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Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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Bruce-Hickman D, Sajeed SM, Pang YH, Seow CS, Chen W, Gulati Kansal M. Bowel ulceration following tocilizumab administration in a COVID-19 patient. BMJ Open Gastroenterol 2020; 7:e000484. [PMID: 32816957 PMCID: PMC7437943 DOI: 10.1136/bmjgast-2020-000484] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Tocilizumab, a monoclonal antibody against interleukin-6, has been used to treat cytokine release syndrome (CRS) in a subset of patients with severe COVID-19 disease. Acute ulcerative bowel disease has been only rarely documented in patients treated for rheumatological conditions. The gastrointestinal side effects seen when used in the context of COVID-19 are unknown. We present a case of COVID-19 CRS in which acute terminal ileum and perforated caecal ulceration evolved after tocilizumab exposure. We raise awareness of a possible causal relationship between even a single dose of tocilizumab and gut ulceration in patients with COVID-19. Any such drug enteropathy relationship requires watchful monitoring during upcoming trials of tocilizumab in patients with COVID-19.
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Affiliation(s)
- Damian Bruce-Hickman
- Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Shanaz Matthew Sajeed
- Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Yin Huei Pang
- Department of Pathology, National University Hospital, Singapore
| | - Choon Sheong Seow
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Weihao Chen
- Gastroenterology and Hepatology, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Monika Gulati Kansal
- Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
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Cimaz R, Maioli G, Calabrese G. Current and emerging biologics for the treatment of juvenile idiopathic arthritis. Expert Opin Biol Ther 2020; 20:725-740. [PMID: 32116038 DOI: 10.1080/14712598.2020.1733524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The management of a child with juvenile idiopathic arthritis (JIA) requires a combination of pharmacological, physical, and psychosocial therapies in order to induce disease remission, by controlling articular and systemic inflammation. This review aims to provide a comprehensive discussion on the biological therapies currently in use in the treatment of JIA referring to existing recommendations and clinical evidence. We also discuss on the emerging biological drugs actually under consideration. AREAS COVERED Recent findings on immunological mechanisms involved in the pathogenesis of the disease allowed us to identify several specific targets for biologic therapies. A systematic literature review was conducted between January 1997 and January 2020 on PubMed including national and international guidelines and recommendations, trials and case-control studies. EXPERT OPINION There is now a plethora of therapies that are directed against variable targets, and the physician has to choose the most appropriate available medication in order to achieve early and sustained remission with as few side effects as possible. Research is advancing very fast in order to be more and more specific in suppressing inflammatory pathways without harming natural defenses. Finally, pharmacoeconomic considerations will also be very important to deal with, considering the high cost of most of these molecules.
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Affiliation(s)
- Rolando Cimaz
- Pediatric Rheumatology Department, ASST-Gaetano Pini-CTO, Department of Clinical Sciences and Community Health, University of Milan , Milan, Italy.,Pediatric Rheumatology Department, ASST-Gaetano Pini-CTO, University of Milan , Milan, Italy
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Abstract
Juvenile idiopathic arthritis (JIA) is a chronic childhood arthritis. Its pathogenesis is very complicated, with the involvement of not only immune cells but various types of parenchymal cells, and is affected by both genetic and environmental predispositions. The clinical spectrum from inflammation to related conditions is largely mediated by cytokines including interleukin (IL)-6. Fluctuations in IL-6 and its related molecules can modulate the pathogenesis and the clinical presentation positively or negatively. The recent clinical impact of IL-6 blockade on JIA has begun a therapeutic paradigm shift. This review describes the characteristics of JIA, mainly focused on IL-6 with the current therapeutic perspective.
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Affiliation(s)
- Shinji Akioka
- a Department of Pediatrics , Kyoto Prefectural University of Medicine , Kyoto , Japan
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Bielak M, Husmann E, Weyandt N, Haas JP, Hügle B, Horneff G, Neudorf U, Lutz T, Lilienthal E, Kallinich T, Tenbrock K, Berendes R, Niehues T, Wittkowski H, Weißbarth-Riedel E, Heubner G, Oommen P, Klotsche J, Foell D, Lainka E. IL-6 blockade in systemic juvenile idiopathic arthritis - achievement of inactive disease and remission (data from the German AID-registry). Pediatr Rheumatol Online J 2018; 16:22. [PMID: 29622022 PMCID: PMC5887199 DOI: 10.1186/s12969-018-0236-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Systemic juvenile idiopathic arthritis (sJIA) is a complex disease with an autoinflammatory component of unknown etiology related to the innate immune system. A major role in the pathogenesis has been ascribed to proinflammatory cytokines like interleukin-6 (IL-6), and effective drugs inhibiting their signaling are being developed. This study evaluates sJIA patients treated with the IL-6 inhibitor tocilizumab (TCZ) concerning clinical response rate, disease course and adverse effects in a real-life clinical setting. METHODS In 2009 a clinical and research consortium was established, including an online registry for autoinflammatory diseases (AID) ( https://aid-register.de ). Data for this retrospective TCZ study were documented by 13 centers. RESULTS From 7/2009 to 4/2014, 200 patients with sJIA were recorded in the AID-registry. Out of these, 46 (19 m, 27 f, age 1-18 years) received therapy with TCZ. Long term treatment (median 23 months) has been documented in 24/46 patients who were evaluated according to Wallace criteria (active disease 6/24, inactive disease 5/24, remission 13/24 cases). Under observation co-medication were used in 40/46 cases. Adverse events were reported in 11/46 patients. The clinical response rate (no clinical manifestation, no increased inflammation parameters) within the first 12 weeks of treatment was calculated to be 35%. CONCLUSION Out of 200 sJIA children reported in the German AID-registry, 46 were treated with TCZ, showing a clinical response rate of 35% during the first 12 weeks, and inactive disease and/or remission under medication in 75% after one year. Adverse events were seen in 24% and severe adverse events in 4%. TRIAL REGISTRATION The AID-Registry is funded by the BMBF (01GM08104, 01GM1112D, 01GM1512D).
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Affiliation(s)
- M. Bielak
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - E. Husmann
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - N. Weyandt
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - J.-P. Haas
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - B. Hügle
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - G. Horneff
- Department of Pediatrics, Asklepios Clinic Sankt Augustin, Centre for Pediatric Rheumatology, Sankt Augustin, Germany ,0000 0000 8852 305Xgrid.411097.aDepartment of Pediatric and Adolescents medicine, Medical faculty, University Hospital of Cologne, Cologne, Germany
| | - U. Neudorf
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - T. Lutz
- 0000 0001 0328 4908grid.5253.1Center for Pediatric and Adolescent Medicine/Pediatric Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - E. Lilienthal
- 0000 0004 0490 981Xgrid.5570.7Department of Pediatrics, Ruhr-University Bochum, Bochum, Germany
| | - T. Kallinich
- 0000 0001 2218 4662grid.6363.0Department of Pediatric Pneumology and Immunology and Center for Chronically Sick Children of the Charité, Charité University Medicine Berlin, Berlin, Germany
| | - K. Tenbrock
- 0000 0001 0728 696Xgrid.1957.aDepartment of Pediatric Pneumology, Allergology and Immunology, RWTH Aachen University, Aachen, Germany
| | - R. Berendes
- Department of Pediatric Rheumatology, St. Marien’s Children’s Hospital Landshut, Landshut, Germany
| | - T. Niehues
- HELIOS Children’s Hospital Krefeld, Pediatric Immunology and Rheumatology, Krefeld, Germany
| | - H. Wittkowski
- 0000 0001 2172 9288grid.5949.1Department of Pediatric Rheumatology and Immunology, University of Münster, Münster, Germany
| | - E. Weißbarth-Riedel
- 0000 0001 2180 3484grid.13648.38Department of Pediatric Rheumatology, University Children’s Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - G. Heubner
- Children’s Hospital Dresden-Neustadt, Dresden, Germany
| | - P. Oommen
- 0000 0001 2176 9917grid.411327.2Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - J. Klotsche
- 0000 0000 9323 8675grid.418217.9German Rheumatism Research Centre Berlin, Berlin, Germany
| | - Dirk Foell
- 0000 0001 2172 9288grid.5949.1Department of Pediatric Rheumatology and Immunology, University of Münster, Münster, Germany
| | - E. Lainka
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
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Mesquida M, Molins B, Llorenç V, de la Maza MS, Adán A. Targeting interleukin-6 in autoimmune uveitis. Autoimmun Rev 2017; 16:1079-1089. [PMID: 28778705 DOI: 10.1016/j.autrev.2017.08.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 01/01/2023]
Abstract
Interleukin-6 (IL-6) is a key cytokine that is strongly up-regulated during infection and inflammation. Featuring pleiotropic activity, IL-6 is responsible for the induction of hepatic acute-phase proteins, trafficking of acute and chronic inflammatory cells, differentiation of adaptive T cell responses, homeostatic regulation, and tissue regeneration. Dysregulated IL-6 production has been associated with the development of a wide variety of systemic immune-mediated, chronic diseases, and even certain types of cancer. From the ocular perspective, significant elevation of IL-6 has been found in ocular fluids derived from diabetic macular edema, retinal vein occlusion, and refractory/chronic uveitis patients. During the last decade, tocilizumab, a neutralizing monoclonal antibody (mAb) that targets the IL-6 receptor (IL-6R), has been approved for the treatment of rheumatoid arthritis in >100 countries worldwide. Furthermore, it has been reported to be effective for the treatment of a number of autoimmune diseases including uveitis and its associated macular edema. Currently numerous candidate molecular strategies targeting the IL-6 signaling pathways are in progress through clinical trials in various disorders. Herein we discuss the basic biology of IL-6 and its pathological role in the development of immune-mediated conditions, particularly focusing on inflammatory eye diseases. It also provides an overview of the on-going clinical trials with the new anti-IL-6 mAbs and their potential use in the clinical practice.
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Affiliation(s)
- Marina Mesquida
- Uveitis Unit, Institut Clinic d'Oftalmologia, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain; Fundació Clínic per a la Recerca Biomèdica, IDIBAPS, Barcelona, Spain.
| | - Blanca Molins
- Fundació Clínic per a la Recerca Biomèdica, IDIBAPS, Barcelona, Spain
| | - Víctor Llorenç
- Uveitis Unit, Institut Clinic d'Oftalmologia, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Maite Sáinz de la Maza
- Uveitis Unit, Institut Clinic d'Oftalmologia, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Alfredo Adán
- Uveitis Unit, Institut Clinic d'Oftalmologia, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
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Villiger PM, Adler S, Kuchen S, Wermelinger F, Dan D, Fiege V, Bütikofer L, Seitz M, Reichenbach S. Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial. Lancet 2016; 387:1921-7. [PMID: 26952547 DOI: 10.1016/s0140-6736(16)00560-2] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Giant cell arteritis is an immune-mediated disease of medium and large-sized arteries that affects mostly people older than 50 years of age. Treatment with glucocorticoids is the gold-standard and prevents severe vascular complications but is associated with substantial morbidity and mortality. Tocilizumab, a humanised monoclonal antibody against the interleukin-6 receptor, has been associated with rapid induction and maintenance of remission in patients with giant cell arteritis. We therefore aimed to study the efficacy and safety of tocilizumab in the first randomised clinical trial in patients with newly diagnosed or recurrent giant cell arteritis. METHODS In this single centre, phase 2, randomised, double-blind, placebo-controlled trial, we recruited patients aged 50 years and older from University Hospital Bern, Switzerland, who met the 1990 American College of Rheumatology criteria for giant cell arteritis. Patients with new-onset or relapsing disease were randomly assigned (2:1) to receive either tocilizumab (8 mg/kg) or placebo intravenously. 13 infusions were given in 4 week intervals until week 52. Both groups received oral prednisolone, starting at 1 mg/kg per day and tapered down to 0 mg according to a standard reduction scheme defined in the study protocol. Allocation to treatment groups was done using a central computerised randomisation procedure with a permuted block design and a block size of three, and concealed using central randomisation generated by the clinical trials unit. Patients, investigators, and study personnel were masked to treatment assignment. The primary outcome was the proportion of patients who achieved complete remission of disease at a prednisolone dose of 0·1 mg/kg per day at week 12. All analyses were intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01450137. RESULTS Between March 3, 2012, and Sept 9, 2014, 20 patients were randomly assigned to receive tocilizumab and prednisolone, and ten patients to receive placebo and glucocorticoid; 16 (80%) and seven (70%) patients, respectively, had new-onset giant cell arteritis. 17 (85%) of 20 patients given tocilizumab and four (40%) of ten patients given placebo reached complete remission by week 12 (risk difference 45%, 95% CI 11-79; p=0·0301). Relapse-free survival was achieved in 17 (85%) patients in the tocilizumab group and two (20%) in the placebo group by week 52 (risk difference 65%, 95% CI 36-94; p=0·0010). The mean survival-time difference to stop glucocorticoids was 12 weeks in favour of tocilizumab (95% CI 7-17; p<0·0001), leading to a cumulative prednisolone dose of 43 mg/kg in the tocilizumab group versus 110 mg/kg in the placebo group (p=0·0005) after 52 weeks. Seven (35%) patients in the tocilizumab group and five (50%) in the placebo group had serious adverse events. INTERPRETATION Our findings show, for the first time in a trial setting, the efficacy of tocilizumab in the induction and maintenance of remission in patients with giant cell arteritis. FUNDING Roche and the University of Bern.
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Affiliation(s)
- Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland.
| | - Sabine Adler
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Kuchen
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
| | - Felix Wermelinger
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
| | - Diana Dan
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
| | - Veronika Fiege
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | | | - Michael Seitz
- Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Bern, Switzerland
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