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Sen R, Riofrio M, Singh JA. A narrative review of the comparative safety of disease-modifying anti-rheumatic drugs used for the treatment of rheumatoid arthritis. Expert Opin Drug Saf 2024; 23:687-714. [PMID: 38695151 DOI: 10.1080/14740338.2024.2348575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Disease-modifying anti-rheumatic drugs (DMARDs) have improved the outcomes of patients with rheumatoid arthritis (RA). DMARDs are classified into three categories: conventional synthetic DMARDs, biological DMARDs (including biosimilars), and targeted synthetic DMARDs. DMARDs, by way of their effect on the immune system, are associated with increased risk of adverse events, including infections, malignancies, cardiovascular disease, gastrointestinal perforations, and other less common events. AREAS COVERED In this narrative literature review performed with searches of the PubMed database from 1 January 2010 through 1 January 2023, we compare the risk of safety events between DMARDs using data from both randomized clinical trials and observational studies. EXPERT OPINION DMARD use in RA is associated with higher rates of serious infections, tuberculosis reactivation, opportunistic infections, and possibly malignancies. Specific biologic DMARDs and higher doses are associated with elevated risks of various adverse events (gastrointestinal perforations, thromboembolism, serious infection). Shared decision-making is paramount when choosing a treatment regimen for patients based on their own comorbidities. JAKi are the newest class of medications used for RA with robust safety data provided in clinical trials. However, more real-world evidence and phase-IV pharmacovigilance data are needed to better understand comparative safety profile of DMARDs in RA.
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Affiliation(s)
- Rouhin Sen
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
| | - Maria Riofrio
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
| | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, The University of Alabama Birmingham, Birmingham, AL, USA
- Medicine/Rheumatology Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, AL, USA
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA
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2
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Jeong R, Bulyk ML. Chromatin accessibility variation provides insights into missing regulation underlying immune-mediated diseases. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.12.589213. [PMID: 38659802 PMCID: PMC11042205 DOI: 10.1101/2024.04.12.589213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Most genetic loci associated with complex traits and diseases through genome-wide association studies (GWAS) are noncoding, suggesting that the causal variants likely have gene regulatory effects. However, only a small number of loci have been linked to expression quantitative trait loci (eQTLs) detected currently. To better understand the potential reasons for many trait-associated loci lacking eQTL colocalization, we investigated whether chromatin accessibility QTLs (caQTLs) in lymphoblastoid cell lines (LCLs) explain immune-mediated disease associations that eQTLs in LCLs did not. The power to detect caQTLs was greater than that of eQTLs and was less affected by the distance from the transcription start site of the associated gene. Meta-analyzing LCL eQTL data to increase the sample size to over a thousand led to additional loci with eQTL colocalization, demonstrating that insufficient statistical power is still likely to be a factor. Moreover, further eQTL colocalization loci were uncovered by surveying eQTLs of other immune cell types. Altogether, insufficient power and context-specificity of eQTLs both contribute to the 'missing regulation.'
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Affiliation(s)
- Raehoon Jeong
- Division of Genetics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
- Bioinformatics and Integrative Genomics Graduate Program, Harvard University, Cambridge, MA 02138, USA
| | - Martha L. Bulyk
- Division of Genetics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
- Bioinformatics and Integrative Genomics Graduate Program, Harvard University, Cambridge, MA 02138, USA
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
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3
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Yoo WH, Ha GW, Kim KM, Choi Y. When treatment takes a turn: tocilizumab-induced bowel perforation in a patient with COVID-19-afflicted rheumatoid arthritis. Scand J Rheumatol 2024; 53:155-157. [PMID: 38198126 DOI: 10.1080/03009742.2023.2294580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Affiliation(s)
- W-H Yoo
- Department of Internal Medicine, Division of Rheumatology, Jeonbuk National University Medical School, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute, Jeonbuk National University, Jeonju, South Korea
| | - G W Ha
- Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute, Jeonbuk National University, Jeonju, South Korea
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, South Korea
| | - K M Kim
- Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute, Jeonbuk National University, Jeonju, South Korea
- Department of Pathology, Jeonbuk National University Medical School, Jeonju, South Korea
| | - Y Choi
- Department of Internal Medicine, Division of Rheumatology, Jeonbuk National University Medical School, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute, Jeonbuk National University, Jeonju, South Korea
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Zhao J, Huh Y, Bortsov A, Diatchenko L, Ji RR. Immunotherapies in chronic pain through modulation of neuroimmune interactions. Pharmacol Ther 2023; 248:108476. [PMID: 37307899 PMCID: PMC10527194 DOI: 10.1016/j.pharmthera.2023.108476] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Abstract
It is generally believed that immune activation can elicit pain through production of inflammatory mediators that can activate nociceptive sensory neurons. Emerging evidence suggests that immune activation may also contribute to the resolution of pain by producing distinct pro-resolution/anti-inflammatory mediators. Recent research into the connection between the immune and nervous systems has opened new avenues for immunotherapy in pain management. This review provides an overview of the most utilized forms of immunotherapies (e.g., biologics) and highlight their potential for immune and neuronal modulation in chronic pain. Specifically, we discuss pain-related immunotherapy mechanisms that target inflammatory cytokine pathways, the PD-L1/PD-1 pathway, and the cGAS/STING pathway. This review also highlights cell-based immunotherapies targeting macrophages, T cells, neutrophils and mesenchymal stromal cells for chronic pain management.
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Affiliation(s)
- Junli Zhao
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Yul Huh
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; Department of Cell Biology, Duke University Medical Center, Durham, NC 27710, USA
| | - Andrey Bortsov
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Luda Diatchenko
- Alan Edwards Centre for Research on Pain, McGill University, Montréal, QC H3A 0G4, Canada; Faculty of Dental Medicine and Oral Health Sciences, Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC H3A 0G4, Canada
| | - Ru-Rong Ji
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; Department of Cell Biology, Duke University Medical Center, Durham, NC 27710, USA; Department of Neurobiology, Duke University Medical Center, Durham, NC 27710, USA.
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Chaudhry B, Alekseyev K, Didenko L, Chaudhry M. A Case of Abdominal Perforation in a COVID+ Patient Treated With Tocilizumab and Corticosteroids. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231173870. [PMID: 37342097 PMCID: PMC10278419 DOI: 10.1177/11795476231173870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) was first identified in Wuhan province in China in late 2019. Around 15% of patients that develop severe acute respiratory syndrome from COVID-19 also develop severe COVID-19 pneumonia. Since the pandemic's start, various treatments including remdesivir, dexamethasone, baricitinib, convalescent plasma, and tocilizumab have been approved by the Center for Disease Control (CDC). We present a case of a 62-year-old male hospitalized due to COVID-19 pneumonia and was initially treated with methylprednisolone and remdesivir, and later with tocilizumab. Soon after, he developed an abdominal perforation which was surgically treated. In terms of abdominal perforation, proposed mechanisms including the pathogenesis due to the presence of specific angiotensin-converting enzyme 2 (ACE-2) receptors located throughout the gastrointestinal tract, glucocorticoid steroid inflammatory suppression, in addition to the documented adverse effects from tocilizumab which has been previously reported. In summary, tocilizumab may increase the risk of abdominal perforation, especially when used in combination with steroids to treat COVID-19 because steroids may suppress clinical exam findings for abdominal perforation.
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Affiliation(s)
| | - Kirill Alekseyev
- Post-Acute Medical Rehabilitation Hospital of Dover, Dover, DE, USA
| | - Lidiya Didenko
- Post-Acute Medical Rehabilitation Hospital of Dover, Dover, DE, USA
| | - Maaria Chaudhry
- Saint Louis University School of Medicine, St. Louis, MO, USA
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Guiritan AT, Cataluña JG. A Case Report of Bowel Perforation in a Gravid COVID-19 Patient. Case Rep Med 2023; 2023:7737433. [PMID: 36937039 PMCID: PMC10017220 DOI: 10.1155/2023/7737433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/21/2023] Open
Abstract
Background Bowel perforation in a pregnant patient with COVID-19 infection is a rarely reported complication. With the uncovering of the different treatment modalities and complications of this disease, this case highlights diagnostic and therapeutic dilemmas and limitations in a special population. Clinical Presentation. A 35-year-old female, Gravida 2 Para 1 at 31 weeks age of gestation (AOG) who underwent cesarean section for nonreassuring fetal status in 2019, was admitted for severe COVID-19 infection presenting with dyspnea. During her hospitalization, she developed progressive dyspnea from worsening of COVID-19 infection. Patient was eventually intubated and was given a total of two doses of tocilizumab, adequate antibiotic treatment, remdesivir, and dexamethasone. An emergency repeat cesarean section was performed due to maternal deterioration and poor variability of the fetus. She delivered to a live preterm baby girl, with an Apgar score of 1 and 7 on the 1st and 5th minute of life respectively. During the postoperative days, patient remained intubated and sedated. Increasing residuals were noted per nasogastric tube (NGT). Serial scout film of the abdomen (SFA) and medical management were performed. Upon weaning from sedation, patient complained of right lower quadrant pain. A whole abdominal computed tomography (CT) scan with contrast was requested which revealed large bowel obstruction. Patient was referred to surgery service. Upon assessment, abdomen was noted to be rigid with guarding during palpation. A scout film of the abdomen was requested and revealed extensive amount of pneumoperitoneum with scanty to absent colonic gas suggestive of bowel perforation. Patient underwent emergency exploratory laparotomy. Upon opening the peritoneum, free air was evacuated. Approximately 1.4 liters of fecaloid peritoneal fluid was suctioned and adhesive band was noted at the pelvic area. A 2 cm full thickness perforation at the cecum with 17 cm serosal tear from the cecum to ascending colon was noted. Bowel loops proximal to the perforation were dilated. Nasogastric tube was inserted for bowel decompression. Right hemicolectomy was performed. Specimen was sent for histopathology. Acute inflammatory cells infiltrating the blood vessels and possible microthrombi and beginning thrombus formation were noted in the subserosa. Patient eventually expired on the 14th hospital day from sepsis. Conclusion This case highlights a rarely reported complication of COVID-19 infection. Confluence of factors that predisposed the patient include pregnancy, COVID-19 infection, use of tocilizumab, and recent surgery. High index of suspicion is vital in the management and improvement of outcomes.
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Kastrati K, Aletaha D, Burmester GR, Chwala E, Dejaco C, Dougados M, McInnes IB, Ravelli A, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar MJH, Winthrop K, Smolen JS, Kerschbaumer A. A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases. RMD Open 2022; 8:rmdopen-2022-002359. [PMID: 36260501 PMCID: PMC9462104 DOI: 10.1136/rmdopen-2022-002359] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/30/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases. Methods A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration. Results 187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still’s disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman’s disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors. Conclusion IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
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Affiliation(s)
- Kastriot Kastrati
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Gerd R Burmester
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Eva Chwala
- University Library, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria
- Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, Istituto Giannina Gaslini, Genova, Italy
| | - Naveed Sattar
- Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna Department of Medicine III, Wien, Austria
| | | | - Marieke J H Voshaar
- Department of Pharmacy and Department of Research & Innovation, Sint Maartenskliniek, Ubbergen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Winthrop
- Schools of Medicine and Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
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Cohen SB, Tanaka Y, Mariette X, Curtis JR, Lee EB, Nash P, Winthrop KL, Charles-Schoeman C, Wang L, Chen C, Kwok K, Biswas P, Shapiro A, Madsen A, Wollenhaupt J. Long-term safety of tofacitinib up to 9.5 years: a comprehensive integrated analysis of the rheumatoid arthritis clinical development programme. RMD Open 2021; 6:rmdopen-2020-001395. [PMID: 33127856 PMCID: PMC7722371 DOI: 10.1136/rmdopen-2020-001395] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 12/26/2022] Open
Abstract
Objective Tofacitinib is an oral Janus kinase (JAK) inhibitor for the treatment of rheumatoid arthritis (RA). We report the largest integrated safety analysis of tofacitinib, as of March 2017, using data from phase I, II, III, IIIb/IV and long-term extension studies in adult patients with RA. Methods Data were pooled for patients with RA who received ≥1 tofacitinib dose. Incidence rates (IRs; patients with events/100 patient-years [PY]; 95% CIs) of first-time occurrences were obtained for adverse events (AEs) of interest. Results 7061 patients received tofacitinib (total exposure: 22 875 PY; median [range] exposure: 3.1 [0 to 9.6] years). IRs (95% CI) for serious AEs, serious infections, herpes zoster (all), opportunistic infections (excluding tuberculosis [TB]) and TB were 9.0 (8.6 to 9.4), 2.5 (2.3 to 2.7), 3.6 (3.4 to 3.9), 0.4 (0.3 to 0.5) and 0.2 (0.1 to 0.2), respectively. IRs (95% CI) for malignancies (excluding non-melanoma skin cancer [NMSC]), NMSC and lymphomas were 0.8 (0.7 to 0.9), 0.6 (0.5 to 0.7) and 0.1 (0.0 to 0.1), respectively. IRs (95% CI) for gastrointestinal perforations, deep vein thrombosis, pulmonary embolism, venous thromboembolism, arterial thromboembolism and major adverse cardiovascular events were 0.1 (0.1 to 0.2), 0.2 (0.1 to 0.2), 0.1 (0.1 to 0.2), 0.3 (0.2 to 0.3), 0.4 (0.3 to 0.5) and 0.4 (0.3 to 0.5), respectively. IR (95% CI) for mortality was 0.3 (0.2 to 0.3). IRs generally remained consistent across 6-month intervals to >78 months. Conclusion This represents the largest clinical dataset for a JAK inhibitor in RA to date. IRs remained consistent with previous reports from the tofacitinib RA clinical development programme, and stable over time. Trial registration numbers NCT01262118; NCT01484561; NCT00147498; NCT00413660; NCT00550446; NCT00603512; NCT00687193; NCT01164579; NCT00976599; NCT01059864; NCT01359150; NCT02147587; NCT00960440; NCT00847613; NCT00814307; NCT00856544; NCT00853385; NCT01039688; NCT02187055; NCT00413699; NCT00661661. For summary of phase I, phase II, phase III, phase IIIb/IV and LTE studies included in the integrated safety analysis, see online supplemental table 1.
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Affiliation(s)
- Stanley B Cohen
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Xavier Mariette
- Paris-Saclay University, AP-HP, INSERM, Le Kremlin Bicêtre, France
| | | | - Eun Bong Lee
- Seoul National University, Seoul, Korea (the Democratic People's Republic of)
| | - Peter Nash
- Department of Medicine, Griffith University, Brisbane, Australia
| | | | | | - Lisy Wang
- Pfizer Inc, Groton, Connecticut, USA
| | | | | | | | | | | | - Jürgen Wollenhaupt
- Struenseehaus Centre for Rheumatology and Clinical Immunology, Hamburg, Germany
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Barbulescu A, Delcoigne B, Askling J, Frisell T. Gastrointestinal perforations in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs in Sweden: a nationwide cohort study. RMD Open 2021; 6:rmdopen-2020-001201. [PMID: 32669452 PMCID: PMC7425111 DOI: 10.1136/rmdopen-2020-001201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/07/2020] [Accepted: 06/25/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To compare incidence rates of gastrointestinal (GI) perforations between patients with RA and the general population, and between patients treated with tumour necrosis factor inhibitors (TNFi) and non-TNFi biologics. METHODS In this nationwide cohort study, a total of 63 532 patients with RA, with 26 050 biological treatment episodes (TNFi, rituximab, abatacept or tocilizumab) and 76 304 general population controls, were followed between 2009 and 2017 until the first outcome event. The main outcome was hospitalisation or death due to lower GI perforations, identified according to a prespecified list of ICD-10 (International Classification of Diseases, 10th revision) codes. Inverse probability of treatment weighting was used for adjustment. RESULTS The sex-standardised and age-standardised incidence rates of lower GI perforations were 1.1 (95% CI 1.0 to 1.3) events per 1000 person-years among general population controls, 1.6 (1.5-1.7) among bionaïve patients and ranged from 1.8 (1.4-3.6) (TNFi) to 4.5 (2.7-10.4) (tocilizumab) among biologics-treated patients. After adjustment for glucocorticoid use, the risk in bionaïve, TNFi-treated, abatacept-treated or rituximab-treated patients with RA was no longer different from the general population, while for tocilizumab it remained significantly higher. Comparing tocilizumab to TNFi, the adjusted HR for lower GI perforations was 2.2 (1.3-3.8), corresponding to one additional GI perforation per 451 patient-years treated with tocilizumab instead of TNFi. CONCLUSION Tocilizumab was associated with a higher risk of lower GI perforations compared with alternative biologics. In absolute numbers, the risk remained low on all biologics commonly used to treat RA, but the accumulated evidence across settings and outcome definitions supports that this risk should be considered in treatment guidelines for RA.
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Affiliation(s)
- Andrei Barbulescu
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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10
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Burmester GR, Nash P, Sands BE, Papp K, Stockert L, Jones TV, Tan H, Madsen A, Valdez H, Cohen SB. Adverse events of special interest in clinical trials of rheumatoid arthritis, psoriatic arthritis, ulcerative colitis and psoriasis with 37 066 patient-years of tofacitinib exposure. RMD Open 2021; 7:e001595. [PMID: 34045358 PMCID: PMC8162077 DOI: 10.1136/rmdopen-2021-001595] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To analyse adverse events (AEs) of special interest across tofacitinib clinical programmes in rheumatoid arthritis (RA), psoriatic arthritis (PsA), ulcerative colitis (UC) and psoriasis (PsO), and to determine whether the incidence rates (IRs; unique patients with events per 100 patient-years) of these events are consistent across diseases. METHODS The analysis included data from patients exposed to ≥1 dose of tofacitinib in phase 1, 2, 3 or 3b/4 clinical trials and long-term extension (LTE) studies (38 trials) in RA (23 trials), PsA (3 trials), UC (5 trials) and PsO (7 trials). All studies were completed by or before July 2019, except for one ongoing UC LTE study (data cut-off May 2019). IRs were obtained for AEs of special interest. RESULTS 13 567 patients were included in the analysis (RA: n=7964; PsA: n=783; UC: n=1157; PsO: n=3663), representing 37 066 patient-years of exposure. Maximum duration of exposure was 10.5 years (RA). AEs within the 'infections and infestations' System Organ Class were the most common in all diseases. Among AEs of special interest, IRs were highest for herpes zoster (non-serious and serious; 3.6, 1.8, 3.5 and 2.4 for RA, PsA, UC and PsO, respectively) and serious infections (2.5, 1.2, 1.7 and 1.3 for RA, PsA, UC and PsO, respectively). Age-adjusted and sex-adjusted mortality ratios (weighted for country) were ≤0.2 across cohorts. CONCLUSIONS The tofacitinib safety profile in this analysis was generally consistent across diseases and with longer term follow-up compared with previous analyses.
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Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Nash
- Department of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Bruce E Sands
- Dr. Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Kim Papp
- Clinical Research, Probity Medical Research Inc, Waterloo, Ontario, Canada
| | | | | | | | - Ann Madsen
- Pfizer Inc, New York City, New York, USA
| | | | - Stanley B Cohen
- Metroplex Clinical Research Center, Dallas, Texas, USA
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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11
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Beauvais D, Karleskind O, Loridant S, Nyga R, Lamiaux M, Moreau AS, Morschhauser F, Mitra S, Yakoub-Agha I, Sendid B. Potential role of tocilizumab in severe gastrointestinal barrier damage after CAR T-cell therapy. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:327-330. [PMID: 33712404 DOI: 10.1016/j.jmii.2021.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/11/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
We report a septicemia and disseminated candidiasis due to delayed gastrointestinal mucosae repair in a patient treated with tocilizumab after anti-CD19 CAR T-cell therapy. Tocilizumab could have inhibited intestinal tissue repair and furthered bacteria translocation leading to the invasion of intestinal mucosa by yeasts as IL-6 is known to be involved in mucosal wound healing.
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Affiliation(s)
- David Beauvais
- Univ. Lille, CHU Lille, Department of Haematology, F-59000, Lille, France.
| | - Oriane Karleskind
- CHU Lille, Institut de Pathologie, Centre de Biologie Pathologie Génétique, F-59000, Lille, France
| | - Severine Loridant
- Univ. Lille, Inserm U1285, CNRS UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, F-59000 Lille, France; CHU Lille, Service de Parasitologie Mycologie, F-59037 Lille, France
| | - Remy Nyga
- CHU Lille, Service de Parasitologie Mycologie, F-59037 Lille, France
| | - Marie Lamiaux
- CHU Lille, Institut de Pathologie, Centre de Biologie Pathologie Génétique, F-59000, Lille, France
| | | | | | - Suman Mitra
- University of Lille, Inserm, UMR-S 1172, F-59000, Lille, France
| | - Ibrahim Yakoub-Agha
- Univ. Lille, CHU Lille, Department of Haematology, F-59000, Lille, France; University of Lille, CHU Lille, Inserm, Infinite, U1286, F-59000 Lille, France
| | - Boualem Sendid
- Univ. Lille, Inserm U1285, CNRS UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, F-59000 Lille, France; CHU Lille, Service de Parasitologie Mycologie, F-59037 Lille, France
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12
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Gonzálvez Guardiola P, Díez Ares JÁ, Peris Tomás N, Sebastián Tomás JC, Navarro Martínez S. Intestinal perforation in patient with COVID-19 infection treated with tocilizumab and corticosteroids. Report of a clinical case. CIRUGÍA ESPAÑOLA (ENGLISH EDITION) 2021. [PMCID: PMC7826138 DOI: 10.1016/j.cireng.2021.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Gonzálvez Guardiola P, Díez Ares JÁ, Peris Tomás N, Sebastián Tomás JC, Navarro Martínez S. [Intestinal perforation in patient with COVID-19 infection treated with tocilizumab and corticosteroids. Report of a clinical case]. Cir Esp 2020; 99:156-157. [PMID: 32402416 PMCID: PMC7188646 DOI: 10.1016/j.ciresp.2020.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
| | - Jose Ángel Díez Ares
- Hospital Doctor Peset, Valencia, España; Unidad de Cirugía Bariátrica, Hospital Doctor Peset, Valencia, España
| | - Nuria Peris Tomás
- Hospital Doctor Peset, Valencia, España; Unidad de Cirugía Bariátrica, Hospital Doctor Peset, Valencia, España
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Abstract
In 1973, IL-6 was identified as a soluble factor that is secreted by T cells and is important for antibody production by B cells. Since its discovery more than 40 years ago, the IL-6 pathway has emerged as a pivotal pathway involved in immune regulation in health and dysregulation in many diseases. Targeting of the IL-6 pathway has led to innovative therapeutic approaches for various rheumatic diseases, such as rheumatoid arthritis, juvenile idiopathic arthritis, adult-onset Still’s disease, giant cell arteritis and Takayasu arteritis, as well as other conditions such as Castleman disease and cytokine release syndrome. Targeting this pathway has also identified avenues for potential expansion into several other indications, such as uveitis, neuromyelitis optica and, most recently, COVID-19 pneumonia. To mark the tenth anniversary of anti-IL-6 receptor therapy worldwide, we discuss the history of research into IL-6 biology and the development of therapies that target IL-6 signalling, including the successes and challenges and with an emphasis on rheumatic diseases. In this Perspective article, the authors recount the earliest stages of translational research into IL-6 biology and the subsequent development of therapeutic IL-6 pathway inhibitors for the treatment of autoimmune rheumatic diseases and potentially numerous other indications.
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Karkhur S, Hasanreisoglu M, Vigil E, Halim MS, Hassan M, Plaza C, Nguyen NV, Afridi R, Tran AT, Do DV, Sepah YJ, Nguyen QD. Interleukin-6 inhibition in the management of non-infectious uveitis and beyond. J Ophthalmic Inflamm Infect 2019; 9:17. [PMID: 31523783 PMCID: PMC6745304 DOI: 10.1186/s12348-019-0182-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023] Open
Abstract
Background Uveitis consists of a spectrum of inflammatory disorders characterized by ocular inflammation. The underlying pathophysiology consists of a complex interplay of various inflammatory pathways. Interleukin 6 is an important mediator of inflammation in uveitis and constitutes focus of research toward development of newer biological therapies in the management of non-infectious uveitis. Main body Pan-blockade of the inflammatory pathways with steroids is generally the first step in the management of acute non-infectious uveitis. However, long-term therapy with steroids is associated with systemic and ocular side effects, thereby necessitating the need for development of steroid sparing agents. IL-6 is a cytokine produced by various immune cells, in response to molecular patterns and affects multiple inflammatory cells. In particular, IL-6 is involved in differentiation of CD-4 cells into Th-17 cells that have been shown to play a significant role in various immune-mediated diseases such as uveitis. This broad-spectrum immunomodulatory activity makes IL-6 an excellent target for immunomodulatory therapy. Tocilizumab was the first IL-6 inhibitor to demonstrate efficacy in humans. It inhibits IL-6 from binding to both membrane-bound and soluble receptor and can be administered via intravenous (IV) and subcutaneous (SC) routes. It has been FDA approved for treatment of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). Following the approval in systemic diseases, its efficacy was demonstrated in various uveitis studies including a phase 2 clinical trial (STOP-Uveitis). Overall, tocilizumab has shown a good safety profile with the risk of malignancy consistent with that expected in patients with rheumatoid arthritis. However, tocilizumab therapy has been shown to increase the risk for gastrointestinal perforation and dose-dependent neutropenia. Following the success of tocilizumab, several other agents targeting the IL-6 pathway are in the pipeline. These include sirukumab, siltuximab, olokizumab, clazakizumab, and EBI-031 which target IL-6; Sarilumab and ALX-0061 act on the IL-6 receptor. Conclusion Studies have shown that IL-6 inhibitors can be effective in the management of NIU. In addition, the levels of IL-6 are elevated in other ocular vascular diseases such as retinal vein occlusion and diabetic macular edema. The roles of IL-6 inhibition may be broadened in the future to include the management of retinal vascular diseases and non-uveitic macular edema.
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Affiliation(s)
- Samendra Karkhur
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,Department of Ophthalmology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Murat Hasanreisoglu
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,Department of Ophthalmology, School of Medicine, Gazi University, Ankara, Turkey
| | - Erin Vigil
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Muhammad Sohail Halim
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Muhammad Hassan
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Carlos Plaza
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,Department of Ophthalmology, Hospital Universitario de León, León, Spain
| | - Nam V Nguyen
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.,University of Nebraska, Lincoln, USA
| | - Rubbia Afridi
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Anh T Tran
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Diana V Do
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Yasir J Sepah
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Quan Dong Nguyen
- Byers Eye Institute, Spencer Center for Vision Research, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.
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16
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Curtis JR, Mariette X, Gaujoux-Viala C, Blauvelt A, Kvien TK, Sandborn WJ, Winthrop K, de Longueville M, Huybrechts I, Bykerk VP. Long-term safety of certolizumab pegol in rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, psoriasis and Crohn's disease: a pooled analysis of 11 317 patients across clinical trials. RMD Open 2019; 5:e000942. [PMID: 31245056 PMCID: PMC6560674 DOI: 10.1136/rmdopen-2019-000942] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 12/17/2022] Open
Abstract
Objective To review long-term certolizumab pegol (CZP) safety across all approved indications: rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), psoriasis (PSO) and Crohn’s disease (CD). Methods Data were pooled across 49 UCB-sponsored CZP clinical trials (27 RA, one axSpA, one PsA, five PSO, 15 CD) to August 2017. Serious adverse events (SAEs) of interest (infections, malignancies, autoimmunity/hypersensitivity events, major adverse cardiovascular events (MACE), gastrointestinal (GI) perforations, psoriasis events, laboratory abnormalities) and deaths were medically reviewed by an external expert committee, using predefined case rules. Incidence rates (IRs)/100 patient-years (PY) are presented by indication; standardised mortality and malignancy rates were calculated using WHO/GLOBOCAN/SEER databases. Pregnancies with maternal CZP exposure are also reported. Results Of 11 317 CZP-treated patients across indications (21 695 PY CZP exposure; maximum: 7.8 years), infections were the most common SAEs (overall IR: 3.62/100 PY; IRs ranged from 1.50/100 PY(PSO) to 5.97/100 PY(CD)). The IR for malignancies was 0.82/100 PY, including lymphoma (0.06/100 PY). MACE and GI perforation IRs in CZP-treated patients were 0.47/100 PY and 0.08/100 PY and were highest in RA and CD, respectively. Patients with PSO had the lowest SAE rates. The incidence of deaths and malignancies aligned with expected general population data. Conclusion This extensive overview of the CZP safety profile in clinical trials, across all indications, provides large-scale confirmation of previous reports. No new safety signals or relevant non-disease-related laboratory abnormalities were identified. The study demonstrated some indication-specific differences in certain SAE rates that may be attributable to the underlying inflammatory disease.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Xavier Mariette
- Service de Rhumatologie, Université Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier University, Nîmes, France
| | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - William J Sandborn
- Division of Gastroenterology, University of California, La Jolla, California, USA
| | - Kevin Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Vivian P Bykerk
- Division of Rheumatology, Hospital for Special Surgery, New York City, New York, USA
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17
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Eskandary F, Dürr M, Budde K, Doberer K, Reindl-Schwaighofer R, Waiser J, Wahrmann M, Regele H, Spittler A, Lachmann N, Firbas C, Mühlbacher J, Bond G, Halloran PF, Chong E, Jilma B, Böhmig GA. Clazakizumab in late antibody-mediated rejection: study protocol of a randomized controlled pilot trial. Trials 2019; 20:37. [PMID: 30635033 PMCID: PMC6329051 DOI: 10.1186/s13063-018-3158-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 12/22/2018] [Indexed: 01/23/2023] Open
Abstract
Background Late antibody-mediated rejection (ABMR) triggered by donor-specific antibodies (DSA) is a cardinal cause of kidney allograft dysfunction and loss. Diagnostic criteria for this rejection type are well established, but effective treatment remains a major challenge. Recent randomized controlled trials (RCT) have failed to demonstrate the efficacy of widely used therapies, such as rituximab plus intravenous immunoglobulin or proteasome inhibition (bortezomib), reinforcing a great need for new therapeutic concepts. One promising target in this context may be interleukin-6 (IL-6), a pleiotropic cytokine known to play an important role in inflammation and adaptive immunity. Methods This investigator-driven RCT was designed to assess the safety and efficacy of clazakizumab, a genetically engineered humanized monoclonal antibody directed against IL-6. The study will include 20 DSA-positive kidney allograft recipients diagnosed with ABMR ≥ 365 days after transplantation. Participants will be recruited at two study sites in Austria and Germany (Medical University of Vienna; Charité University Medicine Berlin). First, patients will enter a three-month double-blind RCT (1,1 randomization, stratification according to ABMR phenotype and study site) and will receive either clazakizumab (subcutaneous administration of 25 mg in monthly intervals) or placebo. In a second open-label part of the trial (months 4–12), all patients will receive clazakizumab at 25 mg every month. The primary endpoint is safety and tolerability. Secondary endpoints are the pharmacokinetics and pharmacodynamics of clazakizumab, its effect on drug metabolism in the liver, DSA characteristics, morphological ABMR lesions and molecular gene expression patterns in three- and 12-month protocol biopsies, serum/urinary biomarkers of inflammation and endothelial activation/injury, Torque Teno viral load as a measure of overall immunosuppression, kidney function, urinary protein excretion, as well as transplant and patient survival. Discussion Currently, there is no treatment proven to be effective in halting the progression of late ABMR. Based on the hypothesis that antagonizing the effects of IL-6 improves the outcome of DSA-positive late ABMR by counteracting DSA-triggered inflammation and B cell/plasma cell-driven alloimmunity, we suggest that our trial has the potential to provide proof of concept of a novel treatment of this type of rejection. Trial registration ClinicalTrials.gov, NCT03444103. Registered on 23 February 2018 (retrospective registration). Electronic supplementary material The online version of this article (10.1186/s13063-018-3158-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Michael Dürr
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Johannes Waiser
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Heinz Regele
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Andreas Spittler
- Core Facility Flow Cytometry, Medical University of Vienna, Vienna, Austria
| | - Nils Lachmann
- Centre for Tumor Medicine, H&I Laboratory, Charité University Medicine Berlin, Berlin, Germany
| | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Jakob Mühlbacher
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Philipp F Halloran
- Alberta Transplant Applied Genomics Centre, Faculty of Medicine & Dentistry, #250 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
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Biggioggero M, Crotti C, Becciolini A, Favalli EG. Tocilizumab in the treatment of rheumatoid arthritis: an evidence-based review and patient selection. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 13:57-70. [PMID: 30587928 PMCID: PMC6304084 DOI: 10.2147/dddt.s150580] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by articular and systemic manifestations, such as anemia, fatigue, osteoporosis, and increased risk for cardiovascular diseases. The pathogenesis of RA is driven by a complex network of proinflammatory cytokines, with a pivotal role of IL-6 and tumor necrosis factor (TNF). The management of RA has been dramatically changed during the last years by the introduction of a treat-to-target approach aiming to achieve an acceptable disease control. Nowadays, TNF inhibitors (TNFis) are the most frequently prescribed class of biologic therapies, but the significant proportion of patients experiencing the failure of a TNFi led to the development of alternative therapeutic options targeted on different pathways. Considering the increasing number of targeted therapeutic options for RA, there is a growing interest in the identification of potential predictors of clinical response to each available mechanism of action, with the aim to drive the management of the disease toward a personalized approach according to the concept of precision medicine. Tocilizumab (TCZ) is the first humanized anti-IL-6 receptor subunit alpha (anti-IL-6R) monoclonal antibody approved for the treatment of RA refractory to methotrexate or TNFis. TCZ inhibits both the cis- and trans-signaling cascades involving the Janus kinase-signal transducer and the activator of transcription pathway, playing a crucial role in modulating not only joint inflammation but also the previously mentioned extra-articular manifestations and comorbidities of RA, such as fatigue, anemia, bone loss, depression, type 2 diabetes, and increased cardiovascular risk. In this review, moving from pathogenetic insights and evidence-based clinical data from randomized controlled trials and real-life observational studies, we will discuss the drivers for the selection of patient candidates to receive TCZ, in order to clarify the current positioning of this drug in the treatment algorithm of RA.
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Affiliation(s)
| | - Chiara Crotti
- Department of Clinical Sciences and Health Community, University of Milan, Division of Rheumatology, Gaetano Pini Institute, Milan, Italy
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Gastrointestinal Perforations with Biologics in Patients with Rheumatoid Arthritis: Implications for Clinicians. Drug Saf 2018; 41:545-553. [PMID: 29392593 DOI: 10.1007/s40264-018-0639-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Gastrointestinal (GI) perforations are rare events in rheumatoid arthritis (RA) patients, but cause significant morbidity and mortality. Several studies indicate that RA patients may be at higher risk of GI perforation. Traditional RA treatments such as glucocorticoids and non-steroidal anti-inflammatory drugs increase the risk of perforation. In the past two decades, a new class of therapeutic agents called biologics has been added to the RA treatment armamentarium. Biologics are effective in controlling disease activity and are generally well tolerated; however, reports of GI perforations in association with biologics have arisen. In particular, drugs that inhibit the interleukin (IL)-6 cytokine receptor have demonstrated a higher risk of perforation compared with other therapies. Recent reports also suggest that janus kinase inhibitors may increase the risk of perforation, perhaps via downstream effects on IL-6 signaling. In this review, we discuss current data on the risk of GI perforations among RA patients receiving targeted therapies and its clinical relevance.
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Tornero Molina J, Balsa Criado A, Blanco García F, Blanco Alonso R, Bustabad S, Calvo Alen J, Corominas H, Fernández Nebro A, Román Ivorra JA, Sanmartí R. Expert Recommendations on the Interleukin 6 Blockade in Patients with Rheumatoid Arthritis. ACTA ACUST UNITED AC 2018; 16:272-281. [PMID: 30098882 DOI: 10.1016/j.reuma.2018.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To draft recommendations on interleukin 6 (IL-6) blockade in rheumatoid arthritis (RA), based on best evidence and experience. METHODS A group of 10 experts on IL-6 blockade in RA was selected. The 2 coordinators formulated 23 questions about IL-6 blockade (indications, efficacy, safety, etc.). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (Medline, EMBASE and the Cochrane Library were searched). Two different reviewers selected the articles. Evidence tables were created. At the same time, European League Against Rheumatism and American College of Rheumatology abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted on in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Centre for Evidence Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). RESULTS The 8 preliminary recommendations were accepted after the Delphi process. They covered aspects such as the use of these therapies in monotherapy, in combination, in patients with refractory disease or intolerant patients, response evaluation, optimization and risk management. CONCLUSIONS The manuscript aims to solve frequently asked questions and aid in decision making strategies when treating RA patients with IL-6 blockade.
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Affiliation(s)
- Jesús Tornero Molina
- Servicio de Reumatología, Hospital Universitario de Guadalajara; Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, España.
| | | | - Francisco Blanco García
- Servicio de Reumatología, Complexo Hospitalario Universitario A Coruña (CHUAC), La Coruña, España
| | - Ricardo Blanco Alonso
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Sagrario Bustabad
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Jaime Calvo Alen
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, España
| | - Héctor Corominas
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, España
| | - Antonio Fernández Nebro
- Unidad de Gestión Clínica de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, España
| | | | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, España
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Rubbert-Roth A, Furst DE, Nebesky JM, Jin A, Berber E. A Review of Recent Advances Using Tocilizumab in the Treatment of Rheumatic Diseases. Rheumatol Ther 2018; 5:21-42. [PMID: 29502236 PMCID: PMC5935615 DOI: 10.1007/s40744-018-0102-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Indexed: 12/20/2022] Open
Abstract
Tocilizumab (TCZ) is the first humanized anti-interleukin-6 (IL-6) receptor monoclonal antibody approved for the treatment of patients with rheumatoid arthritis (RA), Castleman's disease, polyarticular and systemic juvenile idiopathic arthritis, and, most recently, giant cell arteritis as well as for the treatment of chimeric antigen receptor T cell therapy-induced cytokine release syndrome. The global clinical development program for TCZ provides a wealth of clinical data on intravenous TCZ, and more recent studies in patients with RA have provided evidence characterizing the role of intravenous TCZ as monotherapy in early disease and led to the introduction of a subcutaneous formulation of TCZ. In addition, recently published open-label extension and observational studies continue to support the long-term efficacy and safety of TCZ in both clinical trial and real-world settings. Given the involvement of IL-6-mediated signaling in inflammatory disorders, TCZ is also being investigated in other immunological diseases. In particular, a phase 2 trial on the safety and efficacy of subcutaneous TCZ in adults with systemic sclerosis shows clinically relevant improvements in skin sclerosis and lung function in these patients. Another anti-IL-6 receptor agent, sarilumab, targeting the IL6 receptor alpha subunit, was recently approved for the treatment of patients with RA, although long-term data for this biologic are not yet published. In this article we review the placement of TCZ in current treatment guidelines; recent clinical trial data, including quality of life in patients with RA; recent updates to the TCZ safety profile; recent investigations of TCZ in other immunological diseases; and the clinical development of other novel IL-6-targeted agents.
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Affiliation(s)
- Andrea Rubbert-Roth
- Kantonsspital St Gallen, St Gallen, Switzerland.
- Clinic for Rheumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
| | - Daniel E Furst
- University of California, Los Angeles, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
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22
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Abstract
Intravenous (IV) and subcutaneous (SC) tocilizumab (RoActemra®), an IL-6 receptor antagonist, are approved (± methotrexate) in numerous countries throughout the world, for the treatment of adults with moderate to severe active rheumatoid arthritis (RA). Extensive clinical experience has firmly established the short- and long-term efficacy and safety of tocilizumab [monotherapy or in combination with conventional synthetic DMARDs (csDMARDs)] in adults with early-stage and longer-duration established RA. In the clinical trial and real-world settings, tocilizumab monotherapy or combination therapy provided rapid and sustained improvements in clinical and radiographic outcomes and health-related quality of life. The safety profile of tocilizumab is consistent over time and, in general, is consistent with that of other immunomodulatory agents. This narrative review, written from an EU perspective, summarizes the clinical use of IV and SC tocilizumab in RA. Given its low risk of immunogenicity, the flexibility of IV and SC administration and the convenience of the once-weekly, self-administered, SC regimen, tocilizumab provides an effective treatment for severe, active and progressive RA in adults not previously treated with methotrexate and an effective biologic first- or subsequent-line treatment for moderate to severe active RA in adults who have either responded inadequately to or were intolerant of previous therapy with ≥ 1 csDMARD or TNF inhibitor.
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Affiliation(s)
- Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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