM) index, urinary protein/creatinine ratio (Up/cr), serum creatinine and serological lupus markers (complement C3, complement hemolytic activity, CH50, and anti-dsDNA antibody titer). Data on these parameters were collected prospectively. The median follow-up was 42 months. RESULTS Baseline characteristics of the patients were as follows: mean age, 18 years; Up/cr, 0.89 ± 1.17; serum C3, 68.1 ± 23.2 mg/dl (normal, 79-152 mg/dl); serum CH50, 26.4 ± 10.5 U/ml (normal, 23-46 U/ml); serum anti-dsDNA antibody titer, 69.3 ± 67.5 IU/ml (normal, <12.0 IU/ml); serum creatinine, 0.55 ± 0.18 mg/dl, and ECLAM index, 4.6 ± 1.9. Despite gradually tapering the dose of concomitantly administered prednisolone, a marked improvement compared with baseline values was observed in all outcome measures as early as 3 months after the initiation of treatment, and the favorable changes persisted throughout the treatment period in most of the patients. Sustained improvements in the outcome measures compared with the baseline values were confirmed after a mean of 42 months of treatment: ECLAM index, 1.1 ± 1.1; serum CH50, 36.0 ± 12.8 U/ml, anti-dsDNA antibody titer, 22.5 ± 26.5 IU/ml (all p < 0.01); Up/cr ratio, 0.35 ± 0.58, and serum C3 level, 79.7 ± 17.6 mg/dl (both p < 0.05). Serum creatinine level remained within the normal range in all the study participants. Complete response was achieved in 12 patients (63%), and a partial response was achieved in 5 patients (26%). The remaining 2 patients showed no response. No serious adverse effects were observed. CONCLUSION The data suggest that long-term, relatively low-dose Tac-based immunosuppressive treatment is beneficial and has low cytotoxicity, and therefore represents an attractive option for the treatment of young patients with LN in daily clinical practice. Further studies involving a larger number of patients are needed to confirm these results.
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Affiliation(s)
- Hiroshi Tanaka
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan.
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Kalloo S, Aggarwal N, Mohan P, Radhakrishnan J. Lupus Nephritis: Treatment of Resistant Disease. Clin J Am Soc Nephrol 2013; 8:154-61. [DOI: 10.2215/cjn.05870612] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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32
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Successful treatment of rectal ulcers in a patient with systemic lupus erythematosus using corticosteroids and tacrolimus. Mod Rheumatol 2012. [DOI: 10.1007/s10165-012-0775-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Marlaka JR, Papadogiannakis N, Fischler B, Casswall TH, Beijer E, Németh A. Tacrolimus without or with the addition of conventional immunosuppressive treatment in juvenile autoimmune hepatitis. Acta Paediatr 2012; 101:993-9. [PMID: 22646819 DOI: 10.1111/j.1651-2227.2012.02745.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIM To investigate tacrolimus (Tac)-based treatment in juvenile autoimmune hepatitis (AIH). Twenty patients (13 girls; age, 8-17 years; median, 13.25 years) with AIH were treated with two daily oral doses of Tac. Six of them had advanced liver disease and/or cirrhosis. METHODS Drug concentrations in blood were measured regularly, and the target trough levels were 2.5-5 ng/mL. The patients were followed up for 1 year. Their clinical, biochemical, immunological and histological status was obtained at baseline and after 1 year. RESULTS In three cases, Tac alone led to complete remission. In 14 cases, additional low doses of prednisolone or azathioprine were used for a short time to achieve remission. In two cases, the treatment was discontinued: in one because of therapeutic failure, in another because of a suspected but unverified adverse event. Ten patients reported headache and/or recurrent abdominal pain. Two patients developed inflammatory bowel disease. Renal function remained intact. CONCLUSION Tac is a promising alternative first line of treatment for AIH. Although monotherapy with Tac is usually not sufficient to achieve complete remission, the prednisolone and azathioprine doses can be drastically reduced, and most of their side effects avoided.
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Hahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, FitzGerald JD, Karpouzas GA, Merrill JT, Wallace DJ, Yazdany J, Ramsey-Goldman R, Singh K, Khalighi M, Choi SI, Gogia M, Kafaja S, Kamgar M, Lau C, Martin WJ, Parikh S, Peng J, Rastogi A, Chen W, Grossman JM. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012. [DOI: 10.1002/acr.21664 5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, Fitzgerald JD, Karpouzas GA, Merrill JT, Wallace DJ, Yazdany J, Ramsey-Goldman R, Singh K, Khalighi M, Choi SI, Gogia M, Kafaja S, Kamgar M, Lau C, Martin WJ, Parikh S, Peng J, Rastogi A, Chen W, Grossman JM. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012; 64:797-808. [PMID: 22556106 PMCID: PMC3437757 DOI: 10.1002/acr.21664] [Citation(s) in RCA: 934] [Impact Index Per Article: 77.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Bevra H Hahn
- School of Medicine, University of California-Los Angeles, CA 90095-1670, USA.
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Recent progress in the treatment of lupus nephritis. Mod Rheumatol 2012; 22:803-13. [PMID: 22584472 DOI: 10.1007/s10165-012-0655-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
Abstract
The treatment of lupus nephritis has seen significant advances during the past decade mainly due to the publication of well-designed randomized clinical trials (RCTs). The choice of treatment is guided by the histopathologic classification but is also influenced by demographic, clinical, and laboratory characteristics that allow for the identification of patients at risk for more aggressive disease. For the induction arm, low-dose cyclophosphamide regimens and mycophenolate mofetil have been validated as alternatives to the established National Institutes of Health regimen of high-dose cyclophosphamide; for the maintenance phase, azathioprine and mycophenolate compete for treatment of first choice. Rituximab is efficacious in real-life clinical practice but ineffective in clinical trials. The role of recently approved belimumab in lupus nephritis eagerly awaits further documentation. Aggressive management of comorbid conditions, such as hypertension and dyslipidemia, is of utmost importance. Here, we review the latest advances in lupus nephritis therapy with a focus on recent RCTs as well as new biologic agents under development. Furthermore, we propose a therapeutic algorithm in an effort to facilitate clinical decision-making in this gradually changing landscape. Upcoming European and American recommendations should provide further clarification.
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Mizoribine, tacrolimus, and corticosteroid combination therapy successfully induces remission in patients with lupus nephritis. Clin Exp Nephrol 2012; 16:760-6. [DOI: 10.1007/s10157-012-0632-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 03/26/2012] [Indexed: 01/26/2023]
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Onishi A, Sugiyama D, Tsuji G, Nakazawa T, Kogata Y, Tsuda K, Naka I, Nishimura K, Misaki K, Kurimoto C, Hayashi H, Kageyama G, Saegusa J, Sugimoto T, Kawano S, Kumagai S, Morinobu A. Mycophenolate mofetil versus intravenous cyclophosphamide for induction treatment of proliferative lupus nephritis in a Japanese population: a retrospective study. Mod Rheumatol 2012; 23:89-96. [PMID: 22447557 DOI: 10.1007/s10165-012-0634-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/08/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Recent studies have shown that mycophenolate mofetil (MMF) is similar to intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis (LN), but that treatment response may vary according to location and race/ethnicity. Moreover, no studies have been conducted to compare the efficacy of MMF with that of IVC for a Japanese population. We therefore conducted a retrospective study to clarify the efficacy and safety of MMF compared with that of IVC for induction therapy for active LN, classes III and IV, in a Japanese population of 21 patients, 11 of whom received MMF and 10 IVC. METHODS The primary endpoint was expressed as the percentage of responders, who in turn were defined as the patients who met complete or partial response criteria according to the European consensus statement. The secondary endpoints comprised the renal activity component and serological activity. RESULTS The primary endpoint was achieved in nine (81.8 %) patients receiving MMF and in four (40.0 %) receiving IVC, with no significant difference between the two groups (p = 0.081), while there was also no significant difference between them in terms of secondary endpoints. However, the MMF group suffered significantly fewer hematologic toxic effects than the IVC group. CONCLUSIONS MMF may be used as an alternative to IVC for inducing renal remission of LN in Japanese patients.
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Affiliation(s)
- Akira Onishi
- Department of Evidence Based Laboratory Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Lupus nephritis: an overview of recent findings. Autoimmune Dis 2012; 2012:849684. [PMID: 22536486 PMCID: PMC3318208 DOI: 10.1155/2012/849684] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 11/30/2011] [Indexed: 11/18/2022] Open
Abstract
Lupus nephritis (LN) is one of the most serious complications of systemic lupus erythematosus (SLE) since it is the major predictor of poor prognosis. In susceptible individuals suffering of SLE, in situ formation and deposit of immune complexes (ICs) from apoptotic bodies occur in the kidneys as a result of an amplified epitope immunological response. IC glomerular deposits generate release of proinflammatory cytokines and cell adhesion molecules causing inflammation. This leads to monocytes and polymorphonuclear cells chemotaxis. Subsequent release of proteases generates endothelial injury and mesangial proliferation. Presence of ICs promotes adaptive immune response and causes dendritic cells to release type I interferon. This induces maturation and activation of infiltrating T cells, and amplification of Th2, Th1 and Th17 lymphocytes. Each of them, amplify B cells and activates macrophages to release more proinflammatory molecules, generating effector cells that cannot be modulated promoting kidney epithelial proliferation and fibrosis. Herein immunopathological findings of LN are reviewed.
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Ruiz-Irastorza G, Espinosa G, Frutos MA, Jiménez Alonso J, Praga M, Pallarés L, Rivera F, Robles Marhuenda Á, Segarra A, Quereda C. [Diagnosis and treatment of lupus nephritis]. Rev Clin Esp 2012; 212:147.e1-30. [PMID: 22361331 DOI: 10.1016/j.rce.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, España.
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Recent advances in the treatment of lupus nephritis. Clin Exp Nephrol 2011; 16:202-13. [PMID: 22057583 DOI: 10.1007/s10157-011-0556-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 10/17/2011] [Indexed: 10/15/2022]
Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus (SLE) which is associated with significant morbidity and mortality. The concept of two phases of therapy for lupus nephritis, such as an induction phase and a maintenance phase, is widely accepted. Since the renal involvement in SLE is heterogeneous, the treatment of lupus nephritis is governed by its pathological type and ranges from nonspecific measures, such as maintenance of adequate blood pressure control and blockade of the renin-angiotensin-aldosterone system, to the use of immunosuppressive agents. Cyclophosphamide (CYC) in combination with prednisone has been the standard method of treatment of the proliferative forms of lupus nephritis. However, the high rates of progression to end-stage renal disease coupled with the adverse effects of CYC and prednisone have led to an intensive search for more effective and less toxic therapies for lupus nephritis. We review the options available for the treatment of proliferative and membranous lupus nephritis and summarize the results of recently published clinical trials that add new perspectives to the management of kidney disease in SLE.
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Li X, Ren H, Zhang Q, Zhang W, Wu X, Xu Y, Shen P, Chen N. Mycophenolate mofetil or tacrolimus compared with intravenous cyclophosphamide in the induction treatment for active lupus nephritis. Nephrol Dial Transplant 2011; 27:1467-72. [PMID: 21917733 DOI: 10.1093/ndt/gfr484] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Although the use of aggressive immunosuppression has improved both patient and renal survival of patients with lupus nephritis (LN), the optimal treatment of LN remains challenging. The objective of this study is to assess the efficacy and safety of mycophenolate mofetil (MMF) and tacrolimus compared with intravenous cyclophosphamide (IVC) as induction therapies for active lupus nephritis (ALN). METHODS In this open-label, 24-week prospective study, 60 patients with biopsy-proven ALN (Classes III, IV, V or combination) were randomly assigned to receive MMF, tacrolimus or IVC in combination with corticosteroids. The remission of proteinuria, systemic lupus erythematosus disease active index and adverse events were compared. RESULTS The response rates at 24 weeks were 70% (14/20) in the MMF group, 75% (15/20) in the tacrolimus group and 60% (12/20) in the IVC group (P>0.05). The complete remission rates were also similar in the three groups (40, 45 and 30%, respectively; P>0.05). There were more cases of infection in the IVC group (8/20) and the MMF group (8/20) than the tacrolimus group (3/20) and more hyperglycemia in the tacrolimus group (5/20) than the other two groups (2 or 3/20), but the results were not statistically significant among the three groups. Proteinuria decreased and serum albumin increased more quickly in the patients treated with tacrolimus (P=0.0051 and P=0.048). CONCLUSIONS This pilot study suggests that both MMF and tacrolimus are possible alternatives to IVC as induction therapies for ALN in Chinese patients. Tacrolimus possibly results in a faster resolution of proteinuria and hypoalbuminemia. Further studies are necessary to determine the optimal dosage and duration of the therapies.
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Affiliation(s)
- Xiao Li
- Department of Nephrology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Watanabe H, Hirase N, Goda H, Nishikawa H, Ikuyama S. Oral low-dose tacrolimus therapy for refractory hemophagocytic syndrome associated with systemic lupus erythematosus. Mod Rheumatol 2011; 22:284-9. [PMID: 21720923 DOI: 10.1007/s10165-011-0491-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 06/03/2011] [Indexed: 11/29/2022]
Abstract
Hemophagocytic syndrome (HPS) is an unusual disorder associated with systemic lupus erythematosus (SLE). A 64-year-old woman was admitted because of fever and urticarial vasculitis. Laboratory data revealed pancytopenia and immunological abnormalities, suggesting elevated disease activity. Prednisolone monotherapy failed to improve the pancytopenia despite the amelioration of other clinical findings. Because her condition was suggestive of HPS, tacrolimus at 2-3 mg/day was added to the prednisolone regimen. Eventually, the pancytopenia improved and prednisolone could be effectively tapered. Tacrolimus could be an additional or alternative modality for treating refractory HPS.
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Affiliation(s)
- Hideyuki Watanabe
- Department of Rheumatology, Hematology, and Metabolic Diseases, Kyushu University Hospital at Beppu, 4546 Tsurumibaru, Beppu, Oita 874-0838, Japan.
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Koike R, Tanaka M, Komano Y, Sakai F, Sugiyama H, Nanki T, Ide H, Jodo S, Katayama K, Matsushima H, Miwa Y, Morita K, Nakashima H, Nakamura H, Natsumeda M, Sato Y, Semba S, Tateishi M, Miyasaka N, Harigai M. Tacrolimus-induced pulmonary injury in rheumatoid arthritis patients. Pulm Pharmacol Ther 2011; 24:401-6. [PMID: 21300166 DOI: 10.1016/j.pupt.2011.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/27/2011] [Accepted: 01/29/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tacrolimus (TAC) was approved in Japan in 2005 for rheumatoid arthritis (RA) patients having inadequate response to other disease-modifying anti-rheumatic drugs. As of May 2007, spontaneous reports identified twenty-seven cases of exacerbation or new development of interstitial pneumonia among RA patients given TAC in Japan. OBJECTIVE To describe the clinical and radiological characteristics of TAC-induced pulmonary injury (TIPI). PATIENTS AND METHODS Eleven RA patients diagnosed with de novo pulmonary injury or exacerbation of IP during treatment with TAC were identified. Clinical, radiological, and laboratory data of ten of these cases were retrospectively analyzed. RESULTS Baseline data for the ten patients were a mean age of 69.7 years; gender, 70% female; mean RA disease duration, 9.1 years; and pulmonary comorbidities, 90%. Six cases were classified as presumptive TAC-induced pulmonary injury (TIPI) and four as probable TIPI. Among the six presumptive cases, TIPI developed at an average of 84 days after initiation of treatment (n = 5) or four days after reinstitution of TAC (n = 1). Five cases were an exacerbation of pre-existing interstitial pneumonia and one was a de novo pulmonary injury. Radiological patterns of thoracic computed tomography (CT) scans of patients in the presumptive TIPI cases were hypersensitivity pneumonia like-pattern (n = 3), ground-glass opacity (n = 2), and organizing pneumonia-pattern (n = 1). All patients with presumptive TIPI were treated with high dosage glucocorticosteroids and one received concomitant immunosuppressants. Two of the six presumptive TIPI patients died. CONCLUSION Rheumatologists should be aware of this rare but potentially life-threatening adverse event in RA patients receiving TAC.
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Affiliation(s)
- Ryuji Koike
- Tokyo Medical and Dental University, Tokyo, Japan.
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Takahashi S, Hiromura K, Sakurai N, Matsumoto T, Ikeuchi H, Maeshima A, Kaneko Y, Kuroiwa T, Nojima Y. Efficacy and safety of tacrolimus for induction therapy in patients with active lupus nephritis. Mod Rheumatol 2010; 21:282-9. [PMID: 21188448 DOI: 10.1007/s10165-010-0398-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 11/14/2010] [Indexed: 11/25/2022]
Abstract
After the completion of a double-blind placebo-controlled trial, tacrolimus (TAC) was approved for the treatment of lupus nephritis (LN) in Japan. However, the approved maximal dose, 3 mg/day, is almost half the dose used for induction therapy outside Japan. In this study, we retrospectively evaluated the efficacy and safety of low-dose TAC (≤3 mg/day) for induction therapy in 13 adult patients (2 men and 11 women) with active LN. Eight patients were treated for LN flares. Twelve patients underwent renal biopsies: 8 with class IV, 2 with class III + V, 1 with class IV + V, and 1 with class V renal histology, according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification. The mean initial doses of prednisone and TAC were 34.6 ± 14.5 and 2.7 ± 0.6 mg/day, respectively. All the patients achieved a complete remission (CR) at 7.7 ± 6.7 months (mean ± SD) after the last administration of TAC, except for 2 patients who discontinued TAC treatment; 1 because of worsening systemic lupus erythematosus and 1 because of hypertension. Two patients experienced a flare-up after achieving CR. The mean blood TAC concentration 12 h after the last administration (C12) was significantly lower among the patients with flare-ups than among those with a sustained CR (1.5 ± 1.5 vs. 5.1 ± 1.9 ng/mL, P = 0.034). These data showed that low-dose TAC was effective for induction therapy in patients with active LN, although a lower TAC concentration may be associated with a poor outcome.
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Affiliation(s)
- Satoshi Takahashi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma 371-8511, Japan
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Abstract
Proliferative lupus nephritis is the most severe form of lupus nephritis. Outcomes of this disease are affected by ethnicity, clinical characteristics, irreversible damage on renal biopsy, initial response to treatment and future disease course (for example, the occurrence of renal flares). Initial intensive (induction) treatment of proliferative lupus nephritis is aimed at achieving remission, but optimal duration and intensity are not well defined. A combination of intravenous cyclophosphamide and corticosteroids have been shown to decrease the risk of end-stage renal disease, but are associated with substantial acute toxic effects (such as infections) and chronic toxic effects (such as ovarian failure). In white populations, low-dose cyclophosphamide is a reasonable alternative to high-dose cyclophosphamide as it is similarly effective and associated with less toxicity. Mycophenolate mofetil is as effective as high-dose intravenous cyclophosphamide in terms of inducing remission and similar in terms of safety. Although most patients respond to induction treatment, remission is often only achieved after patients are switched to maintenance treatment. As maintenance treatment, mycophenolate mofetil is superior to azathioprine and azathioprine is similarly effective to ciclosporin in terms of prevention or reducing the risk of relapse. Rituximab should be reserved for patients with refractory disease. Treatment of lupus nephritis should be individually tailored to patients, with more aggressive therapy reserved for patients at high risk of renal dysfunction and progression of renal disease.
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Efficacy and cytokine modulating effects of tacrolimus in systemic lupus erythematosus: a review. J Biomed Biotechnol 2010; 2010:686480. [PMID: 20625508 PMCID: PMC2896715 DOI: 10.1155/2010/686480] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Accepted: 03/31/2010] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex systemic autoimmune disease with involvement of both B cells and cytotoxic T lymphocytes and several cytokines aberrations. Standard therapy for SLE has its limitations. Tacrolimus, a novel calcineurin inhibitor with potent immunosuppressive effects, has been shown in the recent years to be effective in SLE therapy. This paper serves to collate the experimental and clinical data on the efficacy of tacrolimus in the treatment of SLE and lupus nephritis. Tacrolimus as a key component of multitarget therapy in SLE is also discussed. The immunocytokine modulatory effects of tacrolimus are also reviewed with reference to SLE. It can be concluded that tacrolimus has an established role in the management of SLE.
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