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Hofmann NN, Ambühl RA, Jordan S, Distler O. Calcineurin inhibitors in systemic sclerosis – a systematic literature review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221092374. [PMID: 35619877 PMCID: PMC9127851 DOI: 10.1177/1759720x221092374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/20/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Nina N. Hofmann
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Robert A. Ambühl
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Suzana Jordan
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Schmelzbergstr. 24, Zurich 8091, Switzerland
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Abstract
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.
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Guo X, Higgs BW, Bay-Jensen AC, Karsdal MA, Yao Y, Roskos LK, White WI. Suppression of T Cell Activation and Collagen Accumulation by an Anti-IFNAR1 mAb, Anifrolumab, in Adult Patients with Systemic Sclerosis. J Invest Dermatol 2015; 135:2402-2409. [DOI: 10.1038/jid.2015.188] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 03/30/2015] [Accepted: 04/27/2015] [Indexed: 12/23/2022]
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Brinckmann J, Hunzelmann N, Kahle B, Rohwedel J, Kramer J, Gibson MA, Hubmacher D, Reinhardt DP. Enhanced fibrillin-2 expression is a general feature of wound healing and sclerosis: potential alteration of cell attachment and storage of TGF-beta. J Transl Med 2010; 90:739-52. [PMID: 20195245 DOI: 10.1038/labinvest.2010.49] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Wound healing and sclerosis are characterized by an increase of extracellular matrix proteins, which are characteristically expressed in the embryo-fetal period. We analyzed the expression of fibrillin-2, which is typically found in embryonic tissues, but only scarcely in adult skin. In wound healing and sclerotic skin diseases such as lipodermatosclerosis and scleroderma, a marked increase of fibrillin-2 expression was found by immunohistology. Double labelling of fibrillin-2 and tenascin-C, which is also expressed in wound healing and sclerosis, showed co-localization of both proteins. Solid-phase and slot blot-overlay assays showed a dose-dependent binding of the recombinant N-terminal half of fibrillin-2 (rFBN2-N) to tenascin-C. Real-time PCR showed an increase of the fibrillin-2 gene expression in cell culture triggered by typical mediators for fibroblast activation such as serum, IL-4, and TGF-beta. By contrast, prolonged hypoxia is not associated with changes in fibrillin-2 expression. Tenascin-C is an anti-adhesive substrate for fibroblasts, whereas fibrillin-2 stimulates cell attachment. Attachment assays using mixed substrates showed decreased cell attachment when tenascin-C and rFBN2-N were coated together, compared with the attachment to rFBN2-N alone. Fibrillins are involved in storage and activation of TGF-beta. Immunohistology with an antibody against the latency-associated peptide (LAP (TGF-beta1)) showed a marked increase of inactive LAP-bound TGF-beta1 in wound healing and sclerotic skin whereas normal skin showed only a weak expression. Double immunofluorescence confirmed a partial colocalization of both proteins. In conclusion, we show that a stimulation of the fibrillin-2 expression is a characteristic feature of fibroblasts present in wound healing and sclerosis, which may be involved in the alteration of cell attachment and storage of inactive TGF-beta in the matrix.
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Human autoimmune diseases are specific antigen-driven T-cell diseases: identification of the antigens. Immunol Res 2007; 38:359-72. [DOI: 10.1007/s12026-007-0044-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 10/23/2022]
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Sakkas LI, Platsoucas CD. Is systemic sclerosis an antigen-driven T cell disease? ACTA ACUST UNITED AC 2004; 50:1721-33. [PMID: 15188347 DOI: 10.1002/art.20315] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Lazaros I Sakkas
- Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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7
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Abstract
Systemic sclerosis (SS) is characterized by sclerosis of the dermis and internal organs and by vascular abnormalities. Although the pathophysiology of the disease has been partly elucidated, the efficacy of long-term treatments remains limited, with no significant increase in survival in prospective studies. Conventional drug treatments are disappointing in clinical practice, and in a recent prospective randomized study standard-dose D-penicillamine was not more effective than mini-dose D-penicillamine. New long-term treatments are emerging for diffuse SS, including cyclophosphamide for patients with progressive interstitial lung disease or stem cell transplantation for those with early organ involvement. The most effective treatments remain symptomatic, such as angiotensin-converting enzyme inhibitors for acute renal crisis, calcium channel antagonists for Raynaud's phenomenon, and proton pump inhibitors for the complications of gastroesophageal reflux. This review article focuses on long-term treatments that are most likely to be effective and suggests symptomatic treatment strategies tailored to specific organ involvements.
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Affiliation(s)
- L Mouthon
- Internal Medicine Department, Hôpital Avicenne, Université Paris-Nord, Bobigny France.
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Lim KK, Su WP, Schroeter AL, Sabers CJ, Abraham RT, Pittelkow MR. Cyclosporine in the treatment of dermatologic disease: an update. Mayo Clin Proc 1996; 71:1182-91. [PMID: 8945493 DOI: 10.4065/71.12.1182] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment with cyclosporine is beneficial for many dermatologic diseases such as psoriasis, lichen planus, Behçet disease, atopic dermatitis, pyoderma gangrenosum, and epidermolysis bullosa acquisita. The selective action of cyclosporine on helper T cells and its rapid therapeutic action and weak myelotoxicity are the key advantages in the treatment of many dermatologic diseases. Nevertheless, drug toxicity, especially nephrotoxicity, high rates of relapse after treatment cessation, and high cost have limited its use to those diseases refractory to other therapies. Herein we discuss the use of cyclosporine for dermatologic diseases relative to efficacy, dosage, safety profile, and monitoring. In addition, we review the formulations and metabolism of cyclosporine; discuss its mechanism of action, clinical indications in dermatology, and side effects; and provide usage guidelines for this drug. Cyclosporine can be safely administered when potential toxicities, dosing, and monitoring guidelines are known.
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Affiliation(s)
- K K Lim
- Department of Dermatology, Mayo Clinic Rochester, MN 55905, USA
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Casoli P, Carretti C, Tumiati B. Scleroderma renal crisis as a possible complication of cyclosporin A withdrawal. Clin Rheumatol 1994; 13:126-8. [PMID: 8187435 DOI: 10.1007/bf02229882] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- P Casoli
- 2nd Department of Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy
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10
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Affiliation(s)
- A B Kauvar
- Ronald O. Perelman Department of Dermatology, New York University Medical Center, New York
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Clements PJ, Lachenbruch PA, Sterz M, Danovitch G, Hawkins R, Ippoliti A, Paulus HE. Cyclosporine in systemic sclerosis. Results of a forty-eight-week open safety study in ten patients. ARTHRITIS AND RHEUMATISM 1993; 36:75-83. [PMID: 8424841 DOI: 10.1002/art.1780360113] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- P J Clements
- Department of Medicine, University of California, Los Angeles School of Medicine 90024
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Ono M, Hatamochi A, Arakawa M, Ueki H. Effects of cyclosporin A on cell proliferation and collagen production by human skin fibroblasts. J Dermatol Sci 1991; 2:274-80. [PMID: 1911565 DOI: 10.1016/0923-1811(91)90051-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Cyclosporin A (CSA) is a potent immunosuppressive drug that has been used clinically for the treatment of organ rejection after transplantation as well as for patients with a wide variety of immune-mediated disorders. CSA has recently been reported to be effective in systemic sclerosis, which is a disease of the connective tissues leading to fibrosis of the skin and other involved organs. In this study, we investigated whether CSA affects the cell proliferation and collagen synthesis of human skin fibroblasts. CSA inhibited the DNA synthesis and cell growth of cultured fibroblasts at concentrations of 10(-8) M to 10(-5) M in a dose-dependent manner. The production of both collagen and non-collagenous protein at both the mRNA and protein levels was not affected by 10(-8) to 10(-6) M CSA, but was decreased in the presence of 10(-5) M CSA. These results suggest that CSA may inhibit the proliferation of fibroblasts, but not their synthesis of collagenous and non-collagenous proteins at therapeutic concentrations.
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Affiliation(s)
- M Ono
- Department of Dermatology, Kawasaki Medical School, Okayama, Japan
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Abstract
This article reviews the indications, efficacy, and possible mechanisms of action of cyclosporine in the treatment of nonpsoriatic dermatoses. These dermatoses can be categorized according to their responsiveness to cyclosporine therapy as excellent, moderate, variable, and nonresponsive. The advantages and disadvantages of cyclosporine are discussed and guidelines are proposed for its use in nonpsoriatic dermatoses.
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Affiliation(s)
- V C Ho
- Division of Dermatology, University of British Columbia, Vancouver, Canada
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Ghersetich I, Matucci-Cerinic M, Lotti T. A pathogenetic approach to the management of systemic sclerosis (scleroderma). Int J Dermatol 1990; 29:616-22. [PMID: 2272732 DOI: 10.1111/j.1365-4362.1990.tb02581.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- I Ghersetich
- Department of Dermatology, University of Florence, Italy
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Zachariae H, Halkier-Sørensen L, Heickendorff L, Zachariae E, Hansen HE. Cyclosporin A treatment of systemic sclerosis. Br J Dermatol 1990; 122:677-81. [PMID: 2354119 DOI: 10.1111/j.1365-2133.1990.tb07290.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ten patients with severe progressive systemic sclerosis were treated with cyclosporin A at dosages of 1.5-7.5 mg/kg per day:two patients showed a marked improvement with softening of the involved skin; in one patient there was healing of persistent digital ulcers; one patient showed initial improvement followed by a marked exacerbation; one patient was slightly improved; two patients were unchanged. The clinical results correlated well with levels of serum aminoterminal propeptide of type III procollagen. In the eight patients completing treatment, side-effects such as slight tremor and a transient increase in the serum creatinine and blood pressure were either absent or reverted to normal when the dosage was decreased, except one case who had to be treated with anti-hypertensive drugs.
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Affiliation(s)
- H Zachariae
- Department of Dermatology, Marselisborg Hospital, Aarhus, Denmark
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Vayssairat M, Baudot N, Boitard C, Fiessinger JN, Bach JF. Cyclosporine therapy for severe systemic sclerosis associated with the anti-Scl-70 autoantibody. J Am Acad Dermatol 1990; 22:695-6. [PMID: 2319032 DOI: 10.1016/s0190-9622(08)81052-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- M Vayssairat
- Department of Angiology, Broussais Hospital, Paris, France
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