1
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Leavis HL, van Daele PLA, Mulders-Manders C, Michels R, Rutgers A, Legger E, Bijl M, Hak EA, Lam-Tse WK, Bonte-Mineur F, Fretter P, Simon A, van Paassen P, van der Goes MC, Flendrie M, Vercoutere W, van Lieshout AWT, Leek A, Vastert SJ, Tas SW. Management of adult-onset Still's disease: evidence- and consensus-based recommendations by experts. Rheumatology (Oxford) 2024; 63:1656-1663. [PMID: 37669122 PMCID: PMC11147545 DOI: 10.1093/rheumatology/kead461] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES Adult-onset Still's disease (AOSD) is a rare condition characterized by fevers, rash, and arthralgia/arthritis; most doctors treating AOSD in the Netherlands treat <5 patients per year. Currently, there is no internationally accepted treatment guideline for AOSD. The objectives of this study were to conduct a Delphi panel aimed at reaching consensus about diagnostic and treatment strategies for patients with AOSD and to use the outcomes as a basis for a treatment algorithm. METHODS The Delphi panel brought together 18 AOSD experts: rheumatologists, internists and paediatricians. The Delphi process consisted of three rounds. In the first two rounds, online lists of questions and statements were completed. In the third round, final statements were discussed during a virtual meeting and a final vote took place. Consensus threshold was set at 80%. Two targeted literature searches were performed identifying the level of evidence of the consensus-based statements. RESULTS Consensus was reached on 29 statements, including statements related to diagnosis and diagnostic tests, definition of response and remission, the therapy, the use of methotrexate and tapering of treatment. The panel consented on reduction of the use of glucocorticoids to avoid side effects, and preferred the use of biologics over conventional treatment. The role of IL-1 and IL-6 blocking agents was considered important in the treatment of AOSD. CONCLUSION In this Delphi panel, a high level of consensus was achieved on recommendations for diagnosis and therapy of AOSD that can serve as a basis for a treatment guideline.
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Affiliation(s)
- Helen L Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul L A van Daele
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Elizabeth Legger
- Department of Pediatric Rheumatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc Bijl
- Department of Rheumatology and Clinical Immunology, Martini Hospital, Groningen, The Netherlands
| | - Elisabeth A Hak
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Wai-Kwan Lam-Tse
- Department Rheumatology, Franciscus Hospital, Rotterdam, The Netherlands
| | - Femke Bonte-Mineur
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Peter Fretter
- Department of Rheumatology, Treant Hospitals, Emmen/Hoogeveen/Stadskanaal, The Netherlands
| | - Anna Simon
- Department of Internal medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Marcel Flendrie
- Department of Rheumatology, Maartenskliniek, Nijmegen, The Netherlands
| | - Ward Vercoutere
- Department of Rheumatology, Reumazorg Zuid-West Nederland, Goes-Terneuzen-Oostburg, The Netherlands
| | | | - Arjen Leek
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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2
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Ruscitti P, McGonagle D, Garcia VC, Rabijns H, Toennessen K, Chappell M, Edwards M, Miller P, Hansell N, Moss J, Graziadio S, Feist E. Systematic Review and Metaanalysis of Pharmacological Interventions in Adult-Onset Still Disease and the Role of Biologic Disease-Modifying Antirheumatic Drugs. J Rheumatol 2024; 51:442-451. [PMID: 38302170 DOI: 10.3899/jrheum.2023-0995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To conduct a systematic review of the effectiveness and safety of pharmacological treatments for adult-onset Still disease (AOSD). METHODS Six databases, 2 trial registries, and conference abstracts were searched from January 2012 to February 2023 for studies of pharmacological interventions in people with AOSD. Outcomes were rates of remission and response, discontinuation of concurrent treatments, complications of AOSD, and treatment-related adverse events. Risk of bias was assessed with the Cochrane risk of bias tool and the Joanna Briggs Institute tool for case series. RESULTS Forty-four studies evaluated treatments, including nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids (CS), conventional synthetic disease-modifying antirheumatic drugs (DMARDs), and biologic DMARDs (bDMARDs). For bDMARDs, tocilizumab (TCZ), anakinra (ANK), and canakinumab (CNK) had the most available data. Although 3 randomized controlled trials did not show statistically significant benefits of bDMARDs, metaanalyses showed high rates of complete remission and CS discontinuation. Complete remission was 80% (95% CI 59-92%, I 2 36%), 73% (95% CI 58-84%, I 2 66%), and 77% (95% CI 29-97%, I 2 82%) and CS discontinuation was 57% (95% CI 29-81%, I 2 66%), 47% (95% CI 18-78%, I 2 79%), and 34% (95% CI 6-81%, I 2 59%), respectively, for TCZ, ANK, and CNK. Studies with a higher proportion of patients previously treated with bDMARDs showed a trend toward lower rates of CS discontinuation (P = 0.05). The analyses had high clinical heterogeneity, largely because treatments were prescribed as different lines of therapy. CONCLUSION Evidence supports TCZ, ANK, and CNK therapy for AOSD. However, the magnitude of effect and comparative effectiveness of treatments is uncertain.
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Affiliation(s)
- Piero Ruscitti
- P. Ruscitti, MD, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy;
| | - Dennis McGonagle
- D. McGonagle, PhD, Leeds NIHR Biomedical Centre and School of Medicine, University of Leeds, Leeds, UK
| | - Viviam Canon Garcia
- V.C. Garcia, MD, H. Rabijns, MPharm, K. Toennessen, MSc, Novartis Pharma AG, Basel, Switzerland
| | - Hilde Rabijns
- V.C. Garcia, MD, H. Rabijns, MPharm, K. Toennessen, MSc, Novartis Pharma AG, Basel, Switzerland
| | - Katrin Toennessen
- V.C. Garcia, MD, H. Rabijns, MPharm, K. Toennessen, MSc, Novartis Pharma AG, Basel, Switzerland
| | - Mary Chappell
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Mary Edwards
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Paul Miller
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Neil Hansell
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Joe Moss
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Sara Graziadio
- M. Chappell, PhD, M. Edwards, MA, P. Miller, MSc, N. Hansell, BSc, J. Moss, PhD, S. Graziadio, PhD, York Health Economics Consortium (YHEC), University of York, York, UK
| | - Eugen Feist
- E. Feist, MD, Helios Clinic for Rheumatology and Clinical Immunology, Gommern, Germany
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3
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Fujisawa Y, Horita S, Wakabayashi K. A Case of Macrophage Activation Syndrome With Elderly Onset Still's Disease Under Tocilizumab Treatment. Cureus 2024; 16:e59285. [PMID: 38813312 PMCID: PMC11135383 DOI: 10.7759/cureus.59285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Adult-onset Still's disease in older adults is referred to as elderly onset Still's disease (EOSD). Few cases of tocilizumab (TCZ) use for EOSD management have been reported. Here, we report the case of an 87-year-old Japanese woman with EOSD who was not previously taking any medication. She had fatigue, sore throat, and loss of appetite for several days and gradually experienced difficulty walking. On examination, she was found to have a fever and erythema on the buttocks and extremities. Laboratory tests revealed leukocytosis with neutrophil predominance, elevated C-reactive protein (CRP) levels, and hyperferritinemia. A contrast-enhanced computed tomography scan of the chest to the abdomen showed no abnormalities. Antimicrobial therapy was initiated; however, the fever did not resolve. On day seven, 40 mg/day prednisolone (PDN) was started for EOSD in the absence of an obvious infection or a malignancy. On day 20, the fever recurred, and the patient was started on intravenous methylprednisolone (mPDN) half-pulse therapy (500 mg/day for three days). The fever resolved, and the CRP level decreased to 1 mg/dL but did not return to normal. On day 35, the fever recurred; therefore, 320 mg of TCZ was injected intravenously, and the PDN was tapered. On day 43, the patient tested positive for cytomegalovirus (CMV) antigenemia and improved on ganciclovir. On day 70, the patient developed fever, decreased white blood cell (WBC) and hemoglobin (Hb) levels, high lactate dehydrogenase (LDH) levels, hyperferritinemia, and elevated liver enzymes. Macrophage activation syndrome (MAS) was diagnosed due to hemophagocytosis on bone marrow examination. The patient was started on pulse therapy with glucocorticosteroids and cyclosporine. The patient's fever decreased, and her WBC count and LDH level normalized. The patient continued rehabilitation for muscle weakness due to prolonged hospitalization and high-dose steroid use and was discharged from the hospital on day 150. The findings in this case suggest that the use of TCZ during the remission induction phase of EOSD may lead to MAS.
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Affiliation(s)
- Yuhei Fujisawa
- Internal Medicine, Saiseikai Kanazawa Hospital, Kanazawa, JPN
| | - Shigeto Horita
- Internal Medicine, Saiseikai Kanazawa Hospital, Kanazawa, JPN
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Adachi S, Takase-Minegishi K, Maeda A, Nagai H, Horita N, Yoshimi R, Kirino Y, Nakajima H. Risk of Macrophage Activation Syndrome in Patients with Adult-Onset Still's Disease Treated with IL-1 and IL-6 Inhibitors: A Meta-analysis and Single-Center Experience. Rheumatol Ther 2023; 10:1623-1636. [PMID: 37794210 PMCID: PMC10654298 DOI: 10.1007/s40744-023-00600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/12/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Patients with adult-onset Still's disease (AOSD) are at risk of developing macrophage activation syndrome (MAS), a life-threatening condition. Some cases of MAS have been reported following the use of biological agents, highlighting the need to identify contributing factors. This study aims to examine the characteristics of MAS in patients with AOSD treated with anakinra (ANA) or tocilizumab (TCZ). METHODS A systematic search was conducted across four online databases to identify studies reporting the incidence rates of MAS in patients with AOSD treated with ANA or TCZ. Meta-analysis was performed using a random-effects model and the generic inverse variance method to estimate the pooled incidence rates. The difference in incidence rates of MAS between TCZ and ANA was assessed. Additionally, we analyzed laboratory data and clinical features of AOSD cases at our institution, stratifying them into two groups: those who developed MAS after TCZ administration and those who did not. RESULTS Of the 455 screened articles, we included five ANA and six TCZ studies. The pooled incidence rates of MAS were 1.50% (95% confidence interval [CI], 0-3.36) for ANA (345 patients) and 14.01% (95% CI 4.51-23.51) for TCZ (94 patients). MAS incidence was significantly higher in the TCZ group (P = 0.01). Among the 17 patients from our institution, the six patients who developed MAS had significantly higher white blood cell and neutrophil counts, as well as elevated levels of lactate dehydrogenase, C-reactive protein, and ferritin before TCZ induction (P < 0.05). CONCLUSIONS In patients with AOSD, the manifestation of MAS is influenced by multiple causative factors. Consequently, the administration of TCZ should be approached with caution, particularly in patients exhibiting elevated inflammatory markers. TRIAL REGISTRATION This study was registered with the Clinical Trial Registry of the University Hospital Medical Information Network (Japan) as UMIN000049243.
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Affiliation(s)
- Soichiro Adachi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan.
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Hideto Nagai
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Kaneko Y, Kameda H, Ikeda K, Yamashita K, Ozaki R, Tanaka Y. Treatment pattern and changes in oral glucocorticoid dose after tocilizumab treatment in patients with adult Still's disease: An analysis of a Japanese claims database. Int J Rheum Dis 2023; 26:1967-1978. [PMID: 37545194 DOI: 10.1111/1756-185x.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 08/08/2023]
Abstract
AIM Intravenous tocilizumab (TCZ-IV) was approved for the treatment of adult Still's disease (ASD) in Japan in May 2019 based on its efficacy and safety in a phase III randomized controlled trial. This study determined treatment patterns in patients with ASD and assessed oral glucocorticoid (GC) dose changes after TCZ-IV administration in Japanese clinical practice. METHODS Patients in the Medical Data Vision database aged 16 years or older with one or more of International Classification of Diseases, 10th revision codes M061 (ASD) or M082 (systemic juvenile idiopathic arthritis) during January 2017-March 2021 (cohort 1) and those initiating TCZ-IV during May 2019-March 2021 (cohort 2) were included. RESULTS In cohort 1, the proportion of patients who were prescribed interleukin-6 inhibitors (mainly TCZ-IV) increased from 10.8% (January-April 2019 [before TCZ-IV approval]; n = 2002) to 18.3% (January-March 2021 [after TCZ-IV approval]; n = 2008). In cohort 2 (n = 193), 84.5% of patients were on oral GCs (≤5 mg/day: 23.8%) at index date (initial TCZ-IV prescription date); 46/70 (65.7%) were on oral GC at 5 mg/day or higher 12 months after TCZ-IV treatment (primary outcome). After 12 months of treatment, the TCZ-IV retention rate was 73.6% and the TCZ-IV administration interval was every 4 weeks and every 2 weeks in 31.9% and 27.7% of patients, respectively. CONCLUSION The use of interleukin-6 inhibitors increased by 7.5% points in Japanese patients with ASD ~2 years after TCZ-IV approval, suggesting that an unmet medical need existed. This study suggests the potential GC-sparing effect of TCZ-IV in patients with ASD in clinical practice.
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Affiliation(s)
- Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, Dokkyo Medical University, Tochigi, Japan
| | | | - Ryoto Ozaki
- Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Sun Z, Li R, Wang Y, Han F, Wei W, Li X. Efficacy of Baricitinib in Patients with Refractory Adult-Onset Still's Disease. Drugs R D 2023:10.1007/s40268-023-00417-7. [PMID: 37010773 DOI: 10.1007/s40268-023-00417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Adult-onset Still's disease (AOSD) is an idiopathic systemic inflammatory disease of unknown aetiology. Some patients exhibit resistance to conventional treatment during long-term therapy. Janus kinase inhibitors (JAKinibs) may contribute to the improvement in AOSD symptoms via the JAK-signal transducer and activator of transcription (STAT) pathway. We aimed to explore the efficacy and safety of baricitinib in patients with refractory AOSD. METHODS Patients were enrolled if they fulfilled the Yamaguchi AOSD classification criteria in China between 2020 and 2022. All patients were recognized as having refractory AOSD and were treated with oral baricitinib at a dosage of 4 mg once daily. A systemic score and prednisone dosage were used to evaluate the efficacy of baricitinib at months 1, 3, and 6 and at the last follow-up visit. The safety profiles were recorded and analysed at every assessment. RESULTS Seven female patients with refractory AOSD received baricitinib. The median age was 31 (IQR 10) years. Treatment was terminated in one patient due to progressive macrophage activation syndrome (MAS). Others continued baricitinib treatment until the last assessment. The systemic score decreased significantly at 3 months (p = 0.0216), 6 months (p = 0.0007), and the last follow-up visit (p = 0.0007) compared with baseline. One month after the initiation of baricitinib, the rates of improvement in fever, rash, sore throat, and myalgia symptoms were 71.4% (5/7), 40% (2/5), 80% (4/5), and 66.7% (2/3), respectively. Five patients remained symptom-free at the last follow-up visit. In most patients, their laboratory values had returned to normal by the last follow-up visit. A significant reduction in the levels of C-reactive protein (CRP) (p = 0.0165) and ferritin (p = 0.0047) was observed at the last visit compared with baseline. The daily prednisolone dosage significantly decreased from 35.7 ± 15.1 mg/day at baseline to 8.8 ± 4.4 mg/day by month 6 (p = 0.0256), and it was 5.8 ± 4.7 mg/day at the last assessment (p = 0.0030). Leukopenia due to MAS was noted in one patient. Except for mild abnormalities in lipid parameters, no other severe adverse events occurred during follow-up. CONCLUSIONS Our findings suggest that baricitinib therapy could provide rapid and durable clinical and laboratory improvement in patients with refractory AOSD. Treatment seemed to be well tolerated by these patients. The long-term efficacy and safety of baricitinib therapy for AOSD should be assessed further in prospective controlled clinical trials in the future. TRIAL REGISTRATION Trial registration number (TRN): ChiCTR2200061599. Date of registration: 29 June 2022 (retrospectively registered).
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Affiliation(s)
- Ziyi Sun
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Rongqi Li
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Yingai Wang
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Feng Han
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Xin Li
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China.
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7
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Vordenbäumen S, Feist E, Rech J, Fleck M, Blank N, Haas JP, Kötter I, Krusche M, Chehab G, Hoyer B, Kiltz U, Fell D, Reiners J, Weseloh C, Schneider M, Braun J. Diagnosis and treatment of adult-onset Still's disease: a concise summary of the German society of rheumatology S2 guideline. Z Rheumatol 2023; 82:81-92. [PMID: 36520170 DOI: 10.1007/s00393-022-01294-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Stefan Vordenbäumen
- Rheinisches Rheuma-Zentrum St. Elisabeth-Hospital Meerbusch, Meerbusch-Lank, Germany. .,Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.
| | - Eugen Feist
- Rheumazentrum Sachsen-Anhalt, Helios Fachklinik Vogelsang-Gommern, Kooperationspartner der Otto-von-Guericke Universität Magdeburg, Vogelsang-Gommern, Germany
| | - Jürgen Rech
- Medizinische Klinik 3-Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, 91054, Erlangen, Germany
| | - Martin Fleck
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg, Germany.,Klinik für Rheumatologie/Klinische Immunologie, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Norbert Blank
- Medizinische Klinik 5, Sektion Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Johannes-Peter Haas
- Kinderklinik Garmisch-Partenkirchen gGmbH, Deutsches Zentrum für Kinder- und Jugendrheumatologie, Garmisch-Partenkirchen, Germany
| | - Ina Kötter
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gamal Chehab
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Bimba Hoyer
- Medizinische Fakultät, Sektion Rheumatologie und klinische Immunologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Uta Kiltz
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
| | - Dorothea Fell
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | - Julia Reiners
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | | | - Matthias Schneider
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.,Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany
| | - Jürgen Braun
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
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8
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Matsushita S, Sada K, Manabe A, Kashihara E, Tagawa S, Akebo H, Miyake H, Minoda Sada R, Hatta K. Elevated White Blood Cell Count and Lactate Dehydrogenase Levels Are Important Markers for Diagnosing Relapse of Adult-onset Still's Disease under Tocilizumab Use. Intern Med 2022; 61:3743-3747. [PMID: 35527029 PMCID: PMC9841101 DOI: 10.2169/internalmedicine.9487-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We encountered a case of refractory adult-onset Still's disease (AOSD) with two relapses. Prednisolone and methotrexate were begun as induction therapy, resulting in the patient's first relapse during tapering of prednisolone. After the introduction of tocilizumab, she achieved remission. However, she experienced a second relapse following prednisolone tapering. While lactate dehydrogenase (LDH) levels and white blood cell (WBC) counts increased in both relapses, interleukin-6 (IL-6) suppression resulted in stable C-reactive protein and ferritin levels in the second relapse. A comparison of the two relapses indicated that increases in both WBC counts and LDH levels can aid in the diagnosis of AOSD relapse.
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Affiliation(s)
- Sho Matsushita
- Department of General Internal Medicine, Tenri Hospital, Japan
| | - Kenei Sada
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Japan
| | - Atsushi Manabe
- Department of General Internal Medicine, Tenri Hospital, Japan
| | - Eriko Kashihara
- Department of General Internal Medicine, Tenri Hospital, Japan
| | - Shunsuke Tagawa
- Department of General Internal Medicine, Tenri Hospital, Japan
| | - Hiroyuki Akebo
- Department of General Internal Medicine, Tenri Hospital, Japan
| | - Hirofumi Miyake
- Department of General Internal Medicine, Tenri Hospital, Japan
| | | | - Kazuhiro Hatta
- Department of General Internal Medicine, Tenri Hospital, Japan
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10
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Macovei LA, Burlui A, Bratoiu I, Rezus C, Cardoneanu A, Richter P, Szalontay A, Rezus E. Adult-Onset Still's Disease-A Complex Disease, a Challenging Treatment. Int J Mol Sci 2022; 23:12810. [PMID: 36361602 PMCID: PMC9655522 DOI: 10.3390/ijms232112810] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 12/02/2022] Open
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder with an unknown cause characterized by high-spiking fever, lymphadenopathy, hepatosplenomegaly, hyperferritinemia, and leukocytosis. The clinical course can be divided into three significant patterns, each with a different prognosis: Self-limited or monophasic, intermittent or polycyclic systemic, and chronic articular. Two criteria sets have been validated. The Yamaguchi criteria are the most generally used, although the Fautrel criteria offer the benefit of adding ferritin and glycosylated ferritin values. AOSD's pathogenesis is not yet completely understood. Chemokines and pro-inflammatory cytokines, including interferon (IFN)-γ, tumor necrosis factor α (TNFα), interleukin (IL)-1, IL-6, IL-8, and IL-18, play a crucial role in the progression of illness, resulting in the development of innovative targeted therapeutics. There are no treatment guidelines for AOSD due to its rarity, absence of controlled research, and lack of a standard definition for remission and therapy objectives. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids (CS), and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are used in AOSD treatment. Biological therapy, including IL-1, IL-6, IL-18, and IL-17 inhibitors, as well as TNFα or Janus-kinases (JAKs) inhibitors, is administered to patients who do not react to CS and csDMARDs or achieve an inadequate response.
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Affiliation(s)
- Luana Andreea Macovei
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Alexandra Burlui
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Anca Cardoneanu
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Andreea Szalontay
- Department of Psychiatry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Psychiatry “Socola”, 700282 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
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11
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Yamabe T, Ohmura SI, Uehara K, Naniwa T. Macrophage activation syndrome in patients with adult-onset Still's disease under tocilizumab treatment: A single-center observational study. Mod Rheumatol 2022; 32:169-176. [PMID: 33719871 DOI: 10.1080/14397595.2021.1899565] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Macrophage activation syndrome (MAS) developed under tocilizumab treatment poses a diagnostic challenge. This study aims to demonstrate the frequency and the clinical features of MAS developed in patients with adult-onset Still's disease (AOSD) receiving tocilizumab. METHODS The consecutive AOSD patients treated with tocilizumab in our institution from April 2008 to March 2020 were studied. The frequency of clinically diagnosed MAS during tocilizumab treatment, their conformity to the several criteria relevant for MAS, and laboratory characteristics compared to AOSD flare were investigated. RESULTS Of the 20 AOSD patients treated with tocilizumab, six developed clinically diagnosed MAS, four immediately after starting tocilizumab and two after long-term treatment. Some of them had already met the MAS criteria before starting tocilizumab. At MAS diagnosis, although some did not meet the MAS criteria due to lack of fever and/or the lower ferritin levels, all consistently showed sharp increases in ferritin along with marked abnormal changes in two or more different markers of organ damage, unlike the AOSD flares. CONCLUSION MAS is not a rare complication in AOSD patients receiving tocilizumab. The clinical similarities between systemic AOSD and MAS, and substantial alterations in MAS features by inhibition of interleukin-6 signaling may limit the utility of the existing diagnostic/classification criteria in diagnosing MAS under tocilizumab treatment. The emergence of abnormalities in MAS-related organ damage markers with a rapid elevation of ferritin should be considered as MAS development in AOSD patients receiving tocilizumab even if the patients are afebrile or have relatively low ferritin levels.
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Affiliation(s)
- Toru Yamabe
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shin-Ichiro Ohmura
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Koji Uehara
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Taio Naniwa
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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12
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Li R, Liu X, Chen G, Tang G, Chen X, Liu X, Wang J, Lu L. Clinical phenotypes and prognostic factors of adult-onset Still's disease: data from a large inpatient cohort. Arthritis Res Ther 2021; 23:300. [PMID: 34879864 PMCID: PMC8653615 DOI: 10.1186/s13075-021-02688-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives To define different clinical phenotypes and assess prognostic factors of adult-onset Still’s disease (AOSD). Methods Overall, 492 patients with AOSD seen between 2004 and 2018 at a single centre were retrospectively studied. Results Of these patients, 78% were female, and the median age at onset was 34 (25–49) years [median (25th–75th percentile)]. The median follow-up time was 7 (3–10) years [median (25th–75th percentile)]. Clinical manifestations at admission were used to subdivide patients with AOSD as follows: systemic inflammation (cluster 1), pure (cluster 2), and intermediate (cluster 3). Each subtype had distinct clinical manifestations and prognoses: cluster 1 (34.6%)—multiple organ manifestations, highest infection rate and mortality, and more than half of the patients with at least one relapse during follow-up; cluster 2 (21.3%)—exclusively female, rash and joint involvement, no internal organ involvement, no mortality, and most of the patients with a monocyclic course; and cluster 3 (44.1%)—less infection rate, no serious complications, and lower mortality rate. The 5- and 10-year survival rates after diagnosis were 92.4% and 86.9%, respectively. Independent risk factors for mortality were age at onset ≥50 (hazard ratio (HR): 6.78, 95% CI: 2.10–21.89), hepatomegaly (HR: 5.05, 95% CI: 1.44–17.70), infection (HR: 15.56, 95% CI: 5.88–41.20), and MAS (HR: 26.82, 95% CI: 7.52–95.60). Conclusion Three subtypes of AOSD were identified with distinct clinical manifestations and prognoses. Age at onset ≥50, hepatomegaly, infection, and MAS were prognostic factors for AOSD mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02688-4.
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Affiliation(s)
- Rui Li
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Xiaolei Liu
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Guangliang Chen
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, 200032, China
| | - Guo Tang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Xiaoxiang Chen
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Xuesong Liu
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Juan Wang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
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13
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Tang KT, Hsieh CW, Chen HH, Chen YM, Chang SH, Huang PH, Lan JL, Chen DY. The effectiveness of tocilizumab in treating refractory adult-onset Still's disease with dichotomous phenotypes: IL-18 is a potential predictor of therapeutic response. Clin Rheumatol 2021; 41:557-566. [PMID: 34535869 DOI: 10.1007/s10067-021-05921-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/19/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder with clinical heterogeneity. Although tocilizumab (TCZ), an interleukin (IL)-6 receptor inhibitor, is an effective treatment for AOSD, the evidence regarding its efficacy on systemic or articular subtypes is conflicting. Furthermore, the predictors of therapeutic response are still elusive and worthy of exploration. METHODS This two-center retrospective study analyzed the effectiveness and safety profile of TCZ treatment in 28 patients with refractory AOSD. The 28-joint disease activity score (DAS28) and systemic activity score were assessed before and during TCZ treatment period at weeks 12, 24, 36, and 48. Plasma levels of proinflammatory cytokines at baseline were determined using ELISA method. RESULTS Among the systemic subtype patients, 10 (58.8%), 13 (76.5%), 14 (82.4%), and 15 (88.2%) patients achieved complete remission at week 12, 24, 36, and 48, respectively, in comparison to 2 (22.2%), 5 (55.6%), 6 (66.7%), and 7 (77.8%) who achieved disease remission (DAS28 < 2.6) at weeks 12, 24, 36, and 48, respectively, among articular subtype patients. The systemic activity scores and inflammatory parameters were significantly decreased after 12-week TCZ therapy, and TCZ could significantly reduce corticosteroid dose in AOSD patients. Multivariate analysis reveals that baseline IL-18 level is a significant predictor of poor therapeutic response at week 24 (odds ratio 7.86, p < 0.05). CONCLUSION AOSD patients refractory to high-dose corticosteroids and methotrexate may respond well to TCZ treatment with a steroid-sparing effect and an acceptable safety. A high baseline IL-18 level may be a predictor of poor therapeutic response. Key Points • Tocilizumab may be effective and well-tolerated in refractory AOSD patients regardless of disease subtypes. • High plasma levels of IL-18 may predict poor response to tocilizumab in AOSD patients.
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Affiliation(s)
- Kuo-Tung Tang
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chia-Wei Hsieh
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsin-Hua Chen
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Faculty of Medicine, National Yang Ming University, Taipei, Taiwan.,Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Yi-Ming Chen
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, National Yang Ming University, Taipei, Taiwan.,Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Hsin Chang
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Rheumatology and Immunology Center, China Medical University Hospital, No. 2, Yude Road, Taichung, 40447, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Po-Hao Huang
- Rheumatology and Immunology Center, China Medical University Hospital, No. 2, Yude Road, Taichung, 40447, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Joung-Liang Lan
- Rheumatology and Immunology Center, China Medical University Hospital, No. 2, Yude Road, Taichung, 40447, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Der-Yuan Chen
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan. .,Rheumatology and Immunology Center, China Medical University Hospital, No. 2, Yude Road, Taichung, 40447, Taiwan. .,College of Medicine, China Medical University, Taichung, Taiwan. .,Translational Medicine Laboratory, Rheumatology and Immunology Center, Taichung, Taiwan.
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Ma Y, Meng J, Jia J, Wang M, Teng J, Zhu D, Yang C, Hu Q. Current and emerging biological therapy in adult-onset Still's disease. Rheumatology (Oxford) 2021; 60:3986-4000. [PMID: 34117886 PMCID: PMC8410009 DOI: 10.1093/rheumatology/keab485] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/31/2021] [Indexed: 12/27/2022] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare, but characteristic non-familial, multi-genic systemic auto-inflammatory disorder, characterized by high spiking fever, salmon-like evanescent skin rash, polyarthritis, sore throat, hyperferritinemia and leucocytosis. The hallmark of AOSD is a cytokine storm triggered by dysregulation of inflammation. Nowadays, with advances in anti-cytokine biologic agents, the treatment of AOSD is no longer limited to NSAIDs, glucocorticoids or conventional synthetic DMARDs. In this review, we focussed on the roles of these cytokines in the pathogenesis of AOSD and summarized the current and emerging biological therapy.
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Affiliation(s)
- Yuning Ma
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Jianfen Meng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai.,Department of Rheumatology and Immunology, The Fourth Affiliated Hospital of Nantong University, The First People's Hospital of Yancheng, Yancheng, China
| | - Jinchao Jia
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Dehao Zhu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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15
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Kaneko Y, Takeuchi T. Interleukin-6 inhibition: a therapeutic strategy for the management of adult-onset Still's disease. Expert Opin Biol Ther 2021; 22:79-85. [PMID: 34126828 DOI: 10.1080/14712598.2021.1942832] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction:Patients with adult-onset Still's disease have markedly elevated serum levels of proinflammatory cytokines, such as IL-1β, IL-6, and IL-18, suggesting the potential of these molecules as therapeutic targets. IL-6 accelerates macrophage and cytotoxic T-cell differentiation and neutrophil and macrophage chemotaxis and is one of the most important cytokines in the pathogenesis of adult-onset Still's disease.Areas covered:The review summarizes the importance of IL-6 in the pathogenesis of adult-onset Still's disease and clinical aspects of IL-6 inhibition from retrospective and prospective studies.Expert opinion:Adult-onset Still's disease is a systemic inflammatory disease of unknown etiology and characterized by elevated various proinflammatory cytokines. In particular, serum concentrations of IL-6 is significantly high in patients with active adult-onset Still's disease, and many case reports, cohort studies and one randomized, placebo-controlled trail have shown the efficacy of IL-6 blockade in patients with adult-onset Still's disease who were refractory to glucocorticoids and other immunosuppressive treatments. IL-6 inhibition is effective for both systemic and joint manifestations with arthritis improving slowly. There is still a concern over the triggering of macrophage activation syndrome; however, the IL-6 inhibition strategy has introduced better management of adult-onset Still's disease.
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Affiliation(s)
- Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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16
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Kır S, Özgen M, Zontul S. Adult-onset still's disease and treatment results with tocilizumab. Int J Clin Pract 2021; 75:e13936. [PMID: 33332679 DOI: 10.1111/ijcp.13936] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022] Open
Abstract
AIMS Adult-onset Still's disease (AOSD) is a rare and non-familial auto-inflammatory disorder. Increased levels of IL-6 and other pro-inflammatory cytokines have been shown in AOSD. To evaluate the efficacy and safety profile of tocilizumab (TCZ), an IL-6 receptor antagonist monoclonal antibody, in AOSD. METHODS Thirty-nine patients followed up with the diagnosis of AOSD between 2013 and 2019 were retrospectively evaluated and the 16 patients (10 Female/6 Male) treated with TCZ for refractory AOSD were included in the study group. Among the remaining 23 patients 16 had non-biological treatments and had no important complications at the presentation. TCZ was given to patients at a dose of 4-8 mg/kg every 4 weeks. Patients were evaluated after 3-6 months of TCZ treatment for side effects, inflammatory and clinical response and concomitant treatments. RESULTS In TCZ (+) patients, the majority were female (62.5%), the mean age at disease onset was 38.5 ± 17.9 (20-81) years, and the most common symptoms and signs were myalgia (81.3%), fever (81.3%) and skin eruptions (75%). There was no difference between TCZ (+) and TCZ (-) groups for age, sex and clinical presentations. There was a significant decrease in dose of prednisolone, sedimentation rate, leucocyte count, C-reactive protein and ferritin levels and improvement in all clinical complaints after TCZ treatment. There were no relapses during the treatment. Three patients are in remission and under follow-up without any treatment after cessation of TCZ (4 months-3 years). No exacerbation of disease yet seen in those patients. CONCLUSIONS TCZ is an effective and well-tolerated treatment option for treatment resistant AOSD and contributes to the glucocorticoid-sparing. Since TCZ is a new drug in the treatment of AOSD, further studies are needed to assess whether the complications reported during the treatment are because of TCZ or natural course of the disease or coincidental findings.
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Affiliation(s)
- Seher Kır
- Department of Internal Medicine, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Metin Özgen
- Department of Internal Medicine, Rheumatology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Sezgin Zontul
- Department of Physical Therapy and Rehabilitation, Rheumatology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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Tomaras S, Goetzke CC, Kallinich T, Feist E. Adult-Onset Still's Disease: Clinical Aspects and Therapeutic Approach. J Clin Med 2021; 10:733. [PMID: 33673234 PMCID: PMC7918550 DOI: 10.3390/jcm10040733] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/27/2021] [Accepted: 02/07/2021] [Indexed: 12/22/2022] Open
Abstract
Adult-onset Still's disease (AoSD) is a rare systemic autoinflammatory disease characterized by arthritis, spiking fever, skin rash and elevated ferritin levels. The reason behind the nomenclature of this condition is that AoSD shares certain symptoms with Still's disease in children, currently named systemic-onset juvenile idiopathic arthritis. Immune dysregulation plays a central role in AoSD and is characterized by pathogenic involvement of both arms of the immune system. Furthermore, the past two decades have seen a large body of immunological research on cytokines, which has attributed to both a better understanding of AoSD and revolutionary advances in treatment. Additionally, recent studies have introduced a new approach by grouping patients with AoSD into only two phenotypes: one with predominantly systemic features and one with a chronic articular disease course. Diagnosis presupposes an extensive diagnostic workup to rule out infections and malignancies. The severe end of the spectrum of this disease is secondary haemophagocytic lymphohistiocytosis, better known as macrophage activation syndrome. In this review, we discuss current research conducted on the pathogenesis, diagnosis, classification, biomarkers and complications of AoSD, as well as the treatment strategy at each stage of the disease course. We also highlight the similarities and differences between AoSD and systemic-onset juvenile idiopathic arthritis. There is a considerable need for large multicentric prospective trials.
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Affiliation(s)
- Stylianos Tomaras
- Department of Rheumatology, Helios Clinic Vogelsang-Gommern, 39245 Gommern, Germany;
| | - Carl Christoph Goetzke
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), 10117 Berlin, Germany; (C.C.G.); (T.K.)
- German Rheumatism Research Center (DRFZ), Leibniz Association, 10117 Berlin, Germany
- Berlin Institute of Health, 10178 Berlin, Germany
| | - Tilmann Kallinich
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), 10117 Berlin, Germany; (C.C.G.); (T.K.)
- German Rheumatism Research Center (DRFZ), Leibniz Association, 10117 Berlin, Germany
- Berlin Institute of Health, 10178 Berlin, Germany
| | - Eugen Feist
- Department of Rheumatology, Helios Clinic Vogelsang-Gommern, 39245 Gommern, Germany;
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Li S, Zheng S, Tang S, Pan Y, Zhang S, Fang H, Qiao J. Autoinflammatory Pathogenesis and Targeted Therapy for Adult-Onset Still's Disease. Clin Rev Allergy Immunol 2020; 58:71-81. [PMID: 31147820 DOI: 10.1007/s12016-019-08747-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Adult-onset Still's disease (AOSD) is a rare multisystem autoinflammatory disorder of unknown etiology. AOSD is generally characterized by high spiking fever, arthralgia or arthritis, skin rash, leukocytosis, and hyperferritinemia. Traditionally, AOSD has been treated with non-steroidal anti-inflammatory drugs, corticosteroids, and immunosuppressants. An increasing number of studies have shown that proinflammatory cytokines, such as interleukin-1β, -18, -6, and tumor necrosis factor-α, play key roles in AOSD and may serve as therapeutic targets. In the current review, we provided insights into the roles of these cytokines in the pathogenesis of AOSD and also provided a commentary on the clinical studies of biologic therapy against AOSD.
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Affiliation(s)
- Sheng Li
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Siting Zheng
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Shunli Tang
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Yunlei Pan
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Shan Zhang
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Hong Fang
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China.
| | - Jianjun Qiao
- Department of Dermatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310003, China.
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Nagalli S, Sharma A, Shankar Kikkeri N, Sherif N. A Case Report on Adult-Onset Still’s Disease Successfully Treated With Tocilizumab: A Brief Review on its Safety and Efficacy. Cureus 2020; 12:e10098. [PMID: 33005519 PMCID: PMC7522176 DOI: 10.7759/cureus.10098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Adult-onset Still’s disease (AOSD) is a rare autoimmune disease of unknown etiology with systemic inflammatory manifestations consisting of a triad of fevers, evanescent skin rash, and arthritis. Although steroids are the first line of therapy, about 20%-30% of patients are refractory, intolerant, and or relapse during tapering or upon discontinuation of steroids. There are no clinical guidelines in treating such patients and treatment in these patients is challenging. Previously used biological agents have limited efficacy and hence there is a need for new therapies. Tocilizumab (TCZ), an interleukin (IL)-6 receptor antibody has been used with a clinical benefit and has shown to decrease the dose of steroids in patients with adult-onset still disease. The aim of this case report is to highlight the use of tocilizumab in relapsing and steroid intolerant cases of AOSD. The use of this drug in patients with AOSD is currently off-label. Randomized control studies can provide additional information that offers better visibility in treating AOSD patients who are steroid-resistant or intolerant. The rarity of disease possesses additional challenges in conducting these studies.
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Kedor C, Listing J, Zernicke J, Weiß A, Behrens F, Blank N, Henes JC, Kekow J, Rubbert-Roth A, Schulze-Koops H, Seipelt E, Specker C, Feist E. Canakinumab for Treatment of Adult-Onset Still's Disease to Achieve Reduction of Arthritic Manifestation (CONSIDER): phase II, randomised, double-blind, placebo-controlled, multicentre, investigator-initiated trial. Ann Rheum Dis 2020; 79:1090-1097. [PMID: 32404342 PMCID: PMC7392486 DOI: 10.1136/annrheumdis-2020-217155] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inhibition of interleukin (IL)-1 represents a promising treatment option in adult-onset Still's disease (AOSD). OBJECTIVE To investigate the efficacy and safety of canakinumab in patients with AOSD and active joint involvement by means of a multicentre, double-blind, randomised, placebo-controlled trial. METHODS Patients with AOSD and active joint involvement (tender and swollen joint counts of ≥4 each) were treated with canakinumab (4 mg/kg, maximum 300 mg subcutaneous every 4 weeks) or placebo. The primary endpoint was the proportion of patients with a clinically relevant reduction in disease activity at week 12 as determined by the change in disease activity score (ΔDAS28>1.2). RESULTS At enrolment, patients had high active disease with a mean DAS28(ESR) of 5.4 in the canakinumab and 5.3 in the placebo group, respectively. In the intention-to-treat analysis, 12 patients (67%) in the canakinumab group and 7 patients (41%) in the placebo group fulfilled the primary outcome criterion (p=0.18). In the per-protocol analysis, significantly higher American College of Rheumatology (ACR) 30% (61% vs 20%, p=0.033), ACR 50% (50% vs 6.7%, p=0.009) and ACR 70% (28% vs 0%, p=0.049) response rates were observed in the canakinumab group compared with the placebo group. Two patients in the canakinumab group experienced a serious adverse event. CONCLUSION Although the study was terminated prematurely and the primary endpoint was not achieved, treatment with canakinumab led to an improvement of several outcome measures in AOSD. The overall safety findings were consistent with the known profile of canakinumab. Thus, our data support indication for IL-1 inhibition with canakinumab in AOSD.
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Affiliation(s)
- Claudia Kedor
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Listing
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Weiß
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Frank Behrens
- CIRI/Rheumatology and Fraunhofer TMP, Goethe-University, Frankfurt, Germany
| | - Norbert Blank
- Internal Medicine 5, University of Heidelberg, Heidelberg, Germany
| | - Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Haematology, Immunology, Rheumatology, Pulmology), University Hospital Tuebingen, Tuebingen, Germany
| | - Joern Kekow
- Clinic of Rheumatology and Orthopaedics, Otto-von-Guericke University Magdeburg, Vogelsang-Gommern, Germany
| | - Andrea Rubbert-Roth
- Division of Rheumatology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Eva Seipelt
- Abteilung Rheumatologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Standort Berlin-Buch, Berlin, Germany
| | - Christof Specker
- Klinik für Rheumatologie und Klinische Immunologie, KEM Kliniken Essen-Mitte, Essen, Germany
| | - Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Ohmura SI, Uehara K, Yamabe T, Tamechika S, Maeda S, Naniwa T. Successful use of short-term add-on tocilizumab for refractory adult-onset still's disease with macrophage activation syndrome despite treatment with high-dose glucocorticoids, cyclosporine, and etoposide. Mod Rheumatol Case Rep 2020; 4:202-207. [PMID: 33086994 DOI: 10.1080/24725625.2020.1741073] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/07/2020] [Indexed: 06/11/2023]
Abstract
Macrophage activation syndrome (MAS) is a form of secondary hemophagocytic lymphohistiocytosis (HLH) and is a life-threatening complication of adult-onset Still disease. MAS has been usually treated with high-dose glucocorticoid with additional immunosuppressive agents, such as cyclosporine. Etoposide has been used for the treatment of severe refractory MAS based on the successful results of HLH-2004 protocol in patients with mostly primary form of HLH. We herein describe a case of severe refractory MAS secondary to adult-onset Still disease in an elderly woman that inadequately responded to etoposide but remarkably responded to additional tocilizumab. Furthermore, short-term tocilizumab led her into remission and enabled tapering off glucocorticoids after 15 months. Tocilizumab may be effective for the treatment of refractory HLH after the failure of the etoposide-containing induction regimen.
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Affiliation(s)
- Shin-Ichiro Ohmura
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Koji Uehara
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Toru Yamabe
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Shinya Tamechika
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Shinji Maeda
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Japan
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Reihl Crnogaj M, Čubelić D, Babić A, Mayer M, Anić B. Treatment of refractory adult onset Still's disease with tocilizumab-a single centre experience and literature review. Rheumatol Int 2020; 40:1317-1325. [PMID: 32506202 DOI: 10.1007/s00296-020-04622-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
Adult-onset Still's disease (AOSD) is defined as a systemic inflammatory disorder of unknown aetiology and is classified as a multigene autoinflammatory disease. Treatment of AOSD still remains mostly empirical with nonsteroidal anti-inflammatory drugs, glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs or cyclosporin A. Inhibitors of tumour necrosis factor-alpha and interleukin-1 (IL-1) antagonists have shown efficacy in certain subsets of patients with AOSD. The IL-6 molecule is one of the potential targets in treating AOSD considering that its level is increased in both the systemic and chronic articular forms of the disease. We present a series of eight patients from our centre with refractory AOSD treated with tocilizumab (TCZ). The drug was administered intravenously (6-8 mg/kg every 3-4 weeks) or subcutaneously (162 mg weekly). One patient had a disease relapse during TCZ therapy, and the drug had to be withdrawn in one patient due to a severe infection, while five out of six patients currently treated are in stable remission.Many previous reports have suggested that TCZ is an efficacious option for the treatment of refractory AOSD and the cases presented herein support this finding. A literature search revealed two previous reports of subcutaneous TCZ administration TCZ in AOSD, and our experience supports subcutaneous TCZ as a promising option for treatment of refractory AOSD patients.
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Affiliation(s)
- Mirna Reihl Crnogaj
- Division of Physical Medicine, Rehabilitation and Rheumatology, Vukovar General Hospital, Županijska 35, 32000, Vukovar, Croatia.
| | - Darija Čubelić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Antonija Babić
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Miroslav Mayer
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Branimir Anić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
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Hu Q, Wang M, Jia J, Teng J, Chi H, Liu T, Liu HL, Cheng X, Ye J, Su Y, Sun Y, Zhou Z, Wan L, Wang Z, Wang F, Shi H, Yang C. Tofacitinib in refractory adult-onset Still's disease: 14 cases from a single centre in China. Ann Rheum Dis 2020; 79:842-844. [PMID: 32079571 PMCID: PMC7286046 DOI: 10.1136/annrheumdis-2019-216699] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinchao Jia
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huihui Chi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong-Lei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liyan Wan
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhihong Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Adult-Onset Still’s Disease. PERIODIC AND NON-PERIODIC FEVERS 2020. [PMCID: PMC7123329 DOI: 10.1007/978-3-030-19055-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adult-onset Still’s disease (AoSD) is a rare but clinically well-known, polygenic, systemic autoinflammatory disease. It is typically characterized by four main (cardinal) symptoms: spiking fever ≥39 °C, arthralgia or arthritis, skin rash, and hyperleukocytosis (≥10,000 cells/mm3). However, many other clinical features are possible, and it can appear in all age groups with potentially severe inflammatory onset accompanied by a broad spectrum of disease manifestation and complications. Hence, it remains a diagnostic challenge, and the clinician should first rule out infectious, tumoral, or inflammatory differential diagnoses. Determination of the total and glycosylated ferritin levels, although not pathognomonic, can help in diagnosis. New biomarkers have recently been described, but they need to be validated. The disease evolution of AoSD can be monocyclic, polycyclic, or chronic. In chronic disease, a joint involvement is often predominant, and erosions are noted in one-third of patients. Many progresses have been made in the understanding of the pathogenesis over the last decades. This chapter provides a comprehensive insight into the complex and heterogeneous nature of AoSD describing the identified cytokine signaling pathways and biomarkers. It also discusses the current evidence for the usage of biologics in AoSD to provide guidance for treatment decisions, taking into account both the efficacy and the safety of the different therapeutic options.
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25
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Wang MY, Jia JC, Yang CD, Hu QY. Pathogenesis, disease course, and prognosis of adult-onset Still's disease: an update and review. Chin Med J (Engl) 2019; 132:2856-2864. [PMID: 31856058 PMCID: PMC6940076 DOI: 10.1097/cm9.0000000000000538] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is a rare but clinically well-known polygenic systemic autoinflammatory disease. In this review, we aim to present frontiers in the pathogenesis, clinical features, diagnosis, biomarkers, disease course, prognosis, and treatment in AOSD. DATA SOURCES We retrieved information from the PubMed database up to July 2019, using various search terms and relevant words, including AOSD and Still's disease. STUDY SELECTION We included data from peer-reviewed journals. Both basic and clinical studies were selected. RESULTS Pathogenesis of AOSD involves genetic background, infectious triggers, and immunopathogenesis, mainly the activation of macrophages and neutrophils followed by a cytokine storm. Diagnosis and prognosis evaluation of AOSD is still challenging; therefore, there is an urgent need to identify better biomarkers. Biologic agents, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α antagonists in the treatment of AOSD, have good prospect. CONCLUSION This review highlights the advances in pathogenesis, potential biomarkers, disease course, and treatment in AOSD.
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Affiliation(s)
- Meng-Yan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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26
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Feist E, Mitrovic S, Fautrel B. Mechanisms, biomarkers and targets for adult-onset Still's disease. Nat Rev Rheumatol 2019; 14:603-618. [PMID: 30218025 PMCID: PMC7097309 DOI: 10.1038/s41584-018-0081-x] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Adult-onset Still’s disease (AoSD) is a rare but clinically well-known, polygenic, systemic autoinflammatory disease. Owing to its sporadic appearance in all adult age groups with potentially severe inflammatory onset accompanied by a broad spectrum of disease manifestation and complications, AoSD is an unsolved challenge for clinicians with limited therapeutic options. This Review provides a comprehensive insight into the complex and heterogeneous nature of AoSD, describing biomarkers of the disease and its progression and the cytokine signalling pathways that contribute to disease. The efficacy and safety of biologic therapeutic options are also discussed, and guidance for treatment decisions is provided. Improving the approach to AoSD in the future will require much closer cooperation between paediatric and adult rheumatologists to establish common diagnostic strategies, treatment targets and goals. Adult-onset Still’s disease (AoSD) is not easily diagnosed, and treatment options are limited. This Review provides an overview of the disease and its pathogenesis, clinical trial results, therapeutic options and a plan to diagnose and clinically manage these patients. Similar to systemic-onset juvenile idiopathic arthritis, adult-onset Still’s disease (AoSD) is a rare systemic autoinflammatory disease with potentially severe inflammatory onset accompanied by a broad spectrum of disease manifestation and complications. AoSD should be considered in patients with persistent fever, and the diagnosis is based on the combination of clinical and laboratory findings as well as the exclusion of other inflammatory conditions. Central to the pathogenesis of AoSD is the intense activation of innate immune cells and overproduction of several pro-inflammatory cytokines including IL-1, IL-6 and IL-18. Two IL-1 antagonists have been approved for treatment of AoSD, and growing evidence suggests that other biologic agents are therapeutic options, such as anti-IL-6 and anti-IL-18 therapeutics. As a reliable prediction of response and outcome is not possible, therapeutic decisions have to be made on the basis of clinical, biological or imaging characteristics of disease. A close cooperation between paediatric and adult rheumatologists is required to establish common diagnostic strategies, treatment targets and goals.
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Affiliation(s)
- Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité- Universitätsmedizin, Berlin, Germany.
| | - Stéphane Mitrovic
- Department of Rheumatology, AP-HP, Pitié-Salpêtrière Hospital, AP-HP, Paris, France. .,Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France.
| | - Bruno Fautrel
- Department of Rheumatology, AP-HP, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Sorbonne Université, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
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Affiliation(s)
- Dae Hyun Yoo
- Department of Rheumatology, Hospital for Rheumatic Diseases, College of Medicine, Hanyang University, Seoul, Korea
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28
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Wang CY, Guo SH, Wang LP, Shen HL. Refractory adult-onset Still disease treated by tocilizumab combined with methotrexate: A STROBE-compliant article. Medicine (Baltimore) 2019; 98:e16682. [PMID: 31393368 PMCID: PMC6708626 DOI: 10.1097/md.0000000000016682] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Some patients have poor response to adult-onset Still disease (AOSD) traditional treatment, which easily recurs during the reduction of prednisone. We observed the efficacy and safety of tocilizumab combined with methotrexate (MTX) in the treatment of refractory AOSD, and to explore the possibility of reducing the dosage of tocilizumab after disease control.A total of 28 refractory AOSD cases who had an inadequate response to corticosteroids combined with at least 1 traditional immunosuppressive agent, and even large-dose prednisone could not relieve their conditions after recurrence, were selected in this study. They were treated with tocilizumab (intravenous 8 mg/kg) combined with MTX (oral 12.5 mg once a week). In detail, tocilizumab was firstly given every 4 weeks and after 6-month remission, it was then given every 8 weeks. Some items including body temperature, skin rash, joint swelling and pain, hepatosplenomegaly, blood routine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum ferritin, and dosage of prednisone were observed before treatment as well as 2, 4, 8, 12, 24, 36, and 48 weeks after treatment. The adverse reactions occurring during the treatment were recorded.The body temperature was normal, the skin rash as well as joint swelling and pain disappeared, and laboratory indexes including CRP, ESR, white blood cell, neutrophilic granulocyte, platelet, hemoglobin, and ferritin were significantly improved after 8-week treatment (all P < .05). The clinical symptoms and laboratory indexes above mentioned were continuously improved 12, 24, 36, and 48 weeks after treatment. The mean dosage of prednisone was reduced from 71.4 ± 20.7 mg/day to 55.0 ± 11.1 mg/day after 2-week treatment, and to 3.3 ± 2.1 mg/day after 48-week treatment (all P < .05). Prednisone was discontinued in 5 cases after 36-week treatment and in 7 cases after 48-week treatment. No serious adverse reactions occurred during the treatment.Tocilizumab can rapidly and markedly improve the clinical symptoms and laboratory indexes and contribute to reduction and discontinuation of prednisone in refractory AOSD. The patients' conditions are stable after reduction or discontinuation of prednisone and the tocilizumab possesses good safety.
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Castañeda S, Martínez-Quintanilla D, Martín-Varillas JL, García-Castañeda N, Atienza-Mateo B, González-Gay MA. Tocilizumab for the treatment of adult-onset Still’s disease. Expert Opin Biol Ther 2019; 19:273-286. [DOI: 10.1080/14712598.2019.1590334] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Catedra de EPID-Futuro, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Dolores Martínez-Quintanilla
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Catedra de EPID-Futuro, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - José L. Martín-Varillas
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Noelia García-Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Catedra de EPID-Futuro, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Belén Atienza-Mateo
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Miguel A. González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
- Department of Medicine, University of Cantabria, Santander, Spain
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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The Two-Faced Cytokine IL-6 in Host Defense and Diseases. Int J Mol Sci 2018; 19:ijms19113528. [PMID: 30423923 PMCID: PMC6274717 DOI: 10.3390/ijms19113528] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/07/2023] Open
Abstract
Interleukein-6 (IL-6), is produced locally from infectious or injured lesions and is delivered to the whole body via the blood stream, promptly activating the host defense system to perform diverse functions. However, excessive or sustained production of IL-6 is involved in various diseases. In diseases, the IL-6 inhibitory strategy begins with the development of the anti-IL-6 receptor antibody, tocilizumab (TCZ). This antibody has shown remarkable effects on Castleman disease, rheumatoid arthritis and juvenile idiopathic arthritis. In 2017, TCZ was proven to work effectively against giant cell arteritis, Takayasu arteritis and cytokine releasing syndrome, initiating a new era for the treatment of these diseases. In this study, the defensive functions of IL-6 and various pathological conditions are compared. Further, the diseases of which TCZ has been approved for treatment are summarized, the updated results of increasing off-label use of TCZ for various diseases are reviewed and the conditions for which IL-6 inhibition might have a beneficial role are discussed. Given the involvement of IL-6 in many pathologies, the diseases that can be improved by IL-6 inhibition will expand. However, the important role of IL-6 in host defense should always be kept in mind in clinical practice.
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Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still's disease. J Autoimmun 2018; 93:24-36. [PMID: 30077425 DOI: 10.1016/j.jaut.2018.07.018] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 02/06/2023]
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology usually affecting young adults; spiking fever, arthritis and evanescent rash are commonly observed during the disease. Other frequently observed clinical features include sore throat, hepatomegaly, splenomegaly, lymphadenopathy and serositis. Furthermore, AOSD patients may experience different life-threating complications. Macrophage activation syndrome (MAS) has been reported up to 15% of AOSD patients and it is considered to be the most severe complication of the disease being characterised by high mortality rate. During AOSD, laboratory tests reflect the systemic inflammatory process showing high levels of erythrocyte sedimentation rate and C-reactive protein. In addition, the ferritin levels are typically higher than those observed in other autoimmune, inflammatory, infectious, or neoplastic diseases. Analysing AOSD disease course, 3 different clinical patterns of AOSD have been identified: i. monocyclic pattern, characterised by a systemic single episode; ii. polycyclic pattern, characterised by multiple, ≤ 1 year lasting, flares, alternating with remissions; iii. chronic pattern, related to a persistently active disease with associated polyarthritis. At present, AOSD therapeutic strategy is aimed at targeting pro-inflammatory signs and symptoms, preventing organ damage and life-threating complications and minimising adverse effects of treatment. However, the treatment of AOSD remains largely empirical, lacking controlled clinical trials. High dosages of corticosteroids are usually the first line therapy when the systemic symptoms predominate. Despite this treatment, a large percentage of patients experiences several flares with an evolution toward the chronic disease course and up to 16% of patients die during the follow up, due to AOSD-related complications. On these bases, in the last years, biological agents have been successfully used in refractory cases. Finally, multiple recent lines of evidence have suggested new insights in AOSD pathogenesis unmasking further therapeutic targets. In fact, small molecules, used in experimental MAS models, might represent new therapeutic options.
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Affiliation(s)
- Roberto Giacomelli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Piero Ruscitti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Kumaki D, Nakamura Y, Suzuki T, Kato H. Efficacy of Denosumab for Osteoporosis in Two Patients with Adult-Onset Still's Disease-Denosumab Efficacy in Osteoporotic Still's Disease Patients. J Clin Med 2018; 7:E63. [PMID: 29565301 PMCID: PMC5920437 DOI: 10.3390/jcm7040063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/07/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022] Open
Abstract
Adult-onset Still's disease (AOSD) is an autoimmune inflammatory disorder. Glucocorticoids are often used for AOSD, which may induce complicating glucocorticoid-induced osteoporosis (GIO). An anti-resorption drug, denosumab, has recently been approved for osteoporosis treatment in Japan. However, the drug's efficacy for GIO in AOSD is largely unknown. This retrospective, consecutive case series investigated two patients with GIO in AOSD to examine the effects of denosumab on bone metabolism. Bone turnover markers, and bone mineral density (BMD) of the lumbar 1-4 spine (L-BMD) and bilateral total hips (H-BMD) were followed for six months in a male patient and for twelve months in a female patient. No fractures or severe side effects, such as hypocalcemia, were observed during the observational period. Bone turnover markers were basically suppressed, and L-BMD and H-BMD were increased by denosumab in both patients. Our findings suggest that denosumab is a suitable candidate drug for GIO in AOSD.
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Affiliation(s)
- Daiki Kumaki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
| | - Yukio Nakamura
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
- Department of Orthopaedic Surgery, Showa Inan General Hospital, Akaho 3230, Komagane 399-4117, Japan.
| | - Takako Suzuki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
| | - Hiroyuki Kato
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
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