Cyclosporin A treatment of systemic sclerosis

Calcineurin inhibitors in systemic sclerosis - a systematic literature review

Objective

To review treatment effectiveness and adverse events of calcineurin inhibitors (CNIs) such as cyclosporin A (CsA) and tacrolimus in patients with systemic sclerosis (SSc).

Methods

A systematic literature search was performed on PubMed and Web of Science using the predefined keywords 'systemic sclerosis', scleroderma, cyclosporin*, and tacrolimus. Articles were eligible for inclusion, if SSc patients had been treated with CNIs and data on treatment effects were available.

Results

This systematic literature review identified 37 papers (19 case reports, 15 case series, 2 controlled studies, and 1 retrospective study) including 134 SSc patients treated with CNIs. In 34 of 37 papers, CsA was used. An improvement of skin fibrosis was observed in 77 of 96 (80.2%) patients using a wide variety of outcome measures and dose regimes. Both controlled studies showed significant improvements, one using a historical control group and one using a no-treatment control group. Improvement in pulmonary function tests (PFTs) occurred in 67.9% (19/28) of the patients who had reduced PFTs at baseline. In 58 (43.3%) cases, adverse renal events were reported, of which 7 (5.2%) were severe such as scleroderma renal crisis (SRC), CsA-associated nephropathy, or death by renal insufficiency. Adverse events led to dose reduction, treatment interruption, or withdrawal in 39 of 134 (29.1%).

Conclusion

In this systematic literature review, signals for potential effectiveness of CsA for skin and pulmonary fibrosis were found, but the evidence level of the identified studies was too low to allow robust conclusions. Randomized controlled double-blind trials are needed to conclude on the effectiveness of CNIs in SSc. Renal toxicity of CNIs was confirmed in this review and needs to be considered in the design of such studies.

The Use of Cyclosporine A in Rheumatology: a 2016 Comprehensive Review

Cyclosporine A, an inhibitor of calcineurin, exerts an immunomodulator action interfering with T cell activation. Even though novel therapeutic tools have emerged, CyA still represents a suitable option in several clinical rheumatology settings. This is the case of refractory nephritis and cytopenias associated with systemic lupus erythematosus. Furthermore, CyA is a valued therapeutic tool in the management of uveitis and thrombophlebitis in course of Behçet's disease. Topical CyA has been proven to be beneficial in the dry eye of Sjogren's syndrome, whereas oral treatment with CyA can be considered for the severe complications of adult onset Still's disease. CyA provides a therapeutic option in psoriatic arthritis, being rather effective in skin disease. CyA is currently regarded as a second-line option for patients with inflammatory myopathies refractory to standard regimen. CyA is used even in paediatric rheumatology, in particular in the management of juvenile dermatomyositis and macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Importantly, CyA has been shown to suppress the replication of HCV, and it can thus be safely prescribed to those patients with chronic hepatitis C. Noteworthy, CyA can be administered throughout the gestation course. Surely, caution should be paid to CyA safety profile, in particular to its nephrotoxicity. Even though most evidence comes from small and uncontrolled studies with few randomised controlled trials, CyA should be still regarded as a valid therapeutic tool in 2016 rheumatology.

Digital ulcers in systemic sclerosis

Digital ulcers (DUs) are a common visible manifestation of the progressive vascular disease that characterizes the SSc disease process. DUs not only impact significantly on patients' quality of life and hand function, but are also a biomarker of internal organ involvement and of disease severity. The aetiology of (digital) vascular disease in SSc is multifactorial, and many of these factors are potentially amenable to therapeutic intervention. The management of DU disease in SSc is multifaceted. Patient education and non-pharmacological interventions (e.g. smoking cessation) should not be neglected. There are a number of drug therapies available to prevent (e.g. phosphodiesterase type-5 inhibitors and ET receptor-1 antagonists) and treat (e.g. i.v. iloprost) DUs. DUs are also important for two other reasons: firstly, as a primary end point in SSc-related clinical trials; and secondly, DUs are included in the ACR/EULAR SSc classification criteria. However, the reliability of rheumatologists to grade DUs is poor to moderate at best, and this poses challenges in both clinical practice and research. The purpose of this review is to provide the reader with a description of the spectrum of DU disease in SSc including pathophysiology, epidemiology and clinical burden, all of which inform the multifaceted approach to management.

Scleroderma therapy: clinical overview of current trends and future perspective

Systemic sclerosis is a chronic autoimmune condition with a complex pathogenesis and a high rate of mortality and morbidity. Internal organ involvement requires interdisciplinary approach in individual patient management. New discoveries in the pathogenesis of scleroderma herald a drastic change in the traditional outlook to therapy and have led to the development of the target-based approach in management. The challenge at present is to translate these advances in molecular mechanisms into well-designed clinical trials that will recognize potential disease-modifying therapies. This article is an evidence-based review of prevailing treatment options and future therapeutic targets in systemic sclerosis.

The use of cyclosporine in dermatology: part I

Cyclosporine is a calcineurin inhibitor that acts selectively on T cells. It has been used in dermatology since 1997 for its US Food and Drug Administration indication of psoriasis and off-label for various other inflammatory skin conditions, including atopic dermatitis, blistering disorders, and connective tissue diseases. In the last decade, many dermatologists have hesitated to use this important drug in their clinical practices because of its toxicity profile. The purpose of this article is to review the mechanism of action of cyclosporine and its current uses and dosing schedules. It is our goal to create a framework in which dermatologists feel comfortable and safe incorporating cyclosporine into their prescribing regimens.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to describe the mechanism of action of cyclosporine, recognize the potential role of cyclosporine in dermatology and the evidence to support this role, and incorporate cyclosporine into his or her prescribing regimens.

Current treatment options in systemic Sclerosis (Scleroderma)

Systemic Sclerosis (SSc) or Scleroderma is a generalized autoimmune disease with variable involvement of the skin and major organs. Etiology and pathogenesis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena can be observed, and a pivotal role of T lymphocytes in SSc pathogenesis is postulated. The rarity of the disease, the wide spectrum of clinical manifestations and severity as well as a variable course render therapy in SSc a major challenge. In view of the immunopathogenesis of SSc, many (presumed) immunomodulatory agents have been used, but no single agent has been proven to be convincingly effective. Trials with extracorporeal therapies (such as photopheresis, plasmapheresis) or even stem cell transplantation are in progress. In contrast to the hitherto unsuccessful therapeutic approaches for the overall disease course, some life-threatening organ manifestations can often be treated successfully, e.g. interstitial pneumonitis with i.v. cyclophosphamide and scleroderma renal crisis with ACE inhibitors and haemodialysis, respectively. Furthermore, pharmacological and supportive treatment of Raynaud's phenomenon and gastrointestinal involvement can alleviate the burden of the disease. Current therapeutic options as well as hitherto investigated immunomodulators are reviewed in this article.

Distinct autoreactive T cell responses to native and fragmented DNA topoisomerase I: influence of APC type and IL-2

Systemic sclerosis (SSc) is an autoimmune connective tissue disease of unknown etiology in which T cell responses to various autoantigens, including DNA topoisomerase I (Topo I), have been implicated. We investigated whether dendritic cells, generally considered to be the most potent APCs for the initiation of immune responses, would present either of two forms of Topo I to T cells more efficiently than PBMC APCS: Using cells from healthy controls and SSc patients, several important observations were made. First, neither APC type was able to initiate T cell proliferative responses to full-length native Topo I unless exogenous IL-2 was added. This is in contrast to vigorous T cell proliferation in response to Topo I polypeptide fragments presented by either APC type. Second, T cell responses to the full-length form of Topo I presented by dendritic cells were considerably lower than responses to Ag presented by PBMC APCS: Finally, no secondary T cell responses were observed unless the same Ag/APC combination as that used in the primary stimulation was maintained. These data indicate that different peptides are generated based upon the form of the Topo I and the APC that processes it. Taken together, these results suggest that a very specific combination of antigenic form and APC may be involved in breaking tolerance to Topo I in the early stages of development of SSC:

Scleroderma and related disorders: therapeutic aspects

Improvements in management of systemic sclerosis have occurred through a growing understanding of pathogenic events accompanied by advances in diagnosis and assessment, as well as developments in organ-based therapeutics. Unfortunately, disease-modifying therapies of proven efficacy remain elusive and several agents in current use have been shown in well-controlled clinical trials to be of questionable benefit. More positively, there have been advances in the treatment of major visceral complications such as renal crisis, pulmonary fibrosis, pulmonary hypertension, gastrointestinal involvement and in the management of scleroderma-associated Raynaud's phenomenon. Current approaches are reviewed, evidence supporting or refuting the use of putative disease-modifying agents is discussed, and new strategies are described that are currently being considered for this fascinating but complex multisystem connective tissue disease.

Renal toxicity of long-term cyclosporin

An analysis of the literature on renal toxicity of long-term cyclosporin A (CsA) in auto-immune diseases reveals that besides functional renal toxicity also de novo morphological kidney damage can be induced already after 12 months with low dose (< or = 5 mg CsA/kg/day). In the early stage the findings are light changes. However, after two years treatment they are light to moderate. In a blinded study on 30 patients with psoriasis, including 18 with psoriatic arthritis, the severity of findings increased with length of therapy, and after four years all but one had arteriolar hyalinosis, with interstitial fibrosis pronounced in five and moderate in six of eleven patients, and at the same time glomerular sclerosis had become significant. The data presented indicate the necessity of an evaluation of the risk-benefit ratio for each patient. Accepted guide-lines should be strictly followed, and after two years treatment a rotation to other therapies, or a careful following by glomerular filtration rate (GFR) together with sequential renal biopsies should be considered.

A meta-analysis and morphological review of cyclosporine-induced nephrotoxicity in auto-immune diseases

BACKGROUND

The risk-benefit ratio of cyclosporine A (CsA) is much more critical in some auto-immune diseases in comparison to transplantation medicine, due to its renal toxic potential. The present meta-analysis is based on an a priori defined methodology, and is linked with a review of CsA-induced morphological lesions, in order to draw relevant conclusions with regard to CsA-induced nephrotoxicity in auto-immune diseases.

METHODS

Only controlled, randomized trials with a treatment period of two months or more, published from January 1979 to August 1996, were selected for the evaluation of functional renal impairment due to CsA treatment. To assess the risk of developing nephrotoxicity during CsA therapy, individual peak rises in serum creatinine level were compared between the CsA-treated group and the control group. Nephrotoxicity was defined as an increase in serum creatinine level of 50% or more above baseline at least once during the study period. Papers reporting CsA-induced renal morphological lesions were reviewed.

RESULTS

A risk difference of 20.9% for developing nephrotoxicity, between a therapy with CsA and an alternative therapy, was found. Already after a treatment period of 12 months with low dose CsA (< or = 5 mg/kg/day), de novo nonspecific morphological damage could be induced in patients with auto-immune diseases.

CONCLUSIONS

From this analysis of the literature, it is obvious that a therapy with CsA in patients affected by auto-immune diseases is not without risk. A rigorous evaluation of the risk-benefit ratio is strongly recommended for each patient, with strict monitoring of serum creatinine and CsA trough levels during treatment. Renal biopsies during treatment must be seriously taken into consideration in patients who develop even a slight renal functional impairment, particularly when prolonged therapy of longer than one year, even with low dose CsA (< or = 5 mg/kg/day), is given.

Cyclosporine, FK-506, rapamycin, and other immunomodulators

Immunomodulatory agents represent a unique group of therapies that are not biologics and have relatively specific, noncytotoxic effects on the immune system. Cyclosporine has been the most widely tested of the immunomodulatory agents and shown efficacy in a variety of autoimmune diseases as well as monotherapy in established rheumatoid arthritis. FK-506 and rapamycin, agents similar to cyclosporine, are being tested in human transplantation, with only arthritis studies having been done in animals. Tilomisole, imuthiol, and mycophenolate mofetil have been studied in limited rheumatoid arthritis trials with positive effects. Although more specific and with manageable short-term side effects, this group of therapies requires more studies to establish their efficacy and long-term safety.

The use of serologic markers for collagen synthesis and degradation in systemic sclerosis

BACKGROUND

Systemic sclerosis is characterized by excessive accumulation of collagen in all involved organs. Serum markers of collagen synthesis and degradation, the aminoterminal propeptide of type III procollagen (PIIINP), the carboxyterminal propeptide of type I procollagen (PICP), and the crosslinked telopeptide of type I collagen (ICTP), can be measured.

OBJECTIVE

Our purpose was to investigate these markers in different subgroups of untreated patients with systemic sclerosis and in patients before and after various types of therapy. PIIINP and PICP were also investigated in blister fluid from involved and uninvolved skin.

METHODS

Sera from 97 patients and suction blister fluid from 13 patients were radioimmunoassayed.

RESULTS

The highest levels of PIIINP and PICP were found in blister fluid from involved skin. Patients with systemic sclerosis had higher serum levels of PIIINP than control subjects. The highest levels were found in patients with diffuse cutaneous systemic (type III) sclerosis; increased serum PIIINP was also characteristic of type II limited cutaneous systemic sclerosis. Most patients with limited cutaneous type I systemic sclerosis had normal levels. Serum PICP was within normal limits in all three types of systemic sclerosis. Variations in ICTP type I collagen degradation in general followed PICP. Immunosuppressive drugs significantly reduced PIIINP, whereas no significant decrease was found after photopheresis. PICP and ICTP also diminished after treatment with D-penicillamine and cyclophosphamide given together with prednisone.

CONCLUSION

PIIINP can be recommended for monitoring collagen synthesis in systemic sclerosis. Our data support the use of immunosuppressive therapy for this disease.

Scleroderma renal crisis as a possible complication of cyclosporin A withdrawal

The pharmacological treatment of systemic sclerosis (SSc) has been discouraging. In view of this, therapeutic trials with cyclosporine A (CyA) are outstanding particularly in patients with a rapid cutaneous involvement. We report the case of a patient whose SSc cutaneous manifestations dramatically improved with CyA therapy. Its subsequent withdrawal led to a quick onset of a fatal sclerodermal renal crisis. We believe that in our patient there could have been a cause and effect relationship between the suspension of CyA and kidney sclerodermal complication.

Extracorporeal photochemotherapy in progressive systemic sclerosis

BACKGROUND

Extracorporeal photochemotherapy, an immune-modulating form of therapy, has been shown to be effective in the treatment of autoimmune diseases. We evaluated the effects of extracorporeal photochemotherapy in the treatment of patients with progressive systemic sclerosis (PSS).

METHODS

Nine patients with active progressive systemic sclerosis were treated with extracorporeal photochemotherapy on 2 successive days monthly. The duration of therapy ranged from 6 to 21 months.

RESULTS

A significant improvement was noted in the skin, musculoskeletal system, functional index, and symptoms including Raynaud's phenomenon, dyspnea, fatigue, dysphagia, and arthralgias, as well as improvement of cutaneous ulcers. Stabilization of the pulmonary function studies was also noted in the majority of patients over the course of therapy. No serious side effects were noted throughout the course of therapy in the 9 patients.

CONCLUSIONS

The results suggest that photopheresis may be beneficial in selected early cases of progressive systemic sclerosis.

Progressive systemic sclerosis with CNS vasculitis and cyclosporin A therapy

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Systemic sclerosis

Systemic sclerosis affects the connective tissue of various organs. It is characterized by alteration of the microvasculature with a dense inflammatory cellular infiltrate, followed by massive deposition of collagen. This review discusses diagnostic criteria, clinical subsets, survival data, clinical evaluation, epidemiology, pathogenesis, immunobiology, genetics, and therapy for systemic sclerosis in adults. Because the diagnosis of systemic sclerosis is most dependent on its cutaneous involvement, knowledge of this is essential in the evaluation and management of patients with this disorder.

Cyclosporine in systemic sclerosis. Results of a forty-eight-week open safety study in ten patients

OBJECTIVE

To evaluate safety and efficacy of cyclosporin A (CSA) treatment in systemic sclerosis (SSc).

METHODS

Ten patients with < or = 60 months of SSc were entered into a 48-week open study of CSA. Patients with hypertension or azotemia were excluded. Concurrent use of nonsteroidal antiinflammatory agents or diuretics was not permitted. The extent of cutaneous and visceral involvement at 48 weeks and at study entry were compared.

RESULTS

Adverse reactions (especially nephrotoxicity) were frequent, usually transient, often dose-limiting, and usually associated with CSA doses > or = 3-4 mg/kg/day. Skin thickening decreased significantly (P < 0.001), while pulmonary and cardiac involvement remained unchanged.

CONCLUSION

CSA should undergo blinded controlled study in patients with SSc.

Primary pulmonary hypertension in a patient with systemic-onset juvenile arthritis

We describe a 16-year-old girl with systemic-onset juvenile arthritis who presented with pulmonary hypertension, without evidence of pleural or parenchymal involvement of the lung, pulmonary vasculitis, or immune deposition in the pulmonary vasculature. Pleuropulmonary involvement occurs occasionally in juvenile arthritis, but primary pulmonary hypertension has not, to our knowledge, been previously reported. Histocompatibility typing showed positivity for HLA-DR3 and DRw52, both of which are associated with idiopathic pulmonary hypertension in children, and with pulmonary hypertension among patients with systemic sclerosis. Treatment with cyclosporine and corticosteroids resulted in a marked improvement in the clinical findings and pulmonary function in our patient.