Immunosuppressive therapy. 1

Favourable Tolerability and Drug Survival of Tioguanine Versus Methotrexate After Failure of Conventional Thiopurines in Crohn's Disease

BACKGROUND AND AIMS

Both methotrexate and tioguanine can be considered as treatment options in patients with Crohn's disease after failure of conventional thiopurines. This study aimed to compare tolerability and drug survival of methotrexate and tioguanine therapy after failure of conventional thiopurines in patients with Crohn's disease.

METHODS

We conducted a retrospective, multicentre study, including patients with Crohn's disease initiating monotherapy methotrexate or tioguanine after failure [all causes] of conventional thiopurines. Follow-up duration was 104 weeks or until treatment discontinuation. The primary outcome was cumulative therapy discontinuation incidence due to adverse events. Secondary outcomes included total number of [serious] adverse events, and ongoing monotherapy.

RESULTS

In total, 219 patients starting either methotrexate [n = 105] or tioguanine [n = 114] were included. In all 65 [29.7%] patients (methotrexate 43.8% [46/105 people], tioguanine 16.7% [19/114 people], p <0.001) discontinued their treatment due to adverse events during follow-up. Median time until discontinuation due to adverse events was 16 weeks (interquartile range [IQR] 7-38, p = 0.812). Serious adverse events were not significantly different. Patients treated with methotrexate experienced adverse events more often [methotrexate 83%, tioguanine 46%, p <0.001]. Total monotherapy drug survival after 104 weeks was 22% for methotrexate and 46% for tioguanine [p <0.001].

CONCLUSIONS

We observed a higher cumulative discontinuation incidence due to adverse events for methotrexate [44%] compared with tioguanine [17%] in Crohn's disease patients after failure of conventional thiopurines. The total adverse events incidence during methotrexate use was higher, whereas serious adverse events incidence was similar. These favourable results for tioguanine treatment may guide the selection of immunosuppressive therapy after failure of conventional thiopurines.

An Analysis of the Infections and Determination of Empiric Antibiotic Therapy in Cats and Dogs with Cancer-Associated Infections

Cancer patients commonly develop infectious complications over the course of the disease. One thousand patients receiving treatment for an oncologic disease at a single veterinary teaching hospital were retrospectively reviewed for concurrent infections. A total of 153 confirmed bacterial infections were identified, 82 of which were abscesses or wounds, 13 of which were respiratory infections, 3 of which were ear infections, and 55 of which were urinary tract infections. It was observed that the majority of the infections were caused by bacteria that are normally associated with that specific site location. Escherichia coli was the most common pathogen linked to infections in general, but Staphylococcus pseudintermedius was a frequently identified pathogen associated with wound infections. The susceptibility to diverse antimicrobials varied with the site of infection. Eleven cases (7.1%) were caused by opportunistic infections of the site, and E. coli and Pseudomonas aeruginosa were the pathogens isolated. Those bacteria were resistant to many antibiotics but showed susceptibility to aminoglycosides, imipenem, quinolones, and polymyxin B. In conclusion, veterinary patients with cancer or those under treatment for tumors develop infections by commonly encountered bacteria in the different sites of the body, with a susceptibility to antibiotics that is not out of line from what is expected. A small subset of cases developed opportunistic infections, with microbes that were more resistant to many classes of antibiotics.

How I treat autoimmune hemolytic anemias in adults

Autoimmune hemolytic anemia is a heterogeneous disease with respect to the type of the antibody involved and the absence or presence of an underlying condition. Treatment decisions should be based on careful diagnostic evaluation. Primary warm antibody autoimmune hemolytic anemias respond well to steroids, but most patients remain steroid-dependent, and many require second-line treatment. Currently, splenectomy can be regarded as the most effective and best-evaluated second-line therapy, but there are still only limited data on long-term efficacy and adverse effects. The monoclonal anti-CD20 antibody rituximab is another second-line therapy with documented short-term efficacy, but there is limited information on long-term efficacy and side effects. The efficacy of immunosuppressants is poorly evaluated. Primary cold antibody autoimmune hemolytic anemias respond well to rituximab but are resistant to steroids and splenectomy. The most common causes of secondary autoimmune hemolytic anemias are malignancies, immune diseases, or drugs. They may be treated in a way similar to primary autoimmune hemolytic anemias, by immunosuppressants or by treatment of the underlying disease.

tert-Butyl N-[N,N-bis-(2-chloro-ethyl)sulfamo-yl]-N-(2-chloro-ethyl)carbamate

The title compound, C(11)H(21)Cl(3)N(2)O(4)S, was produced as part of a development programme of a new synthetic route to chloro-ethyl-nitro-sosulfamides (CENS) with three chloro-ethyl moieties. These compounds possess structural features that confer potential biological activity and act as alkyl-ating agents. The packing is governed by four weak C-H⋯O inter-actions, forming an infinite three-dimensional network.

Drug-induced acute malaria

The case of an elderly woman with asymptomatic P. malariae infection that acutely reactivated after 45 y of latency following treatment with chlorambucil and methylprednisolone is reported. Only 1 similar case with methotrexate-induced acute malaria has been reported in the English literature thus far.

Effect of cyclophosphamide on the clearance of IgG-sensitized red cells in mice

The effects of cyclophosphamide (Cy) on the clearance of IgG-sensitized erythrocytes (EA) were examined. The results clearly indicate that Cy treatment enhances the capacity of the mononuclear phagocytic system to remove antibody-coated cells from the circulation in normal and decomplemented mice. The enhanced rate of clearance is the consequence of an increased uptake of EA by the liver and spleen. We explored the possibility that the enhancement of Fc receptor-mediated clearance might be an important effect to be taken into account in the search for a more effective therapy of immune complexes diseases.

Nutrition and cellular immunity in hospital patients

1. The interrelations between nutritional and cellular immune function measurements were studied in seventy patients suffering from various degrees of malnutrition. They included patients with liver disease, inflammatory bowel disease, neoplastic disease, neurological patients, post-operative surgical patients and patients with respiratory problems. 2. Nutritional measurements included: anthropometry, serum proteins, various vitamins and trace elements, and a prognostic nutritional index (PNI) was calculated. 3. Immunological measurements included: (1) natural killer (NK) cell activity, (2) antibody-dependent cellular cytotoxicity (ADCC), (3) lymphocyte proliferation in response to the mitogens concanavalin A (Con A), phytohaemagglutinin (PHA) and pokeweed mitogen (PWM) in both AB and autologous serum. 4. There was no association between anthropometric measurements and tests of immune function. 5. The lymphocyte proliferation in response to mitogenic stimulation in the malnourished patients was depressed in autologous serum compared with the response of the same lymphocytes in pooled AB serum. The lymphocyte proliferation in response to Con A correlated with transferrin in autologous serum (r 0.46, n 49, P less than 0.01) and to a lesser extent in AB serum (r 0.33, n 51, P less than 0.05). There was a difference in the Con A-stimulated tritiated-thymidine uptake between patients with low and normal serum zinc levels (P less than 0.05) for cultures performed in autologous serum, but not AB serum. 6. There was a significant correlation between NK cell activity and vitamin C (r 0.43, n 60, P less than 0.01). There was no relation between nutritional measurements and ADCC or the lymphocyte response to stimulation with PHA or PWM. 7. The results suggest that the severity of overall malnutrition does not influence several different aspects of the cellular immune response. However, the results do suggest that certain individual nutrients, particularly vitamin C and Zn, do influence the immunoreactivity of different lymphocyte subpopulations.

Pharmacotherapy of juvenile rheumatoid arthritis

Salicylate is the drug of first choice in the initial treatment of juvenile rheumatoid arthritis. In therapeutic dosage it will adequately control joint symptoms in the majority of patients. For children who do not respond to or are intolerant of salicylate, a change to one of the other nonsteroidal anti-inflammatory agents is appropriate. In progressive polyarthritis unresponsive to the above agents, the addition of gold, antimalarials, or penicillamine is indicated, preferably in that order. Corticosteroid therapy should be reserved for selected patients meeting specific criteria. Pharmacotherapy of juvenile rheumatoid arthritis should always be individualized. For optimal treatment of the whole child it must be combined with both physical and educational measures.

Immune Hemolytic anemia

Immune hemolytic anemia is an acquired anemia resulting from the premature destruction of red cells caused by the presence of antibody and/or complement on the red cell surface. The Coombs test, modified and improved, remains the mainstay of diagnosis.

Severe glomerulonephritis complicated by coagulopathy: treatment with anticoaguland and immunosuppresive drugs

Serial determinations, using plasma fibrinogen gel chromatography as well as standard methodology, demonstrated that six children with severe glomerulonephritis, characterized on renal biopsy by glomerular necrosis and crescent formation, had persistent evidence of intravascular coagulation. Based on these observations, therapy with anticoagulants and azathicoagulants and azathioprine was instituted for one year; treatment with anticoagulants was continued for a second year. Anticoagulant therapy was initiated with heparin, followed by oral anticoagulation with phenindione and dipyridamole. In contrast to our earlier experience with similar patients, each of the present patients improved. Urinalyses returned to normal and glomerular filtration rates to near normal values in all patients at the end of the treatment period and have remained so for up to 3.9 years since treatment has been completed. Post-treatment biopsies showed remarkable improvement, with virtually no glomerulosclerosis even in patients who had had a high incidence of glomerular crescents before treatment. It is suggested that the therapeutic regimen favorably influenced the natural history of disease and that plasma fibrinogen chromatographic findings may be helpful in selecting patients likely to benefit from the use of anticoagulant therapy.

Generalized urticaria to cyclophosphamide: Type I hypersensitivity to an immunosuppressive agent

A 6-yr-old white boy, Patient L. B., who was receiving cyclophosphamide (CY) for chemotherapy of a localized undifferentiated small cell sarcoma of the chest wall, developed generalized urticaria on three separate occasions immediately after CY administration. Serum samples were obtained 2 and 5 wk after the patient's last reaction and were examined for reaginic activity to the drug. Homocytotropic antibody activity to CY was found in the 2-wk postreaction sample by Prausnitz-Küstner type passive transfer skin testing to chimpanzees. This homocytotropic antibody was found to be of the IgE type, by means of an in vitro double-antibody coprecipitation assay measuring binding of free 14C-CY by specific immunoglobulin E and G fractions. Sera from 3 CY-treated patients who did not have adverse reactions to the drug and 6 normal, age-matched volunteers were used as control samples for the coprecipitation assay. None of the 3 CY-treated control patients had significant binding of 14C-CY by IgE when compared to normal individuals. However, it was found that all CY-treated patients had significant binding of 14C-CY by their IgG fraction when compared to normal subjects.

Treatment of idiopathic autoimmune hemolytic anemia in children. Review and report of two fatal cases in infancy

Report of two cases of severe idiopathic autoimmune hemolytic anemia (AIHA) in infants who underwent splenectomy and received corticosteroids and cyclophosphamide without benefit. One infant, additionally, was treated with thymectomy and azathioprine without influencing his disease. Experience of therapy for childhood AIHA is reviewed. Four children with AIHA have been thymectomized. Two of these failed to benefit from surgery. There have been fifteen previous trials with immunosuppressive agents in childhood AIHA. About 60% of the children so treated (9 of 15) have shown improvement. Additional clinical trials with this agent are warranted.

The acute and transient nature of idiopathic immune hemolytic anemia in childhood

The records of 22 children with the diagnosis of idiopathic immune hemolytic anemia were reviewed. Fifty per cent of the children had a history of an antecedent infection and 32% had underlying immune deficiency or lymphoproliferative diseases. The majority (77%) of the patients had an acute self-limited disease which was frequently associated with a positive complement or nongamma Coombs test. The anemia was usually severe, and a number of the children had reticulocytopenia at the time of diagnosis. These children responded rapidly to transfusions and corticosteroids and generally remained well on follow-up. Immunosuppressive drugs did not prove useful in two patients refractory to prednisone, but splenectomy was apparently beneficial in three of four patients so treated. Mortality rate was 18%, with most of the deaths related to an underlying disease.

Studies on pure red cell aplasia. Maintenance therapy with immunosuppressive drugs

Two patients with pure red cell aplasia, whose marrow cells were capable of increasing their rate of haem synthesis when incubated in vitro with erythropoietin concentrate, had a complete remission associated with the administration of cyclophosphamide and prednisone. Both patients relapsed when the drugs were withdrawn. The patients again went into remission when therapy was reinstituted. Maintenance of normal erythropoiesis was dependent on the continued administration of these drugs. This study provides additional evidence for a causal relationship between immunosuppressive therapy and the resumption of erythropoiesis in patients with this disease and demonstrates the value of this therapy for the maintenance of a remission.

Kinetics of the reactive cell clones after immunosuppression and induction of tolerance: (1) inhibition of 19 S and 7 S plaque-forming cells in the primary and secondary immune response to sheep red blood cells by cyclophosphamide and 036.5122 (Asta)

The kinetics of the reactive cell clones after primary and secondary immunization with SRBC1) modified by cyclophosphamide and a newly synthesized cyclophosphamide analogue 036.5122 (Asta), have been studied. After primary immunization, both substances caused a severe and dose dependent depletion of 19 S PFC2). The 7 S PFC in the late primary response were only slightly inhibited by cyclophosphamide in low dose ranges, indicating, that sensitization could not be prevented by this substance. In contrast, 0.36.5122 was fully able to suppress 7 S PFC. Thus, treatment with 0.36.5122 after primary immunization can fully prevent the expression of the specific response. Experiments dealing with inhibition of a secondary immune response revealed that both test substances were able to strongly suppress the 19 S as well as the 7 S PFC. In general, 036.5122 demonstrates a higher suppressive potency, and the timing of its application for optimal suppression is less delicate than that of cyclophosphamide. 036.5122 was equally well inhibitory, whether given directly before or after antigenic challenge. The hypothesis is discussed, whether the immunosuppressive effect of 036.5122 given before antigenic challenge in the secondary immune response is due to cytotoxic damage of antigen reactive clones stimulated by persisting antigen.

The prognostic and therapeutic implications of DNA:anti-DNA immune complexes in systemic lupus erythematosus (SLE)

Serum samples serially obtained from 50 patients with systemic lupus erythematosus (SLE) were studied for antibody to deoxyribonucleic acid (DNA) and circulating DNA:anti-DNA complexes during the active and inactive phases of their disease. The patients were divided into four categories: Group I: six patients without clinical evidence of central nervous system (CNS) or renal involvement. Group II: three patients with CNS lupus. Group III: nine patients with normal urinalyses and glomerular filtration rates, but morphologic evidence of glomerular disease. Group IV: 32 patients with overt lupus nephritis. Elevated anti-DNA levels were observed in 16 of 18 patients (88 per cent) in groups I, II and III during active disease. This persisted in 14 (77 per cent) during remission. DNA:anti-DNA complexes were demonstrated in four of 18 (22 per cent) during active disease and disappeared in all but one patient with progressive disease. In 30 of the 32 patients (94 per cent) in group IV, DNA binding was increased during active disease; this persisted in 21 (70 per cent) despite remission. Complexes were observed in 25 of the patients in group IV (78 per cent) with active disease. In six of these patients, complexes have persisted; two have died, one has progressed to renal failure and the remaining three patients continue to manifest active disease. This study suggests that measurement of DNA:anti-DNA complexes provides a valuable additional index of disease activity and prognosis in SLE.

Cyclophosphamide suppression of established cell-mediated immunity. Quantitative vs. qualitative changes in lymphocyte populations

The characteristics of cyclophosphamide-induced suppression of established ccll mediated immunity were studied in guinea pigs previously senstized to tuberculin. Cyclophosphamide treatment for 5 days produced a dose-dependent peripheral lymphoctopenia and disproportionatley greater neutrophenia which was particularly striking at high doses of 20 mg/kg per day(approximaetly 200 mg/kg-2 per day). Lymphoctes remianing in the circulation of cyclophosphamide treeated aniamls showed a doses-dependent reduction to both in vitro proliferactive and macrophage migration inhibitory factor responses to tuberculin compared to lymphocte responses of controls. Proliferative responses to phytohemaggultinin and concanavalin a were not significatly suppressed. Additional studies showed that cyclophosphamide suppressed the porliferactive and migration inhibitroy factor responses to tuberculin of lymph node and splenic as well as cirulating lymphocte populations. These studies showed that relatively short-term cyclophospamide administration produced immunosuppresion by quantitative as well as qualitative changes in lymphocyte populations. Significant suppresion of lymphocte function, howerver, was achived only with doses of cyclophoshamide which also produced a severe neutropenia.