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Cavanaugh C, Orroth K, Qian X, Kumparatana P, Klyachkin Y, Colgan S, Cordey M. Diabetes and obesity burden and improvements in cardiometabolic parameters in patients with psoriasis or psoriatic arthritis receiving apremilast in a real-world setting. JAAD Int 2024; 16:244-251. [PMID: 39072263 PMCID: PMC11279948 DOI: 10.1016/j.jdin.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 07/30/2024] Open
Abstract
Introduction Patients with psoriasis and psoriatic arthritis have a higher prevalence of cardiometabolic comorbidities compared to the general population. Clinical data suggest apremilast may reduce weight and glycated hemoglobin (HbA1c). Objective To describe changes in cardiometabolic parameters among patients with psoriasis and psoriatic arthritis newly treated with apremilast by prediabetes/diabetes or obesity status. Methods This was a retrospective cohort study of electronic medical records from patients with psoriasis and/or psoriatic arthritis in the OM1 Real-World Data Cloud who newly initiated apremilast. Changes from baseline in body mass index, weight, HbA1c, and lipids were evaluated at 6 and 12 months using a multivariable linear regression model stratified by prediabetes/diabetes or obesity status. Results Of 8487 patients initiating apremilast, 24% had diabetes. Of 8250 patients with body mass index available, 27% were obese and 34% were severely obese. Patients experienced decreases in body mass index and weight at 6 and 12 months regardless of diabetes or obesity status, with the greatest reductions seen in those with diabetes and obesity. Reductions in HbA1c at 6 months were seen in patients without diabetes and patients with severe obesity. Conclusions Treatment with apremilast may provide the greatest cardiometabolic benefit to those with the greatest burden of cardiometabolic disease.
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Affiliation(s)
| | | | - Xi Qian
- OM1, Inc, Boston, Massachusetts
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Williams JC, Hum RM, Rogers K, Maglio C, Alam U, Zhao SS. Metabolic syndrome and psoriatic arthritis: the role of weight loss as a disease-modifying therapy. Ther Adv Musculoskelet Dis 2024; 16:1759720X241271886. [PMID: 39161788 PMCID: PMC11331474 DOI: 10.1177/1759720x241271886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 07/02/2024] [Indexed: 08/21/2024] Open
Abstract
Psoriatic arthritis (PsA) is an inflammatory joint and entheseal disease associated with significant personal and public health burden. PsA has a prevalence of up to 1%, affecting ~20% of people suffering with psoriasis. PsA is frequently accompanied by metabolic syndrome (MetS), and both conditions are characterised by a chronic pro-inflammatory state, with several key cytokines in PsA (interleukin (IL)-17 and IL-23) also elevated in those with MetS. This narrative review aims to provide an update on MetS in PsA, focusing on its prevalence, pathogenesis, prognosis, treatment interactions and future therapeutic options. MetS is particularly prevalent in PsA compared to other inflammatory arthritides. Cohort studies indicate a higher risk of PsA in individuals with obesity, while Mendelian randomization studies link childhood obesity, insulin resistance, and dyslipidaemia to PsA. Weight loss interventions have been shown to reduce disease activity in PsA. Additionally, MetS negatively impacts the efficacy of tumour necrosis factor inhibitor (TNFi) drugs in treating PsA. Drugs given for PsA may also affect the conditions constituting MetS. Leflunomide has been shown to reduce body weight but also increase blood pressure. TNFi drugs lead to weight gain but reduce cardiovascular risk. Janus kinase inhibitors increase lipid levels and cardiovascular risk among high-risk groups. Anti-IL-17 and anti-IL-12/IL-23 drugs may cause a short-term increase in cardiovascular risk, although the long-term effects have yet to be established. Weight loss represents an unexplored avenue for disease modification in PsA, alongside a plethora of general health benefits. Dietary and exercise modifications are the cornerstone of weight management but vary substantially across individuals. Novel therapies to treat weight loss, such as glucagon-like peptide 1 agonists and sodium-glucose cotransporter 2 inhibitors, may prove useful alongside disease-modifying therapies for those with PsA and MetS and should be investigated as potential therapeutic adjuncts.
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Affiliation(s)
- Jacob Corum Williams
- NIHR/Wellcome Trust Clinical Research Facility, Manchester University NHS Foundation Trust, Grafton St, Manchester M13 9WL, UK
| | - Ryan Malcolm Hum
- Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kira Rogers
- School of Medical Sciences, University of Manchester, Manchester, UK
| | - Cristina Maglio
- Department of Rheumatology and Inflammation Research, University of Gothenburg, Gothenburg, Sweden
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
| | - Sizheng Steven Zhao
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Science, School of Biological Sciences, The University of Manchester, Manchester, UK
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Barbarroja N, López-Medina C, Escudero-Contreras A, Arias-de la Rosa I. Clinical and molecular insights into cardiovascular disease in psoriatic patients and the potential protective role of apremilast. Front Immunol 2024; 15:1459185. [PMID: 39170613 PMCID: PMC11335487 DOI: 10.3389/fimmu.2024.1459185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024] Open
Abstract
Psoriatic disease, encompassing both psoriasis (Pso) and psoriatic arthritis (PsA), is closely intertwined with a significantly elevated risk of developing cardiovascular diseases. This connection is further compounded by a higher prevalence of cardiometabolic comorbidities, including type 2 diabetes, obesity, insulin resistance, arterial hypertension, and dysregulated lipid profiles. These comorbidities exceed the rates seen in the general population and compound the potential for increased mortality among those living with this condition. Recognizing the heightened cardiometabolic risk inherent in psoriatic disease necessitates a fundamental shift in the treatment paradigm. It is no longer sufficient to focus solely on mitigating inflammation. Instead, there is an urgent need to address and effectively manage the metabolic parameters that have a substantial impact on cardiovascular health. Within this context, apremilast emerges as a pivotal treatment option for psoriatic disease. What sets apremilast apart is its dual-action potential, addressing not only inflammation but also the critical metabolic parameters. This comprehensive treatment approach opens up new opportunities to improve the well-being of people living with psoriatic disease. This review delves into the multifaceted aspects involved in the development of cardiovascular disease and its intricate association with psoriatic disease. We then provide an in-depth exploration of the pleiotropic effects of apremilast, highlighting its potential to simultaneously mitigate metabolic complications and inflammation in individuals affected by these conditions.
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Affiliation(s)
- Nuria Barbarroja
- Rheumatology Service, Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), University of Cordoba, Reina Sofia University Hospital, Córdoba, Spain
| | | | | | - Iván Arias-de la Rosa
- Rheumatology Service, Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), University of Cordoba, Reina Sofia University Hospital, Córdoba, Spain
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Campione E, Zarabian N, Cosio T, Borselli C, Artosi F, Cont R, Sorge R, Shumak RG, Costanza G, Rivieccio A, Gaziano R, Bianchi L. Apremilast as a Potential Targeted Therapy for Metabolic Syndrome in Patients with Psoriasis: An Observational Analysis. Pharmaceuticals (Basel) 2024; 17:989. [PMID: 39204094 PMCID: PMC11357209 DOI: 10.3390/ph17080989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 09/03/2024] Open
Abstract
Psoriasis (PsO) is a chronic inflammatory dermatosis that often presents with erythematous, sharply demarcated lesions. Although psoriasis is primarily a dermatological disease, its immune-mediated pathogenesis produces systemic effects and is closely associated with various comorbid conditions such as cardiovascular disease (CVD), metabolic syndrome (MetS), and diabetes mellitus type II (DMII). Apremilast, an oral phosphodiesterase 4 (PDE-4) inhibitor, has shown promise in treating moderate-to-severe psoriasis and is associated with potential cardiometabolic benefits. In a 12-month prospective observational study involving 137 patients with moderate-to-severe psoriasis, we assessed changes in psoriasis clinimetric scores and metabolic profiles from baseline (T0) to 52 weeks (T1) to evaluate the efficacy of apremilast. After 52 weeks of apremilast treatment, we documented a statistically significant decrease in low-density lipoprotein (LDL) and total cholesterol, triglycerides, and glucose levels. Our findings even suggest a potential synergistic effect among patients treated with apremilast, alongside concomitant statin and/or insulin therapy. Although the results of our study must be validated on a larger scale, the use of apremilast in the treatment of psoriatic patients with cardio-metabolic comorbidities yields promising results.
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Affiliation(s)
- Elena Campione
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Nikkia Zarabian
- School of Medicine and Health Sciences, George Washington University, 2300 I St NW, Washington, DC 20052, USA;
| | - Terenzio Cosio
- Department of Experimental Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (T.C.); (R.G.)
- Dynamyc Research Team 7380, Université de Paris-Est-Créteil, 94000 Créteil, France
| | - Cristiana Borselli
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Fabio Artosi
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Riccardo Cont
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Roberto Sorge
- Laboratory of Biometry, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Ruslana Gaeta Shumak
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Gaetana Costanza
- Unit of Virology, Department of Experimental Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy;
| | - Antonia Rivieccio
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
| | - Roberta Gaziano
- Department of Experimental Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (T.C.); (R.G.)
| | - Luca Bianchi
- Dermatology Unit, Department of Systems Medicine, Tor Vergata University Hospital, 00133 Rome, Italy; (C.B.); (F.A.); (R.C.); (R.G.S.); (A.R.); (L.B.)
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Malone SG, Davis CN, Piserchia Z, Setzer MR, Toikumo S, Zhou H, Winterlind EL, Gelernter J, Justice A, Leggio L, Rentsch CT, Kranzler HR, Gray JC. Alcohol use disorder and body mass index show genetic pleiotropy and shared neural associations. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.03.24306773. [PMID: 38746260 PMCID: PMC11092735 DOI: 10.1101/2024.05.03.24306773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background The prevalence of co-occurring heavy alcohol consumption and obesity is increasing in the United States. Despite neurobiological overlap in the regulation of alcohol consumption and eating behavior, alcohol- and body mass index (BMI)-related phenotypes show no or minimal genetic correlation. We hypothesized that the lack of genetic correlation is due to mixed effect directions of variants shared by AUD and BMI. Methods We applied MiXeR, to investigate shared genetic architecture between AUD and BMI in individuals of European ancestry. We used conjunctional false discovery rate (conjFDR) analysis to detect loci associated with both phenotypes and their directional effect, Functional Mapping and Annotation (FUMA) to identify lead single nucleotide polymorphisms (SNPs), Genotype-Tissue Expression (GTEx) samples to examine gene expression enrichment across tissue types, and BrainXcan to evaluate the shared associations of AUD and BMI with brain image-derived phenotypes. Results MiXeR analysis indicated polygenic overlap of 80.9% between AUD and BMI, despite a genetic correlation (r g ) of -.03. ConjFDR analysis yielded 56 lead SNPs with the same effect direction and 76 with the opposite direction. Of the 132 shared lead SNPs, 53 were novel for both AUD and BMI. GTEx analyses identified significant overexpression in the frontal cortex (BA9), hypothalamus, cortex, anterior cingulate cortex (BA24), hippocampus, and amygdala. Amygdala and caudate nucleus gray matter volumes were significantly associated with both AUD and BMI in BrainXcan analyses. Conclusions More than half of variants significantly associated with AUD and BMI had opposite directions of effect for the traits, supporting our hypothesis that this is the basis for their lack of genetic correlation. Follow-up analyses identified brain regions implicated in executive functioning, reward, homeostasis, and food intake regulation. Together, these findings clarify the extensive polygenic overlap between AUD and BMI and elucidate several overlapping neurobiological mechanisms.
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Sen R, Caplan L, Danila MI. Cardiovascular disease in spondyloarthritis: a narrative review of risk factors and the effect of treatments. Curr Opin Rheumatol 2024; 36:95-107. [PMID: 38126207 DOI: 10.1097/bor.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the recent evidence available regarding the epidemiology of cardiovascular disease in spondyloarthritis (SpA), including the effect of disease modifying drugs on cardiovascular risk. RECENT FINDINGS People with SpA suffer from an increased risk of cardiovascular disease compared to the general population. This elevated risk is explained by the high prevalence of traditional cardiovascular risk factors and inflammation from disease activity leading to endothelial dysfunction and accelerated atherosclerosis. Consequently, the American College of Cardiology/American Heart Association and the European League Against Rheumatism recommend enhanced cardiovascular risk screening in SpA patients. There is evidence from observational studies that methotrexate and tumor necrosis factor inhibitors reduce the risk of cardiovascular events in SpA. Unlike what is observed in the general population, the use of nonsteroidal anti-inflammatory drugs does not appear to increase cardiovascular disease risk in SpA. SUMMARY Cardiovascular diseases are increasingly recognized in patients suffering from SpA, especially axial SpA and psoriatic arthritis. Cardiovascular diseases can cause significant morbidity, mortality, and add to the overall disease burden. Disease modifying drugs may mitigate some of the cardiovascular risk; however, a multidisciplinary team is needed to monitor patients and improve cardiovascular health status.
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Affiliation(s)
- Rouhin Sen
- The University of Alabama Birmingham, Division of Clinical Immunology and Rheumatology
- Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, Alabama
| | - Liron Caplan
- Rocky Mountain Regional VAMC
- University of Colorado, Division of Rheumatology, Aurora, Colorado, USA
| | - Maria I Danila
- The University of Alabama Birmingham, Division of Clinical Immunology and Rheumatology
- Birmingham Veterans Affairs Medical Center (VAMC), Birmingham, Alabama
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Queiro R, Loredo M, Braña I, Pardo E, Alonso S, Alperi M. Managing psoriatic arthritis in different clinical scenarios. Expert Rev Clin Immunol 2023; 19:1469-1484. [PMID: 37589128 DOI: 10.1080/1744666x.2023.2249235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Psoriatic arthritis (PsA) is a chronic, immune-mediated disease characterized by synovio-entheseal inflammation. It is estimated to affect around 30% of patients with psoriasis and significantly reduces patients' physical function and quality of life. There is a growing number of treatment options for PsA, but due to the heterogeneous clinical features of the disease and prevalence of comorbidities, managing PsA can be challenging. AREAS COVERED In this article, we review current understanding of the disease and available pharmacological options. Based on published treatment guidelines, emerging evidence and clinical experience, we provide our expert opinion on treatment strategies, taking into consideration the predominant disease domain and the presence of comorbidities, which can impact treatment decisions and clinical outcomes. EXPERT OPINION Biological and targeted synthetic disease-modifying agents are dramatically improving the lives of patients with PsA. Biosimilar TNF inhibitors offer a particularly versatile and cost-effective option, whilst newer biologics and targeted synthetic molecules that can be used to treat most domains of psoriatic disease are an attractive alternative to TNF inhibitors. Despite a lack of consensus on treatment sequencing and tapering, it is important that PsA patients, especially those with comorbidities, are looked after by a multidisciplinary team to optimize their care.
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Affiliation(s)
- Rubén Queiro
- Rheumatology & ISPA Translational Immunology Division, Central University Hospital of Asturias, Oviedo, Spain
- Department of Medicine, Oviedo University School of Medicine, Oviedo, Spain
| | - Marta Loredo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Ignacio Braña
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Estefanía Pardo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Sara Alonso
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Mercedes Alperi
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
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Blake T, Gullick NJ, Hutchinson CE, Bhalerao A, Wayte S, Weedall A, Barber TM. More than skin-deep: visceral fat is strongly associated with disease activity, function and metabolic indices in psoriatic disease. Arthritis Res Ther 2023; 25:108. [PMID: 37353811 PMCID: PMC10288730 DOI: 10.1186/s13075-023-03085-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/04/2023] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVE To compare body composition between patients with psoriatic disease (PsD), including cutaneous psoriasis (PsO) and psoriatic arthritis (PsA), and controls, and to explore associations between disease activity and measures of function and metabolic derangement. METHODS Body composition was assessed by air displacement plethysmography (ADP) and MRI-derived fat segmentation using an automated pipeline (FatSegNet). Function was assessed by Health Assessment Questionnaire (HAQ) and metabolic status by fasting lipid profile, insulin and adiponectin. Active and inactive PsO and PsA were defined by body surface area (BSA) and Psoriasis Area Severity Index (PASI) and minimal disease activity (MDA), respectively. RESULTS Thirty patients (median disease duration 15 years; median age 52 years) and 30 BMI-matched controls were enrolled. Compared with controls, all MRI-derived body composition parameters-whole-body volume, subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), abdominal adipose tissue (AAT), VAT/AAT and VAT/SAT-were higher in the PsD group, specifically, those with active disease. Body mass, body fat, whole-body volume and whole-body VAT were correlated with higher triglycerides, cholesterol:HDL (high-density lipoprotein), insulin resistance and lower adiponectin as well as higher HAQ and lower MDA. CONCLUSIONS In this pilot study, patients with PsD revealed excessive total adipose tissue and a greater volume of metabolically unfavourable ectopic fat, including VAT, compared with BMI-matched controls, which also correlated with HAQ, disease activity and overall dysmetabolism. We also provide the first evidence in patients with PsD for the clinical application of FatSegNet: a novel, automated and rapid deep learning pipeline for providing accurate MRI-based measurement of fat segmentation. Our findings suggest the need for a more integrated approach to the management of PsD, which considers both the metabolic and inflammatory burden of disease. More specifically, visceral fat is a surrogate marker of uncontrolled PsD and may be an important future target for both pharmacological and lifestyle interventions.
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Affiliation(s)
- Tim Blake
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK.
| | - Nicola J Gullick
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Charles E Hutchinson
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Abhir Bhalerao
- Department of Computer Science, University of Warwick, Coventry, CV4 7EZ, UK
| | - Sarah Wayte
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Andrew Weedall
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
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Gialouri CG, Pappa M, Evangelatos G, Nikiphorou E, Fragoulis GE. Effect of body mass index on treatment response of biologic-/targeted synthetic-DMARDs in patients with rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. A systematic review. Autoimmun Rev 2023; 22:103357. [PMID: 37150489 DOI: 10.1016/j.autrev.2023.103357] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Overweight and/or obese patients with inflammatory arthritis (IA) have higher disease activity and lower chances of achieving and/or maintaining the treatment targets. Weight/obesity also appears to negatively affect the response to tumor necrosis factor (TNF) inhibitors in patients with IA, including rheumatoid arthritis -RA, psoriatic arthritis -PsA, axial spondyloarthritis -AxSpA. We conducted a systematic literature review (SLR) for the effect of weight/body-mass-index (BMI) in the efficacy of all approved b- and targeted-synthetic (ts)- DMARDs for the treatment of IA. METHODS For this PROSPERO-registered SLR, we searched PubMed, Scopus and Cohrane-Library from inception up to June 21st 2022. Clinical-trials (randomized and non-randomized) and observational studies of RA, PsA or AxSpA patients that reported the effect of weight/BMI on response (all possible outcomes) to b/ts-DMARDs were included. Risk-of-bias was assessed via RoB2-Cochrane-tool and Newcastle-Ottawa-scale for randomized and non-randomized studies, respectively. FINDINGS Out of 996 references, 75 eventually fulfilled the inclusion criteria (of which 10 studies were retrieved through manual-search). Among the included studies (TNF-inhibitors: 34, IL-12/23 inhibitors: 4, IL-23 inhibitor: 1, IL-17 inhibitors: 7, tocilizumab: 18, abatacept: 8, rituximab: 3, JAK-inhibitors: 5), most had medium RoB. Efficacy of TNF-inhibitors was affected by BMI in all forms of IA. Data are not robust to compare the effect among various TNF-inhibitors. In contrast, favorable results of IL-23 and IL-17 inhibitors did not appear to be influenced by increased BMI in PsA or AxSpA patients. Similar evidence exists for tocilizumab (in RA) and for abatacept (in RA and PsA), while no conclusion can be drawn for rituximab. More data are needed for JAK-inhibitors, although the effect of weight/BMI does not seem to be significant so far. INTERPRETATION Weight/BMI should be considered in the treatment-plan of patients with IA, with its effect being more pronounced for TNF-inhibitors compared to other b/ts-DMARDs.
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Affiliation(s)
- Chrysoula G Gialouri
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece; Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, Medical School, National and Kapodistrian University of Athens, "Hippocration" General Hospital, Athens, Greece
| | - Maria Pappa
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece; Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Gerasimos Evangelatos
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece; Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK; Rheumatology Department, King's College Hospital, London, UK
| | - George E Fragoulis
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece; Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece.; Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK..
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Irelan D, Boyd A, Fiedler E, Lochmaier P, McDonough W, Aragon IV, Rachek L, Abou Saleh L, Richter W. Acute PDE4 Inhibition Induces a Transient Increase in Blood Glucose in Mice. Int J Mol Sci 2023; 24:ijms24043260. [PMID: 36834669 PMCID: PMC9963939 DOI: 10.3390/ijms24043260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
cAMP-phosphodiesterase 4 (PDE4) inhibitors are currently approved for the treatment of inflammatory diseases. There is interest in expanding the therapeutic application of PDE4 inhibitors to metabolic disorders, as their chronic application induces weight loss in patients and animals and improves glucose handling in mouse models of obesity and diabetes. Unexpectedly, we have found that acute PDE4 inhibitor treatment induces a temporary increase, rather than a decrease, in blood glucose levels in mice. Blood glucose levels in postprandial mice increase rapidly upon drug injection, reaching a maximum after ~45 min, and returning to baseline within ~4 h. This transient blood glucose spike is replicated by several structurally distinct PDE4 inhibitors, suggesting that it is a class effect of PDE4 inhibitors. PDE4 inhibitor treatment does not reduce serum insulin levels, and the subsequent injection of insulin potently reduces PDE4 inhibitor-induced blood glucose levels, suggesting that the glycemic effects of PDE4 inhibition are independent of changes in insulin secretion and/or sensitivity. Conversely, PDE4 inhibitors induce a rapid reduction in skeletal muscle glycogen levels and potently inhibit the uptake of 2-deoxyglucose into muscle tissues. This suggests that reduced glucose uptake into muscle tissue is a significant contributor to the transient glycemic effects of PDE4 inhibitors in mice.
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Affiliation(s)
- Daniel Irelan
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Abigail Boyd
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Edward Fiedler
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Peter Lochmaier
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Will McDonough
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Ileana V. Aragon
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Lyudmila Rachek
- Department of Pharmacology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Lina Abou Saleh
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
| | - Wito Richter
- Department of Biochemistry & Molecular Biology and Center for Lung Biology, Whiddon College of Medicine, University of South Alabama, Mobile, AL 36688, USA
- Correspondence:
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11
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Panagiotopoulos A, Fragoulis GE. Comorbidities in Psoriatic Arthritis: A Narrative Review. Clin Ther 2023; 45:177-189. [PMID: 36737317 DOI: 10.1016/j.clinthera.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/03/2023] [Accepted: 01/12/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Psoriatic arthritis (PsA) is a common type of inflammatory arthritis. Patients with PsA present with certain extra-articular manifestations and comorbidities (often collectively called psoriatic disease). The purpose of the present review was to highlight the main comorbidities in the setting of PsA. METHODS A narrative review was performed using data from articles found in a search of PubMed and Scopus using the terms psoriatic arthritis and comorbidities. FINDINGS Cardiovascular disease (CVD), as well as metabolic and mental health disorders, are the most common comorbidities in patients with PsA. In most cases, underlying inflammation seems to be involved in the increased risk for CVD in PsA, while a bidirectional relationship seems to operate between mental health disorders and psoriatic disease. The treatment of patients with PsA, especially with biologic disease-modifying antirheumatic drugs, has been shown to lead to favorable outcomes regarding the CVD risk. However, it is debatable whether specific drug classes are more effective than others or should be avoided in patients with CVD risk factors. Comorbidity of mental health disorders is even more complex, given the difficulties in measuring and reporting these comorbidities in clinical trials and in clinical practice. IMPLICATIONS Future studies are needed for a better understanding of the pathogenic mechanisms of, and the development of better protocols for the identification and treatment of patients with, comorbidities in patients with PsA. The education of clinicians, health care professionals in rheumatology, and patients could be useful in achieving this goal.
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Affiliation(s)
- Alexandros Panagiotopoulos
- Joint Academic Rheumatology Program, First Department of Propedeutic Internal Medicine, University of Athens, Athens, Greece
| | - George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propedeutic Internal Medicine, University of Athens, Athens, Greece; Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom.
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12
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Sattar N, Welsh P, Leslie WS, Thom G, McCombie L, Brosnahan N, Richardson J, Gill JM, Crawford L, Lean ME. Dietary weight-management for type 2 diabetes remissions in South Asians: the South Asian diabetes remission randomised trial for proof-of-concept and feasibility (STANDby). THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 9:100111. [PMID: 36777452 PMCID: PMC9904218 DOI: 10.1016/j.lansea.2022.100111] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022]
Abstract
Background We aimed to assess whether a structured weight management programme incorporating a total diet replacement (TDR) (3-5 months ∼850 kcal/day formula diet) weight loss phase is acceptable to people of South Asian ethnicity and can achieve type 2 diabetes (T2D) remissions similarly to other populations. Methods Adults of South Asian ethnicity, aged 18-65 years, with T2D for ≤4 years, and BMI 25-45 kg/m2 were recruited from primary care and social media, and randomised to commence TDR either immediately (iTDR), or delayed (dTDR) for 3-5 months as a usual care control arm during this period. Intervention effects were tested in randomised comparisons powered to detect significant weight loss, and in an expanded observational analysis to determine remission effect size, including both iTDR and dTDR groups. Acceptability in those recruited was explored by questionnaire and weight change. Trial registration Current Controlled Trials, ISRCTN10720065. Date of Registration 27/09/2017. Findings Twenty-five eligible individuals were recruited. Mean baseline (SD) age was 45.8 (11.1) years, weight 88.2 (13.7) kg, BMI 32.1 (3.8) kg/m2, HbA1c 60.4 (11.3) mmol/mol, liver fat by MRI 15.6 (9.4)%. In the RCT, mean(SD) weight change after TDR was -7.7 (7.2)% in the intervention group (n = 13), and -1.2 (1.4)% in the usual-care control group (n = 12) (p = 0.005), with T2D remission achieved by 5/13, compared to 0/12 respectively (p = 0.039). In the observational study, 23/25 started TDR and 19/23 participants completed the TDR phase. Median time spent in TDR was 105 days (IQR 77-134 days). T2D remission was achieved in 10/23 (43%), and weight changes were concordant with the RCT. Overall, 8/23 (35%) lost over 10% bodyweight. Absolute liver fat proportion near halved from 15.3% at the start of TDR to 8.6% (p < 0.001). Interpretation In UK-based South Asians, TDR-led weight loss and T2D remission rates are comparable to those observed in white cohorts, and the intervention was acceptable in most of those recruited. There is potential to further improve outcomes, but one-third lost >10% body weight, and the mechanism underpinning T2D remission appears similar, driven by weight change with loss of excess ectopic body-fat. Funding We gratefully acknowledge funding for the MRI scans from the, Miss MJM Smith Trust (registered charity: SC040586). No other external funds were provided for this trial. NS is supported by the British Heart Foundation Research Excellence Award (RE/18/6/34217).
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Affiliation(s)
- Naveed Sattar
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
- Corresponding author.
| | - Paul Welsh
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Wilma S. Leslie
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G31 2ER, UK
| | - George Thom
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G31 2ER, UK
| | - Louise McCombie
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G31 2ER, UK
| | - Naomi Brosnahan
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G31 2ER, UK
- Counterweight Ltd, London, UK
| | - Janice Richardson
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Jason M.R. Gill
- School of Cardiovascular and Metabolic Health, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Luisa Crawford
- NHS Forth Valley, Stirling Community Hospital, Livilands Gate, Stirling, FK8 2AU, UK
| | - Michael E.J. Lean
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G31 2ER, UK
- Corresponding author. Human Nutrition, School of Medicine, Dentistry and Nursing, R2.19, Level 2, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK.
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13
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Damiani G, Silocchi L. Dermatological management in special population affected by psoriasis: A case report of an amputated transgender with psoriasis treated with apremilast. DERMATOL SIN 2023. [DOI: 10.4103/ds.ds-d-22-00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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14
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Gelfand JM, Shin DB, Armstrong AW, Tyring SK, Blauvelt A, Gottlieb S, Lockshin BN, Kalb RE, Fitzsimmons R, Rodante J, Parel P, Manyak GA, Mendelsohn L, Noe MH, Papadopoulos M, Syed MN, Werner TJ, Wan J, Playford MP, Alavi A, Mehta NN. Association of Apremilast With Vascular Inflammation and Cardiometabolic Function in Patients With Psoriasis: The VIP-A Phase 4, Open-label, Nonrandomized Clinical Trial. JAMA Dermatol 2022; 158:1394-1403. [PMID: 36129688 PMCID: PMC9494263 DOI: 10.1001/jamadermatol.2022.3862] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/24/2022] [Indexed: 01/13/2023]
Abstract
Importance Psoriasis is an inflammatory condition associated with metabolic and cardiovascular disease. Apremilast, a phosphodiesterase 4 inhibitor, is commonly used for psoriasis and can cause weight loss. Objective To determine the association between apremilast and aortic vascular inflammation as assessed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), cardiometabolic markers (primary outcomes at week 16), and abdominal fat composition. Design, Setting, and Participants A single-arm, open-label, interventional, nonrandomized clinical trial in which the imaging and laboratory outcomes were measured by an investigator who was blinded to time was conducted between April 11, 2017, and August 17, 2021, at 7 dermatology sites in the United States. A total of 101 patients with moderate to severe psoriasis were screened, 70 enrolled, 60 completed week 16, and 39 completed week 52. Intervention Apremilast, 30 mg, twice daily. Main Outcomes and Measures Aortic vascular inflammation (measured by FDG-PET/CT), 68 cardiometabolic biomarkers, and abdominal fat composition (measured by CT) at week 16 and week 52 compared with baseline. Results The mean (SD) age of the 70 patients was 47.5 (14.6) years, 54 were male (77.1%), 4 were Black (5.7%), and 58 were White (82.9%). There was no change in aortic vascular inflammation at week 16 (target to background ratio, -0.02; 95% CI, -0.08 to 0.05; P = .61) or week 52 (target to background ratio, -0.07; 95% CI, -0.15 to 0.01; P = .09) compared with baseline. At week 16, potentially beneficial decreases in interleukin 1b, valine, leucine, isoleucine, fetuin A, and branched-chain amino acids were observed. At week 52 compared with baseline, potentially beneficial decreases in ferritin, β-hydroxybutyrate, acetone, and ketone bodies, with an increase in apolipoprotein A-1, were observed, but there was a reduction in cholesterol efflux. There was an approximately 5% to 6% reduction in subcutaneous and visceral adiposity at week 16 that was maintained at week 52. Conclusions and Relevance The findings of this nonrandomized clinical trial suggest that apremilast has a neutral association with aortic vascular inflammation, variable but generally beneficial associations with a subset of cardiometabolic biomarkers, and associations with reductions in visceral and subcutaneous fat, indicating that the drug may have an overall benefit for patients with cardiometabolic disease and psoriasis. Trial Registration ClinicalTrials.gov Identifier: NCT03082729.
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Affiliation(s)
- Joel M. Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Daniel B. Shin
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - April W. Armstrong
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Stephen K. Tyring
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston
| | | | - Scott Gottlieb
- Dermatology and Skin Surgery Center, Exton, Pennsylvania
| | | | - Robert E. Kalb
- SUNY at Buffalo School of Medicine and Biomedical Sciences, Department of Dermatology, Buffalo Medical Group, Buffalo, New York
| | - Robert Fitzsimmons
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Justin Rodante
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Philip Parel
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Grigory A. Manyak
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Laurel Mendelsohn
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Megan H. Noe
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryte Papadopoulos
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maha N. Syed
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Thomas J. Werner
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joy Wan
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Martin P. Playford
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Abass Alavi
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nehal N. Mehta
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
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15
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Apremilast Improves Endothelial Glycocalyx Integrity, Vascular and Left Ventricular Myocardial Function in Psoriasis. Pharmaceuticals (Basel) 2022; 15:ph15020172. [PMID: 35215285 PMCID: PMC8876564 DOI: 10.3390/ph15020172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 01/18/2023] Open
Abstract
The phosphodiesterase 4 inhibitor apremilast is used for the treatment of psoriasis. We investigated the effects of apremilast on endothelial glycocalyx, vascular and left ventricular (LV) myocardial function in psoriasis. One hundred and fifty psoriatic patients were randomized to apremilast (n = 50), anti-tumor necrosis factor-α (etanercept; n = 50), or cyclosporine (n = 50). At baseline and 4 months post-treatment, we measured: (1) Perfused boundary region (PBR), a marker of glycocalyx integrity, in sublingual microvessels with diameter 5–25 μm using a Sidestream Dark Field camera (GlycoCheck). Increased PBR indicates damaged glycocalyx. Functional microvascular density, an index of microvascular perfusion, was also measured. (2) Pulse wave velocity (PWV-Complior) and (3) LV global longitudinal strain (GLS) using speckle-tracking echocardiography. Compared with baseline, PBR5–25 μm decreased only after apremilast (−12% at 4 months, p < 0.05) whereas no significant changes in PBR5–25 μm were observed after etanercept or cyclosporine treatment. Compared with etanercept and cyclosporine, apremilast resulted in a greater increase of functional microvascular density (+14% versus +1% versus −1%) and in a higher reduction of PWV. Apremilast showed a greater increase of GLS (+13.5% versus +7% versus +2%) than etanercept and cyclosporine (p < 0.05). In conclusion, apremilast restores glycocalyx integrity and confers a greater improvement of vascular and myocardial function compared with etanercept or cyclosporine after 4 months.
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16
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Gialouri CG, Fragoulis GE. Cardiovascular disease in Psoriatic arthritis: facts and unmet needs. Rheumatology (Oxford) 2021; 61:1305-1306. [PMID: 34508550 DOI: 10.1093/rheumatology/keab655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chrysoula G Gialouri
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George E Fragoulis
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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