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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton CP, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri V, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2024; 38:1251-1280. [PMID: 38456584 DOI: 10.1111/jdv.19912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - P Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - F Rongioletti
- Vita Salute University IRCSS San Raffaele Hospital, Milan, Italy
| | - C P Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - L Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - M Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genoa, Italy
| | - V Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - A Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - A B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - A Jalili
- Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - V Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- The Skin Clinic, Copenhagen, Denmark
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - J Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT, UMR 5164, Bordeaux, France
| | - M Sticherling
- Department of Dermatology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Tanew
- Private Practice, Vienna, Austria
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - T Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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Scheen M, Dominati A, Olivier V, Nasr S, De Seigneux S, Mekinian A, Issa N, Haidar F. Renal involvement in systemic sclerosis. Autoimmun Rev 2023; 22:103330. [PMID: 37031831 DOI: 10.1016/j.autrev.2023.103330] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
Systemic sclerosis is a rare autoimmune vasculopathy associated with dysregulated innate and adaptive immunity that leads to generalized systemic fibrosis. Renal involvement occurs in a significant proportion of systemic sclerosis patients, and is associated with worse outcome. Scleroderma renal crisis (SRC) is the most studied and feared renal complication described in systemic sclerosis. However, with the emergence of ACE inhibitors and better management, the mortality rate of SRC has significantly decreased. Renal disease in systemic sclerosis offers a wide array of differential diagnoses that may be challenging for the clinician. The spectrum of renal manifestations in systemic sclerosis ranges from an isolated decrease in glomerular filtration rate, increased intrarenal arterial stiffness, and isolated proteinuria due to SRC to more rare manifestations such as association with antiphospholipid antibody nephropathy and ANCA-associated vasculitis. The changes observed in the kidneys in systemic sclerosis are thought to be due to a complex interplay of various factors, including renal vasculopathy, as well as the involvement of the complement system, vasoactive mediators such as endothelin-1, autoimmunity, prothrombotic and profibrotic cytokines, among others. This literature review aims to provide an overview of the main renal manifestations in systemic sclerosis by discussing the most recent epidemiological and pathophysiological data available and the challenges for clinicians in making a diagnosis of renal disease in patients with systemic sclerosis.
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Affiliation(s)
- Marc Scheen
- Hôpitaux Universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland.
| | - Arnaud Dominati
- Hôpitaux Universitaires de Genève, Service d'allergologie et immunologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Valérie Olivier
- Hôpitaux Universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Samih Nasr
- Mayo Clinic College of Medicine and Science, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sophie De Seigneux
- Hôpitaux Universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne, 75012 Paris, France
| | - Naim Issa
- Mayo Clinic College of Medicine and Science, Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Fadi Haidar
- Hôpitaux Universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
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Ciechomska M, Roszkowski L, Burakowski T, Massalska M, Felis-Giemza A, Roura AJ. Circulating miRNA-19b as a biomarker of disease progression and treatment response to baricitinib in rheumatoid arthritis patients through miRNA profiling of monocytes. Front Immunol 2023; 14:980247. [PMID: 37056771 PMCID: PMC10086423 DOI: 10.3389/fimmu.2023.980247] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionA number of studies have demonstrated a key role of miRNA isolated from cells, tissue or body fluids as disease-specific biomarkers of autoimmune rheumatic diseases including rheumatoid arthritis (RA) and systemic sclerosis (SSc). Also, the expression level of miRNA is changing during disease development, therefore miRNA can be used as biomarkers monitoring RA progression and treatment response. In this study we have investigated the monocytes-specific miRNA that could serve as potential biomarkers of disease progression observed in sera and synovial fluids (SF) in early (eRA) and advanced (aRA) RA and in RA patients before and 3 months after selective JAK inhibitor (JAKi) -baricitinib treatment.MethodsSamples from healthy control (HC) (n=37), RA (n=44) and SSc (n=10) patients were used. MiRNA-seq of HC, RA, and SSc monocytes was performed to find versatile miRNA present in different rheumatic diseases. Selected miRNAs were validated in body fluids in eRA (<2 years disease onset) and aRA (>2 years disease onset) and RA patients receiving baricitinib.ResultsUsing miRNA-seq, we selected top 6 miRNA out of 95 that were significantly changed in both RA and SSc monocytes compared to HC. To identify circulating miRNA predicting RA progression, these 6 miRNA were measured in eRA and aRA sera and SF. Interestingly, miRNA (-19b-3p, -374a-5p, -3614-5p) were significantly increased in eRA sera vs HC and even further upregulated in SF vs aRA sera. In contrast, miRNA-29c-5p was significantly reduced in eRA sera vs HC and even further decreased in SF vs aRA sera. Kegg pathway analysis predicted that miRNA were involved in inflammatory-mediated pathways. ROC analysis demonstrated that miRNA-19b-3p (AUC=0.85, p=0.04) can be used as biomarker predicting JAKi response.DiscussionIn conclusion, we identified and validated miRNA candidates which were present simultaneously in monocytes, sera, SF and that can be used as biomarkers predicting joint inflammation and monitoring therapy response to JAKi in RA patients.
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Affiliation(s)
- Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- *Correspondence: Marzena Ciechomska,
| | - Leszek Roszkowski
- Department of Outpatient Clinics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Tomasz Burakowski
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Magdalena Massalska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Anna Felis-Giemza
- Biologic Therapy Center, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Adria-Jaume Roura
- Laboratory of Molecular Neurobiology, Nencki Institute of Experimental Biology, Warsaw, Poland
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
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Foocharoen C, Tonsawan P, Pongkulkiat P, Anutrakulchai S, Mahakkanukrauh A, Suwannaroj S. Management review of scleroderma renal crisis: An update with practical pointers. Mod Rheumatol 2023; 33:12-20. [PMID: 35349704 DOI: 10.1093/mr/roac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/20/2022] [Accepted: 03/14/2022] [Indexed: 01/05/2023]
Abstract
Scleroderma renal crisis (SRC) represents severe, fatal internal organ involvement brought on by systemic sclerosis. A high rate of renal replacement therapy and mortality persists despite various treatments. Depending on the stage of SRC, a vasodilator called angiotensin-converting enzyme inhibitor is the treatment of choice. The efficacy of various other vasodilators (i.e. endothelin-1 receptor antagonist) and complement cascade blocker for SRC have been investigated; however, no randomized control trial has been conducted. A new approach has been proposed for the management of SRC, categorized by specific clinical features of narrowly defined SRC and systemic sclerosis-thrombotic microangiopathy. SRC prophylaxis using angiotensin-converting enzyme inhibitor might be harmful, leading to a poor renal outcome, so the pathogenesis of SRC needs to be clarified in order to identify other possible preventions or therapies.
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Affiliation(s)
- Chingching Foocharoen
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pantipa Tonsawan
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Patnarin Pongkulkiat
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sirirat Anutrakulchai
- Department of Medicine, Division of Nephrology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Division of Rheumatology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Chennakesavulu PV, Uppaluri S, Koyi J, Jhaveri S, Avanthika C, Sakhamuri LT, Ashokbhai PK, Singh P. Pulmonary Hypertension in Scleroderma- Evaluation and Management. Dis Mon 2022:101468. [PMID: 36163292 DOI: 10.1016/j.disamonth.2022.101468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/hemodynamic criteria that are a consequence of several etiologies. Systemic Sclerosis (SSc), one of the most common causes of PAH, is an autoimmune disorder of the connective tissue leading to fibrosis that involves the skin, gastrointestinal tract, lungs, heart, kidney etc. SSc has an annual prevalence of one to five cases for every 1000 individuals and nearly 15 percent of all cases develop PAH. At its core, Pulmonary hypertension (PH) in SSc is an obliterative vasculopathy in small to medium-sized pulmonary arterioles. A host of other local and systemic mechanisms operate in concert to gradually alter the hemodynamics resulting in elevated pulmonary vascular resistance and thus right ventricular afterload. A diagnosis of PAH in SSc is virtually a death sentence, with studies reporting a mortality rate of 50 per cent in the 3 years of diagnosis. Therefore, developing and implementing a robust screening and diagnosis protocol is crucial in the fight against this pervasive disease. This review aims to summarize the current literature of PAH in SSc, with a special focus on the screening and diagnosis protocols, newer treatment options and prognostic indicators for the same.
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Affiliation(s)
| | - Srikar Uppaluri
- Kamineni Academy of medical sciences and research centre, Hyderabad, India.
| | | | | | | | | | | | - Priyanka Singh
- United health services hospital, Wilson medical center, New York
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Park R, Nevskaya T, Baron M, Pope JE. Immunosuppression use in early systemic sclerosis may be increasing over time. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:33-41. [PMID: 35386940 PMCID: PMC8922673 DOI: 10.1177/23971983211000971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/06/2021] [Indexed: 02/03/2023]
Abstract
Background Immunosuppression remains the main treatment for progressing skin involvement, interstitial lung disease and inflammatory joint or muscle disease in systemic sclerosis. This study investigated the pattern and trends in immunosuppressive agents used in early systemic sclerosis (diagnosed before and after 2007) to determine whether the changes in the preferred type, timing and combination of immunosuppression took place over the past decade. Methods In total, 397 Canadian Scleroderma Research Group database patients (183 diffuse cutaneous systemic sclerosis and 214 limited cutaneous systemic sclerosis) who had baseline and follow-up visits within 3 years (mean: 1.8 ± 0.8) after disease onset were included: 82% females, age at diagnosis 53 ± 13 years. Bivariate, chi-square, analysis of variance and adjusted regression analyses were used. Results In total, 115 diffuse cutaneous systemic sclerosis patients (63%) and 62 limited cutaneous systemic sclerosis (29%) received immunosuppressive drugs, most commonly methotrexate, followed by mycophenolate mofetil and cyclophosphamide. In diffuse cutaneous systemic sclerosis, immunosuppressants were prescribed after 2007 more often (74% vs 50%, p = 0.001), especially methotrexate (p = 0.02) and mycophenolate mofetil (p = 0.04), and earlier (peak at 2 years after onset). Immunosuppressive therapy was associated with male gender, interstitial lung disease, anti-Scl70 positivity, ACA negativity and inflammatory joint disease in limited cutaneous systemic sclerosis and with ACA negativity and a higher modified Rodnan skin score in diffuse cutaneous systemic sclerosis. Multivariate regression analysis showed that the use of immunosuppressants after 2007 was predicted only by ACA negativity in limited cutaneous systemic sclerosis and by younger age in diffuse cutaneous systemic sclerosis. Conclusion Over the past decade, there has been a trend to prescribe immunosuppressants more often and earlier in diffuse cutaneous systemic sclerosis patients, regardless of modified Rodnan skin score. Methotrexate is being more frequently used, and mycophenolate mofetil has gained favour over cyclophosphamide. Autoantibody status was the most consistent predictor of immunosuppressive therapy.
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Affiliation(s)
- Ryan Park
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, Department of Medicine, St. Joseph’s Health Care, London, ON, Canada
| | - Murray Baron
- Division of Rheumatology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Janet E Pope
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada,Division of Rheumatology, Department of Medicine, St. Joseph’s Health Care, London, ON, Canada,Janet Pope, Division of Rheumatology, Department of Medicine, St. Joseph’s Health Care, 268 Grosvenor Street, London, ON N6A 4V2, Canada.
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7
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Chen Y, Wu L, J Hernández-Muñoz J, J Miller M, Pope M, Huyan Y, Zhong L. The economic burden of systemic sclerosis-A systematic review. Int J Rheum Dis 2021; 25:110-120. [PMID: 34970861 DOI: 10.1111/1756-185x.14270] [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: 09/02/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 11/27/2022]
Abstract
AIM Systemic sclerosis (SSc) is a rare, chronic autoimmune disease associated with a substantial economic burden. This study aimed to assess the costs associated with SSc and to identify major cost drivers. METHODS A systematic search was conducted in MEDLINE and Embase to identify relevant studies. Two independent reviewers evaluated studies based on inclusion/exclusion criteria and performed data extraction. Costs were converted into 2017 US dollars by purchasing power parity. The review was conducted following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guideline. RESULTS The original literature search identified 113 potentially relevant citations, of which 10 articles met all the inclusion/exclusion criteria and were included in the data extraction and analysis. The identified studies evaluated costs associated with SSc in 11 countries from North America, Europe, and Australia published between 2009 and 2018. Eight studies reported direct costs and seven studies reported indirect costs. Direct costs varied from $3356 (Hungary) to $27 032 (Germany) with hospitalization and medication being two of the biggest components of direct medical costs in most studies. The indirect costs for lost productivity varied from $2433 (Italy) to $20 663 (UK), accounting for a significant portion of the total economic burden. CONCLUSIONS Large variations existed in annual costs of SSc, but all studies found that SSc imposed a substantial economic burden on patients and their families. The identified studies were mostly from high-income countries and there is still a knowledge gap regarding the cost of SSc in other parts of the world.
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Affiliation(s)
- Yongcong Chen
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Lin Wu
- Health Sciences Library, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Michael J Miller
- Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Melinda Pope
- College of Pharmacy, Texas A&M University College Station, College Station, Texas, USA
| | - Yidan Huyan
- School of Public Health, Texas A&M University College Station, College Station, Texas, USA
| | - Lixian Zhong
- College of Pharmacy, Texas A&M University College Station, College Station, Texas, USA.,Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA.,Houston Methodist Academic Institute, Houston, TX, USA
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Spierings J, Chiu YH, Voortman M, van Laar JM. Autologous stem-cell transplantation in systemic sclerosis-associated interstitial lung disease: early action in selected patients rather than escalation therapy for all. Ther Adv Musculoskelet Dis 2021; 13:1759720X211035196. [PMID: 34394749 PMCID: PMC8361525 DOI: 10.1177/1759720x211035196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/07/2021] [Indexed: 12/29/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare rheumatic disease characterised by inflammation, vasculopathy and fibrosis of skin and internal organs. A common complication and a leading cause of death in SSc is interstitial lung disease (ILD). The current armamentarium of treatments in SSc-ILD mainly includes immunosuppressive therapies and has recently been expanded with anti-fibrotic agent nintedanib. Autologous stem cell transplantation (SCT) is increasingly used in progressive diffuse cutaneous SSc. This intensive treatment has been studied in three randomised trials and demonstrated to improve survival and quality of life. In the subsets of patients with SSc-ILD, SCT resulted in stabilisation and modest improvement of lung volumes and disease extent on high resolution computed tomography, but less impact was seen on diffusion capacity. Comparison of SCT outcomes with results from SSc-ILD trials is difficult though, as lung involvement per se was not an inclusion criterion in all SCT trials. Also, baseline characteristics differed between studies. The risk of severe treatment-related complications from SCT is still considerable and patients with extensive lung disease are particularly at risk of complications during transplantation. Therefore SCT should only be provided by experienced multidisciplinary teams in carefully selected patients. Future research needs to include comprehensive pulmonary evaluation and establish whether SCT early in the disease might prevent irreversible pulmonary damage and reduce treatment-related complications. Also, more insight in mechanisms of action of SCT in the lung and predictors for response will improve the use of this treatment in SSc-ILD. In this review the role of SCT in the treatment of SSc-ILD is summarised.
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Affiliation(s)
- J. Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, the Netherlands
- Division of Medicine, Department of Inflammation, Centre for Rheumatology and Connective Tissue Diseases, Royal Free and University College Medical School, University College London, London, UK
| | - Y-H. Chiu
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
- Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - M. Voortman
- Department of Pulmonology, Division of Heart and Lungs, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J. M. van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
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9
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Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Berezne A, Bouthors AS, Condette-Wojtasik G, Constans J, De Groote P, Diot E, Dumas F, Jego P, Joly F, Launay D, Le Guern V, Le Quintrec JS, Lescaille G, Meune C, Moulin B, Nguyen C, Omeish N, Pene F, Richard MA, Rochefort J, Roren A, Sitbon O, Sobanski V, Truchetet ME, Mouthon L. French recommendations for the management of systemic sclerosis. Orphanet J Rare Dis 2021; 16:322. [PMID: 34304732 PMCID: PMC8310704 DOI: 10.1186/s13023-021-01844-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.
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Affiliation(s)
- Eric Hachulla
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France.
| | - Christian Agard
- Internal Medicine, Nantes University Hospital, University of Nantes, Nantes, France
| | - Yannick Allanore
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Jerome Avouac
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Brigitte Bader-Meunier
- Department of Pediatric Immunology and Rheumatology; Hospital Necker, APHP, Paris, France
| | - Alexandre Belot
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, Bron, France
| | - Alice Berezne
- Department of Internal Medicine, CHR Annecy-Genevois, Annecy, France
| | - Anne-Sophie Bouthors
- Anaesthesia Intensive Care Unit, Jeanne de Flandre Women Hospital, Academic Hospital, ULR 7365 - GRITA - Groupe de Recherche Sur Les Formes Injectables Et Les Technologies Associées, University Lille, Lille, France
| | - Geraldine Condette-Wojtasik
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Joël Constans
- Vascular Medicine Department, Bordeaux University Hospital Centre, Saint André Hospital, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) PeripherAL Artery DIsease Network (PALADIN), Bordeaux, France
| | - Pascal De Groote
- Cardiology Department, Lung-Heart Institute, CHU de Lille, 59000, Lille, France
| | | | - Florence Dumas
- Emergency Department, Cochin Hospital, Paris University, Paris, France
| | - Patrick Jego
- Internal Medicine and Clinical Immunology Unit, CHU Rennes, Rennes, France
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, University of Paris, Clichy, France
| | - David Launay
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Veronique Le Guern
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France
| | | | - Geraldine Lescaille
- Centre d'Immunologie et Maladies Infectieuses (CIMI-Paris), Department of Odontology, Paris Diderot/Paris 07, Sorbonne Paris Cité, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Meune
- Cardiology Department, Hôpital Avicenne, AP-HP, Université de Paris, Paris, France
| | - Bruno Moulin
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Christelle Nguyen
- Physical Medicine and Rehabilitation Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Nadine Omeish
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Frederic Pene
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP. Centre & Université de Paris, Paris, France
| | - Marie-Aleth Richard
- Department of Dermatology, Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Juliette Rochefort
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Alexandra Roren
- AP-HP Cochin Hospital, Université Paris Descartes Sorbonne Paris Cité, INSERM U1153, Paris, France
| | - Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Laboratoire d'Excellence en Recherche Sur le Médicament et Innovation Thérapeutique, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Vincent Sobanski
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | | | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France.
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10
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Abstract
PURPOSE OF REVIEW To review the recently published data and provide a practical overview for management of systemic sclerosis-interstitial lung disease (SSc-ILD). RECENT FINDINGS Published evidence shows considerable practitioner variability in screening patients for ILD. Recent published data support use of cyclophosphamide or mycophenolate mofetil as first-line treatment of SSc-ILD. For patients not responding to first-line therapies, consideration is given to rituximab as rescue therapy. Recent trials of hematopoietic autologous stem cell transplantation have demonstrated benefit in patients with progressive SSc-ILD. Antifibrotic agents are approved in idiopathic pulmonary fibrosis; studies with antifibrotics are underway for SSc-ILD. SUMMARY The specter of rapidly progressive lung disease requires clinicians to risk stratify patients according to known predictors for progression and rigorously monitor for symptoms and advancing disease. The abovementioned therapies promise improved efficacy and favorable side-effect profiles compared to cyclophosphamide.
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11
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Gale SL, Trinh H, Mathew N, Jahreis A, Lin CJF, Sarsour K. Characterizing Disease Manifestations and Treatment Patterns Among Adults with Systemic Sclerosis: A Retrospective Analysis of a US Healthcare Claims Population. Rheumatol Ther 2020; 7:89-99. [PMID: 31734871 PMCID: PMC7021840 DOI: 10.1007/s40744-019-00181-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Real-world use of immunomodulating therapy (IMT) in patients with systemic sclerosis (SSc) was investigated for the first time in a descriptive, retrospective cohort analysis of claims made in a healthcare insurance database to characterize treatment patterns and their alignment with SSc disease manifestations. METHODS Treatment patterns and disease manifestations, symptoms, complications, and comorbidities were assessed in patients with SSc enrolled in a US healthcare claims database who received treatment between January 2006 and December 2013 and for whom data were available 6 months before and 12 months after SSc diagnosis. RESULTS Among 7812 eligible patients, 6852 received treatments of interest for SSc and 2404 (30.8%) received IMT during the first year after SSc diagnosis. In the first year after diagnosis, the most common claims were for antibiotics (61.7%), opioids (50.6%), glucocorticoids (46.5%), and proton pump inhibitors (35.4%); the most common organs involved with complications among patients with SSc were lung (30.5%), heart (17.4%), and gastrointestinal tract (22.4%); the most common signs or symptoms were musculoskeletal (16.1%) and fatigue (10.5%); 1035 patients (15.1%) had infections and 14 (0.2%) had malignancies. Among patients who received IMT, 43.8% received at least hydroxychloroquine and 21.1% received at least methotrexate; 460 patients switched to a second IMT, 23.0% to at least methotrexate and 22.8% to at least mycophenolate mofetil. The most common comorbidities reported with first IMT were in lung (11.8%), overlap syndrome (8.4%), heart (5.3%), and gastrointestinal (6.8%) categories. CONCLUSION One-third of patients with SSc in the healthcare claims population received IMTs during the first year after diagnosis. However, patients who received IMTs had disease manifestations similar to those of the overall SSc healthcare claims population.
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12
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Pope JE. Recommendations for the Treatment of Systemic Sclerosis: Agreement May Not Translate into Uptake. J Rheumatol 2020; 47:164-165. [PMID: 32007942 DOI: 10.3899/jrheum.190582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Janet E Pope
- Schulich School of Medicine, University of Western Ontario, St. Joseph's Health Care, London, Ontario, Canada.
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13
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Pauling JD, Saketkoo LA, Matucci-Cerinic M, Ingegnoli F, Khanna D. The patient experience of Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2019. [PMID: 29538754 DOI: 10.1093/rheumatology/key026] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RP is the most common manifestation of SSc and a major cause of disease-related morbidity. This review provides a detailed appraisal of the patient experience of SSc-RP and potential implications for disease classification, patient-reported outcome instrument development and SSc-RP clinical trial design. The review explores the clinical features of SSc-RP, the severity and burden of SSc-RP symptoms and the impact of SSc-RP on function, work and social participation, body image dissatisfaction and health-related quality of life in SSc. Where management of SSc-RP is concerned, the review focuses on the 'patient experience' of interventions for SSc-RP, examining geographic variation in clinical practice and potential barriers to the adoption of treatment recommendations concerning best-practice management of SSc-RP. Knowledge gaps are highlighted that could form the focus of future research. A more thorough understanding of the patient experience could support the development of novel reported outcome instruments for assessing SSc-RP.
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Affiliation(s)
- John D Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.,Royal National Hospital for Rheumatic Diseases (part of Royal United Hospitals), Upper Borough Walls, Bath, UK
| | - Lesley Ann Saketkoo
- School of Medicine, University of Tulane Medical Center, New Orleans, LA, USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine, Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Ingegnoli
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Universita degli Studi di Milano, Milano, Italy
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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14
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Ebata S, Yoshizaki A, Fukasawa T, Miura S, Takahashi T, Sumida H, Asano Y, Sato S. Rituximab therapy is more effective than cyclophosphamide therapy for Japanese patients with anti-topoisomerase I-positive systemic sclerosis-associated interstitial lung disease. J Dermatol 2019; 46:1006-1013. [PMID: 31502326 DOI: 10.1111/1346-8138.15079] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/15/2019] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is the most frequent cause of death for SSc but there is still no sufficient treatment available. Although cyclophosphamide (CYC) therapy is a common treatment which has shown statistical efficacy against SSc-ILD to date, its effects are temporary and not enough. Rituximab (RTX), the anti-CD20 monoclonal antibody, has recently shown efficacy in many autoimmune diseases. In SSc-ILD, RTX is also considered to be one of the novel treatment candidates. However, studies of SSc-ILD in Japanese treated with RTX have only a few case reports. Therefore, in this study, we retrospectively compared nine patients treated with RTX and 30 patients treated with CYC to investigate the efficacy of RTX treatment for Japanese anti-topoisomerase I-positive SSc-ILD patients. At the 24-month evaluation, the improvement rates of percent predicted of forced vital capacity and percent predicted of diffusing capacity of the lung carbon monoxide in the RTX-treated group were significantly higher than those in the CYC-treated group (20.6 ± 8.8% vs 1.1 ± 3.9%; P < 0.05 and 34.0 ± 6.0% vs -1.5 ± 2.8%; P < 0.01, respectively). In addition, skin thickness scores also showed a marked improvement from 13.5 points before the start of treatment to 5.8 points after 24 months by RTX therapy (P < 0.05). These results suggest that RTX treatment is more effective for Japanese SSc-ILD patients than CYC treatment. In the future, it is expected that large-scale clinical trials will show the usefulness of RTX treatment for SSc-ILD.
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Affiliation(s)
- Satoshi Ebata
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takemichi Fukasawa
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Miura
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takehiro Takahashi
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hayakazu Sumida
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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15
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Gordon SM, Hughes JB, Nee R, Stitt RS, Bailey WT, Little DJ, Edison JD, Olson SW. Systemic sclerosis medications and risk of scleroderma renal crisis. BMC Nephrol 2019; 20:279. [PMID: 31345158 PMCID: PMC6659266 DOI: 10.1186/s12882-019-1467-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/17/2019] [Indexed: 01/13/2023] Open
Abstract
Background Scleroderma Renal Crisis (SRC) is associated with significant morbidity and mortality. While prednisone is strongly associated with SRC, there are no previous large cohort studies that have evaluated ace inhibitor (ACEi) calcium channel blocker (CCB), angiotensin receptor blocker (ARB), endothelin receptor blocker (ERB), non-steroidal anti-inflammatory drug (NSAID), fluticasone, or mycophenolate mofetil (MMF) use in systemic sclerosis (SSc) and the risk of SRC. Methods In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the use of ACEi, ARB, CCB, NSAID, ERB, fluticasone, and MMF after SSc diagnosis for 31 cases who subsequently developed SRC to 322 SSc without SRC disease controls. Results ACEi was associated with an increased risk for SRC adjusted for age, race, and prednisone use [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.6–10.2, P = 0.003]. On stratified analyses, ACEi was only associated with SRC in the presence [OR 5.3, 95% CI 1.1–29.2, p = 0.03], and not the absence of proteinuria. In addition, a doubling of ACEi dose [61% vs. 12%, p < 0.001) and achieving maximum ACEi dose [45% vs. 4%, p < 0.001] after SSc diagnosis was associated with future SRC. CCB, ARB, NSAIDs, ERB, fluticasone, and MMF use were not significantly associated with SRC. Conclusion ACEi use at SSC diagnosis was associated with an increased risk for SRC. Results suggest that it may be a passive marker of known SRC risk factors, such as proteinuria, or evolving disease. SSC patients that require ACEi should be more closely monitored for SRC.
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Affiliation(s)
- S M Gordon
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J B Hughes
- Department of Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - R Nee
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - R S Stitt
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - W T Bailey
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - D J Little
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J D Edison
- Rheumatology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, USA
| | - S W Olson
- Nephrology Department, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
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16
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Satteson ES, Chung MP, Chung LS, Chang J. Microvascular Hand Surgery for Digital Ischemia in Scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 5:130-136. [PMID: 34095502 DOI: 10.1177/2397198319863565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Periarterial sympathectomy and arterial bypass are microsurgical techniques which the literature suggests can provide improvement in digital pain and ulceration in patients with systemic sclerosis (SSc) who have persistent symptoms despite medication management. This review summarizes the relevant anatomy, medical therapies, operative techniques, and surgical outcomes and complications associated with the management of the vascular manifestations of SSc in the hand. Multidisciplinary collaboration between dermatology, rheumatology, and hand surgery can facilitate optimal medical and surgical management for SSc patients.
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Affiliation(s)
- Ellen S Satteson
- Division of Plastic Surgery, Department of Surgery, The Robert A. Chase Hand Center, Stanford University Medical Center, Palo Alto, CA, USA
| | - Melody P Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Lorinda S Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA.,Division of Rheumatology, Department of Medicine, Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - James Chang
- Division of Plastic Surgery, Department of Surgery, The Robert A. Chase Hand Center, Stanford University Medical Center, Palo Alto, CA, USA
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17
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Henao J, Fernandez R, Tejada Arias K, Chae C. Diffused Alveolar Hemorrhage in the Setting of Scleroderma Renal Crisis. Cureus 2019; 11:e4932. [PMID: 31431838 PMCID: PMC6695237 DOI: 10.7759/cureus.4932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systemic sclerosis (SS) is a chronic, connective tissue disorder that can affect the skin, subcutaneous tissues, and internal organs. There are two different categories of SS, limited cutaneous systemic sclerosis (LCSS) and diffuse cutaneous systemic sclerosis (DCSS). One of the most fearful situations faced in DCSS is scleroderma renal crisis (SRC). This is a rare but potentially life-threatening complication characterized by an acute, usually symptomatic, increase in blood pressure, rise in serum creatinine levels, oliguria, and thrombotic microangiopathic changes. Pulmonary involvement in the setting of SCR is an even more rare combination and usually can progress into acute hypoxic respiratory failure and lead to worse outcomes. We present herein a case of scleroderma renal crisis complicated with diffuse pulmonary hemorrhage.
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Affiliation(s)
- Jose Henao
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Raynieri Fernandez
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Karla Tejada Arias
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Chu Chae
- Critical Care, Advocate Illinois Masonic Medical Center, Chicago, USA
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18
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Johnson SR, Devakandan K. Guidelines and Recommendations Towards Evidence-Based Management of Systemic Sclerosis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00120-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Montrief T, Koyfman A, Long B. Scleroderma renal crisis: a review for emergency physicians. Intern Emerg Med 2019; 14:561-570. [PMID: 31076978 DOI: 10.1007/s11739-019-02096-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/27/2019] [Indexed: 12/15/2022]
Abstract
Scleroderma renal crisis (SRC) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of SRC. While SRC remains a rare clinical presentation, surveillance data suggest an overall incidence between 4 and 6% of patients with scleroderma. The diagnostic criteria for SRC include a new onset blood pressure > 150/85 mm Hg OR increase ≥ 20 mm Hg from baseline systolic blood pressure, along with a decline in renal function, defined as an increase serum creatinine of ≥ 10% and supportive features. There are many risk factors for SRC, including diffuse and rapidly progressive skin thickening, palpable tendon friction rubs, and new anemia or cardiac events. Critical patients should be evaluated in the resuscitation bay, and consultation with the nephrology team for appropriate patients improves patient outcomes.
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MESH Headings
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Antibodies, Antineutrophil Cytoplasmic/analysis
- Antibodies, Antineutrophil Cytoplasmic/blood
- Emergency Service, Hospital/organization & administration
- Humans
- Kidney Failure, Chronic/drug therapy
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/physiopathology
- Purpura, Thrombotic Thrombocytopenic/blood
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/physiopathology
- Renal Dialysis/methods
- Risk Factors
- Scleroderma, Systemic/blood
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/physiopathology
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Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Hospital/Miller School of Medicine, University of Miami, 1611 N.W. 12th Avenue, Miami, FL, 33136, USA
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
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20
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Iloprost use and medical management of systemic sclerosis-related vasculopathy in Italian tertiary referral centers: results from the PROSIT study. Clin Exp Med 2019; 19:357-366. [DOI: 10.1007/s10238-019-00553-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/10/2019] [Indexed: 01/04/2023]
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21
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Shimizu T, Iwamoto N, Okamoto M, Endo Y, Tsuji S, Takatani A, Igawa T, Umeda M, Fukui S, Sumiyoshi R, Kitamura M, Koga T, Kawashiri SY, Ichinose K, Tamai M, Nakamura H, Origuchi T, Nishino T, Kawakami A. Scleroderma Renal Crisis Complicated with Thrombotic Microangiopathy Triggered by Influenza B Virus Infection. Intern Med 2019; 58:441-445. [PMID: 30146597 PMCID: PMC6395120 DOI: 10.2169/internalmedicine.1441-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 44-year-old Japanese man with a 14-year history of limited cutaneous systemic sclerosis (SSc) was admitted with a fever, hypertension, anemia, thrombocytopenia, and renal dysfunction. On admission, hypertension, hyperreninemia, acute renal dysfunction, hemolytic anemia, and thrombocytopenia led to the diagnosis of scleroderma renal crisis (SRC) complicated with thrombotic microangiopathy (TMA). The patient had also been infected with influenza B virus almost six days before admission. Following treatment with plasma exchange, an angiotensin-converting enzyme inhibitor, and an anti-virus agent, his general condition improved. He had no risk factors for SRC. In SSc patients, an influenza virus infection might trigger SRC complicated with TMA.
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Affiliation(s)
- Toshimasa Shimizu
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Momoko Okamoto
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yushiro Endo
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Sosuke Tsuji
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Ayuko Takatani
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takashi Igawa
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Masataka Umeda
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shoichi Fukui
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Remi Sumiyoshi
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shin-Ya Kawashiri
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hideki Nakamura
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoki Origuchi
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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22
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Management of Raynaud’s phenomenon in systemic sclerosis—a practical approach. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:102-110. [DOI: 10.1177/2397198318823951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
Abstract
Raynaud’s phenomenon is nearly universal in systemic sclerosis. Vasculopathy is part of systemic sclerosis. Raynaud’s phenomenon can cause of complications and impairment, especially when tissue ischemia and digital ulcers develop. There are many treatment options for Raynaud’s phenomenon in systemic sclerosis often with sparse data and few robust studies comparing the different treatment options. Recommendations from guidelines usually include calcium channel blockers as first-line pharmacological treatment. In the clinical setting, multiple variables such as financial factors, geography where access to medications varies, and patient factors, baseline hypotension, can influence the treatment for Raynaud’s phenomenon and digital ulcers. Prostacyclins and PDE-5 inhibitors are reserved for more severe Raynaud’s phenomenon or healing of digital ulcers. Prevention of digital ulcers may also include endothelin receptor blocker (bosentan) in some countries. Other treatments had less consensus. Algorithms developed by systemic sclerosis experts might be helpful in deciding which treatment to choose for each setting, using a step-wise strategy, which intends to complement guidelines. This review focuses on a practical approach to the treatment of Raynaud’s phenomenon and digital ulcers in systemic sclerosis, based on algorithms designed by systemic sclerosis experts using consensus, and we review the evidence that supports treatment from initial to second and third-line options.
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23
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Cottin V, Brown KK. Interstitial lung disease associated with systemic sclerosis (SSc-ILD). Respir Res 2019; 20:13. [PMID: 30658650 PMCID: PMC6339436 DOI: 10.1186/s12931-019-0980-7] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 01/07/2019] [Indexed: 12/18/2022] Open
Abstract
Background Systemic sclerosis (SSc) is a rare connective tissue disease with a heterogeneous clinical course. Interstitial lung disease (ILD) is a common manifestation of SSc and a leading cause of death. Main body All patients newly diagnosed with SSc should receive a comprehensive clinical evaluation, including assessment of respiratory symptoms, a high-resolution computed tomography (HRCT) scan of the chest, and pulmonary function tests. ILD can develop in any patient with SSc, including those with pulmonary hypertension, but the risk is increased in those with diffuse (rather than limited) cutaneous SSc, those with anti-Scl-70/anti-topoisomerase I antibody, and in the absence of anti-centromere antibody. While it can occur at any time, the risk of developing ILD is greatest early in the course of SSc, so patients should be monitored closely in the first few years after diagnosis. An increased extent of lung fibrosis on HRCT and a low forced vital capacity (FVC) are predictors of early mortality. While not all patients will require treatment, current approaches to the treatment of progressive SSc-ILD focus on immunosuppressant therapies, including cyclophosphamide and mycophenolate mofetil. In patients with severe and/or rapidly progressive disease, both haematopoietic stem cell transplantation (HSCT) and lung transplantation have been successfully used. A number of medications, including the two drugs approved for the treatment of idiopathic pulmonary fibrosis (IPF), are under active investigation as potential new therapies for SSc-ILD. Conclusions Physicians managing patients with SSc should maintain a high level of suspicion and regularly monitor for ILD, particularly in the first few years after diagnosis.
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Affiliation(s)
- Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Claude Bernard University Lyon 1, 28 Avenue du Doyen Lepine, 69677 Lyon Cedex, Lyon, France.
| | - Kevin K Brown
- National Jewish Health, 1400 Jackson Street, Denver, CO, 80206, USA
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Fernández-Codina A, Walker KM, Pope JE. Treatment Algorithms for Systemic Sclerosis According to Experts. Arthritis Rheumatol 2018; 70:1820-1828. [PMID: 29781586 DOI: 10.1002/art.40560] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There is a lack of agreement regarding treatment for many aspects of systemic sclerosis (SSc). We undertook this study to generate SSc treatment algorithms endorsed by a high percentage of SSc experts. METHODS Experts from the Scleroderma Clinical Trials Consortium and the Canadian Scleroderma Research group (n = 170) were asked whether they agreed with SSc algorithms from 2012. Two consensus rounds refined agreement; 62, 54, and 48 experts (36%, 32%, and 28%, respectively) completed the first, second, and third surveys, respectively. RESULTS For treatment of scleroderma renal crisis, 81% of experts agreed (first-, second-, and third-line treatments were angiotensin-converting enzyme inhibitors, then adding calcium-channel blockers [CCBs], then adding angiotensin receptor blockers [ARBs], respectively). For pulmonary arterial hypertension (PAH), 81% of experts agreed (for mild PAH, treatments were phosphodiesterase 5 [PDE5] inhibitors, then endothelin receptor antagonists plus PDE5 inhibitors, then prostanoids, respectively; for severe PAH, prostanoids were first-line treatment). For mild Raynaud's phenomenon (RP), 79% of experts agreed (treatments were CCBs, then adding PDE5 inhibitors, then ARBs or switching to another CCB, respectively; after the third line of treatment, mild RP was deemed severe). For severe RP, the first- through fourth-line treatments were CCBs, then adding PDE5 inhibitors or prostanoids, then adding PDE5 inhibitors (if not added as second-line treatment) or prostanoids (if not added as second-line treatment), then switching to another CCB, respectively. For active treatment of digital ulcers, 66% of experts agreed (first- and second-line treatments were CCBs and PDE5 inhibitors, respectively). For interstitial lung disease, 69% of experts agreed (for induction therapy, treatments were mycophenolate mofetil [MMF], intravenous cyclophosphamide [IV CYC], and rituximab, respectively; for maintenance, first-line treatment was MMF). For skin involvement, 71% of experts agreed (for a modified Rodnan skin thickness score [MRSS] of 24, first- and second-line treatments were methotrexate [MTX] and MMF, respectively; for an MRSS of 32, first- through fourth-line treatments were MMF, MTX, IV CYC, and hematopoietic stem cell transplantation, respectively). For inflammatory arthritis, 79% of experts agreed (first- through fourth-line treatments were MTX, low-dose glucocorticoids, hydroxychloroquine, and rituximab or tocilizumab, respectively). Algorithms for cardiac and gastrointestinal involvement had ≥75% agreement. CONCLUSION Total agreement for SSc algorithms was considerable. These algorithms may guide treatment.
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Affiliation(s)
- Andreu Fernández-Codina
- University of Western Ontario, London, Ontario, Canada, and Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kyle M Walker
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Janet E Pope
- University of Western Ontario, London, Ontario, Canada
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25
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Ferreli C, Gasparini G, Parodi A, Cozzani E, Rongioletti F, Atzori L. Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:306-336. [PMID: 28712039 DOI: 10.1007/s12016-017-8625-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud's phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.
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Affiliation(s)
- Caterina Ferreli
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Giulia Gasparini
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Franco Rongioletti
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Atzori
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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26
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Chalifoux SL, Konyn PG, Choi G, Saab S. Extrahepatic Manifestations of Primary Biliary Cholangitis. Gut Liver 2018; 11:771-780. [PMID: 28292174 PMCID: PMC5669592 DOI: 10.5009/gnl16365] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/16/2016] [Indexed: 12/11/2022] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by progressive destruction of the intrahepatic bile ducts, leading to cholestasis. PBC is known to have both hepatic and extrahepatic manifestations. Extrahepatic manifestations are seen in up to 73% of patients with PBC, with the most common being Sjogren’s syndrome, thyroid dysfunction and systemic sclerosis. It is thought that patients with PBC are at increased risk of developing these extrahepatic manifestations, almost all of which are autoimmune, because patients with autoimmune disease are at higher risk of developing another autoimmune condition. Due to the high prevalence of extrahepatic diseases in patients with PBC, it is important to complete a thorough medical history at the time of diagnosis. Prompt recognition of extrahepatic disease can lead to improved patient outcomes and quality of life. The following review summarizes the most common extrahepatic conditions associated with PBC.
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Affiliation(s)
- Sara L Chalifoux
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Peter G Konyn
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Gina Choi
- Department of Medicine, University of California, Los Angeles, CA, USA.,Department of Surgery, University of California, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California, Los Angeles, CA, USA.,Department of Surgery, University of California, Los Angeles, CA, USA
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Blank RB, Nwawka OK, Yusov AA, Gordon JK. Inflammatory arthritis in systemic sclerosis: What to do? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 4:3-16. [DOI: 10.1177/2397198318779532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/08/2018] [Indexed: 01/16/2023]
Abstract
Musculoskeletal involvement, including arthritis and tendinopathy, is a common and important determinant of disability and impaired quality of life in systemic sclerosis. However, the treatment of arthritis in systemic sclerosis has not been studied as a primary outcome in randomized controlled trials, and arthritis-specific outcome measures for systemic sclerosis have not been sufficiently validated to date. Rheumatologists caring for patients with systemic sclerosis must address these complaints regularly despite the fact that the level of evidence for the treatment of systemic sclerosis–related inflammatory arthritis is limited. Consensus statements, based on treatments for related musculoskeletal aspects of rheumatoid arthritis, systemic lupus erythematosus, and other autoimmune diseases, support the use of methotrexate and hydroxychloroquine. Newer biologics, which have efficacy in the treatment of other autoimmune conditions, may show promise in the treatment of arthritis in systemic sclerosis. In this article, we review the current literature on the assessment and treatment of systemic sclerosis arthritis in order to address management considerations.
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Affiliation(s)
- Rebecca B Blank
- NewYork-Presbyterian/Weill Cornell Medicine Center, New York, NY, USA
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28
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Pauling JD. The challenge of establishing treatment efficacy for cutaneous vascular manifestations of systemic sclerosis. Expert Rev Clin Immunol 2018; 14:431-442. [PMID: 29641934 DOI: 10.1080/1744666x.2018.1464390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The cutaneous vascular manifestations of systemic sclerosis (SSc) comprise Raynaud's phenomenon, cutaneous ulceration, telangiectasia formation and critical digital ischaemia; each of which are associated with significant disease-related morbidity. Despite the availability of multiple classes of vasodilator therapy, many of which have been the subject of RCTs, a limited number of pharmacological interventions are currently approved for the management of cutaneous vascular manifestations of SSc. Areas covered: A major challenge has been demonstrating treatment efficacy with examples of promising therapies yielding contrasting results in controlled trial settings. Differences between consensus best-practice guidelines, evidence-based recommendations and marketing approvals in different jurisdictions has resulted in geographic variation in clinical practice concerning the management of cutaneous vascular manifestations of SSc. Difficulty demonstrating treatment efficacy risks waning industry engagement for drug development programmes in this field. This article highlights the key challenges in establishing treatment efficacy and barriers that must be overcome to support successful clinical trial programmes across the spectrum of cutaneous vascular manifestations of SSc. Expert commentary: The paucity of approved treatments for cutaneous vascular manifestations of SSc relates as much to challenges in clinical trial design and the need for reliable clinical trial endpoints, as to lack of therapeutic options.
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Affiliation(s)
- John D Pauling
- a Department of Rheumatology, Royal National Hospital for Rheumatic Diseases , Royal United Hospitals NHS Foundation Trust , Bath , UK.,b Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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30
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Hinchcliff M, Toledo DM, Taroni JN, Wood TA, Franks JM, Ball MS, Hoffmann A, Amin SM, Tan AU, Tom K, Nesbeth Y, Lee J, Ma M, Aren K, Carns MA, Pioli PA, Whitfield ML. Mycophenolate Mofetil Treatment of Systemic Sclerosis Reduces Myeloid Cell Numbers and Attenuates the Inflammatory Gene Signature in Skin. J Invest Dermatol 2018; 138:1301-1310. [PMID: 29391252 DOI: 10.1016/j.jid.2018.01.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/08/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022]
Abstract
Fewer than half of patients with systemic sclerosis demonstrate modified Rodnan skin score improvement during mycophenolate mofetil (MMF) treatment. To understand the molecular basis for this observation, we extended our prior studies and characterized molecular and cellular changes in skin biopsies from subjects with systemic sclerosis treated with MMF. Eleven subjects completed ≥24 months of MMF therapy. Two distinct skin gene expression trajectories were observed across six of these subjects. Three of the six subjects showed attenuation of the inflammatory signature by 24 months, paralleling reductions in CCL2 mRNA expression in skin and reduced numbers of macrophages and myeloid dendritic cells in skin biopsies. MMF cessation at 24 months resulted in an increased inflammatory score, increased CCL2 mRNA and protein levels, modified Rodnan skin score rebound, and increased numbers of skin myeloid cells in these subjects. In contrast, three other subjects remained on MMF >24 months and showed a persistent decrease in inflammatory score, decreasing or stable modified Rodnan skin score, CCL2 mRNA reductions, sera CCL2 protein levels trending downward, reduction in monocyte migration, and no increase in skin myeloid cell numbers. These data summarize molecular changes during MMF therapy that suggest reduction of innate immune cell numbers, possibly by attenuating expression of chemokines, including CCL2.
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Affiliation(s)
- Monique Hinchcliff
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Diana M Toledo
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jaclyn N Taroni
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Tammara A Wood
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jennifer M Franks
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michael S Ball
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Aileen Hoffmann
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sapna M Amin
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ainah U Tan
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin Tom
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Jungwha Lee
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Madeleine Ma
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kathleen Aren
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary A Carns
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patricia A Pioli
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Michael L Whitfield
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
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Adler S, Huscher D, Siegert E, Allanore Y, Czirják L, DelGaldo F, Denton CP, Distler O, Frerix M, Matucci-Cerinic M, Mueller-Ladner U, Tarner IH, Valentini G, Walker UA, Villiger PM, Riemekasten G. Systemic sclerosis associated interstitial lung disease - individualized immunosuppressive therapy and course of lung function: results of the EUSTAR group. Arthritis Res Ther 2018; 20:17. [PMID: 29382380 PMCID: PMC5791165 DOI: 10.1186/s13075-018-1517-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/11/2018] [Indexed: 12/27/2022] Open
Abstract
Background Interstitial lung disease in systemic sclerosis (SSc-ILD) is a major cause of SSc-related death. Imunosuppressive treatment (IS) is used in patients with SSc for various organ manifestations mainly to ameliorate progression of SSc-ILD. Data on everyday IS prescription patterns and clinical courses of lung function during and after therapy are scarce. Methods We analysed patients fulfilling American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) 2013 criteria for SSc-ILD and at least one report of IS. Types of IS, pulmonary function tests (PFT) and PFT courses during IS treatment were evaluated. Results EUSTAR contains 3778/11,496 patients with SSc-ILD (33%), with IS in 2681/3,778 (71%). Glucocorticoid (GC) monotherapy was prescribed in 30.6% patients with GC combinations plus cyclophosphamide (CYC) (11.9%), azathioprine (AZA) (9.2%), methotrexate (MTX) (8.7%), or mycophenolate mofetil (MMF) (7.3%). Intensive IS (MMF + GC, CYC or CYC + GC) was started in patients with the worst PFTs and ground glass opacifications on imaging. Patients without IS showed slightly less worsening in forced vital capacity (FVC) when starting with FVC 50–75% or >75%. GC showed negative trends when starting with FVC <50%. Regarding diffusing capacity for carbon monoxide (DLCO), negative DLCO trends were found in patients with MMF. Conclusions IS is broadly prescribed in SSc-ILD. Clusters of clinical and functional characteristics guide individualised treatment. Data favour distinguished decision-making, pointing to either watchful waiting and close monitoring in the early stages or start of immunosuppressive treatment in moderately impaired lung function. Advantages of specific IS are difficult to depict due to confounding by indication. Data do not support liberal use of GC in SSc-ILD. Electronic supplementary material The online version of this article (10.1186/s13075-018-1517-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sabine Adler
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Freiburgstrasse 4, 3010, Bern, Switzerland.
| | - Dörte Huscher
- German Rheumatism Research Center, A Leibniz Institute, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Elise Siegert
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Yannick Allanore
- Department of Rheumatology A, Descartes University, APHP, Cochin Hospital, Paris, France
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pecs, Pecs, Hungary
| | | | - Christopher P Denton
- UCL Division of Medicine, Centre for Rheumatology, Royal Free Hospital, London, UK
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Marc Frerix
- Department of Rheumatology and Clinical Immunology, Osteology and Physical Therapy, Justus-Liebig-University Giessen, Kerckhoff Klinik, Bad Nauheim, Germany
| | - Marco Matucci-Cerinic
- Department Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Osteology and Physical Therapy, Justus-Liebig-University Giessen, Kerckhoff Klinik, Bad Nauheim, Germany
| | - Ingo-Helmut Tarner
- Department of Rheumatology and Clinical Immunology, Osteology and Physical Therapy, Justus-Liebig-University Giessen, Kerckhoff Klinik, Bad Nauheim, Germany
| | | | - Ulrich A Walker
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Freiburgstrasse 4, 3010, Bern, Switzerland
| | - Gabriela Riemekasten
- Department of Rheumatology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Ah Kioon MD, Tripodo C, Fernandez D, Kirou KA, Spiera RF, Crow MK, Gordon JK, Barrat FJ. Plasmacytoid dendritic cells promote systemic sclerosis with a key role for TLR8. Sci Transl Med 2018; 10:10/423/eaam8458. [PMID: 29321259 PMCID: PMC9865429 DOI: 10.1126/scitranslmed.aam8458] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/17/2017] [Accepted: 11/14/2017] [Indexed: 01/25/2023]
Abstract
Systemic sclerosis (SSc) is a multisystem life-threatening fibrosing disorder that lacks effective treatment. The link between the inflammation observed in organs such as the skin and profibrotic mechanisms is not well understood. The plasmacytoid dendritic cell (pDC) is a key cell type mediating Toll-like receptor (TLR)-induced inflammation in autoimmune disease patients, including lupus and skin diseases with interface dermatitis. However, the role of pDCs in fibrosis is less clear. We show that pDCs infiltrate the skin of SSc patients and are chronically activated, leading to secretion of interferon-α (IFN-α) and CXCL4, which are both hallmarks of the disease. We demonstrate that the secretion of CXCL4 is under the control of phosphatidylinositol 3-kinase δ and is due to the aberrant presence of TLR8 on pDCs of SSc patients, which is not seen in healthy donors or in lupus pDCs, and that CXCL4 primarily acts by potentiating TLR8- but also TLR9-induced IFN production by pDCs. Depleting pDCs prevented disease in a mouse model of scleroderma and could revert fibrosis in mice with established disease. In contrast, the disease was exacerbated in mice transgenic for TLR8 with recruitment of pDCs to the fibrotic skin, whereas TLR7 only partially contributed to the inflammatory response, indicating that TLR8 is the key RNA-sensing TLR involved in the establishment of fibrosis. We conclude that the pDC is an essential cell type involved in the pathogenesis of SSc and its removal using depleting antibodies or attenuating pDC function could be a novel approach to treat SSc patients.
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Affiliation(s)
- Marie Dominique Ah Kioon
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Claudio Tripodo
- Tumor Immunology Unit, Department of Health Science, Human Pathology Section, University of Palermo School of Medicine, Palermo, Italy
| | - David Fernandez
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Kyriakos A. Kirou
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Robert F. Spiera
- Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY 10021, USA
| | - Mary K. Crow
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA.,Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Jessica K. Gordon
- Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY 10021, USA
| | - Franck J. Barrat
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA.,Corresponding author.
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Fischer A, Zimovetz E, Ling C, Esser D, Schoof N. Humanistic and cost burden of systemic sclerosis: A review of the literature. Autoimmun Rev 2017; 16:1147-1154. [PMID: 28899803 DOI: 10.1016/j.autrev.2017.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 08/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Systemic sclerosis (SSc), or systemic scleroderma, is a chronic multisystem autoimmune disease characterised by widespread vascular injury and progressive fibrosis of the skin and internal organs. Patients with SSc have decreased survival, with pulmonary involvement as the main cause of death. Current treatments for SSc manage a range of symptoms but not the cause of the disease. Our review describes the humanistic and cost burden of SSc. METHODS A structured review of the literature was conducted, using predefined search strategies to search PubMed, Embase, and the Cochrane Library. Grey literature searches also were conducted. RESULTS In total, 2226 articles were identified in the databases and 52 were included; an additional 10 sources were included from the grey literature. The review identified six studies reporting relevant cost estimates conducted in five different countries and four studies that assessed the humanistic burden of SSc. Total direct annual medical costs per patient for Europe varied from €3544 to €8452. For Canada, these costs were reported to be from Can$5038 to Can$10,673. In the United States, the total direct health care costs were reported to be US$17,365 to US$18,396. Different key drivers of direct costs were reported, including hospitalisations, outpatients, and medication. The total annual costs per patient were reported at Can$18,453 in Canada and varied from €11,074 to €22,459 in Europe. Indirect costs represented the largest component of the total costs. EQ-5D utility scores were lower for patients with SSc than those observed in the general population, with reported mean values of 0.49 and 0.68, respectively. The average value of the Health Assessment Questionnaire for patients with SSc was significantly higher than the control population (0.94), and the average value of the SF-36 was significantly lower than the control population: 49.99 for the physical dimension and 58.42 for the mental dimension. CONCLUSIONS Overall, there is a paucity of information on the burden of SSc. Nonetheless, our review indicates that the quality of life of patients with SSc is considerably lower than that of the general population. In addition, SSc places a considerable economic burden on health care systems and society as a whole.
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Affiliation(s)
- Aryeh Fischer
- University of Colorado School of Medicine, Denver, CO, USA.
| | | | | | - Dirk Esser
- Boehringer Ingelheim GmbH, Ingelheim, Germany.
| | - Nils Schoof
- Boehringer Ingelheim GmbH, Ingelheim, Germany.
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Giacomelli R, Afeltra A, Alunno A, Baldini C, Bartoloni-Bocci E, Berardicurti O, Carubbi F, Cauli A, Cervera R, Ciccia F, Cipriani P, Conti F, De Vita S, Di Benedetto P, Doria A, Drosos AA, Favalli EG, Gandolfo S, Gatto M, Grembiale RD, Liakouli V, Lories R, Lubrano E, Lunardi C, Margiotta DPE, Massaro L, Meroni P, Minniti A, Navarini L, Pendolino M, Perosa F, Pers JO, Prete M, Priori R, Puppo F, Quartuccio L, Ruffatti A, Ruscitti P, Russo B, Sarzi-Puttini P, Shoenfeld Y, Somarakis GA, Spinelli FR, Tinazzi E, Triolo G, Ursini F, Valentini G, Valesini G, Vettori S, Vitali C, Tzioufas AG. International consensus: What else can we do to improve diagnosis and therapeutic strategies in patients affected by autoimmune rheumatic diseases (rheumatoid arthritis, spondyloarthritides, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome and Sjogren's syndrome)? Autoimmun Rev 2017; 16:911-924. [DOI: 10.1016/j.autrev.2017.07.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/20/2017] [Indexed: 02/06/2023]
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Knobler R, Moinzadeh P, Hunzelmann N, Kreuter A, Cozzio A, Mouthon L, Cutolo M, Rongioletti F, Denton CP, Rudnicka L, Frasin LA, Smith V, Gabrielli A, Aberer E, Bagot M, Bali G, Bouaziz J, Braae Olesen A, Foeldvari I, Frances C, Jalili A, Just U, Kähäri V, Kárpáti S, Kofoed K, Krasowska D, Olszewska M, Orteu C, Panelius J, Parodi A, Petit A, Quaglino P, Ranki A, Sanchez Schmidt JM, Seneschal J, Skrok A, Sticherling M, Sunderkötter C, Taieb A, Tanew A, Wolf P, Worm M, Wutte NJ, Krieg T. European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes. J Eur Acad Dermatol Venereol 2017; 31:1401-1424. [PMID: 28792092 DOI: 10.1111/jdv.14458] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Moinzadeh
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - N Hunzelmann
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - A Cozzio
- Department of Dermatology, Venereology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - L Mouthon
- Service de Médecine Interne, Centre de référence maladies rares: vascularites et sclérodermie systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - M Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - F Rongioletti
- Dermatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - C P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - L Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - L A Frasin
- Dermatology Unit, Hospital of Lecco, Lecco, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Gabrielli
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - E Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Bagot
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - G Bali
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - J Bouaziz
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - A Braae Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - I Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - A Jalili
- Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - U Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - V Kähäri
- Department of Dermatology and Venereology, Turku University Hospital and University of Turku, Turku, Finland
| | - S Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - K Kofoed
- Department of Dermato-Allergology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - D Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | - M Olszewska
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - C Orteu
- Department of Dermatology, Connective Tissue Diseases Service, Royal Free Hospital, London, UK
| | - J Panelius
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - A Parodi
- Department of Dermatology, IRCCS San Martino, University Medical School of Genoa, Genoa, Italy
| | - A Petit
- Department of Dermatology, Hôpital Saint-Louis, Hôpitaux Universitaires, Paris, France
| | - P Quaglino
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Ranki
- Department of Dermatology, Allergology and Venereology, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Sanchez Schmidt
- Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - M Sticherling
- Department of Dermatology, University Hospital of Erlangen, Erlangen, Germany
| | - C Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - A Taieb
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, Bordeaux, France
| | - A Tanew
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N J Wutte
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Krieg
- Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany
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Álvarez-Barreneche MF, Velásquez-Franco CJ, Mesa-Navas MA. Enfermedad pulmonar intersticial en pacientes con esclerosis sistémica. Revisión narrativa de la literatura. IATREIA 2017. [DOI: 10.17533/udea.iatreia.v30n3a03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Zhang H, Liang J, Tang X, Wang D, Feng X, Wang F, Hua B, Wang H, Sun L. Sustained benefit from combined plasmapheresis and allogeneic mesenchymal stem cells transplantation therapy in systemic sclerosis. Arthritis Res Ther 2017; 19:165. [PMID: 28724445 PMCID: PMC5518166 DOI: 10.1186/s13075-017-1373-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/21/2017] [Indexed: 12/12/2022] Open
Abstract
Background Systemic sclerosis (SSc) is an autoimmune disease involving the skin and several internal organs. Most therapies available for this disease are symptomatic. Given the difficulty in treating SSc, we conducted this study to investigate the effect of combined plasmapheresis (PE) and allogeneic mesenchymal stem cells transplantation (MSCT) therapy on SSc. Methods Fourteen patients underwent three repeated PE treatments with subsequent pulse cyclophosphamide on days 1, 3 and 5. Patients received a single MSCT (1 × 106 cells/kg of body weight) on day 8. During follow up, evaluations performed included complete physical examination, serologic testing, and organ function. Results The mean modified Rodnan skin score (MRSS) improved from 20.1 ± 3.1 to 13.8 ± 10.2 (P < 0.001) at 12 months of follow up. Three patients had interstitial lung disease, all had improvement of lung function and improved computed tomography (CT) images after 12 months of combined therapy. This combined treatment also significantly decreased the anti-Scl70 autoantibody titer and serum transforming growth factor-β and vascular endothelial growth factor levels during follow up. Conclusion The results indicate that PE combined with MSCT is a feasible treatment associated with possible clinical benefit for SSc patients. Trial registration ClinicalTrials.gov, NCT00962923. Registered on 19 August 2009.
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Affiliation(s)
- Huayong Zhang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Jun Liang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xiaojun Tang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Dandan Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Fan Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Bingzhu Hua
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hong Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
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Abstract
Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are
leading causes of morbidity and mortality in systemic sclerosis (SSc). As
symptoms are often under-reported in SSc, early screening of ILD and PAH is of
paramount importance, and early treatment may be associated with better clinical
outcomes. Serologies are particularly helpful in identifying patients at risk
for pulmonary involvement. Pulmonary function testing, high-resolution computed
tomography of the chest and echocardiography are important tools in the initial
screening of these patients. Extensive research has also led to an improved
understanding of the mediators involved in the pathogenesis of ILD and PAH. As a
result, there have been significant advances in the development of novel
targeted therapeutics and an increase in the number of early-phase clinical
trials in SSc.
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Affiliation(s)
- Sara R Schoenfeld
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 2C-2100, Boston, MA 02114, USA
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Shoulders BR, Smithburger PL, Tchen S, Buckley M, Lat I, Kane-Gill SL. Characterization of Guideline Evidence for Off-label Medication Use in the Intensive Care Unit. Ann Pharmacother 2017. [PMID: 28622741 DOI: 10.1177/1060028017699635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Non-Food and Drug Administration (FDA) or off-label medication prescribing occurs commonly in the intensive care unit (ICU). Off-label medication use creates a concern for untoward adverse effects; however, this worry may be alleviated by supportive literature. OBJECTIVE To evaluate the evidence behind off-label medication use by determining the presence of guideline support and compare graded recommendations to an online tertiary resource, DRUGDEX. METHODS Off-label medication use was identified prospectively over 3 months in medical ICUs in 3 academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website to determine the presence of guideline support. DRUGDEX was also searched for strength-of-evidence ratings to serve as a comparator. RESULTS A total of 287 off-label medication indication searches resulted in 44% (126/287) without identified evidence; 253 guidelines were identified for 56% (161/287) of indications. Of the published guidelines, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, whereas 33% (47/144) of the gradings matched the online database. CONCLUSION Because more than half of off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines to inform off-label medication use in the ICU. Still, there is a considerable amount of off-label medication use in the ICU that lacks supporting evidence, and use remains concerning because it may lead to inappropriate treatment and adverse events.
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Affiliation(s)
| | - Pamela L Smithburger
- 1 UPMC Presbyterian Shadyside, Pittsburgh, PA, USA.,2 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Stephanie Tchen
- 2 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | - Ishaq Lat
- 4 Rush University Medical Center, Chicago, IL, USA
| | - Sandra L Kane-Gill
- 1 UPMC Presbyterian Shadyside, Pittsburgh, PA, USA.,2 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Abstract
INTRODUCTION Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.
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Affiliation(s)
- Ariane L Herrick
- a Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,b NIHR Manchester Musculoskeletal Biomedical Research Unit , Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
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Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016. [DOI: 10.5301/jsrd.5000228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy. Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs. The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.
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Pellar RE, Pope JE. Evidence-based management of systemic sclerosis: Navigating recommendations and guidelines. Semin Arthritis Rheum 2016; 46:767-774. [PMID: 28088339 DOI: 10.1016/j.semarthrit.2016.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a rare heterogeneous connective tissue disease. Recommendations addressing the major issues in the management of SSc including screening and treatment of organ complications are needed. METHODS The updated European League Against Rheumatism/European Scleroderma Trial and Research (EULAR/EUSTAR) and the British Society of Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guidelines were compared and contrasted. RESULTS The updated EULAR/EUSTAR guidelines focus specifically on the management of SSc features and include data on newer therapeutic modalities and mention a research agenda. These recommendations are pharmacologic, with few guidelines regarding investigations and non-pharmacologic management. Recommendations from BSR/BHPR are similar to the organ manifestations mentioned in the EULAR/EUSTAR recommendations, and expand on several domains of treatment, including general measures, non-pharmacologic treatment, cardiac involvement, calcinosis, and musculoskeletal features. The guidelines usually agree with one another. Limitations include the lack of guidance for combination or second-line therapy, algorithmic suggestions, the absence of evidence-based recommendations regarding the treatment of specific complications (i.e., gastric antral ectasia and erectile dysfunction). Consensus for when to treat interstitial lung disease in SSc is lacking. There are differences between Europe and North American experts due to access and indications for certain therapies. CONCLUSIONS Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc and future updates of these recommendations. Care gaps in SSc have been demonstrated so the EULAR/EUSTAR and BSR/BHP guidelines can promote best practices. Certain complications warrant active investigation to further improve outcomes in SSc.
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Affiliation(s)
| | - Janet Elizabeth Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada; St Joseph Health Care, London, ON, Canada.
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Bruni C, Praino E, Guiducci S, Bellando-Randone S, Furst DE, Matucci-Cerinic M. Hydroxychloroquine and joint involvement in systemic sclerosis: Preliminary beneficial results from a retrospective case-control series of an EUSTAR center. Joint Bone Spine 2016; 84:747-748. [PMID: 27932280 DOI: 10.1016/j.jbspin.2016.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/12/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Cosimo Bruni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy.
| | - Emanuela Praino
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Interdisciplinary Department of Medicine, Division of Rheumatology, University of Bari, Piazzale Giulio Cesare 11, 70124 Bari, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy
| | - Daniel E Furst
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Medicine, Division of Rheumatology, University of California at Los Angeles, 405, Hilgard Eve, 90095 Los Angeles (CA), USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy; Department of Geriatric Medicine, Division of Rheumatology AOUC, University of Florence, Viale Gaetano Pieraccini 18, 50134 Florence, Italy
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Abstract
INTRODUCTION Treatment of systemic sclerosis (SSc) is challenging despite advances in medical therapeutics for other rheumatologic diseases. Significant disease modifying therapy is lacking for most patients with SSc, due to the heterogeneous multisystem nature of SSc and its complex pathophysiology. The emergence of organ based management strategies has provided guidance in patient care as well as research and drug development. Areas covered: Design and development of new compounds focused on the underlying fibrotic disease processes have been sparse. Therefore, organ based strategies with targeted approaches have been directed towards the most devastating and life threatening features of systemic sclerosis. These include pulmonary arterial hypertension, interstitial lung disease, peripheral vasculopathy and skin thickening. In this context, new treatment regimens using older drugs as well as discovery of novel compounds based on recent insights of the disease pathophysiology are discussed. Expert opinion: Systemic sclerosis is a heterogeneous rare disease that carries a high burden of morbidity and mortality. Organ based management strategies have improved the natural history of systemic sclerosis using targeted interventions or strategies, particularly vascular features. However, more research is required to better understand disease mechanisms, including an ultimate unifying pathway that explains the multisystem nature of systemic sclerosis.
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Affiliation(s)
- Jason J Lee
- a Schulich School of Medicine , Western University , London , Ontario , Canada
| | - Janet E Pope
- b Schulich School of Medicine , Western University, St. Joseph's Health Care , London , Ontario , Canada
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Abstract
Systemic sclerosis is a devastating multisystem rheumatologic condition that is characterized by autoimmunity, tissue fibrosis, obliterative vasculopathy and inflammation. Clinical presentation and course of the condition vary greatly, which complicates both diagnosis and corresponding treatment. In this regard, recent advances in disease understanding, both clinically and biochemically, have led to newer classification criteria for systemic sclerosis that are more inclusive than ever before. Still, significant disease modifying therapies do not yet exist for most patients. Therefore, organ-based management strategies are employed and research has been directed within this paradigm focusing on either the most debilitating symptoms, such as Raynaud's phenomenon, digital ulcers and cutaneous sclerosis, or life-threatening organ involvement such as interstitial lung disease and pulmonary arterial hypertension. The current trends in systemic sclerosis diagnosis, evidence-based treatment recommendations and potential future directions in systemic sclerosis treatment are discussed.
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Affiliation(s)
- Jason J Lee
- Division of Rheumatology, Department of Medicine, Schulich School of Medicine, Western University, London, ON, Canada
| | - Janet E Pope
- Division of Rheumatology, Department of Medicine, Schulich School of Medicine, Western University, London, ON, Canada. .,Division of Rheumatology, St. Joseph's Health Care, 268 Grosvenor St., London, ON, N6A 4V2, Canada.
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Abstract
Scleroderma renal crisis (SRC) is a rare, potentially life-threatening complication that affects 2-15% of patients with systemic sclerosis (SSc, also known as scleroderma). SRC typically presents in patients with early, rapidly progressive, diffuse cutaneous SSc within the first 3-5 years after the onset of a non-Raynaud sign or symptom. SRC is characterized by an acute, usually symptomatic increase in blood pressure, a rise in serum creatinine levels, oliguria and thrombotic microangiopathy in about 50% of patients. The prognosis of SRC substantially improved in the 1980s with the introduction of angiotensin-converting-enzyme inhibitors for rapid blood pressure control, with additional antihypertensive agents as required. However, the survival of patients with SRC can still be improved. Current patient survival is 70-82% at 1 year, but decreases to 50-60% at 5 years despite dialysis support. Patients with SRC who show no signs of renal functional recovery despite timely blood pressure control are candidates for transplantation. In this Review, we discuss progress made in the identification and proactive management of patients at risk of SRC and make recommendations aimed at optimizing management for those who progress to chronic kidney failure.
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Maria ATJ, Toupet K, Bony C, Pirot N, Vozenin MC, Petit B, Roger P, Batteux F, Le Quellec A, Jorgensen C, Noël D, Guilpain P. Antifibrotic, Antioxidant, and Immunomodulatory Effects of Mesenchymal Stem Cells in HOCl-Induced Systemic Sclerosis. Arthritis Rheumatol 2016; 68:1013-25. [PMID: 26474311 DOI: 10.1002/art.39477] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 10/13/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is a rare intractable disease with unmet medical need and fibrosis-related mortality. Absence of efficient treatments has prompted the development of novel therapeutic strategies, among which mesenchymal stem cells/stromal cells (MSCs) or progenitor stromal cells appear to be one of the most attractive options. The purpose of this study was to use the murine model of hypochlorite-induced SSc to investigate the systemic effects of MSCs on the main features of the diffuse form of the disease: skin and lung fibrosis, autoimmunity, and oxidative status. METHODS We compared the effects of different doses of MSCs (2.5 × 10(5) , 5 × 10(5) , and 10(6) ) infused at different time points. Skin thickness was assessed during the experiment. At the time of euthanasia, biologic parameters were quantified in blood and tissues (by enzyme-linked immunosorbent assay, quantitative reverse transcription-polymerase chain reaction, assessment of collagen content). Assessments of histology and immunostaining were also performed. RESULTS A lower expression of markers of fibrosis (Col1, Col3, Tgfb1, and aSma) was observed in both skin and lung following MSC infusion, which was consistent with histologic improvement and was inversely proportional to the injected dose. Importantly, sera from treated mice exhibited lower levels of anti-Scl-70 autoantibodies and enhanced antioxidant capacity, confirming the systemic effect of MSCs. Of interest, MSC administration was efficient in both the preventive and the curative approach. We further provide evidence that MSCs exerted an antifibrotic role by normalizing extracellular matrix remodeling parameters as well as reducing proinflammatory cytokine levels and increasing antioxidant defenses. CONCLUSION The results of this study demonstrate the beneficial and systemic effects of MSC administration in the HOCl murine model of diffuse SSc, which is a promising finding from a clinical perspective.
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Affiliation(s)
- Alexandre T J Maria
- INSERM U1183, St. Eloi Hospital, and Montpellier University Medical School, Montpellier, France
| | - Karine Toupet
- INSERM U1183, St. Eloi Hospital, and Montpellier University Medical School, Montpellier, France
| | - Claire Bony
- INSERM U1183, St. Eloi Hospital, and Montpellier University Medical School, Montpellier, France
| | - Nelly Pirot
- INSERM U1194 and UMS BioCampus Montpellier, Montpellier, France
| | | | - Benoît Petit
- University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Pascal Roger
- Montpellier University Medical School, Montpellier, France, and Caremeau Hospital, Nîmes, France
| | | | - Alain Le Quellec
- St. Eloi Hospital and Montpellier University Medical School, Montpellier, France
| | - Christian Jorgensen
- INSERM U1183, St. Eloi Hospital, Montpellier University Medical School, and Lapeyronie Hospital, Montpellier, France
| | - Danièle Noël
- INSERM U1183, St. Eloi Hospital, and Montpellier University Medical School, Montpellier, France
| | - Philippe Guilpain
- INSERM U1183, St. Eloi Hospital, and Montpellier University Medical School, Montpellier, France
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Wang Z, Yin X, Gao L, Feng S, Song K, Li L, Lu Y, Shen H. The protective effect of hydrogen sulfide on systemic sclerosis associated skin and lung fibrosis in mice model. SPRINGERPLUS 2016; 5:1084. [PMID: 27468384 PMCID: PMC4947075 DOI: 10.1186/s40064-016-2774-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/06/2016] [Indexed: 01/25/2023]
Abstract
Backgroud Systemic sclerosis (SSc) caused fibrosis can be fatal and it still lack of effective treatment. Hydrogen sulfide (H2S) appears to be an attractive therapeutic candidates. This study aimed to investigate the protective effect of H2S on SSc-associated skin and lung fibrosis. Methods We developed a model of SSc by subcutaneous injecting BLM to female C3H mice. The mice received daily subcutaneous injections of NaHS (56 and 112 μg/kg), an H2S donor. On days 7, 28, and 42, the mice were killed and blood samples were collected to measure the plasma H2S concentration, the skin and lung tissues was harvested for microscopic examination, immunohistochemistry and quantify biological parameters (hydroxyproline content, RT-qPCR and Western blot). Results In model group, the dermis of skin tissues at different time points gradually thickened, collagen deposition increased. The lung tissues presented pathological changes such as obvious inflammatory cell infiltration, increased collagen deposition and the plasma H2S concentrations points significantly decreased. Administration of NaHS markedly decreased the biomarkers of fibrosis such as α-smooth muscle actin, collagen-I, collagen-III, fibronectin, transforming growth factor-β1, Smad2/3 phosphorylation and inflammation including the marker protein of monocyte/macrophage and monocyte chemoattractant protein-1 in the lung. Compared to the low dose group, the expression in the high dose group have decreased trend, but the difference was not significant. Conclusion We demonstrate the beneficial effects of H2S on SSc-associated skin and lung fibrosis. H2S may be a potential therapy against this intractable disease.
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Affiliation(s)
- Zhi Wang
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Xiaoya Yin
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Luyan Gao
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Sheng Feng
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Kai Song
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Lingyun Li
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Ying Lu
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
| | - Huaying Shen
- Department of Nephrology, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Jinchang, Suzhou, 215000 Jiangsu Province China
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Kafaja S, Clements P. Management of Widespread Skin Thickening in Diffuse Systemic Sclerosis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016; 2:49-60. [PMID: 27330933 DOI: 10.1007/s40674-016-0040-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Skin thickening is one of the early organ manifestations of systemic sclerosis (SSc) and has a great impact on quality of life (QOL) as well as overall daily living in patients with SSc. The dynamic changes that occur as the disease progresses and as other organs become further involved present the treating physician with therapeutic challenges. Hence, when considering drug therapy for skin disease, the treating physician should consider a number of factors including disease duration, the rate of skin thickening, the extent of disease progression, organ involvements, and patient-related outcome measures, all of which impact the type of treatments considered. For early diffuse skin disease, we prefer the use of methotrexate (MTX). And when there is evidence of lung involvement or tendon friction rubs (given its association with ILD development), we tend to shift to the use of mycophenolate or cyclophosphamide because these agents have been shown efficacious for the specific indication of lung disease in SSc. We have managed joint disease, on the other hand when present, with MTX or other DMARDs, as well as the use of biologics when there is evidence of inflammatory polyarthritis or rheumatoid arthritis overlap. While the treatment of myositis in the setting of SSc can present a therapeutic dilemma, reluctantly, we may use steroids along with MTX, mycophenolate, intravenous immunoglobulin (IV-Ig), or rituximab. Ongoing clinical trials investigating the use of tocilizumab, abatacept, and other agents offer promising potential therapies. Great strides have been made in treating skin disease in SSc. And with recent trials focusing on early SSc disease, this will allow for a greater insight into the mechanisms underlying SSc especially as it relates to skin, and the expansion of future treatment options in this field.
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Affiliation(s)
- Suzanne Kafaja
- David Geffen School of Medicine at UCLA, Division of Rheumatology, 1000 Veteran Ave, Rm 32-59, Los Angeles, CA, USA
| | - Philip Clements
- David Geffen School of Medicine at UCLA, Division of Rheumatology, 1000 Veteran Ave, Rm 32-59, Los Angeles, CA, USA
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Foocharoen C, Chunlertrith K, Mairiang P, Mahakkanukrauh A, Suwannaroj S, Namvijit S, Wantha O, Nanagara R. Effectiveness of add-on therapy with domperidone vs alginic acid in proton pump inhibitor partial response gastro-oesophageal reflux disease in systemic sclerosis: randomized placebo-controlled trial. Rheumatology (Oxford) 2016; 56:214-222. [PMID: 27179107 DOI: 10.1093/rheumatology/kew216] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/07/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Twice-daily dosing of proton pump inhibitor (PPI), the standard therapy for gastro-oesophageal reflux disease (GERD), is an effective therapy for GERD in SSc. The aim of this study was to compare the efficacy of omeprazole in combination with domperidone vs in combination with algycon in reducing the severity and frequency of reflux symptoms of PPI partial response (PPI-PR) GERD in SSc. METHODS Adult SSc patients having PPI-PR GERD were randomly assigned to receive domperidone plus algycon placebo or algycon plus domperidone placebo in a 1:1 ratio plus omeprazole for 4 weeks. The assessment included severity of symptom grading by visual analogue scale, frequency of symptoms by frequency scale for symptoms of GERD and quality of life (QoL) by EuroQol five-dimensions questionnaire scoring. RESULTS One hundred and forty-eight SSc-GERD patients were enrolled, of whom 88 had PPI-PR. Eighty cases were randomized for either domperidone (n = 38) or algycon (n = 37) therapy. The majority in both groups had the diffuse SSc subset. At the end of the study, no significant difference in symptom grading was found between groups. After treatment and compared with baseline, the severity of symptoms, frequency scale for symptoms of GERD and QoL significantly improved in both groups. Five (13.2%) and 8 (21.6%) respective cases in the domperidone and algycon groups did not respond. CONCLUSION The prevalence of PPI-PR GERD is common. Domperidone and algycon are equally effective treatments in combination with omeprazole. However, ∼17% of patients were non-responsive, so the effectiveness of domperidone, algycon and PPI combination therapy should be further investigated. TRIAL REGISTRATION https://clinicaltrials.gov (NCT01878526).
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Affiliation(s)
- Chingching Foocharoen
- Division of Allergy-Immunology-Rheumatology, Department of Medicine, Faculty of Medicine
| | | | | | - Ajanee Mahakkanukrauh
- Division of Allergy-Immunology-Rheumatology, Department of Medicine, Faculty of Medicine
| | - Siraphop Suwannaroj
- Division of Allergy-Immunology-Rheumatology, Department of Medicine, Faculty of Medicine
| | | | - Orathai Wantha
- Division of Nursing, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ratanavadee Nanagara
- Division of Allergy-Immunology-Rheumatology, Department of Medicine, Faculty of Medicine
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