1
|
Sapart E, Sokolova T, de Montjoye S, Dierckx S, Nzeusseu A, Avramovska A, Meric de Bellefon L, Durez P. Should We Use bDMARDs as an Induction Therapy in Early and Severe Rheumatoid Arthritis? Results at 5 years from the ERA UCLouvain Brussels Cohort. Rheumatol Ther 2023; 10:875-886. [PMID: 37183237 PMCID: PMC10326217 DOI: 10.1007/s40744-023-00551-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
INTRODUCTION This study sought to analyze the benefit of an early induction therapy with a biological disease-modifying anti-rheumatic drugs (bDMARD) during the first year of treatment with a 5-year follow-up in early rheumatoid arthritis (ERA). METHODS We included ERA patients from the UCLouvain Brussels cohort who met the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2010 classification criteria and were naïve to DMARDs. ERA patients were divided into two groups according to whether they received an induction bDMARD therapy or a standard therapy with methotrexate (MTX). Clinical response after the induction treatment at 6 and 12 months followed by a MTX maintenance therapy at 36 and 60 months was evaluated. RESULTS Data from 470 ERA patients were collected, 189 received a bDMARD and 281 initiated MTX alone. In the bDMARD group, disease activity and HAQ were higher at baseline. A total of 391 patients were followed up to 5 years. We then divided each group into two subgroups according to the last treatment they received at 5 years: bDMARD > MTX (n = 95), bDMARD > bDMARD (n = 59); MTX > MTX (n = 134), MTX > bDMARD (n = 103). During the induction, we observed a clinical response with a large number of patients achieving DAS28-CRP remission. According to a treat-to-target (T2T) approach, remission rate was stable on MTX monotherapy or rescued by the addition or prolongation of a bDMARD. Interestingly, bDMARD followed by a MTX maintenance therapy experienced a stable and sustained DAS28-CRP remission rate in 53% of the ERA patients at year 5. CONCLUSIONS Long-term remission is an achievable goal in ERA. Our results suggest that a bDMARD induction therapy followed by MTX maintenance therapy could be an interesting option.
Collapse
Affiliation(s)
- Emilie Sapart
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Tatiana Sokolova
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Stéphanie de Montjoye
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | | | - Adrien Nzeusseu
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Aleksandra Avramovska
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Laurent Meric de Bellefon
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Patrick Durez
- Department of Rheumatology, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 10, Avenue Hippocrate, 1200, Brussels, Belgium.
| |
Collapse
|
2
|
Cai Q, Wei B, Tai Y, Wu H. Case Report: Interventional therapy for portal venous stenosis caused by systemic vasculitis. Front Immunol 2022; 13:1005300. [DOI: 10.3389/fimmu.2022.1005300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Systemic vasculitis are multisystem blood vessel disorders. However, Portal venous involvement is extremely rare, which represents a diagnostic and therapeutic challenge due to the heterogeneous nature, a lack of diagnostic criteria and limited effective therapy of vasculitis. We have reported a 48-year-old woman who was previously diagnosed with systemic vasculitis and was treated with prednisone, presented with gastrointestinal (GI) bleeding on admission. Further abdominal contrast-enhanced computed tomography (CT) with three-dimensional reconstruction suggested atrophic left hepatic lobe, enlarged spleen, and severe stenosis of main portal vein. Liver biopsy showed no evidence of fibrosis/cirrhosis. To prevent rebleeding, portal venous angioplasty by balloon dilation with collateral varices embolization was performed, and the GI hemorrhage was resolved completely. However, refractory ascites presented 8 months postoperatively. Abdominal CT angiography confirmed the recurrence of portal venous stenosis. Portal venous angioplasty by stent implantation was then performed to treat the portal hypertension (PHT)-related complications. After the intervention, the patient received anticoagulation therapy and continued immunosuppressive therapy. During the 5-year follow-up, the patient did not experience any onset of GI bleeding or ascites. Therefore, portal venous angioplasty with stent placement could be an effective treatment to prevent PHT-related complications when immunosuppression therapy failed.
Collapse
|
3
|
Box CD, Cronin O, Hauser B. The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides. Front Endocrinol (Lausanne) 2022; 13:806361. [PMID: 35250864 PMCID: PMC8889574 DOI: 10.3389/fendo.2022.806361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/29/2022] Open
Abstract
Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.
Collapse
Affiliation(s)
| | - Owen Cronin
- Department of Rheumatology, Bon Secours Hospital Cork, Cork, Ireland
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Barbara Hauser,
| |
Collapse
|
4
|
Mukhtyar C, Ducker G, Fordham S, Mansfield-Smith S, Jones C. Improving the quality of care for people with giant cell arteritis. Clin Med (Lond) 2021; 21:e371-e374. [DOI: 10.7861/clinmed.2021-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
5
|
Torp CK, Brüner M, Keller KK, Brouwer E, Hauge EM, McGonagle D, Kragstrup TW. Vasculitis therapy refines vasculitis mechanistic classification. Autoimmun Rev 2021; 20:102829. [PMID: 33872767 DOI: 10.1016/j.autrev.2021.102829] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/19/2021] [Indexed: 12/18/2022]
Abstract
The primary vasculitides constitute a heterogeneous group of immune mediated diseases of incompletely understood pathogenesis currently classified by the size of blood vessels affected (Chapel Hill classification). In recent years, several drugs with well-characterized immunological targets have been tested in clinical trials in large vessel vasculitis and small vessel vasculitis. Such trials provide "reverse translational" or bedside to bench information about underlying pathogenic mechanisms. Therefore, the aim of this systematic literature review was to examine the evidence base for a more refined mechanistic immunological classification of vasculitis. A total of 40 studies (20 randomized controlled trials (RCTs), 16 prospective studies, 1 retrospective cohort study and 3 case series) were included for full qualitative assessment. RCTs concerning biologic therapy for large vessel vasculitis mainly supports interleukin 6 receptor inhibition (tocilizumab). RCTs concerning biologic therapy for granulomatosis with polyangiitis and microscopic polyangiitis mainly support anti-CD20 treatment (rituximab) and complement inhibition with a small molecule C5a receptor antagonist (avacopan) is an emerging treatment option. The biologic treatment of eosinophilic granulomatosis with polyangiitis is centered around interleukin 5 inhibition (mepolizumab). Studies on tumor necrosis factor alpha inhibition (adalimumab, infliximab, and etanercept) showed negative results in giant cell arteritis but some effect in Takayasu arteritis. Taken together, clinical studies with cytokine and cell specific drugs are dissecting the heterogeneous immunopathogenic mechanisms of vasculitis and support a mechanistic immunological classification. Especially, cytokine antagonism is pointing towards immunological distinctions between eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis/microscopic polyangiitis and differences between giant cell arteritis and Takayasu arteritis.
Collapse
Affiliation(s)
| | - Mads Brüner
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.
| | - Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Elisabeth Brouwer
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Rheumatology, Silkeborg Regional Hospital, Silkeborg, Denmark.
| |
Collapse
|
6
|
Valor-Méndez L, Kleyer A, Rech J, Manger B, Schett G. Sustained clinical remission under infliximab/rituximab combination therapy in a patient with granulomatosis with polyangiitis. AUTOIMMUNITY HIGHLIGHTS 2021; 12:5. [PMID: 33676553 PMCID: PMC7936411 DOI: 10.1186/s13317-020-00147-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/01/2020] [Indexed: 11/13/2022]
Abstract
Background Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disease characterized by small and medium vessel vasculitis. The use of biological therapies such as rituximab and infliximab has improved the treatment of ocular manifestations in GPA. Case report We report a case of a 45-year-old Caucasian male suffering with rhinitis, sinubronchitis and exophthalmos. These clinical findings, subsequent biopsy and MRI were consistent with positive anti-neutrophil cytoplasm antibody (ANCA)/proteinase-3 and he was diagnosed with GPA with orbital involvement. He was refractory to cyclophosphamide at stable doses of methotrexate and a therapy with rituximab was started. Eventually and because of family planning methotrexate was replaced by azathioprine. Symptoms worsened and MRI revealed an increase in the granulomatous lesion in the orbit. Therefore, we decided to add infliximab to the combination of azathioprine and rituximab, our patient achieved then a long-term response. During the 10 years of the combined treatment, no adverse effects or systemic involvement occurred. Conclusions This case suggests that the individual use of a combination of rituximab and infliximab may be a promising strategy for the treatment in the long term of refractory orbital GPA.
Collapse
Affiliation(s)
- Larissa Valor-Méndez
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany. .,Deutsches Zentrum für Immuntherapie (DZI) FAU Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
| | - Arnd Kleyer
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.,Deutsches Zentrum für Immuntherapie (DZI) FAU Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.,Deutsches Zentrum für Immuntherapie (DZI) FAU Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.,Deutsches Zentrum für Immuntherapie (DZI) FAU Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.,Deutsches Zentrum für Immuntherapie (DZI) FAU Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| |
Collapse
|