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Cheng W, Li F, Tian J, Xie X, Chen JW, Peng XF, Tang Q, Ge Y. New Insights in the Treatment of SAPHO Syndrome and Medication Recommendations. J Inflamm Res 2022; 15:2365-2380. [PMID: 35444448 PMCID: PMC9013916 DOI: 10.2147/jir.s353539] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare autoinflammatory disease characterized by dermatological disorders and osteoarticular inflammatory lesions. This article reviews the application of biologics and other treatments based on the therapeutic target and the size of molecules in SAPHO syndrome. We found that drugs, especially biologics, have different effects on bone, joint, and skin damage. This may relate to the different inflammatory pathways involved in the osteoarticular and cutaneous symptoms in SAPHO patients. In this study, we provide stratified medication recommendations for SAPHO syndrome. Patients with osteoarticular symptoms can consider tumor necrosis factor blockers, JAK inhibitor, interleukin (IL)-1 inhibitor, and IL-17 inhibitor. Patients with cutaneous symptoms should consider IL-17 and JAK inhibitors. Apremilast, Tripterygium wilfordii Hook F, and bisphosphonates are other effective treatments.
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Affiliation(s)
- Wei Cheng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Fen Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Jing Tian
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Jin-Wei Chen
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Xiao-Fei Peng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Qi Tang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Yan Ge
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
- Correspondence: Yan Ge, Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China, Email
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Peris P, Monegal A, Guañabens N. Bisphosphonates in inflammatory rheumatic diseases. Bone 2021; 146:115887. [PMID: 33592328 DOI: 10.1016/j.bone.2021.115887] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/12/2021] [Accepted: 02/10/2021] [Indexed: 12/25/2022]
Abstract
The main well recognized action of bisphosphonates (BPs) is their antiresorptive capacity, making them first-line drugs in the treatment of osteoporosis and other metabolic bone diseases. In this review we have compiled other possible actions of BPs, particularly in the areas of immunomodulation, anti-inflammatory capacity and in the prevention of structural joint damage in inflammatory rheumatic diseases. The immunomodulatory capacity of BPs has been focused on the mechanisms involved in the acute-phase response associated with the administration of nitrogen containing BPs (N-BPs), with the stimulus of pro-inflammatory cytokines, through the mevalonate pathway, activation of T-cells and the decrease in the cytotoxic T-lymphocyte antigen-4 (CTLA-4). In relation to their anti-inflammatory capacity, special attention has been given to their effect on preventing structural damage in inflammatory joint diseases and on the differential immune response in bone lesions of the most common and representative inflammatory rheumatic diseases, i.e. rheumatoid arthritis and spondyloarthropathies. The present data indicate that more studies are needed to improve the knowledge on the effect of BPs on inflammatory-mediated diseases and particularly on the prevention and/or treatment of the structural damage in these disorders, since these agents could be a potential useful concomitant therapy.
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Affiliation(s)
- Pilar Peris
- Department of Rheumatology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ana Monegal
- Department of Rheumatology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Núria Guañabens
- Department of Rheumatology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain.
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The effectiveness of treatments for patients with SAPHO syndrome: a follow-up study of 24 cases from a single center and review of literature. Clin Rheumatol 2020; 40:1131-1139. [PMID: 32789818 DOI: 10.1007/s10067-020-05322-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 07/10/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of current treatments for SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) by delineating the therapeutic choices and the outcome of patients in a medical center of China and review of the literature. METHOD An observational study was performed on patients diagnosed as SAPHO syndrome in the Peking University First Hospital from 2009 to 2015. Clinical data including osteoarticular and cutaneous manifestations, laboratory and medical imaging findings, treatments, and outcomes were analyzed retrospectively. A literature detailing the usage of medicines and SAPHO syndrome patient responses to treatment were selected. RESULTS Clinical data of 24 patients were analyzed in this study. The mean age was 42.4 ± 15.5 years old at the time of diagnosis. Of a total of 17 patients that received the combination treatments of NSAIDs and DMARDs, 15 of them experienced an improvement in their symptoms. Bisphosphonates were given to 18 patients. Four patients were treated with TNF blockers, and one of them had adalimumab ineffective and then improved by add-on of DMARDs. The mean follow-up period was 2.5 years. Twenty-one patients (87.5%) had a favorable outcome and exhibited improved disease condition in the last follow-up. CONCLUSIONS The majority of patients with SAPHO syndrome respond well to combination therapy of NSAIDs, DMARDs, and bisphosphonates. TNF blockers are effective in a patient refractory to NSAID and DMARDs. However, in case TNF blockers are ineffective, add-on of DMARDs may be effective. Thus, the proper application of conventional DMARDs is still worth a position in the treatment of SAPHO syndrome. Key Points •NSAIDs and DMARDs and/or bisphosphonates can alleviate symptoms of the majority of patients with SAPHO syndrome. •TNF blockers are effective in patients who do not respond well to NSIADs and DMARDs. •In case TNF blockers are ineffective, add-on of conventional DMARDs may be effective.
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Zwaenepoel T, Vlam KD. SAPHO: Treatment options including bisphosphonates. Semin Arthritis Rheum 2016; 46:168-173. [PMID: 27369452 DOI: 10.1016/j.semarthrit.2016.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/07/2016] [Accepted: 04/25/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Both the diagnosis and treatment of the syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) remain difficult. We describe a case series of 21 patients with SAPHO and their response to several pharmacological treatments. METHODS Clinical and biochemical data, along with medical imaging, were collected from the medical records of 21 patients, diagnosed as SAPHO during follow-up between 2005 and 2013. Symptoms and inflammatory markers were recorded twice, once at first patient presentation, and once at the end of follow-up. Synovitis, acne, pustulosis, hyperostosis, and osteitis were labeled as defining features. All treatment options were categorized according to their respective responses (full remission, partial remission, and no disease control). RESULTS There was a female predominance and a median age of 32 years (range: 12-54 years). Median follow-up duration was 45 months (range: 0-188 months). Total prevalence of defining features in this cohort increased for each defining feature during follow-up, except for acne. All patients reached full or partial remission at the end of follow-up. A total of 14 patients were treated with bisphosphonates. Of which 8 of them went into full or partial remission. DISCUSSION AND CONCLUSION In our case series, none of the patients had the full presentation of SAPHO at the first consultation. Some presented with symptoms suggestive for psoriatic arthritis. This explains why diagnosis of SAPHO can be challenging. Full remission was induced in the majority of individuals. Bisphosphonates seem to be a noteworthy treatment option. We suggest a prospective placebo-controlled clinical trial with bisphosphonates to confirm this observation.
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Affiliation(s)
- Tom Zwaenepoel
- Department of Rheumatology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Kurt de Vlam
- Department of Rheumatology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Abstract
The SAPHO syndrome, an acronym for synovitis, acne, pustulosis, hyperostosis and osteitis, is a rare disease which affects bones, joints and the skin. The main osteoarticular features are hyperostosis and osteitis. Osteoarticular symptoms predominantly occur on the anterior chest wall but the spine and the peripheral skeleton can also be involved. The most important skin affections are palmoplantar pustulosis and severe acne. The etiology of this syndrome remains unclear but infectious, immunological and genetic factors are involved. The diagnostic features of SAPHO syndrome are clinical and radiological. The most important diagnostic procedure is Tc-99 m bone scintigraphy but conventional x-rays as well as computed tomography (CT) and magnetic resonance imaging (MRI) can also contribute to the final diagnosis. Bone histology and positron emission tomography CT (PET-CT) may help to differentiate SAPHO syndrome from malignancies and infectious osteomyelitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of treatment. The results obtained using antibiotics and disease-modifying antirheumatic drugs (DMARDs), such as sulfasalazine and methotrexate are inconsistent. Bisphosphonates and anti-tumor necrosis factor (anti-TNF) drugs have shown promising results in small studies but further research is still necessary.
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Witt M, Meier J, Hammitzsch A, Proft F, Schulze-Koops H, Grunke M. Disease burden, disease manifestations and current treatment regimen of the SAPHO syndrome in Germany: results from a nationwide patient survey. Semin Arthritis Rheum 2013; 43:745-50. [PMID: 24816195 DOI: 10.1016/j.semarthrit.2013.10.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/15/2013] [Accepted: 10/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Due to diagnostic and therapeutic advances, quality of life of patients with spondyloarthritides (SpA) has improved substantially in recent years. However, little is known about how patients with the SAPHO syndrome, a heterogeneous disease counted among the SpAs, profit from these advances. OBJECTIVE To investigate current aspects of patient care in a nationwide SAPHO cohort. METHODS Patients were recruited in a university centre and via a nationwide SAPHO patient support group. Medical records were reviewed and patients were asked to complete a questionnaire on the course of diagnosis, disease burden and treatment regimen. RESULTS A total of 64 patients were included in the analysis. The mean time from disease onset to diagnosis was 3.8 ± 5.3 years. The patients' overall satisfaction with the course of diagnosis was 23.0 ± 28.9 on a visual analogue scale (VAS) from 0 to 100. Musculoskeletal symptoms had the highest impact on the patients' wellbeing. The mean overall disease burden on a VAS for pain was 45.4 ± 25.9. Limitations in the quality of life were reported mainly in the general health, bodily pain and vitality dimensions of the SF-36 questionnaire. Current treatments consisted of NSAIDs (77%), DMARDs (27%), glucocorticoids (23%), TNF-inhibitors (16%) and bisphosphonates (11%). CONCLUSIONS The SAPHO syndrome has a high impact on the patients' general health and quality of life. Establishing the diagnosis still takes years and expends multiple medical resources. Effective treatments such as TNF-inhibitors are rarely prescribed and current disease burden is not acceptable.
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Affiliation(s)
- Matthias Witt
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany.
| | - Johanna Meier
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany
| | - Ariane Hammitzsch
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany
| | - Fabian Proft
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany
| | - Mathias Grunke
- Department of Internal Medicine IV, Division of Rheumatology, University of Munich, Munich, Germany
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Abstract
OBJECTIVE To review the epidemiology, presentation, diagnosis, treatment, pathogenesis, and genetics of the syndrome known under the acronym of SAPHO for Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis to heighten awareness of this entity. METHODS We conducted a Medline search using SAPHO syndrome, chronic recurrent multifocal osteitis/osteomyelitis, and related terms as keywords and extracted further relevant articles from the retrieved references. RESULTS The SAHPO acronym identifies a syndrome encompassing a variety of osteoarticular disorders that are frequently accompanied by dermatoses characterized by neutrophilic pseudoabscesses, but can also occur in isolation. SAPHO syndrome is rare, although probably underrecognized because its diagnosis may be challenging because of the wide variability in its musculoskeletal and cutaneous manifestations. This is especially true when atypical sites are involved and when specific skin lesions are absent. There are no standardized treatment protocols available. Current treatments are empirical and have the objective of providing relief from the at times debilitating pain associated with SAPHO syndrome. They include nonsteroidal anti-inflammatory drugs and analgesics as first-line agents. Systemic corticosteroids, disease-modifying anti-rheumatic drugs, biologicals targeting tumor necrosis factor alpha and interleukin-1, and bisphosphonates have all been beneficial in some patients, but ineffective in others. This suggests that the pathogenesis of SAPHO syndrome is multifactorial, but this aspect remains poorly explored, although bacteria and immunological dysfunction are hypothesized to play a role. CONCLUSIONS The early recognition, diagnosis, and prompt treatment of SAPHO syndrome can prevent the unnecessary use of long-term antibiotics or invasive procedures, while rapidly alleviating pain in a majority of affected patients.
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Abstract
SAPHO syndrome is a disorder characterized by Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis. As the osteoarticular and skin manifestations often do not occur simultaneously and there are no validated diagnostic criteria, the diagnosis can be difficult. Clinical and imaging investigation is necessary to establish the many differential diagnoses of SAPHO syndrome. The etiopathogenesis involves infectious (probably Propionibacterium acnes), immunologic, and genetic factors. Treatment is based on information gathered from case reports and small series, and is related to specific skin or articular symptoms.
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Affiliation(s)
- Sueli Carneiro
- State University of Rio de Janeiro - Rua Farme de Amoedo 140/601, Ipanema, Rio de Janeiro 22420-020, Brazil
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Borzutzky A, Stern S, Reiff A, Zurakowski D, Steinberg EA, Dedeoglu F, Sundel RP. Pediatric chronic nonbacterial osteomyelitis. Pediatrics 2012; 130:e1190-7. [PMID: 23071213 DOI: 10.1542/peds.2011-3788] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little information is available concerning the natural history and optimal treatment of chronic nonbacterial osteomyelitis (CNO). We conducted a retrospective review to assess the clinical characteristics and treatment responses of a large cohort of pediatric CNO patients. METHODS Children diagnosed with CNO at 3 tertiary care centers in the United States between 1985 and 2009 were identified. Their charts were reviewed, and clinical, laboratory, histopathologic, and radiologic data were extracted. RESULTS Seventy children with CNO (67% female patients) were identified. Median age at onset was 9.6 years (range 3-17), and median follow-up was 1.8 years (range 0-13). Half of the patients had comorbid autoimmune diseases, and 49% had a family history of autoimmunity. Patients with comorbid autoimmune diseases had more bone lesions (P < .001), higher erythrocyte sedimentation rate (P < .05), and higher use of second line therapy (P = .02). Treatment response to nonsteroidal antiinflammatory drugs (NSAIDs), sulfasalazine, methotrexate, tumor necrosis factor α inhibitors, and corticosteroids was evaluated. The only significant predictor of a positive treatment response was the agent used (P < .0001). Estimated probability of response was 57% for NSAIDs, 66% for sulfasalazine, 91% for methotrexate, 91% for tumor necrosis factor α inhibitors, and 95% for corticosteroids. CONCLUSIONS In a US cohort of 70 children with CNO, coexisting autoimmunity was a risk factor for multifocal involvement and treatment with immunosuppressive agents. Disease-modifying antirheumatic drugs and biologics were more likely to lead to clinical improvement than NSAIDs.
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Affiliation(s)
- Arturo Borzutzky
- Program in Rheumatology, Division of Immunology, Children’s Hospital Boston, Boston, Massachusetts 02115, USA
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A case of SAPHO syndrome with diffuse sclerosing osteomyelitis of the mandible treated successfully with prednisolone and bisphosphonate. J Oral Maxillofac Surg 2011; 70:626-31. [PMID: 21816533 DOI: 10.1016/j.joms.2011.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/08/2011] [Accepted: 04/11/2011] [Indexed: 11/21/2022]
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Sarkar RN, Bhattacharyya K, Phaujdar S, De D. Assessment of the efficacy of pulse Ibandronate therapy in non-steroidal anti-inflammatory drug refractory ankylosing spondylitis: An open prospective study. INDIAN JOURNAL OF RHEUMATOLOGY 2011. [DOI: 10.1016/s0973-3698(11)60058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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