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Mok TC, Mok CC. Non-TNF biologics and their biosimilars in rheumatoid arthritis. Expert Opin Biol Ther 2024; 24:599-613. [PMID: 38766765 DOI: 10.1080/14712598.2024.2358165] [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: 03/07/2024] [Accepted: 05/17/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a chronic inflammatory rheumatic disease that affects both the articular and extra-articular structures, leading to significant joint damage, disability and excess mortality. The treatment algorithm of RA has changed tremendously in the past 1-2 decades because of the emergence of novel biological therapies that target different mechanisms of action in addition to TNFα. AREAS COVERED This article summarizes the evidence and safety of the non-TNF biological DMARDs in the treatment of RA, including those that target B cells, T-cell co-stimulation, interleukin (IL)-6 and granulocyte-monocyte colony-stimulating factor (GM-CSF). The targeted synthetic DMARDs such as the Janus kinase inhibitors are not included. The availability of the less costly biosimilars has enabled more patients to receive biological therapy earlier in the course of the disease. The evidence for the non-TNF biosimilar compounds in RA is also reviewed. EXPERT OPINION There are unmet needs of developing novel therapeutic agents to enhance the response rate and provide more options for difficult-to-treat RA. These include the newer generation biologic and targeted synthetic DMARDs. A personalized treatment strategy in RA requires evaluation of the cellular, cytokine, genomic and transcriptomic profile that would predict treatment response to biologic or targeted DMARDs of different mechanisms of action.
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Affiliation(s)
- Tsz Ching Mok
- Department of Medicine, Ruttonjee Hospital, Hong Kong, China
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
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Kameda H, Tasaka S, Takahashi T, Suzuki K, Soeda N, Tanaka Y. Safety and effectiveness of sarilumab in Japanese patients with rheumatoid arthritis refractory to previous treatments: An interim analysis of a post-marketing surveillance. Mod Rheumatol 2024; 34:444-452. [PMID: 37300807 DOI: 10.1093/mr/road055] [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: 02/01/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES An interim analysis of post-marketing surveillance data to assess the safety and effectiveness of sarilumab in Japanese patients with rheumatoid arthritis refractory to previous treatment. METHODS The interim analysis included patients who initiated sarilumab therapy between June 2018 and January 2021. The primary objective of this surveillance was safety. RESULTS In total, 1036 patients were enrolled and registered by 12 January 2021 (interim cut-off date). Of these, 678 were included in the safety analysis [75.4% female; mean age (± standard deviation) 65.8 ± 13.0 years]. Adverse drug reactions, defined as adverse events classified as possibly or probably related to sarilumab, were reported in 170 patients (incidence: 25.1%), with white blood cell count decreased (4.4%) and neutrophil count decreased (1.6%) most frequently reported. Serious haematologic disorders (3.4%) and serious infections (including tuberculosis) (2.5%) were the most frequently reported priority surveillance items. No malignant tumour was reported. An absolute neutrophil count (ANC) below the minimum standard value did not increase the incidence of serious infections. CONCLUSIONS Sarilumab was well tolerated, and no new safety signals were noted in this analysis. There was no difference in the frequency of serious infections between patients with an ANC below or above normal.
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Affiliation(s)
- Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | | | | | - Naoki Soeda
- Medical Affairs Department, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
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Cannon L, Pan A, Kovalick L, Sarkissian A, Wu EY. Secondary immunodeficiencies and infectious considerations of biologic immunomodulatory therapies. Ann Allergy Asthma Immunol 2023; 130:718-726. [PMID: 36801438 PMCID: PMC10247415 DOI: 10.1016/j.anai.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Abstract
Biologic immunomodulatory medications have rapidly expanded in the previous decades, providing new treatment options for individuals with a spectrum of oncologic, allergic, rheumatologic, and neurologic conditions. Biologic therapies alter immune function and can impair key host defense mechanisms, resulting in secondary immunodeficiency and increased infectious risks. Biologic medications can increase general risk for upper respiratory tract infections but can also be associated with unique infectious risks owing to distinct mechanisms of action. With the widespread use of these medications, providers in every area of medicine will likely care for individuals receiving biologic therapies and understanding their potential infectious complications can help mitigate these risks. This practical review discusses the infectious implications of biologics by class of medication and provides recommendations regarding the examination and screening both before therapy initiation and while the patient is receiving the medication. With this knowledge and background, providers can reduce risk whereas patients receive the treatment benefits of these biologic medications.
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Affiliation(s)
- Laura Cannon
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alice Pan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Pharmacy, UNC Health, Chapel Hill, North Carolina
| | - Leonard Kovalick
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Aliese Sarkissian
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eveline Y Wu
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Pediatric Allergy/Immunology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Alhazzani W, Alshahrani M, Alshamsi F, Aljuhani O, Eljaaly K, Hashim S, Alqahtani R, Alsaleh D, Al Duhailib Z, Algethamy H, Al-Musawi T, Alshammari T, Alqarni A, Khoujah D, Tashkandi W, Dahhan T, Almutairi N, Alserehi HA, Al-Yahya M, Al-Judaibi B, Arabi YM, Abualenain J, Alotaibi JM, Al Bshabshe A, Alharbi R, Al-Hameed F, Elhazmi A, Almaghrabi RS, Almaghlouth F, Abedalthagafi M, Al Khathlan N, Al-Suwaidan FA, Bunyan RF, Baw B, Alghamdi G, Al Hazmi M, Mandourah Y, Assiri A, Enani M, Alawi M, Aljindan R, Aljabbary A, Alrbiaan A, Algurashi F, Alsaawi A, Alenazi TH, Alsultan MA, Alqahtani SA, Memish Z, Al-Tawfiq JA, Al-Jedai A. The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section. J Infect Public Health 2022; 15:142-151. [PMID: 34764042 PMCID: PMC8527699 DOI: 10.1016/j.jiph.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; GUIDE Center, St. Joseph's Healthcare Hamilton, Hamilton, Canada.
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Samaher Hashim
- Department of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | - Rakan Alqahtani
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Doaa Alsaleh
- Department of Population Health Science and Policy, Icahn's School of Medicine at Mount Sinai, NYC, USA; King Abdullah International Medical Research Center, NGHA, Riyadh, Saudi Arabia
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Haifa Algethamy
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tariq Al-Musawi
- Department of Critical Care Medicine, Dr Sulaiman AlHabib Hospital, AlKhobar, Saudi Arabia; Royal College of Surgeons in Ireland- Medical University of Bahrain, Bahrain
| | - Thamir Alshammari
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia; College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Abdullah Alqarni
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wail Tashkandi
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Critical Care, Fakeeh Care Group, Jeddah, Saudi Arabia
| | - Talal Dahhan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, USA
| | - Najla Almutairi
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Maytha Al-Yahya
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jameel Abualenain
- Department of Emergency Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jawaher M Alotaibi
- Department of Medicine, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Medicine/Adult Critical Care, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Reham Alharbi
- Critical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Fahad Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Alyaa Elhazmi
- Dr. Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Reem S Almaghrabi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Fatma Almaghlouth
- Respiratory Care Department, Faculty of Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Malak Abedalthagafi
- Genomics Research Department, Saudi Human Genome Project, King Fahad Medical City and King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Noor Al Khathlan
- Respiratory Care Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faisal A Al-Suwaidan
- Clinical Excellence Administration and King Fahad Medical City, Second Health Cluster in Riyadh, Ministry of Health, Saudi Arabia
| | - Reem F Bunyan
- Center for Improving Value in Health, Saudi Arabia; Department of Neurology, King Fahad Specialist Hospital Dammam, Saudi Arabia
| | - Bandar Baw
- Department of Medicine, McMaster University, Canada; Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ghassan Alghamdi
- Department of Medicine and Intensive Care, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Manal Al Hazmi
- Department of Medicine, King Fahad Specialist-Dammam, E1 Cluster, Dammam, Saudi Arabia
| | - Yasser Mandourah
- General Directorate of Military Medical Services, Ministry of Defense, Saudi Arabia
| | - Abdullah Assiri
- Infection Prevention and Control, Ministry of Health, Riyadh, Saudi Arabia
| | - Mushira Enani
- Section of Infectious Diseases Medical Specialties Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Maha Alawi
- Department of Medical Microbiology, Parasitology, Infection Control and Environmental Health Unit, King Abdulaziz Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reem Aljindan
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Aljabbary
- Department of Intensive Care, Security Forces Hospital Program in Riyadh, Saudi Arabia
| | - Abdullah Alrbiaan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahd Algurashi
- Division of Anesthesia and Critical Care, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Abdulmohsen Alsaawi
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Thamer H Alenazi
- King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | | | - Saleh A Alqahtani
- Liver Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Ziad Memish
- Research and Innovation Center, King Saud Medical City, Ministry of Health, & College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jaffar A Al-Tawfiq
- Infectious Disease Division, Indiana University School of Medicine, IN, USA; Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, USA; Quality Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Ahmed Al-Jedai
- Colleges of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia; Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
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Cantini F, Goletti D, Benucci M, Foti R, Damiani A, Niccoli L. Tailored first-line biologic and targeted synthetic disease modifying anti-rheumatic drugs therapy in patients with rheumatoid arthritis: 2021 updated ITABIO statements. Expert Opin Drug Saf 2021; 21:613-623. [PMID: 34937466 DOI: 10.1080/14740338.2022.2020247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In 2015, the Italian board for the TAilored BIOlogic therapy (ITABIO) proposed evidence-based decisional statements for first-line tailored biologic therapy in patients with rheumatoid arthritis (RA). Taking into account the new licensed drugs, the aim of the present review was to update the previous statements. AREAS COVERED A narrative review of the most recent evidence on the efficacy and safety of old and newly licensed drugs for the treatment of articular and extra-articular RA was performed. In addition, host-related variables potentially driving the therapy choice, such as the infection risk, the cardiovascular risk, the risk of deep vein thrombosis, thromboembolism, pregnancy, and obesity were analyzed. Consequently, several statements for personalized therapy were formulated, thus providing a decisional algorithm useful for proper personalized therapy of RA patients in clinical practice. EXPERT OPINION Several clinical variables related to specific drug and host characteristics may drive the choice toward anti-TNF and non-anti-TNF biologics, or anti-JAKs, thus allowing to personalize the therapy. Consequently, the right therapy for the right patient would ensure a successful therapeutic intervention.
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Affiliation(s)
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Via,Portuense 292, 00149 Rome, Italy
| | - Maurizio Benucci
- Rheumatology Unit, Hospital S. Giovanni di Dio, Azienda USL-Toscana Centro, Florence, Italy
| | - Rosario Foti
- Rheumatology Unit, Vittorio-Emanuele University Hospital of Catania, Catania, Italy
| | - Arianna Damiani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Laura Niccoli
- Rheumatology Department, Hospital of Prato, Prato Italy
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Abstract
ABSTRACT Rheumatoid arthritis (RA) is a multisystem disease that affects the joints and various organs, resulting in compromised quality of life and increased mortality. A wide spectrum of treatment options is available for RA. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are the first-line of treatment for RA, whereas tumor necrosis factor α inhibitors are commonly used as a second-line biological disease-modifying antirheumatic drug following inadequate response to csDMARDs. However, remission remains difficult to achieve. No single agent is effective for all patients. It is important to consider patients' comorbidities, perspectives, and preferences when selecting treatment.Interleukin 6 (IL-6) plays a prominent role in the pathophysiology of RA and is an important therapeutic target for RA. Tocilizumab and sarilumab are approved IL-6 inhibitors, which have demonstrated good efficacy and tolerability as combination therapy or monotherapy in RA patients with inadequate response to csDMARDs or tumor necrosis factor α inhibitors. Apart from alleviating joint symptoms, inducing remission, and reducing structural damage, tocilizumab and sarilumab exhibit additional advantages in alleviating extra-articular symptoms, such as fatigue and morning stiffness, and have positive effect on anemia and glucose metabolism. Additionally, evidence showed that certain patient subgroups, such as those with comorbidities including anemia and diabetes mellitus, those with early RA, those with high baseline IL-6 levels, those at high risk of tuberculosis infection, or those intolerant to methotrexate monotherapy, may benefit from IL-6 inhibition. Given these advantages, tocilizumab and sarilumab can be considered earlier as a rational choice for treating RA in suitable patients. Future clinical investigations will help refine the use of these agents.
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Affiliation(s)
- Ronald Man Lung Yip
- From the Integrated Diagnostic and Medical Centre, Tung Wah Group of Hospitals, Kowloon
| | - Cheuk Wan Yim
- Department of Medicine, Tseung Kwan O Hospital, New Territories, Hong Kong
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Tammam SN, El Safy S, Ramadan S, Arjune S, Krakor E, Mathur S. Repurpose but also (nano)-reformulate! The potential role of nanomedicine in the battle against SARS-CoV2. J Control Release 2021; 337:258-284. [PMID: 34293319 PMCID: PMC8289726 DOI: 10.1016/j.jconrel.2021.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
The coronavirus disease-19 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has taken the world by surprise. To date, a worldwide approved treatment remains lacking and hence in the context of rapid viral spread and the growing need for rapid action, drug repurposing has emerged as one of the frontline strategies in the battle against SARS-CoV2. Repurposed drugs currently being evaluated against COVID-19 either tackle the replication and spread of SARS-CoV2 or they aim at controlling hyper-inflammation and the rampaged immune response in severe disease. In both cases, the target for such drugs resides in the lungs, at least during the period where treatment could still provide substantial clinical benefit to the patient. Yet, most of these drugs are administered systemically, questioning the percentage of administered drug that actually reaches the lung and as a consequence, the distribution of the remainder of the dose to off target sites. Inhalation therapy should allow higher concentrations of the drug in the lungs and lower concentrations systemically, hence providing a stronger, more localized action, with reduced adverse effects. Therefore, the nano-reformulation of the repurposed drugs for inhalation is a promising approach for targeted drug delivery to lungs. In this review, we critically analyze, what nanomedicine could and ought to do in the battle against SARS-CoV2. We start by a brief description of SARS-CoV2 structure and pathogenicity and move on to discuss the current limitations of repurposed antiviral and immune-modulating drugs that are being clinically investigated against COVID-19. This account focuses on how nanomedicine could address limitations of current therapeutics, enhancing the efficacy, specificity and safety of such drugs. With the appearance of new variants of SARS-CoV2 and the potential implication on the efficacy of vaccines and diagnostics, the presence of an effective therapeutic solution is inevitable and could be potentially achieved via nano-reformulation. The presence of an inhaled nano-platform capable of delivering antiviral or immunomodulatory drugs should be available as part of the repertoire in the fight against current and future outbreaks.
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Affiliation(s)
- Salma N Tammam
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt.
| | - Sara El Safy
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt
| | - Shahenda Ramadan
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt
| | - Sita Arjune
- Institute of Biochemistry, Department of Chemistry, Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Eva Krakor
- Institute of Inorganic Chemistry, Department of Chemistry, , University of Cologne, Greinstraße 6, 50939 Cologne, Germany
| | - Sanjay Mathur
- Institute of Inorganic Chemistry, Department of Chemistry, , University of Cologne, Greinstraße 6, 50939 Cologne, Germany
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Aletaha D, Bingham CO, Karpouzas GA, Takeuchi T, Thorne C, Bili A, Agarwal P, Hsu B, Rao R, Brown K, Tanaka Y. Long-term safety and efficacy of sirukumab for patients with rheumatoid arthritis who previously received sirukumab in randomised controlled trials (SIRROUND-LTE). RMD Open 2021; 7:rmdopen-2020-001465. [PMID: 33526709 PMCID: PMC7852950 DOI: 10.1136/rmdopen-2020-001465] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Interleukin (IL)-6 is a pleiotropic cytokine involved in the pathophysiology of rheumatoid arthritis (RA). Sirukumab is a human monoclonal antibody that binds to IL-6 with high affinity and specificity. Methods This long-term extension (LTE) study of the SIRROUND-D and SIRROUND-T studies assessed long-term safety and efficacy of sirukumab in adults with moderate-to-severe RA refractory to conventional disease-modifying antirheumatic drug therapy or antitumor necrosis factor agents. Patients received sirukumab 100 mg subcutaneously (SC) every 2 weeks (q2w) or sirukumab 50 mg SC every 4 weeks (q4w). Results 1820 patients enrolled in the LTE; median exposure was 2.34 and 2.07 years in sirukumab 50 mg q4w and 100 mg q2w groups, respectively. Adverse events (AEs) occurred in similar proportions between groups, with the exception of major adverse cardiovascular events (MACE), which were more common in the 50 mg q4w versus 100 mg q2w group (2.2% vs 1.0%), and injection-site reactions, more common in the 100 mg q2w group versus 50 mg q4w group (7.5% vs 3.7%). The most common serious AEs were infections (10% of the patients); 32 (1.8%) patients died during the study (primarily from serious infection and MACE). Malignancies were reported in 24 (1.3%) patients. Gastrointestinal perforations, hepatobiliary abnormalities and changes in laboratory parameters were rare. Reductions in RA signs and symptoms and improvements in physical function were maintained throughout the LTE. Conclusions The safety profile of sirukumab in the LTE remained consistent with that reported in SIRROUND-D and SIRROUND-T and efficacy was maintained. Trial registration number NCT01856309.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | | | - Tsutomu Takeuchi
- Rheumatology, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Carter Thorne
- The Arthritis Programme, Southlake Regional Health Centre, Newmarket, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Androniki Bili
- Immunology Development, Janssen Research and Development LLC, Spring House, Pennsylvania, USA
| | - Prasheen Agarwal
- Janssen Research and Development LLC, Spring House, Pennsylvania, USA
| | - Benjamin Hsu
- Immunology Development, Janssen Research and Development LLC, Spring House, Pennsylvania, USA
| | | | - Kurt Brown
- GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
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Genovese MC, Durez P, Fleischmann R, Tanaka Y, Furst D, Yamanaka H, Korneva E, Vasyutin I, Takeuchi T. Long-term safety and efficacy of olokizumab in patients with rheumatoid arthritis and inadequate response to tumor necrosis factor inhibitor therapy in phase II studies. Eur J Rheumatol 2021; 8:120-129. [PMID: 34101570 PMCID: PMC9770405 DOI: 10.5152/eurjrheum.2021.19207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the long-term safety and efficacy of olokizumab (OKZ), an anti-interleukin (IL)-6 monoclonal antibody, in patients with rheumatoid arthritis (RA) and inadequate response to tumor necrosis factor-alpha inhibitors. METHODS Eligible patients completed study RA0056, which tested several doses of OKZ, placebo (PBO), and tocilizumab (TCZ) plus methotrexate (MTX) in Western countries, and RA0083 included several doses of OKZ and PBO plus MTX in Asian countries. Both studies were followed by open-label extension (OLE) studies with OKZ 120 mg every 2 weeks, RA0057 and RA0089, respectively. Safety assessments were reported up to 124 weeks in RA0057 and 92 weeks in RA0089. Efficacy assessments were reported up to week 60 in RA0057 and week 52 in RA0089. No formal statistical hypothesis testing was performed, and missing data were not imputed. RESULTS A total of 190 patients in RA0057 and 103 patients in RA0089 received OKZ with median treatment duration of 14.1 and 10.1 months, respectively. Serious adverse events (SAEs) were reported in 44 patients (23.2%, 32.7 events per 100 patient-years [PY]) in RA0057 and in 13 patients (12.6%, 23.6 events per 100 PY) in RA0089. Among treatment-emergent adverse events (TEAEs), including SAEs, infections were the most common events. TEAEs leading to withdrawal were reported in 33 (17.4%) patients in RA0057 and in 7 (6.8%) patients in RA0089. Disease activity score 28-joint count on the basis of C-reactive protein level, clinical disease activity index, and simplified disease activity index, as well as the American College of Rheumatology 20%, 50%, and 70% response rates were maintained during the OLE studies, including in those who switched from PBO or TCZ. Improvements in patient-reported outcomes were maintained in OLEs as well. CONCLUSION In the 2 long-term studies, OKZ treatment demonstrated a safety profile expected for IL-6 blocking agents without new safety signals and led to sustained improvements in RA symptoms, physical function, and quality of life.
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Affiliation(s)
- Mark C. Genovese
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California,
USA
| | - Patrick Durez
- Pôle de Pathologies Rhumatismales, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires Saint-Luc, UCL, Brussels,
Belgium
| | - Roy Fleischmann
- Department of Medicine, University of Texas Southwestern Medical Center and Metroplex Clinical Research Center, Dallas, Texas,
USA
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health School of Medicine, Fukuoka,
Japan
| | - Daniel Furst
- The Geffen School of Medicine, University of California, Los Angeles, California,
USA
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo,
Japan
| | | | | | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo,
Japan
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10
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Fleischmann R, Genovese MC, Maslova K, Leher H, Praestgaard A, Burmester GR. Long-term safety and efficacy of sarilumab over 5 years in patients with rheumatoid arthritis refractory to TNF inhibitors. Rheumatology (Oxford) 2021; 60:4991-5001. [PMID: 33871596 DOI: 10.1093/rheumatology/keab355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/09/2021] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To evaluate long-term safety and efficacy of sarilumab over 5 years in patients with RA refractory to TNF inhibitors (TNFi). METHODS Patients in the 24-week randomized controlled trial (RCT) TARGET (NCT01709578) whoreceived double-blind placebo or sarilumab 150 or 200 mg every 2 weeks (q2w), plus conventionalsynthetic DMARDs (csDMARDs), were eligible to receive open-label sarilumab 200 mg q2w pluscsDMARDs in the open-label extension (OLE), EXTEND (NCT01146652). OLE dose reduction to 150 mg q2w was permitted per investigators' judgement or protocol-mandated safety concerns. Safety and efficacy were assessed through treatment-emergent adverse events (AEs), laboratoryabnormalities and clinical disease activity scores. All statistics are descriptive. RESULTS Of 546 patients, 454 (83%) were treated with sarilumab in the OLE. Cumulative observation period was 1654.8 patient-years (PY; n = 521); 268 patients (51%) had ≥4 years' exposure. Incidencerates per 100 PY of AEs, AEs leading to discontinuation, infection and serious infection were 160.4, 8.1, 57.8 and 3.9, respectively. Neutropenia was the most common AE (15.3 per 100 PY). Absoluteneutrophil count <1000 cells/mm3 (Grade 3/4 neutropenia) was observed in 74 patients (14.2%) and normalized on treatment in 48. Clinical efficacy was sustained through 5 years' follow-up. Efficacy was similar for patients with 1 and >1 TNFi failure, and between patients who either remained on 200mg or reduced to 150 mg. CONCLUSION In patients with RA refractory to TNFi, sarilumab's long-term term safety profile was consistent with previous clinical studies and post-marketing reports. Efficacy was sustained over 5years.
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Affiliation(s)
- Roy Fleischmann
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Metroplex, Clinical Research Center, Dallas, TX, USA
| | - Mark C Genovese
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Karina Maslova
- Immunology and Inflammation Clinical Development, Sanofi Genzyme, Cambridge, MA, USA
| | - Henry Leher
- Department of Translational Medicine, Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
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11
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Abstract
Herpesviruses such as herpes simplex virus (HSV) type 1 and 2, varicella-zoster virus (VZV), and cytomegalovirus (CMV) maintain lifelong latency in the host after primary infection and can reactivate periodically either as asymptomatic viral shedding or as clinical disease. Immunosuppression, including biologic therapy, may increase frequency and severity of herpesvirus reactivation and infection. Licensed biologics are reviewed regarding their risks of potentiating HSV, VZV, and CMV reactivation and infection. Approaches to prophylaxis against HSV, VZV, and CMV infection or reactivation are discussed.
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Affiliation(s)
- Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane Building L-135, Stanford, CA 94305-5107, USA.
| | - Kyle Enriquez
- Stanford University, 450 Serra Mall, Stanford, CA 94305, USA
| | - Ashrit Multani
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue CHS 37-121, Los Angeles, CA 90095-1688, USA
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12
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Curtis JR, Weinblatt ME, Shadick NA, Brahe CH, Østergaard M, Hetland ML, Saevarsdottir S, Horton M, Mabey B, Flake DD, Ben-Shachar R, Sasso EH, Huizinga TW. Validation of the adjusted multi-biomarker disease activity score as a prognostic test for radiographic progression in rheumatoid arthritis: a combined analysis of multiple studies. Arthritis Res Ther 2021; 23:1. [PMID: 33397438 PMCID: PMC7784276 DOI: 10.1186/s13075-020-02389-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The multi-biomarker disease activity (MBDA) test measures 12 serum protein biomarkers to quantify disease activity in RA patients. A newer version of the MBDA score, adjusted for age, sex, and adiposity, has been validated in two cohorts (OPERA and BRASS) for predicting risk for radiographic progression. We now extend these findings with additional cohorts to further validate the adjusted MBDA score as a predictor of radiographic progression risk and compare its performance with that of other risk factors. METHODS Four cohorts were analyzed: the BRASS and Leiden registries and the OPERA and SWEFOT studies (total N = 953). Treatments included conventional DMARDs and anti-TNFs. Associations of radiographic progression (ΔTSS) per year with the adjusted MBDA score, seropositivity, and clinical measures were evaluated using linear and logistic regression. The adjusted MBDA score was (1) validated in Leiden and SWEFOT, (2) compared with other measures in all four cohorts, and (3) used to generate curves for predicting risk of radiographic progression. RESULTS Univariable and bivariable analyses validated the adjusted MBDA score and found it to be the strongest, independent predicator of radiographic progression (ΔTSS > 5) compared with seropositivity (rheumatoid factor and/or anti-CCP), baseline TSS, DAS28-CRP, CRP SJC, or CDAI. Neither DAS28-CRP, CDAI, SJC, nor CRP added significant information to the adjusted MBDA score as a predictor, and the frequency of radiographic progression agreed with the adjusted MBDA score when it was discordant with these measures. The rate of progression (ΔTSS > 5) increased from < 2% in the low (1-29) adjusted MBDA category to 16% in the high (45-100) category. A modeled risk curve indicated that risk increased continuously, exceeding 40% for the highest adjusted MBDA scores. CONCLUSION The adjusted MBDA score was validated as an RA disease activity measure that is prognostic for radiographic progression. The adjusted MBDA score was a stronger predictor of radiographic progression than conventional risk factors, including seropositivity, and its prognostic ability was not significantly improved by the addition of DAS28-CRP, CRP, SJC, or CDAI.
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Affiliation(s)
- Jeffrey R Curtis
- University of Alabama at Birmingham, 510 20th Street S, Birmingham, AL, USA
| | - Michael E Weinblatt
- Divison of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy A Shadick
- Divison of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Cecilie H Brahe
- Copenhagen Center for Arthritis Research and DANBIO, Center for Rheumatology and Spine Diseases, Rigshospitalet, Valdemar Hansens vej 17, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research and DANBIO, Center for Rheumatology and Spine Diseases, Rigshospitalet, Valdemar Hansens vej 17, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research and DANBIO, Center for Rheumatology and Spine Diseases, Rigshospitalet, Valdemar Hansens vej 17, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, Denmark
| | - Saedis Saevarsdottir
- Division of Rheumatology and Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Megan Horton
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, USA
| | - Brent Mabey
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, USA
| | - Darl D Flake
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, USA
| | | | - Eric H Sasso
- Crescendo Bioscience, Inc., 180 Kimball Way, South San Francisco, CA, USA.
| | - T W Huizinga
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
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13
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Favalli EG. Understanding the Role of Interleukin-6 (IL-6) in the Joint and Beyond: A Comprehensive Review of IL-6 Inhibition for the Management of Rheumatoid Arthritis. Rheumatol Ther 2020; 7:473-516. [PMID: 32734482 PMCID: PMC7410942 DOI: 10.1007/s40744-020-00219-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, debilitating autoimmune disorder involving inflammation and progressive destruction of the joints, affecting up to 1% of the population. The majority of patients with RA have one or more comorbid conditions, the most common being cardiovascular disease, osteoporosis, and depression, the presence of which are associated with poorer clinical outcomes and lower health-related quality of life. RA pathogenesis is driven by a complex network of proinflammatory cells and cytokines, and of these, interleukin-6 (IL-6) plays a key role in the chronic inflammation associated with RA. Through cell signaling that can be initiated by both membrane-bound and soluble forms of its receptor, IL-6 acts both locally to promote joint inflammation and destruction, and in the circulation to mediate extra-articular manifestations of RA, including pain, fatigue, morning stiffness, anemia, and weight loss. This narrative review describes the role of IL-6 in the pathogenesis of RA, its comorbidities, and extra-articular systemic manifestations, and examines the effects of the IL-6 receptor inhibitors sarilumab and tocilizumab on clinical endpoints of RA, patient-reported outcomes, and common comorbidities and extra-articular manifestations.
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Affiliation(s)
- Ennio G Favalli
- Department of Rheumatology, ASST Gaetano Pini-CTO Institute, University of Milan, Milan, Italy.
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14
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Davis JS, Ferreira D, Paige E, Gedye C, Boyle M. Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:e00035-19. [PMID: 32522746 PMCID: PMC7289788 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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Affiliation(s)
- Joshua S Davis
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Ferreira
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia
| | - Craig Gedye
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Oncology, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Michael Boyle
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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15
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020; 48:e440-e469. [PMID: 32224769 PMCID: PMC7176264 DOI: 10.1097/ccm.0000000000004363] [Citation(s) in RCA: 612] [Impact Index Per Article: 153.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. CONCLUSION The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Morten Hylander Møller
- Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark
- Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI)
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
- GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org)
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milano, Italy
- ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research & Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University of, Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
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16
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020; 46:854-887. [PMID: 32222812 PMCID: PMC7101866 DOI: 10.1007/s00134-020-06022-5] [Citation(s) in RCA: 1319] [Impact Index Per Article: 329.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy. CONCLUSION The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark
- Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- GUIDE Research Methods Group, Hamilton, Canada
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
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Infectious Implications of Interleukin-1, Interleukin-6, and T Helper Type 2 Inhibition. Infect Dis Clin North Am 2020; 34:211-234. [PMID: 32334983 DOI: 10.1016/j.idc.2020.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Targeting interleukins that drive innate inflammation has expanded treatments of autoinflammatory and autoimmune disorders. Interleukin (IL)-1 inhibition has proven useful for monogenic autoinflammatory syndromes, and IL-6 inhibition for autoimmune arthritides. Biological therapies impeding these pathways impair detection and containment of pathogens, particularly invasive bacteria, reflecting the importance of IL-1 and IL-6 in communicating danger throughout the immune system. Biologics targeting T helper type 2 inflammation are used to treat specific allergic, atopic, and eosinophilic diseases. They may impair protections against local herpesvirus reactivations while augmenting antiviral responses to respiratory viruses. Their risks with helminth exposures have yet to be defined.
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Nasonov EL, Lila AM. The efficacy and safety of sarilumab, fully human monoclonal antibodies against interleukin 6 receptor, in rheumatoid arthritis: new evidence. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-564-57] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia
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Genovese MC, van der Heijde D, Lin Y, St John G, Wang S, van Hoogstraten H, Gómez-Reino JJ, Kivitz A, Maldonado-Cocco JA, Seriolo B, Stanislav M, Burmester GR. Long-term safety and efficacy of sarilumab plus methotrexate on disease activity, physical function and radiographic progression: 5 years of sarilumab plus methotrexate treatment. RMD Open 2019; 5:e000887. [PMID: 31452928 PMCID: PMC6691511 DOI: 10.1136/rmdopen-2018-000887] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 01/12/2023] Open
Abstract
Objective In MOBILITY (NCT01061736), sarilumab significantly reduced disease activity, improved physical function and inhibited radiographic progression at week 52 versus placebo in patients with rheumatoid arthritis (RA) and an inadequate response to methotrexate. We report 5-year safety, efficacy and radiographic outcomes of sarilumab from NCT01061736 and the open-label extension (EXTEND; NCT01146652), in which patients received sarilumab 200 mg every 2 weeks (q2w) + methotrexate. Methods Patients (n=1197) with moderately to severely active RA were initially randomised to placebo, sarilumab 150 mg or sarilumab 200 mg subcutaneously q2w plus weekly methotrexate for 52 weeks. Completers were eligible to enrol in the open-label extension and receive sarilumab 200 mg q2w + methotrexate. Results Overall, 901 patients entered the open-label extension. The safety profile remained stable over 5-year follow-up and consistent with interleukin-6 receptor blockade. Absolute neutrophil count <1000 cells/mm3 was observed but not associated with increased infection rate. Initial treatment with sarilumab 200 mg + methotrexate was associated with reduced radiographic progression over 5 years versus sarilumab 150 mg + methotrexate or placebo + methotrexate (mean±SE change from baseline in van der Heijde-modified Total Sharp Score: 1.46±0.27, 2.35±0.28 and 3.68±0.27, respectively (p<0.001 for each sarilumab dose versus placebo)). Clinical efficacy was sustained through 5 years according to Disease Activity Score (28-joint count) using C reactive protein, Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire-Disability Index. The number of patients achieving CDAI ≤2.8 at 5 years was similar among initial randomisation groups (placebo, 76/398 (19%); sarilumab 150 mg, 68/400 (17%); sarilumab 200 mg, 84/399 (21%)). Conclusion Clinical efficacy, including inhibition of radiographic progression, reduction in disease activity and improvement in physical function, was sustained with sarilumab + methotrexate over 5 years. Safety appeared stable over the 5-year period.
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Affiliation(s)
- Mark C Genovese
- Stanford University Medical Center, Palo Alto, California, USA
| | | | - Yong Lin
- Sanofi Genzyme, Bridgewater, New Jersey, USA
| | | | | | | | - Juan José Gómez-Reino
- Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania, USA
| | | | - Bruno Seriolo
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Marina Stanislav
- Research Rheumatology Institute n. a. V.A. Nasonova, Moscow, Russia
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
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20
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Kato M, Kaneko Y, Tanaka Y, Inoo M, Kobayashi-Haraoka H, Amano K, Miyata M, Murakawa Y, Yasuoka H, Hirata S, Nagasawa H, Tanaka E, Miyasaka N, Yamanaka H, Yamamoto K, Yokota I, Atsumi T, Takeuchi T. Predictive value of serum amyloid a levels for requirement of concomitant methotrexate in tocilizumab initiation: A post hoc analysis of the SURPRISE study. Mod Rheumatol 2019; 30:442-449. [DOI: 10.1080/14397595.2019.1621026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masayuki Inoo
- Department of Internal Medicine, Utazu Hospital, Ehime, Japan
| | | | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Masayuki Miyata
- Department of Internal Medicine, Fukushima Red Cross Hospital, Fukushima, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hayato Nagasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Eiichi Tanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuyuki Miyasaka
- Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuhiko Yamamoto
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Abstract
Sarilumab (Kevzara®), a monoclonal antibody against the interleukin-6 (IL-6) receptor, is approved in various countries, including the USA, those of the EU, and Japan, as a subcutaneous treatment administered every 2 weeks for moderately to severely active rheumatoid arthritis (RA) in adults who have responded inadequately to, or are intolerant of, one or more DMARDs. In placebo-controlled trials, sarilumab improved the signs and symptoms of RA, as well as physical function and health-related quality-of-life (HR-QOL), when administered in combination with conventional synthetic DMARD (csDMARD) therapy in patients with an inadequate response to methotrexate or an inadequate response to, or intolerance of, at least one tumour necrosis factor (TNF) inhibitor; benefits were sustained over ≤ 3 years' therapy in an open-label extension. Sarilumab plus methotrexate inhibited the progression of structural damage in patients who had inadequately responded to methotrexate. As monotherapy in patients who were inappropriate for continued treatment with methotrexate, sarilumab was more effective than adalimumab in reducing the signs and symptoms of RA and improving physical function. The safety profile of sarilumab was consistent with the anticipated effects of IL-6 inhibition. In the minority of patients who tested positive for anti-drug antibodies (ADAs), ADAs did not impact efficacy or increase adverse reactions. Thus, sarilumab extends the available treatment options for adults with moderately to severely active RA who have responded inadequately to, or are intolerant of, at least one DMARD.
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22
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Jones SA, Jenkins BJ. Recent insights into targeting the IL-6 cytokine family in inflammatory diseases and cancer. Nat Rev Immunol 2018; 18:773-789. [DOI: 10.1038/s41577-018-0066-7] [Citation(s) in RCA: 435] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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