1
|
Mitra D, Chopra A, Saraswat N, Mitra B, Talukdar K, Agarwal R. Biologics in Dermatology: Off-Label Indications. Indian Dermatol Online J 2020; 11:319-327. [PMID: 32695686 PMCID: PMC7367577 DOI: 10.4103/idoj.idoj_407_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 11/04/2022] Open
Abstract
Skin and subcutaneous diseases affect millions of people worldwide, causing significant morbidity. Biologics are becoming increasingly useful for the treatment of many skin diseases, particularly as alternatives for patients who have failed to tolerate or respond to conventional systemic therapies. Biological therapies provide a targeted approach to treatment through interaction with specific components of the underlying immune and inflammatory disease processes. Advances in the understanding of disease pathophysiology for inflammatory skin diseases and in drug development have ushered in biologic therapies in dermatology. Biologic therapies are molecules that target specific proteins implicated in immune-mediated disease. This review article highlights the increasing evidence base for biologics in dermatology for off-label use.
Collapse
Affiliation(s)
- Debdeep Mitra
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Ajay Chopra
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Neerja Saraswat
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Barnali Mitra
- Department of Pediatrics, Base Hospital Delhi Cantt, New Delhi, India
| | - Krishna Talukdar
- Department of Dermatology, Jorhat Medical College and Hospital, Jorhat, Assam, India
| | - Reetu Agarwal
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| |
Collapse
|
2
|
Abstract
Sarcoidosis is an inflammatory disease defined by the presence of non-caseating granulomas. It can affect a number of organ systems, most commonly the lungs, lymph nodes, and skin. Cutaneous manifestations of sarcoidosis can impose a significant detriment to patients' quality of life. The accepted first-line therapy for cutaneous sarcoidosis consists of intralesional and oral corticosteroids, but these can fail in the face of resistant disease and corticosteroid-induced adverse effects. Second-line agents include tetracyclines, hydroxychloroquine, and methotrexate. Biologics are an emerging treatment option for the management of cutaneous sarcoidosis, but their role in management is not well-defined. In this article, we reviewed the currently available English-language publications on the use of biologics in managing cutaneous sarcoidosis. Although somewhat limited, the data in published studies support the use of both infliximab and adalimumab as third-line treatments for chronic or resistant cutaneous sarcoidosis. There were also scattered reports of etanercept, rituximab, golimumab, and ustekinumab being utilized as third-line agents with varying degrees of success. Larger and more extensive investigations are required to further assess the adverse effect profile and optimal dosing for managing cutaneous sarcoidosis.
Collapse
|
3
|
Abstract
Background: Von Zumbusch pustular psoriasis is a severe, generalized form of psoriasis. Patients may also suffer from systemic complications, such as fever, arthropathy, congestive heart failure, and infections, which can ultimately prove fatal. Generalized pustular psoriasis can often be recalcitrant, making treatment difficult. Objective: The purpose of this study was to demonstrate the efficacy of infliximab in treating generalized pustular psoriasis. Methods: Four consecutively admitted patients with generalized pustular psoriasis were treated with infliximab 5 mg/kg intravenous infusion. ResultsAfter treatment with infliximab, white blood cell count, sedimentation rate, C-reactive protein, and vital signs normalized in all 4 patients within 24 h of the infusion. PASI scores on discharge had improved in all 4 patients. Conclusion: All 4 patients with generalized pustular psoriasis had rapid and positive responses to infliximab without any significant side effects. This experience adds support to the use of infliximab for generalized pustular psoriasis.
Collapse
Affiliation(s)
- Jennifer T. Trent
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida
| | - Francisco A. Kerdel
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida
| |
Collapse
|
4
|
Abstract
Background: Tumor necrosis factor-alpha (TNF-a) is a proinflammatory cytokine that plays an immunomodulatory role in a variety of systemic and dermatologic diseases. Currently, three anti-TNF-a drugs are available in North America— infliximab (approved in the U.S. for the treatment of rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, ulcerative colitis, and psoriatic arthritis), etanercept (approved in the U.S. for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis), and adalimumab (approved for the treatment of rheumatoid arthritis and psoriatic arthritis). Objective: To review the current literature supporting alternative (and currently off-label) dermatologic uses of TNF-a antagonists. Methods: A MEDLINE search (1966-March 2005) was conducted using the keywords “infliximab,” “etanercept,” “adalimumab,” “TNF inhibitors,” and “off-label” to identify published reports of off-label dermatologic uses of TNF-a inhibitors. Results: Anti-TNF-a therapies have been reported in the following dermatologic diseases: sarcoidosis, hidradenitis suppuritiva, cicatricial pemphigoid, Behçet's disease, pyoderma gangrenosum, multicentric reticulohistiocytosis, apthous stomatitis, Sneddon-Wilkinson disease, SAPHO syndrome, pityriasis rubra pilaris, eosinophilic fasciitis, Panniculitis, Crohn's disease, necrobiosis lipoidica diabeticorum, dermatomyositis, and scleroderma. The vast majority of these reports are in the form of individual case reports and small case series. Only two published randomized controlled trials involving the off-label use of a TNF inhibitor were found. Conclusions: A growing number of published reports suggest that anti-TNF-a therapies may be effective in the treatment of numerous inflammatory skin diseases outside their currently approved indications.
Collapse
Affiliation(s)
- Andrew F. Alexis
- Department of Dermatology, St. Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Bruce E. Strober
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
5
|
Saketkoo LA, Baughman RP. Biologic therapies in the treatment of sarcoidosis. Expert Rev Clin Immunol 2016; 12:817-25. [DOI: 10.1080/1744666x.2016.1175301] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, University Medical Center Comprehensive Pulmonary Hypertension Center, Tulane University Lung Center, New Orleans, LA, USA
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| |
Collapse
|
6
|
Amber KT, Bloom R, Mrowietz U, Hertl M. TNF-α: a treatment target or cause of sarcoidosis? J Eur Acad Dermatol Venereol 2015; 29:2104-11. [PMID: 26419478 DOI: 10.1111/jdv.13246] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/12/2015] [Indexed: 12/27/2022]
Abstract
Sarcoidosis is a systemic granulomatous disease that affects numerous organs, commonly manifesting at the lungs and skin. While corticosteroids remain the first line of treatment, tumour necrosis factor alpha (TNF-α) inhibitors have been investigated as one potential steroid sparing treatment for sarcoidosis. TNF-α is one of many components involved in the formation of granulomas in sarcoidosis. While there have been larger scale studies of biologic TNF-α inhibition in systemic sarcoidosis, studies in cutaneous disease are limited. Paradoxically, in some patients treated with biologic TNF-α inhibitors for other diseases, treatment can induce the development of sarcoidosis. In the light of this complexity, we discuss the role of TNF-α in granuloma formation, the therapeutic role of TNF-α inhibition and immunologic abnormalities following treatment with these TNF-α inhibitors including drug-specific alterations involving interferon-γ, lymphotoxin-α, TNF receptor 2 (TNFR2) and T-regulatory cells.
Collapse
Affiliation(s)
- K T Amber
- Department of Dermatology, University of California Irvine Health, Irvine, CA, USA.,Department of Internal Medicine, MacNeal Hospital, Berwyn, IL, USA
| | - R Bloom
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - U Mrowietz
- Psoriasis-Center, Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - M Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| |
Collapse
|
7
|
|
8
|
In vivo evaluation of TNF-alpha in the lungs of patients affected by sarcoidosis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:401341. [PMID: 25866780 PMCID: PMC4383433 DOI: 10.1155/2015/401341] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/09/2014] [Accepted: 08/11/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Sarcoidosis is a multisystemic granulomatous disorder characterized by multiple noncaseating granulomas involving intrathoracic lymph nodes and lung parenchyma. Recently, the use of anti-tumor necrosis factor alpha (anti-TNFα) agents has been introduced for therapy of chronic and refractory sarcoidosis with controversial results. Infliximab (Remicade) is a chimeric monoclonal antibody (mAb) that recognizes and binds TNFα, neutralizing its biological effects. In the present study, (99m)Tc labelled infliximab was used to study the expression of TNFα in sarcoid lesions and to evaluate its role as a predictive marker in response to therapy with Remicade. MATERIAL AND METHODS A total of 10 patients with newly diagnosed sarcoidosis were enrolled together with 10 control patients affected by rheumatoid arthritis. All patients were studied by planar imaging of the chest with (99m)Tc-infliximab at 6 h and 24 h and total body [(18)F]-FDG PET/CT. Regions of interest were drawn over the lungs and the right arm and target-to-background ratios were analysed for (99m)Tc-infliximab. SUV mean and SUV max were calculated over lungs for FDG. RESULTS AND DISCUSSION Image analysis showed low correlation between T/B ratios and BAL results in patients despite positivity at [(18)F]-FDG PET. CONCLUSION In conclusion, patients with newly diagnosed pulmonary sarcoidosis, with FDG-PET and BAL positivity, showed a negative (99m)Tc-infliximab scintigraphy.
Collapse
|
9
|
Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
Collapse
Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| |
Collapse
|
10
|
Sehgal VN, Riyaz N, Chatterjee K, Venkatash P, Sharma S. Sarcoidosis as a systemic disease. Clin Dermatol 2014; 32:351-63. [DOI: 10.1016/j.clindermatol.2013.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
11
|
Terasaki F, Ishizaka N. Deterioration of cardiac function during the progression of cardiac sarcoidosis: diagnosis and treatment. Intern Med 2014; 53:1595-605. [PMID: 25088870 DOI: 10.2169/internalmedicine.53.2784] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The cardiac involvement of sarcoidosis causes progressive heart failure symptoms and is a life-threatening condition; thus, an early and appropriate diagnosis of this condition is crucial. On the other hand, the decline in the cardiac function is rapid; therefore, patients usually have moderate-severe left ventricular dysfunction when diagnosed with cardiac sarcoidosis, which may decrease the effectiveness of therapies. We herein report three illustrative cases of heart failure due to cardiac sarcoidosis in patients who were or were not diagnosed with preceding systemic sarcoidosis. We also discuss the currently available diagnostic modalities and possible biomarkers for the diagnosis of cardiac sarcoidosis.
Collapse
|
12
|
Mañá J, Marcoval J. Skin manifestations of sarcoidosis. Presse Med 2012; 41:e355-74. [DOI: 10.1016/j.lpm.2012.02.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/27/2012] [Accepted: 02/02/2012] [Indexed: 01/24/2023] Open
|
13
|
Callejas-Rubio JL, López-Pérez L, Ortego-Centeno N. Tumor necrosis factor-alpha inhibitor treatment for sarcoidosis. Ther Clin Risk Manag 2011; 4:1305-13. [PMID: 19337437 PMCID: PMC2643111 DOI: 10.2147/tcrm.s967] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sarcoidosis is a chronic multisystem disease of unknown etiology, characterized by noncaseating granulomatous infiltration of virtually any organ system. Treatment is often undertaken in an attempt to resolve symptoms or prevent progression to organ failure. Previous studies have suggested a prominent role for tumor necrosis factor-alpha (TNF-α) in the inflammatory process seen in sarcoidosis. TNF-α and interleukin-1 are released by alveolar macrophages in patients with active lung disease. Corticosteroids have proved to be efficacious in the treatment of sarcoidosis, possibly by suppressing the production of TNF-α and other cytokines. Three agents are currently available as specific TNF antagonists: etanercept, infliximab, and adalimumab. Although data from noncomparative trials suggest that all three have comparable therapeutic effects in rheumatoid arthritis, their effects in a granulomatous disease such as sarcoidosis are less consistent. In this review, current data on the effectiveness are summarized.
Collapse
|
14
|
Patel R, Cafardi JM, Patel N, Sami N, Cafardi JA. Tumor necrosis factor biologics beyond psoriasis in dermatology. Expert Opin Biol Ther 2011; 11:1341-59. [PMID: 21651458 DOI: 10.1517/14712598.2011.590798] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION TNF-α is a cytokine essential for immune response and its receptors has been shown to be dysregulated in a variety of diseases including psoriasis vulgaris. There are a number of TNF-α inhibitors approved for psoriasis, however there is a growing body of literature supporting their use in a wide variety of dermatological conditions. AREAS COVERED The use of biologic TNF-α antagonists in conditions for which they have not yet been approved by the FDA ('off-label' uses) and the literature that supports the most appropriate agents and conditions for use. A PubMed/MEDLINE search was performed with the keywords 'TNFα antagonist', 'biologic therapy', 'off-label' and 'unapproved'. The list of references and citing articles of the articles retrieved were also used as sources. This complete list was evaluated for inclusion, based on relevance to the proposed goal of this review. EXPERT OPINION There are a large number of conditions for which biologic antagonists of TNFα are effective, beyond those already approved by the FDA. The various agents vary in their efficacy in treatment, with infliximab consistently the most effective, particularly in granulomatous diseases. Although effectiveness varies among these conditions, biologic antagonists of TNF-α are promising for the treatment of these diseases.
Collapse
Affiliation(s)
- Raj Patel
- University of Alabama at Birmingham, Dermatology, 1530 Third Avenue South, EFH suite 414 Birmingham, AL 35294, USA
| | | | | | | | | |
Collapse
|
15
|
Adaptive immune responses in primary cutaneous sarcoidosis. Clin Dev Immunol 2011; 2011:235142. [PMID: 21603192 PMCID: PMC3095245 DOI: 10.1155/2011/235142] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Accepted: 01/27/2011] [Indexed: 12/13/2022]
Abstract
Sarcoidosis is a multisystemic inflammatory disorder with cutaneous lesions present in about one-quarter of the patients. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of nonnecrotizing epithelial cell granulomas on histologic studies. The development and progression of specific cutaneous sarcoidosis involves a complex interaction between cells of the adaptive immune systems, notably T-lymphocytes and dendritic cells. In this paper, we will discuss the role of T-cells and skin dendritic cells in the development of primary cutaneous sarcoidosis and comment on the potential antigenic stimuli that may account for the development of the immunological response. We will further explore the contributions of selected cytokines to the immunopathological process. The knowledge of the adaptive immunological mechanisms operative in cutaneous sarcoidosis may subsequently be useful for identifying prevention and treatment strategies of systemic sarcoidosis.
Collapse
|
16
|
Infliximab et sarcoïdose chronique. L’expérience française à propos de 31 cas. Rev Mal Respir 2010; 27:685-92. [DOI: 10.1016/j.rmr.2010.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2009] [Accepted: 12/13/2009] [Indexed: 12/28/2022]
|
17
|
Toussirot E, Pertuiset E. [TNFα blocking agents and sarcoidosis: an update]. Rev Med Interne 2010; 31:828-37. [PMID: 20510487 DOI: 10.1016/j.revmed.2010.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 12/09/2009] [Accepted: 02/06/2010] [Indexed: 11/30/2022]
Abstract
Increased production of TNFα by alveolar macrophages and involvement of TNFα in granuloma formation suggest that this cytokine is involved in the pathophysiology of sarcoidosis. The three available TNFα blocking agents have been tested in sarcoidosis refractory to corticosteroids or immunosuppressive drugs. Data are available from isolated case reports or limited series of patients treated in open label trials with favourable issue with anti-TNFα monoclonal antibodies. Two randomized placebo controlled studies evaluated the efficacy of infliximab in pulmonary and extra-pulmonary sarcoidosis, showing that infliximab improves significantly extra-pulmonary disease. There is no significant difference between infliximab and placebo in the treatment of pulmonary manifestations. Etanercept showed no efficacy for treating ocular sarcoidosis in a controlled trial and for pulmonary disease in an open label trial. Paradoxical cases of proven sarcoidosis have been reported in patients receiving anti-TNFα agents for chronic inflammatory rheumatic diseases. A literature review identified 28 cases, including 16 with etanercept, eight with infliximab and four with adalimumab. Although these cases were mainly reported with etanercept, paradoxical sarcoidosis has been reported with the three available anti-TNFα agents, suggesting a class effect. Changes in the cytokine balance may be involved in these cases of induced sarcoidosis, which must be known by the clinician.
Collapse
Affiliation(s)
- E Toussirot
- Service de rhumatologie, pôle de pathologies aiguës et chroniques, transplantation, éducation (PACTE), hôpital Minjoz, CHU, 25000 Besançon, France.
| | | |
Collapse
|
18
|
|
19
|
Systemic sarcoidosis with bone marrow involvement responding to therapy with adalimumab: a case report. J Med Case Rep 2009; 3:8573. [PMID: 19830230 PMCID: PMC2737791 DOI: 10.4076/1752-1947-3-8573] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 03/17/2009] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Sarcoidosis is an inflammatory disorder characterized by the presence of non-caseating granulomas in affected organs. The presence of CD4-positive T lymphocytes and macrophages in affected organs suggests an ongoing immune response. Systemic corticosteroids remain the mainstay of treatment, but therapy is often limited by adverse effects. This is the first report of the use of adalimumab (HUMIRA((R)), Abbott Laboratories, North Chicago, IL, USA), an anti-tumor necrosis factor monoclonal antibody, in a patient with systemic sarcoidosis with bone marrow involvement. CASE PRESENTATION A 42-year-old African-American man with a medical history significant for hypertension and diabetes mellitus presented with anemia and thrombocytopenia of two months duration. The patient underwent physical examination, bone marrow aspiration and biopsy, chest X-ray, acid-fast bacilli stain, computed tomography with contrast, and additional laboratory tests. He was diagnosed with systemic sarcoidosis with splenomegaly and bone marrow involvement. Drug therapy included prednisone, which had to be discontinued owing to adverse effects, and adalimumab. CONCLUSION This is the first report describing the use of adalimumab in a patient with systemic sarcoidosis with bone marrow involvement. Tumor necrosis factor antagonism with adalimumab was efficacious and well-tolerated in this patient and may be considered as a treatment option for similar cases.
Collapse
|
20
|
Abstract
BACKGROUND Cutaneous sarcoidosis in black-skinned people is more severe and, in a subset, recalcitrant to therapy. Management of these patients is a challenge. AIM To document the clinical features of recalcitrant cutaneous sarcoidosis (RCS) and its response to sequential therapy. A treatment algorithm is suggested. METHODS A cross-sectional retrospective analysis was made of patients with RCS. Demographic data, clinical features, histology, blood parameters, radiology and management and response to therapy were recorded. RESULTS A total of 30 patients with cutaneous sarcoidosis were seen, of which six had recalcitrant lesions. All had black skin, with a male to female ratio of 1:5. The average age was 48.5 years (41-67) and the average duration of lesions was 11.3 years (2-29). Skin lesions were papules (three), plaques (four), annular (three), nodules (four), ulcers (one), alopecia (one) and lupus pernio (one). Extracutaneous involvement was noted in four of six patients as follows: pulmonary (three of six), dactylitis (two of six) and hepatosplenomegaly (one of six). Histopathology was undertaken in all confirmed non-caseating granulomas. None of the cases responded to systemic prednisone alone. Alternative therapies were: chloroquine (six of six), methotrexate (four of six), doxycycline (two of six), allopurinol (two of six) and isotretinoin (one of six), and azathioprine (one of six). All patients responded well to a stepwise approach to therapy using second-line agents with no relapses during the follow-up period. CONCLUSION Sequential therapy avoids the side effects of toxic drugs whilst controlling aggressive cutaneous lesions.
Collapse
Affiliation(s)
- A Mosam
- Department of Dermatology, Nelson R Mandela School of Medicine, University of Natal, Durban, South Africa.
| | | |
Collapse
|
21
|
Panselinas E, Rodgers JK, Judson MA. Clinical outcomes in sarcoidosis after cessation of infliximab treatment. Respirology 2009; 14:522-8. [PMID: 19386069 DOI: 10.1111/j.1440-1843.2009.01518.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Infliximab appears to be efficacious for the treatment of recalcitrant forms of sarcoidosis. However, there are minimal data concerning the course of sarcoidosis once infliximab is discontinued. METHODS Clinical outcomes in patients who had received infliximab and had discontinued it for at least 2 months were analysed retrospectively. The severity of involvement of the index organ from the time of discontinuation of infliximab was compared with that at the end of the follow-up period. RESULTS Fourteen patients with sarcoidosis who had been treated with infliximab and had discontinued this therapy were identified. Before discontinuation of infliximab, 9 of the 14 patients (64%) responded to infliximab treatment and only one (7%) deteriorated. Patients who discontinued infliximab were followed for a mean of 12 months. At the end of the follow-up period, 12 of the 14 patients (86%) had deteriorated as compared with their status at the time of discontinuation of infliximab and two (14%) had remained stable. Kaplan-Meier analysis of time to clinical deterioration showed that half the patients deteriorated within 3 months of discontinuing infliximab. Patients who had discontinued infliximab appeared to be more likely to have their dose of prednisone increased. CONCLUSION Patients with recalcitrant sarcoidosis who receive infliximab appear likely to deteriorate after discontinuation of this medication.
Collapse
Affiliation(s)
- Efstratios Panselinas
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
| | | | | |
Collapse
|
22
|
Adalimumab-induced noncaseating granuloma in the bone marrow of a patient being treated for rheumatoid arthritis. Rheumatol Int 2008; 29:437-9. [DOI: 10.1007/s00296-008-0691-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Accepted: 08/11/2008] [Indexed: 10/21/2022]
|
23
|
|
24
|
Plard C, Serry G, Faure P, Madelaine-Chambrin I. Bilan de 4 ans du Contrat de bon usage : conformité aux référentiels – cas des anti-TNFα. Therapie 2008; 63:281-9. [DOI: 10.2515/therapie:2008051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
25
|
Affiliation(s)
- Christy B Doherty
- Department of Dermatology, Baylor College of Medicine, Houston, Texas 77005, USA
| | | |
Collapse
|
26
|
Díaz-Ley B, Guhl G, Fernández-Herrera J. Uso de fármacos biológicos en dermatosis fuera de la indicación aprobada. Primera parte: infliximab y adalimumab. ACTAS DERMO-SIFILIOGRAFICAS 2007. [DOI: 10.1016/s0001-7310(07)70159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
|
27
|
Vandevyvere K, Luyten FP, Verschueren P, Lories R, Segaert S, Westhovens R. Pyoderma gangrenosum developing during therapy with TNF-alpha antagonists in a patient with rheumatoid arthritis. Clin Rheumatol 2007; 26:2205-2206. [PMID: 17876646 DOI: 10.1007/s10067-007-0733-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 08/21/2007] [Accepted: 08/29/2007] [Indexed: 12/16/2022]
Affiliation(s)
- K Vandevyvere
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - F P Luyten
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - P Verschueren
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - R Lories
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S Segaert
- Division of Dermatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - R Westhovens
- Division of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
28
|
Sarcoidosis, role of tumor necrosis factor inhibitors and other biologic agents, past, present, and future concepts. Clin Dermatol 2007; 25:341-6. [PMID: 17560312 DOI: 10.1016/j.clindermatol.2007.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tumor necrosis factor is a potent cytokine involved in the inflammatory process of many diseases. Agents that block tumor necrosis factor have been used in the treatment of various immune-mediated diseases, including rheumatoid arthritis, Crohn disease, psoriatic arthritis, and ankylosing spondylitis. Sarcoidosis is an immune-mediated inflammatory disorder of unknown etiology characterized by the formation of noncaseating granulomas. Tumor necrosis factor plays a major role in the inflammatory process seen in sarcoidosis. Sarcoidosis therapies with activity against tumor necrosis factor and specific anti-tumor necrosis factor therapies have been used with variable success. The long-term safety and efficacy of such therapies are yet to be determined in well-designed clinical trials with long-term follow-up.
Collapse
|
29
|
Yanagishita T, Watanabe D, Akita Y, Nakano A, Ohshima Y, Tamada Y, Matsumoto Y. Construction of novel in vitro epithelioid cell granuloma model from mouse macrophage cell line. Arch Dermatol Res 2007; 299:399-403. [PMID: 17704931 DOI: 10.1007/s00403-007-0778-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Revised: 07/21/2007] [Accepted: 08/01/2007] [Indexed: 10/22/2022]
Abstract
There have been several attempts to make granuloma model to clarify the mechanism of granulomatous diseases like sarcoidosis. However, a unique in vitro model that generates multinucleated giant cell (MGC) through epithelioid cells resembled to human granuloma, has not yet been clearly established. In this study, the generation of granuloma model that forms MGC via epithelioid cells from the mouse macrophage cell line was investigated. A RAW 246.7 mouse macrophage cell line was cultured with lipopolysaccharide (LPS) and concanavalin A (Con A) in various concentrations either alone or both. We found that separate treatment of LPS and Con A induced around 35 and 20% MGC respectively whereas cotreatment of these chemicals drastically accelerated granuloma formation rate and it was around 80%. The highest fusion index (MGC formation rate) was observed at days 7. A gradual increase of tumor necrosis factor alpha (TNF-alpha) production in the culture supernatant was analyzed by enzyme-linked immunosorbent assay (ELISA). And the neutralization of the elevated level of TNF-alpha production by its monoclonal antibody leads to significant decrease of MGC formation. Interestingly, we found that the RAW cells were changed into spindle cells, which morphologically resembled to epithelioid cells and eventually MGC was formed from these spindle cells. Our in vitro granuloma model appeared to be similar with in vivo epithelioid cell granulomas like sarcoidosis. Thus, our model would be useful as in vitro epithelioid granuloma model for analyzing the mechanisms and screening the effective drugs of granulomatous diseases in future.
Collapse
Affiliation(s)
- Takeshi Yanagishita
- Department of Dermatology, Aichi Medical University School of Medicine, Nagakute, Aichi, 480-1195, Japan.
| | | | | | | | | | | | | |
Collapse
|
30
|
|
31
|
Denys BG, Bogaerts Y, Coenegrachts KL, De Vriese AS. Steroid-resistant sarcoidosis: is antagonism of TNF-alpha the answer? Clin Sci (Lond) 2007; 112:281-9. [PMID: 17261090 DOI: 10.1042/cs20060094] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Steroid-resistant sarcoidosis has conventionally been treated with various drugs, including methotrexate, azathioprine, cyclophosphamide, cyclosporine, antimalarial drugs and thalidomide, with variable success. There is a compelling need for more efficient and safer alternatives to these agents. Several lines of evidence suggest a critical role of TNF-alpha (tumour necrosis factor-alpha) in the initiation and organization of sarcoid granulomas. Inhibition of TNF-alpha with monoclonal antibodies has therefore received attention as a potential treatment option in therapy-resistant sarcoidosis. A number of case reports and small case series describe successful treatment of refractory disease with infliximab. Preliminary evidence from an RCT (randomized controlled trial) with infliximab in pulmonary sarcoidosis suggests a modest improvement in functional and radiological parameters. In contrast, the results with etanercept have been disappointing, perhaps related to differences in the mechanism of TNF-alpha blockade. The experience with adalimumab in sarcoidosis is too limited to draw conclusions. An open-label study and an RCT evaluating the efficacy of adalimumab in sarcoidosis with pulmonary and cutaneous involvement respectively, have been initiated. Although TNF-alpha antagonists appear relatively safe, especially when compared with conventional agents, caution is warranted in view of the increased incidence of tuberculosis, which may be a particular diagnostic challenge in patients with sarcoidosis. Pending publication of the RCTs, the use of TNF-alpha blockade in sarcoidosis should remain in the realm of experimental treatment.
Collapse
Affiliation(s)
- Bart G Denys
- Department of Internal Medicine, AZ Sint-Jan AV, Ruddershove 10, B-8000 Brugge, Belgium
| | | | | | | |
Collapse
|
32
|
Abstract
BACKGROUND Sarcoidosis is a systemic granulomatous disease of unknown etiology that affects multiple organ systems, including the pulmonary, lymphatic, skeletal, and integumentary systems. Improved understanding of the intrinsic immunology and molecular biology in sarcoidosis can be applied to the treatment of this disease. Alefacept is a human fusion protein consisting of the extracellular domain of leukocyte function-associated antigen 3 fused with the Fc portion of human immunoglobulin G1. It works by blocking the interaction between antigen-presenting cells and T cells to inhibit activation and by inducing apoptosis of CD4+ T cells. In this case report, we describe a 46-year-old patient with recalcitrant lupus pernio who was successfully treated with alefacept. OBJECTIVE To determine whether T-cell inhibition, specifically the use of alefacept, may be used to treat a patient with recalcitrant cutaneous sarcoidosis. METHODS Case report. RESULTS There was a modest clinical improvement after 8 weeks of intramuscular injections of alefacept. CONCLUSION This case report provides further evidence of successful treatment of sarcoidosis with biologic agents directed against T-lymphocyte activation.
Collapse
Affiliation(s)
- Jorge Garcia-Zuazaga
- Department of Dermatology, University Hospitals of Cleveland, Case Western Reserve University, OH 44106, USA.
| | | |
Collapse
|
33
|
Graves JE, Nunley K, Heffernan MP. Off-label uses of biologics in dermatology: Rituximab, omalizumab, infliximab, etanercept, adalimumab, efalizumab, and alefacept (Part 2 of 2). J Am Acad Dermatol 2007; 56:e55-79. [PMID: 17190618 DOI: 10.1016/j.jaad.2006.07.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Revised: 06/30/2006] [Accepted: 07/22/2006] [Indexed: 12/28/2022]
Abstract
Recently, dermatologists have witnessed a revolution in our therapeutic armamentarium with the development of several novel biologic immunomodulators. Although psoriasis remains the only condition in dermatology for which the use of biologic immunomodulators has been approved by the Food and Drug Administration, these drugs have the potential to significantly impact the treatment of several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, and side-effect profile, as well as a review of the current literature on off-label uses of the CD20-positive B-cell antagonist rituximab, the IgE antagonist omalizumab, the tumor necrosis factor-alpha antagonists infliximab, etanercept, and adalimumab, and the T-cell response modifiers efalizumab and alefacept.
Collapse
Affiliation(s)
- Julia E Graves
- Division of Dermatology, Washington University, St Louis, Missouri, USA
| | | | | |
Collapse
|
34
|
Díaz-Ley B, Guhl G, Fernández-Herrera J. Off-Label Use of Biologic Agents in the Treatment of Dermatosis, Part 1: Infliximab and Adalimumab. ACTAS DERMO-SIFILIOGRAFICAS 2007. [DOI: 10.1016/s1578-2190(07)70539-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
35
|
Badgwell C, Rosen T. Cutaneous sarcoidosis therapy updated. J Am Acad Dermatol 2007; 56:69-83. [PMID: 17190623 DOI: 10.1016/j.jaad.2006.06.019] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 04/14/2006] [Accepted: 06/19/2006] [Indexed: 11/30/2022]
Abstract
The widely accepted standard therapy for cutaneous sarcoidosis includes corticosteroids, antimalarials, and methotrexate. However, a better understanding of the basic immunopathogenic properties of sarcoidosis has elucidated a number of steps critical to the persistence and progression of disease that may be vulnerable to treatment by targeted therapy. This article reviews both standard and newer therapeutic options for cutaneous sarcoidosis.
Collapse
Affiliation(s)
- Christy Badgwell
- Dermatology Department, Baylor College of Medicine, and Houston Veterans Affairs Medical Center, Texas, USA
| | | |
Collapse
|
36
|
Kerns MJJ, Graves JE, Smith DI, Heffernan MP. Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update. ACTA ACUST UNITED AC 2006; 25:226-40. [PMID: 17174843 DOI: 10.1016/j.sder.2006.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include adalimumab, alefacept, efalizumab, etanercept, infliximab, IVIg, omalizumab, and rituximab. Most dermatologists are familiar with the indications of these medications that have been approved by the Food and Drug Administration; however, numerous off-label uses have evolved. To update the reader on more recent uses of the biologics for off-label dermatologic use, this article will emphasize more recent published data from 2005 through the date of submission in May 2006.
Collapse
|
37
|
Berliner AR, Haas M, Choi MJ. Sarcoidosis: the nephrologist's perspective. Am J Kidney Dis 2006; 48:856-70. [PMID: 17060009 DOI: 10.1053/j.ajkd.2006.07.022] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 07/27/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Adam R Berliner
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | |
Collapse
|
38
|
Saleh S, Ghodsian S, Yakimova V, Henderson J, Sharma OP. Effectiveness of infliximab in treating selected patients with sarcoidosis. Respir Med 2006; 100:2053-9. [PMID: 16935484 DOI: 10.1016/j.rmed.2006.02.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 01/22/2006] [Accepted: 02/05/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the effectiveness of infliximab (Remicade) in the treatment of patients with sarcoidosis who either do not respond to corticosteroids and other conventional drugs or develop unacceptable side effects to these drugs. DESIGN A clinical, non-randomized, off-label study. SETTING Sarcoidosis clinic at a university teaching hospital. PATIENTS Twelve biopsy-proven sarcoidosis patients, nine women and three men ranging from 45 to 70 years of age with chronic multisystem sarcoidosis refractory to corticosteroids or alternative treatment. INTERVENTION Infliximab was infused at a dedicated ambulatory infusion center. The initial dose was 3mg/kg body weight and subsequent doses were given at weeks 2, 4, 6, 10, and 14. All patients received at least six infusions. RESULTS All 12 patients improved significantly. One patient had a mild allergic drug reaction that responded to antihistamine. One patient, after 3 months of stopping infliximab treatment, died of a ruptured blood vessel in the abdomen. At autopsy a plasma cell dyscrasia was found. CONCLUSION Infliximab is safe and effective in treating those patients with multisystem sarcoidosis who are either refractory or develop side effects to a standard regimen of corticosteroids and immunosuppressive agents.
Collapse
Affiliation(s)
- Samer Saleh
- Department of Medicine, Pulmonary & Critical Care Division, University of Southern California, 1200N, State St., GNH 11900, Los Angeles, CA 90033, USA
| | | | | | | | | |
Collapse
|
39
|
Abstract
BACKGROUND Tumor necrosis factor-alpha (TNF-a) is a proinflammatory cytokine that plays an immunomodulatory role in a variety of systemic and dermatologic diseases. Currently, three anti-TNF-a drugs are available in North America- infliximab (approved in the U.S. for the treatment of rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, ulcerative colitis, and psoriatic arthritis), etanercept (approved in the U.S. for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis), and adalimumab (approved for the treatment of rheumatoid arthritis and psoriatic arthritis). OBJECTIVE To review the current literature supporting alternative (and currently off-label) dermatologic uses of TNF-a antagonists. METHODS A MEDLINE search (1966-March 2005) was conducted using the keywords "infliximab," "etanercept," "adalimumab," "TNF inhibitors," and "off-label" to identify published reports of off-label dermatologic uses of TNF-a inhibitors. RESULTS Anti-TNF-a therapies have been reported in the following dermatologic diseases: sarcoidosis, hidradenitis suppuritiva, cicatricial pemphigoid, Behçet's disease, pyoderma gangrenosum, multicentric reticulohistiocytosis, apthous stomatitis, Sneddon-Wilkinson disease, SAPHO syndrome, pityriasis rubra pilaris, eosinophilic fasciitis, panniculitis, Crohn's disease, necrobiosis lipoidica diabeticorum, dermatomyositis, and scleroderma. The vast majority of these reports are in the form of individual case reports and small case series. Only two published randomized controlled trials involving the off-label use of a TNF inhibitor were found. CONCLUSIONS A growing number of published reports suggest that anti-TNF-a therapies may be effective in the treatment of numerous inflammatory skin diseases outside their currently approved indications.
Collapse
Affiliation(s)
- Andrew F Alexis
- Department of Dermatology, St. Luke's-Roosevelt Hospital Center, New York, NY, USA
| | | |
Collapse
|
40
|
Affiliation(s)
- Leonid Izikson
- Department of Dermatology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, 195 Lothrop Street, Suite 145 Lothrop Hall, Pittsburgh, PA 15213, USA
| | | |
Collapse
|
41
|
Gary A, Modeste AB, Richard C, Jubert C, Majour F, Nouvet G, Remond B, Joly P. [Methotrexate for the treatment of patients with chronic cutaneous sarcoidosis: 4 cases]. Ann Dermatol Venereol 2005; 132:659-62. [PMID: 16230915 DOI: 10.1016/s0151-9638(05)79413-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pathogenesis of sarcoidosis remains partially unknown. Cutaneous lesions are frequent (20 to 35% of cases). Their clinical features and follow-up data are highly variable. Numerous treatments have been proposed. The clinical features and follow up data of four patients with chronic cutaneous sarcoidosis treated with methotrexate are reported. CASE REPORT Mean age of patients (3 female, 1 male) was 40 years old (34-49 years). One patient presented with a lupus pernio, two patients with papules and nodules, and the last with an annular lesion of the face. All patients had been previously treated with topical corticosteroids and/or hydroxychloroquine without any success. Patients were treated with methotrexate at doses ranging from 12.5 mg to 30 mg per week for at least 6 months. Complete remission of cutaneous lesions was observed in 3 of 4 patients after a mean treatment duration of 29 months (16 to 36). Methotrexate side effects were observed in one patient (elevated liver enzymes) leading to methotrexate discontinuation. DISCUSSION Methotrexate seems to be an effective treatment of cutaneous sarcoidosis. It should be used namely in patients who failed to respond to previous treatments with topical corticosteroids or antimalarial drugs.
Collapse
Affiliation(s)
- A Gary
- Clinique Dermatologique, CHU de Rouen
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Philips MA, Lynch J, Azmi FH. Ulcerative cutaneous sarcoidosis responding to adalimumab. J Am Acad Dermatol 2005; 53:917. [PMID: 16243166 DOI: 10.1016/j.jaad.2005.02.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Revised: 02/08/2005] [Accepted: 02/14/2005] [Indexed: 10/25/2022]
|
43
|
Isolated sarcoid granulomatous interstitial nephritis responding to infliximab therapy. Am J Kidney Dis 2005; 45:411-4. [PMID: 15685521 DOI: 10.1053/j.ajkd.2004.10.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sarcoidosis is a systemic disease with multiorgan involvement. In children, renal impairment of sarcoidosis usually is caused by either hypercalcemia leading to nephrocalcinosis or interstitial nephritis with or without granulomata. We report the case of a 13-year-old boy presenting with severe arterial hypertension and acute renal failure caused by an isolated sarcoid granulomatous interstitial nephritis (GIN). Other known causes of GIN, eg, drug intake or fungal or mycobacterial infection, were excluded, and there was no evidence of extrarenal sarcoid involvement. Renal function improved initially with prednisone treatment. Blood pressure was controlled using ramipril, nifedipine, furosemide, dihydralazine, and metoprolol. Later, the patient showed signs of severe steroid toxicity and progressive renal failure. Monthly treatment with infliximab, a tumor necrosis factor-alpha antibody, was started, resulting in steady improvement in renal function and resolution of renal granulomata. In addition, antihypertensive medication could be reduced, and low-dose prednisone therapy was maintained. To our knowledge, this is the first report of successful treatment with infliximab of a patient with sarcoid GIN.
Collapse
|
44
|
Groves R. Cytokine and anti-cytokine therapy in the treatment of inflammatory skin disease. Cytokine 2005; 28:162-6. [PMID: 15588690 DOI: 10.1016/j.cyto.2004.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Revised: 07/21/2004] [Accepted: 07/21/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Richard Groves
- Department of Academic Dermatology, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
| |
Collapse
|
45
|
Hochberg MC, Lebwohl MG, Plevy SE, Hobbs KF, Yocum DE. The Benefit/Risk Profile of TNF-Blocking Agents: Findings of a Consensus Panel. Semin Arthritis Rheum 2005; 34:819-36. [PMID: 15942917 DOI: 10.1016/j.semarthrit.2004.11.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To review the benefits and risks associated with the use of the tumor necrosis factor (TNF)-blockers in various indications (eg, rheumatoid arthritis [RA], Crohn's disease [CD], psoriasis). METHODS The members of the consensus panel were selected based on their expertise. Centocor, Inc provided an educational grant to the Center for Health Care Education to facilitate the consensus panel. Peer-reviewed articles discussing clinical studies and clinical experiences with TNF-blockers form the basis of this review. Emerging data that have not been peer-reviewed are also included. RESULTS The TNF-blockers infliximab, etanercept, and adalimumab are all approved for treatment of RA. All 3 are effective, and there are currently no published data from head-to-head clinical trials to support using 1 agent over another. Preliminary data from small, retrospective studies indicate that switching among agents to overcome inadequate efficacy or poor tolerability is beneficial in some patients. The only TNF-blocker currently approved for the induction and maintenance of remission in CD is infliximab. Preliminary data indicate that etanercept and infliximab are effective in treating psoriasis. Some risks associated with TNF-blockers have become apparent, including congestive heart failure, demyelinating diseases, and systemic lupus erythematosus, but in most cases can be identified and managed. Several of these risks (eg, lymphoma and serious infections) are associated with either the condition per se or the concomitant medication use. Simple screening procedures help manage the risk of tuberculosis infection; however, it is recommended that physicians and patients be alert to the development of any new infection so that appropriate treatment may be initiated promptly. Rare infusion reactions, particularly with infliximab, may also be effectively managed. CONCLUSION TNF-blockers are effective and may be safely used for short- and long-term management of RA or CD. TNF-blockers also show efficacy in other emerging indications.
Collapse
Affiliation(s)
- Marc C Hochberg
- Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore 21201, USA.
| | | | | | | | | |
Collapse
|
46
|
Abstract
Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.
Collapse
Affiliation(s)
- H Nunes
- Service de Pneumologie, Hôpital Avicenne, GHU Nord, Assistance Publique Hôpitaux de Paris et Faculté de Médecine, Université Paris, Bobigny, France
| | | | | |
Collapse
|
47
|
Abstract
BACKGROUND/OBJECTIVES Many patients with sarcoidosis are unable to tolerate corticosteroids or alternative therapeutic agents due to side effects or have disease refractory to these agents. We report our experience using infliximab to treat such patients. METHODS A group of patients in whom traditional sarcoidosis therapy failed, either due to drug failure or intolerable side effects, were prescribed infliximab. Their charts were retrospectively reviewed. RESULTS Ten patients receiving infliximab were reviewed. Nine of the 10 patients reported a symptomatic improvement with therapy, and all 10 demonstrated objective evidence of improvement. A drug reaction developed in one patient after several months of therapy, oral candidiasis developed in one patient, and angioimmunoblastic lymphoma developed in another patient. The corticosteroid dose was reduced in five of the six patients who were receiving corticosteroids at the time of infliximab therapy. CONCLUSION Infliximab appears to be an effective, safe treatment for patients with refractory sarcoidosis, including such manifestations as lupus pernio, uveitis, hepatic sarcoidosis, and neurosarcoidosis. Infliximab appears to be steroid sparing. Patients receiving the drug should be screened for latent tuberculosis and lymphoproliferative disorders.
Collapse
Affiliation(s)
- John D Doty
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 812-CSB, PO Box 250623, Charleston, SC 29425, USA
| | | | | |
Collapse
|
48
|
Phillips K, Weinblatt M. Granulomatous lung disease occurring during etanercept treatment. ACTA ACUST UNITED AC 2005; 53:618-20. [PMID: 16082636 DOI: 10.1002/art.21336] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
49
|
Abstract
BACKGROUND Von Zumbusch pustular psoriasis is a severe, generalized form of psoriasis. Patients may also suffer from systemic complications, such as fever, arthropathy, congestive heart failure, and infections, which can ultimately prove fatal. Generalized pustular psoriasis can often be recalcitrant, making treatment difficult. OBJECTIVE The purpose of this study was to demonstrate the efficacy of infliximab in treating generalized pustular psoriasis. METHODS Four consecutively admitted patients with generalized pustular psoriasis were treated with infliximab 5 mg/kg intravenous infusion. RESULTS After treatment with infliximab, white blood cell count, sedimentation rate, C-reactive protein, and vital signs normalized in all 4 patients within 24 h of the infusion. PASI scores on discharge had improved in all 4 patients. CONCLUSION All 4 patients with generalized pustular psoriasis had rapid and positive responses to infliximab without any significant side effects. This experience adds support to the use of infliximab for generalized pustular psoriasis.
Collapse
Affiliation(s)
- Jennifer T Trent
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida 33136, USA
| | | |
Collapse
|
50
|
|