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Lanzillotta M, Culver E, Sharma A, Zen Y, Zhang W, Stone JH, Della-Torre E. Fibrotic phenotype of IgG4-related disease. THE LANCET. RHEUMATOLOGY 2024; 6:e469-e480. [PMID: 38574746 DOI: 10.1016/s2665-9913(23)00299-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/13/2023] [Accepted: 10/31/2023] [Indexed: 04/06/2024]
Abstract
A prompt response to glucocorticoids is a clinical hallmark of IgG4-related disease. However, manifestations characterised by prominent tissue fibrosis on histological examination can be less responsive to glucocorticoid therapy than other types of IgG4-related disease. These manifestations include retroperitoneal fibrosis, fibrosing mediastinitis, Riedel thyroiditis, orbital pseudotumor, and hypertrophic pachymeningitis, among others. To explain this discrepancy, a preliminary distinction into proliferative and fibrotic phenotypes of IgG4-related disease has been proposed on the basis of clinical presentation, pathological features, and response to immunosuppressive therapy. Implications of this classification for patient management remain an important area of investigation. In this Series paper, we aim to dissect the pathophysiology of tissue fibrosis in IgG4-related disease and discuss how clinicians should approach the management of fibrotic manifestations of IgG4-related disease based on the most recent diagnostic and therapeutic developments.
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Affiliation(s)
- Marco Lanzillotta
- Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma Culver
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Amita Sharma
- Thoracic Imaging and Intervention Division, Massachusetts General Hospital, Boston, MA, USA
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital and King's College London, London, UK
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Batani V, Minici C, Sanvito F, Venturini E, Della-Torre E. Interleukin-6 inhibition for the treatment of IgG4 related vasculitis. Eur J Intern Med 2023; 118:149-151. [PMID: 37722930 DOI: 10.1016/j.ejim.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/20/2023]
Affiliation(s)
- Veronica Batani
- Università Vita-Salute San Raffaele; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR)
| | - Claudia Minici
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR)
| | | | - Elena Venturini
- Unit of Clinical and Experimental Radiology, Experimental Imaging Center. All at IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR).
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Perugino C, Culver EL, Khosroshahi A, Zhang W, Della-Torre E, Okazaki K, Tanaka Y, Löhr M, Schleinitz N, Falloon J, She D, Cimbora D, Stone JH. Efficacy and Safety of Inebilizumab in IgG4-Related Disease: Protocol for a Randomized Controlled Trial. Rheumatol Ther 2023; 10:1795-1808. [PMID: 37792260 PMCID: PMC10654302 DOI: 10.1007/s40744-023-00593-7] [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: 07/11/2023] [Accepted: 08/08/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is a debilitating multiorgan disease characterized by recurring flares leading to organ dysfunction, decreased quality of life, and mortality. Glucocorticoids, the standard of care for IgG4-RD, are associated with substantial treatment-related toxicity. Inebilizumab, an antibody directed against CD19, mediates the rapid and durable depletion of CD19+ B cells thought to be involved in IgG4-RD pathogenesis. We describe the first international, prospective, double-blind, placebo-controlled trial to evaluate the safety and efficacy of B-cell depletion for flare prevention in IgG4-RD (MITIGATE). METHODS The study was designed by an international panel of physicians with expertise in IgG4-RD. Critical trial design decisions included the selection of participants, definition of clinically meaningful primary and secondary endpoints, accommodation of standard of care, and development of flare diagnostic criteria. The study is approved for conduct in 22 countries. PLANNED OUTCOMES The primary efficacy endpoint is time from randomization to the occurrence of the first centrally adjudicated and investigator-treated disease flare during the 1-year randomized controlled period. A set of novel, organ-specific flare diagnostic criteria were developed specifically for this trial, incorporating symptoms and signs, laboratory findings, imaging study results, and pathology data. MITIGATE aims to accrue 39 flares for the primary endpoint, which provides sufficient power to detect a relative risk reduction of 65% in the inebilizumab group. It is anticipated that enrollment of 160 participants will achieve this goal. Additional endpoints include safety, annualized flare rate, flare-free complete remission, quality-of-life measures, and cumulative glucocorticoid use. MITIGATE represents the first randomized, double-blind, placebo-controlled trial of any treatment strategy conducted in IgG4-RD. Data from this study will provide insights into the natural history and pathophysiology of IgG4-RD and the efficacy and safety of B-cell depletion as a therapeutic avenue. TRIAL REGISTRATION NCT04540497.
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Affiliation(s)
- Cory Perugino
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arezou Khosroshahi
- Division of Rheumatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), San Raffaele Hospital, Milan, Italy
| | - Kazuichi Okazaki
- Department of Internal Medicine, Kansai Medical University Kori Hospital, Osaka, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Matthias Löhr
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Schleinitz
- Département de Medecine Interne, CHU Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | | | - Dewei She
- Horizon Therapeutics, Rockville, MD, USA
| | | | - John H Stone
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
- Rheumatology Unit, Massachusetts General Hospital, 55 Fruit Street, Suite Yawkey 4, Boston, MA, 02114, USA.
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Lanzillotta M, Mapelli P, Dagna L, Della-Torre E. B-cell depletion with obinutuzumab for the treatment of IgG4-related disease. Eur J Intern Med 2023; 116:155-156. [PMID: 37481424 DOI: 10.1016/j.ejim.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Marco Lanzillotta
- Università Vita-Salute San Raffaele, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS-San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy.
| | - Paola Mapelli
- Università Vita-Salute San Raffaele, Italy; Nuclear Medicine Department, All at IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Università Vita-Salute San Raffaele, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS-San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS-San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
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Alexander T, Burmester GR. Obexelimab in IgG4-related disease: B-cell inhibition as a novel therapeutic approach. THE LANCET. RHEUMATOLOGY 2023; 5:e428-e429. [PMID: 38251568 DOI: 10.1016/s2665-9913(23)00184-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Deutsches Rheuma-Forschungszentrum, Leibniz Institute, Autoimmunology Group, Berlin, Germany
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany.
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