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Shah A, Tabibian J, Buness C, Holtmann GJ. An 'Adaptive Treatment Strategy' for Oral Vancomycin in Patients with the Orphan Disease Primary Sclerosing Cholangitis. Dig Dis Sci 2024:10.1007/s10620-024-08497-4. [PMID: 38896361 DOI: 10.1007/s10620-024-08497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/09/2024] [Indexed: 06/21/2024]
Abstract
Decision-making in clinical medicine ideally is based upon evidence from randomized, placebo-controlled trials (RCTs) and subsequent systematic reviews and meta-analyses. However, for orphan diseases, the expectation of having one or multiple RCTs that inform clinical guidelines or justify specific treatments can be unrealistic and subsequent therapeutic nihilism can be detrimental to patients. This article discusses the benefits of therapeutic decision-making in the context of orphan diseases, focusing on primary sclerosing cholangitis (PSC) as an example of an orphan disease with poor clinical outcomes. PSC is a rare disorder characterized by inflammation and progressive fibrosis of the bile ducts. It carries a high risk of liver failure, malignancies, and debilitating symptoms that impair quality of life. Liver transplantation is currently the only life-prolonging intervention for PSC, but it is not a curative option. The article highlights the potential benefits of treating PSC patients with oral vancomycin (OV), which has shown significant clinical responses and improved quality of life in some cases. However, access to OV therapy is limited due to the lack of RCTs supporting its use. The standard requirement of having evidence from RCTs may result in withholding potentially life-altering and/or life-saving treatments for patients with orphan diseases. Conducting RCTs is challenging in these patient populations due to difficulties in recruiting the required patient cohorts and limited commercial returns. A standardized 'adaptive treatment strategy' is proposed to address this. This approach leverages the best available evidence for specific treatments, considers individual clinical responses, and adjusts treatment over time.
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - James Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Adventist Health Glendale Medical Center, Glendale, CA, USA
| | - Cynthia Buness
- Global Liver Institute Pediatric and Rare Liver Diseases Research Working Group, Washington, DC, USA
- Autoimmune Liver Disease Network for Kids (A-LiNK), Stanford University, Palo Alto, CA, USA
- National Patient Advocate Foundation, Washington, DC, USA
| | - Gerald J Holtmann
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
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Liu B, Yang GX, Sun Y, Tomiyama T, Zhang W, Leung PSC, He XS, Dhaliwal S, Invernizzi P, Gershwin ME, Bowlus CL. Decreased CD57 expression of natural killer cells enhanced cytotoxicity in patients with primary sclerosing cholangitis. Front Immunol 2022; 13:912961. [PMID: 36059513 PMCID: PMC9434697 DOI: 10.3389/fimmu.2022.912961] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background/aims Primary sclerosing cholangitis (PSC) is a chronic inflammatory biliary disease for which the immunopathological basis remains an enigma. Natural killer (NK) cells are key components of innate immunity and seemingly play diversified roles in different autoimmune disorders (AIDs). The aim of this study was to determine the role of NK cells in the pathogenesis of PSC. Methods The frequency and phenotype of circulating NK cells in a large cohort of patients with PSC and healthy controls (HCs) were systematically examined. In addition, the functional capacity of NK cells including cytotoxicity and cytokine production was studied. Results The frequency of CD3−CD56dimCD16+ (defined as CD56dim) NK cells in PSC patients was significantly lower in comparison to HCs. CD56dim NK cells from PSC displayed a more immature phenotype including high expression of the natural killing receptor NKp46 and downregulation of the highly differentiated NK cell marker CD57. Interestingly, the reduction of CD57 expression of NK cells was associated with the disease severity of PSC. In addition, PSC CD56dim NK cells exhibited increased CD107a degranulation and cytolytic activity toward target cells compared with HCs. Further analysis demonstrated that CD57−CD56dim NK cells from PSC had elevated expression of NKp46, NKp30, IL-2 receptor, and KLRG1 and higher cytotoxic capacity as compared to CD57+CD56dim NK cells. Conclusions Our data demonstrate that the differentiation of PSC NK cells is dysregulated with enhanced cytotoxic activity. This change is likely to be functionally involved in pathogenesis and disease progression, deducing the potential of NK-directed immunotherapy for PSC.
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Affiliation(s)
- Bin Liu
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Department of Rheumatology and Immunology, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guo-Xiang Yang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- *Correspondence: Guo-Xiang Yang, ; Christopher L. Bowlus,
| | - Ying Sun
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Department of Liver Disease, Senior Department of Hepatology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Takashi Tomiyama
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Weici Zhang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Patrick S. C. Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Xiao-Song He
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Sandeep Dhaliwal
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, CA, United States
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, United States
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, CA, United States
- *Correspondence: Guo-Xiang Yang, ; Christopher L. Bowlus,
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