1
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Neve M, Diderichsen PM, Helmer E, de Vries D, Taneja A. Prediction of Disease Progression and Clinical Response in Systemic Sclerosis: Experience From a Proof-of-Concept Trial. ACR Open Rheumatol 2024. [PMID: 38923416 DOI: 10.1002/acr2.11678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/03/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE Using the modified Rodnan skin score (mRSS) as a surrogate for disease activity, a phase 2a study in patients with systemic sclerosis (SSc) measured efficacy of the autotaxin inhibitor ziritaxestat. Mathematical modeling of mRSS was used to predict disease progression, examine candidate trial designs, and predict the probability of successfully discriminating treatment effect. METHODS Patients with SSc receiving 600 mg of ziritaxestat or placebo for 24 weeks were included, in addition to data up to week 52 of the open-label extension (OLE). Longitudinal mRSS data were described using a disease progression model; drug effect was a binary variable. Parameters used to predict the OLE mRSS outcome were estimated using data from the 24-week double-blind phase and validated with observed data. Three trial designs were simulated to identify which had the highest probability of detecting a treatment effect. Power to detect a treatment effect was quantified using the simulations. RESULTS Maximum decreases from baseline in mRSS were 50.4% (ziritaxestat) and 34.7% (placebo). Study designs based on 300 patients randomized 2:1 or 1:1 to 600 mg of ziritaxestat or placebo had similar probabilities of detecting a significant treatment effect. Power to detect a treatment effect was >80% for all simulations. CONCLUSION Disease progression and drug effect could be predicted beyond the range of observed data. This modeling and simulation approach may inform future trial design, including study duration, and predict the probability of success.
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Affiliation(s)
| | | | - Eric Helmer
- Galapagos Biotech Ltd, Cambridge, United Kingdom
| | | | - Amit Taneja
- Galapagos SASU, Romainville, France, and Simulations Plus, Inc, Lancaster, California
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Szűcs G, Szekanecz Z, Szamosi S. Can we define difficult-to-treat systemic sclerosis? Expert Rev Clin Immunol 2024:1-17. [PMID: 38711393 DOI: 10.1080/1744666x.2024.2352450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by microvascular alterations, immunopathology, and widespread fibrosis involving various organs. It is considered difficult to treat due to several reasons: complex pathogenesis, heterogeneity, late diagnosis, limited treatment options for certain organ manifestations, lack of personalized medicine. AREAS COVERED This review presents the heterogeneity, survival and organ manifestations with their risk factors of systemic sclerosis and their current treatment options, while drawing attention to difficult-to-treat forms of the disease, based on literature indexed in PubMed. EXPERT OPINION Despite recent advances in the management of SSc over the last decades, the disease presents significant morbidity and mortality. Although available treatment protocols brought significant advancements in terms of survival in SSc-associated interstitial lung disease and pulmonary arterial hypertension, less success has been achieved in the treatment of Raynaud's phenomenon and digital ulcers and the results are modest in case of heart, gastrointestinal, and renal manifestations. There are patients who do not respond to treatment and deteriorate even with adequate therapy. They can be considered difficult-to treat (D2T) cases. We have created a possible score system based on the individual organ manifestations and highlighted treatment options for the D2T SSc category.
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Affiliation(s)
- Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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3
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Clark KEN, Xu S, Attah M, Ong VH, Buckley CD, Denton CP. Single-cell analysis reveals key differences between early-stage and late-stage systemic sclerosis skin across autoantibody subgroups. Ann Rheum Dis 2023; 82:1568-1579. [PMID: 37580109 PMCID: PMC10646865 DOI: 10.1136/ard-2023-224184] [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: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVES The severity of skin involvement in diffuse cutaneous systemic sclerosis (dcSSc) depends on stage of disease and differs between anti-RNA-polymerase III (ARA) and anti-topoisomerase antibody (ATA) subsets. We have investigated cellular differences in well-characterised dcSSc patients compared with healthy controls (HCs). METHODS We performed single-cell RNA sequencing on 4 mm skin biopsy samples from 12 patients with dcSSc and HCs (n=3) using droplet-based sequencing (10× genomics). Patients were well characterised by stage (>5 or <5 years disease duration) and autoantibody (ATA+ or ARA+). Analysis of whole skin cell subsets and fibroblast subpopulations across stage and ANA subgroup were used to interpret potential cellular differences anchored by these subgroups. RESULTS Fifteen forearm skin biopsies were analysed. There was a clear separation of SSc samples, by disease, stage and antibody, for all cells and fibroblast subclusters. Further analysis revealed differing cell cluster gene expression profiles between ATA+ and ARA+ patients. Cell-to-cell interaction suggest differing interactions between early and late stages of disease and autoantibody. TGFβ response was mainly seen in fibroblasts and smooth muscle cells in early ATA+dcSSc skin samples, whereas in early ARA+dcSSc patient skin samples, the responding cells were endothelial, reflect broader differences between clinical phenotypes and distinct skin score trajectories across autoantibody subgroups of dcSSc. CONCLUSIONS We have identified cellular differences between the two main autoantibody subsets in dcSSc (ARA+ and ATA+). These differences reinforce the importance of considering autoantibody and stage of disease in management and trial design in SSc.
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Affiliation(s)
| | - Shiwen Xu
- Centre for Rheumatology, Royal Free Campus, University College London, London, UK
| | - Moustafa Attah
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Voon H Ong
- Centre for Rheumatology, Royal Free Campus, University College London, London, UK
| | | | - Christopher P Denton
- Centre for Rheumatology, Royal Free Campus, University College London, London, UK
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4
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Herrick AL, Denton CP. Enrichment strategies for clinical trials targeting skin fibrosis and interstitial lung disease in systemic sclerosis. Curr Opin Rheumatol 2023; 35:349-355. [PMID: 37729053 DOI: 10.1097/bor.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW This review gives an update on enrichment strategies for clinical trials in patients with systemic sclerosis (SSc) in two contexts - skin fibrosis in early diffuse cutaneous disease, and SSc-related interstitial lung disease (ILD) - focusing on reports from the last 18 months. Lessons have been learnt from recent studies, making this review timely. RECENT FINDINGS Recent trials have highlighted how patients included into trials must be carefully selected to include 'progressors', that is, those most likely to benefit from treatment, and how drug mechanism action of action will influence trial design. For skin fibrosis, current enrichment strategies are mainly on clinical grounds (including disease duration, extent of skin thickening, tendon friction rubs and anti-RNA polymerase III positivity). Gene expression signatures may play a role in the future. For ILD, current enrichment strategies (degree of lung involvement as assessed by pulmonary function and high-resolution computed tomography) may help to recruit the most informative patients, but should avoid being too stringent to be feasible or for findings to be generalizable. SUMMARY Both skin fibrosis and ILD trials are challenging in SSc. Ongoing work on enrichment strategies should help to differentiate effective new treatments from placebo with smaller sample sizes than have been included in recent studies.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Christopher P Denton
- Centre for Rheumatology, UCL Division of Medicine, Royal Free Campus, London, UK
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5
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Junfei Z, Meihua G, Shuai Z, Xiangting L, Zhidan L, Tianming C, Yajing L, Chu T, Lipu S. Retrospective comparative study of the efficacy of JAK inhibitor (tofacitinib) in the treatment of systemic sclerosis-associated interstitial lung disease. Clin Rheumatol 2023; 42:2823-2832. [PMID: 37335409 DOI: 10.1007/s10067-023-06660-2] [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: 11/18/2022] [Revised: 04/05/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
The oral Janus kinases inhibitor (JAKi) has improved the management of skin manifestations in systemic sclerosis (SSc), and our study aimed to explore the efficacy of non-selective JAKi tofacitinib in ameliorating interstitial lung disease (ILD) in the patients with SSc. The hospitalization data of the SSc-ILD patients from April 2019 to April 2021 were collected, and the changes of pulmonary function and the radiological findings in pulmonary high-resolution CT (HRCT) from the 9 patients who received tofacitinib for at least 6 months and a matched group of 35 SSc-ILD patients treated with conventional immunosuppressants or glucocorticoids, were compared and analyzed. There were no significant differences in demographic data and clinical characteristics between the tofacitinib-treated group (tofa-group) and the matched group. However, in the tofa-group, the changes in serum lactate dehydrogenase (LDH) concentration and serum interleukin-6 levels were significantly lower than those in the matched group. Moreover, the tofa-group showed amelioration in decreased diffusing capacity of the lung for carbon monoxide (DLCO) (62.05 ± 9.47 vs. 66.61 ± 12.39, p = 0.046), reductions in ground-glass attenuation involvement (1.00 ± 0.86 vs. 0.33 ± 0.50, p = 0.024) and irregular pleural thickening (1.33 ± 0.50 vs. 0.67 ± 0.51, p = 0.004) in pulmonary HRCTs, alleviated modified Rodnan skin score (mRSS) of skin sclerosis (9.22 ± 3.81 vs. 7.11 ± 3.92, p = 0.048), and reduced HRCT scores of pulmonary fibrosis (15.00 ± 3.87 vs. 12.66 ± 4.92, p = 0.009). Logistic regression analysis showed that the involvement of ground-glass attenuation (OR 11.43) and the add-on therapy of tofacitinib (OR 9.98) were the relevant factors in the amelioration of HRCT. Our results indicate that the use of JAKi (tofacitinib) may be relevant to significant improvement of the sclerosis and early radiological abnormalities in SSc-ILD patients. Further studies are needed to confirm these findings and to explore its efficacy more precisely. Key Points • The currently available therapies for SSc-ILD have limited therapeutic benefits. • The add-on therapy of the oral JAK inhibitor is available in the real world. • The tofacitinib was promising in the improvement of the sclerosis and early radiological abnormalities in SSc-ILD patients.
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Affiliation(s)
- Zhou Junfei
- Department of Rheumatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7, Weiwu Road, Zhengzhou, 450000, China.
| | - Gao Meihua
- Department of Geriatrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Zhang Shuai
- Department of Dermatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Lu Xiangting
- Department of Dermatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Lei Zhidan
- Department of Radiology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Cheng Tianming
- Department of Radiology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Liu Yajing
- Department of Respiratory, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Tianshu Chu
- Department of Rheumatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7, Weiwu Road, Zhengzhou, 450000, China.
| | - Shi Lipu
- Department of Rheumatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7, Weiwu Road, Zhengzhou, 450000, China
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Vonk MC, Assassi S, Hoffmann-Vold AM. Scleroderma Skin: How Is Treatment Best Guided by Data and Implemented in Clinical Practice? Rheum Dis Clin North Am 2023; 49:249-262. [PMID: 37028833 DOI: 10.1016/j.rdc.2023.01.003] [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: 04/09/2023]
Abstract
As skin involvement is the hall mark of systemic sclerosis (SSc) and changes of skin involvement have shown to correlate with internal organ involvement, assessing the extend of skin involvement is key. Although the modified Rodnan skin score is a validated tool used to evaluate the skin in SSc, it has its drawbacks. Novel imagine methods are promising but should be further evaluated. As for molecule markers for skin progression there are conflicting data on the predictive significance of baseline SSc skin gene expression profiles, but immune cell type signature in SSc skin correlates with progression.
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Affiliation(s)
- Madelon C Vonk
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Huispost 667, PO Box 9101, Nijmegen 6500HB, the Netherlands.
| | - Shervin Assassi
- Division of Rheumatology, The University of Texas Health Science Center at Houston, 6431 Fannin, Houston, TX, USA
| | - Anna-Maria Hoffmann-Vold
- Department of Rheumatology, Oslo University Hospital - Rikshospitalet, Pb 4950, Nydalen, Oslo 0424, Norway
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7
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Domsic RT, Medsger TA, Gao S, Laffoon M, Huang S, Wisniewski S, Spino C, Steen V, Lafyatis R, Khanna D. A data-driven approach finds RNA polymerase III antibody and tendon friction rubs as enrichment tools for early diffuse scleroderma trials. Rheumatology (Oxford) 2023; 62:1543-1551. [PMID: 36031807 PMCID: PMC10072884 DOI: 10.1093/rheumatology/keac501] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Clinical trials in early diffuse SSc have consistently shown a placebo group response with a declining modified Rodnan skin score (mRSS), with negative outcomes. Our objective was to identify strategies using clinical characteristics or laboratory values to improve trial design. METHODS We identified early diffuse SSc patients first seen at the University of Pittsburgh from 1980-2015. Eligible patients had ≥3 visits, with at least two mRSS scores within the first year of follow-up. We performed Kaplan-Meier analyses, group-based trajectory analysis of mRSS scores, followed by multivariable regression analysis and classification tree analysis. We applied the results to the abatacept in early diffuse systemic sclerosis (ASSET) trial outcome data. RESULTS We identified 403 patients with <18 months, and 514 with <36 months disease duration. The median number of mRSS follow-up scores was 14 (interquartile range 8, 25). All methodologic approaches identified skin thickness progression rate, RNA polymerase III (RNAP3) antibody positivity and presence of tendon friction rubs (TFR) as predictors of mRSS trajectory over 5 years of follow-up, and thereby as potential enrichment variables. When applied to the ASSET data, adjustment for both RNAP3 and TFR demonstrated reduction of the placebo mRSS response, particularly at 6 months. A significant difference in the ACR Composite Response Index in Systemic Sclerosis (CRISS) score was found with adjustment by RNAP3 at 6 months, and TFR or RNAP3 at 12 months. CONCLUSION Adjustment for both RNAP3 and TFR predicts mRSS trajectory and diminished the mRSS decline in ASSET placebo group, and identified significant differences in CRISS. RNAP3, particularly, is a stratification or enrichment approach to improve early diffuse SSc trial design.
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Affiliation(s)
- Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas A Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shiyao Gao
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Maureen Laffoon
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Suiyuan Huang
- Division of Rheumatology, Department of Internal Medicine and Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Stephen Wisniewski
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Cathie Spino
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Virginia Steen
- Division of Rheumatology, Department of Medicine, Georgetown University, Washington, DC, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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8
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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9
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Hughes M, Huang S, Alegre-Sancho JJ, Carreira PE, Engelhart M, Hachulla E, Henes J, Kerzberg E, Pozzi MR, Riemekasten G, Smith V, Szücs G, Vanthuyne M, Zanatta E, Distler O, Gabrielli AG, Hoffmann-Vold AM, Steen VD, Khanna D. Late skin fibrosis in systemic sclerosis: a study from the EUSTAR cohort. Rheumatology (Oxford) 2023; 62:SI54-SI63. [PMID: 35731139 DOI: 10.1093/rheumatology/keac363] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The early trajectory of skin fibrosis provides insights into the disease course of systemic sclerosis (SSc) including mortality; however, little is known about late skin fibrosis. The aims of our study were to ascertain the prevalence and characteristics of late skin fibrosis in SSc. METHODS We developed and tested three conceptual scenarios of late (>5 years after first non-RP feature) skin fibrosis including new worsening of skin disease, and failure to improve after worsening within 5-year window. We defined skin worsening as change in modified Rodnan skin score (mRSS) ≥5 units or ≥25%. Using strict inclusion criteria including complete mRSS, we identified 1,043 (out of 19 115) patients within the EUSTAR database for our analysis. We further restricted analysis within 887 (out of 1043) patients who had lcSSc or dcSSc at baseline. RESULTS One-fifth of patients among the whole cohort (n = 208/1043, 19.9%) experienced mRSS worsening, including in patients with lcSSc or dcSSc at baseline (n = 193/887, 21.8%). This was largely due to new skin worsening after the 5-year window or failure to improve with worsening within the 5-year window. Patients with lower baseline mRSS and lcSSc were more likely to develop late skin fibrosis. Anti-Scl-70 was associated with progression from baseline lcSSc to dcSSc, and anticentromere was protective. CONCLUSIONS Late skin fibrosis is not uncommon in SSc. We have identified different patterns relevant to clinical practice and trial design. Late skin fibrosis is a neglected manifestation of SSc and warrants further investigation including to determine clinical outcomes and optimal therapeutic strategy.
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Affiliation(s)
- Michael Hughes
- Tameside Hospital, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne.,Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Suiyuan Huang
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program.,Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Merete Engelhart
- Center for Rheumatology and Spine Diseases, Gentofte Hospital, Hellerup, Denmark
| | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Centre for Rare Systemic Autoimmune Diseases North and North-West of France (CeRAINO, CHU Lille, Univ. Lille, Inserm, U1286 - INFINITE-Institute for Translational Research in Inflammation), Lille, France
| | - Joerg Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases and Department of Internal Medicine II (Hematology, Oncology, Immunology and Rheumatology), University Hospital Tuebingen, Tuebingen, Germany
| | - Eduardo Kerzberg
- Rheumatology Department, J. M. Ramos Mejía Hospital, Buenos Aires, Argentina
| | | | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University Clinic Schleswig-Holstein, University of Lübeck, Lübeck, Germany
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University.,Department of Rheumatology, Ghent University Hospital.,Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Gabriella Szücs
- Division of Rheumatology, Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Marie Vanthuyne
- Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Armando G Gabrielli
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
| | | | - Virginia D Steen
- Division of Rheumatology, Department of Medicine, School of Medicine, Georgetown University, Washington, DC
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program.,University of Michigan Scleroderma Program, Ann Arbor, MI, USA
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10
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Browning JL, Bhawan J, Tseng A, Crossland N, Bujor AM, Akassoglou K, Assassi S, Skaug B, Ho J. Extensive and Persistent Extravascular Dermal Fibrin Deposition Characterizes Systemic Sclerosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.16.523256. [PMID: 36711912 PMCID: PMC9882194 DOI: 10.1101/2023.01.16.523256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by progressive multiorgan fibrosis. While the cause of SSc remains unknown, a perturbed vasculature is considered a critical early step in the pathogenesis. Using fibrinogen as a marker of vascular leakage, we found extensive extravascular fibrinogen deposition in the dermis of both limited and diffuse systemic sclerosis disease, and it was present in both early and late-stage patients. Based on a timed series of excision wounds, retention on the fibrin deposit of the splice variant domain, fibrinogen αEC, indicated a recent event, while fibrin networks lacking the αEC domain were older. Application of this timing tool to SSc revealed considerable heterogeneity in αEC domain distribution providing unique insight into disease activity. Intriguingly, the fibrinogen-αEC domain also accumulated in macrophages. These observations indicate that systemic sclerosis is characterized by ongoing vascular leakage resulting in extensive interstitial fibrin deposition that is either continually replenished and/or there is impaired fibrin clearance. Unresolved fibrin deposition might then incite chronic tissue remodeling.
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Affiliation(s)
- Jeffrey L Browning
- Department of Microbiology, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
- Department of Rheumatology, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
| | - Jag Bhawan
- Department of Dermatopathology, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
| | - Anna Tseng
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
- National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA
| | - Nicholas Crossland
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
- National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA
| | - Andreea M Bujor
- Department of Rheumatology, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
| | - Katerina Akassoglou
- Gladstone Institute of Neurological Disease San Francisco California USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA
| | - Shervin Assassi
- Division of Rheumatology, University of Texas Health Science Center, Houston, TX
| | - Brian Skaug
- Division of Rheumatology, University of Texas Health Science Center, Houston, TX
| | - Jonathan Ho
- Department of Dermatopathology, Boston University Chobanian & Avedesian School of Medicine, Boston, MA
- Section Dermatology University of the West Indies, Mona Jamaica
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11
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Varga J, Wigley FM. Scleroderma–Systemic Sclerosis. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00056-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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12
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Hematopoietic Cell Transplantation for Systemic Sclerosis-A Review. Cells 2022; 11:cells11233912. [PMID: 36497169 PMCID: PMC9739132 DOI: 10.3390/cells11233912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune, multi-organ, connective tissue disease associated with significant morbidity and mortality. Conventional immunosuppressive therapies demonstrate limited efficacy. Autologous hematopoietic stem cell transplantation (HCT) is more efficacious but carries associated risks, including treatment-related mortality. Here, we review HCT as a treatment for SSc, its efficacy and toxicity in comparison to conventional therapies, and the proposed mechanisms of action. Furthermore, we discuss the importance of and recent developments in patient selection. Finally, we highlight the knowledge gaps and future work required to further improve patient outcomes.
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Cavazzana I, Vojinovic T, Airo' P, Fredi M, Ceribelli A, Pedretti E, Lazzaroni MG, Garrafa E, Franceschini F. Systemic Sclerosis-Specific Antibodies: Novel and Classical Biomarkers. Clin Rev Allergy Immunol 2022; 64:412-430. [PMID: 35716254 PMCID: PMC10167150 DOI: 10.1007/s12016-022-08946-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
Disease-specific autoantibodies are considered the most important biomarkers for systemic sclerosis (SSc), due to their ability to stratify patients with different severity and prognosis. Anti-nuclear antibodies (ANA), occurring in subjects with isolated Raynuad's phenomenon, are considered the strongest independent predictors of definite SSc and digital microvascular damage, as observed by nailfold videocapillaroscopy. ANA are present in more than 90% of SSc, but ANA negativity does not exclude SSc diagnosis: a little rate of SSc ANA negative exists and shows a distinct subtype of disease, with less vasculopathy, but more frequent lower gastrointestinal involvement and severe disease course. Anti-centromere, anti-Th/To, and anti-Topoisomerase I antibodies could be considered as classical biomarkers, covering about 60% of SSc and defining patients with well-described cardio-pulmonary complications. In particular, anti-Topoisomerase I represent a risk factor for development of diffuse cutaneous involvement and digital ulcers in the first 3 years of disease, as well as severe interstitial lung disease (ILD). Anti-RNA polymerase III is a biomarker with new clinical implications: very rapid skin thickness progression, gastric antral vascular ectasia, the occurrence of synchronous cancers, and possible association with silicone breast implants rupture. Moreover, novel SSc specific autoantibodies have been globally described in about 10% of "seronegative" SSc patients: anti-elF2B, anti-RuvBL1/2 complex, anti-U11/U12 RNP, and anti-BICD2 depict specific SSc subtypes with severe organ complications. Many autoantibodies could be considered markers of overlap syndromes, including SSc. Anti-Ku are found in 2-7% of SSc, strictly defining the PM/SSc overlap. They are associated with synovitis, joint contractures, myositis, and negatively associated with vascular manifestation of disease. Anti-U3RNP are associated with a well-defined clinical phenotype: Afro-Caribbean male patients, younger at diagnosis, and higher risk of pulmonary hypertension and gastrointestinal involvement. Anti-PM/Scl define SSc patients with high frequency of ILD, calcinosis, dermatomyositis skin changes, and severe myositis. The accurate detection of autoantibodies SSc specific and associated with overlap syndromes is crucial for patients' stratification. ANA should be correctly identified using indirect immunofluorescent assay and a standardized way of patterns' interpretation. The gold-standard technique for autoantibodies' identification in SSc is still considered immunoprecipitation, for its high sensitivity and specificity, but other assays have been widely used in routine practice. The identification of SSc autoantibodies with high diagnostic specificity and high predictive value is mandatory for early diagnosis, a specific follow-up and the possible definition of the best therapy for every SSc subsets. In addition, the validation of novel autoantibodies is mandatory in wider cohorts in order to restrict the gap of so-called seronegative SSc patients.
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Affiliation(s)
- Ilaria Cavazzana
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy.
| | - Tamara Vojinovic
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy
| | - Paolo Airo'
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Ceribelli
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Eleonora Pedretti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Emirena Garrafa
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, piazzale Spedali Civili 1, Brescia, 25123, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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14
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Systemic Scleroderma-Definition, Clinical Picture and Laboratory Diagnostics. J Clin Med 2022; 11:jcm11092299. [PMID: 35566425 PMCID: PMC9100749 DOI: 10.3390/jcm11092299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/08/2022] [Accepted: 04/18/2022] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Scleroderma (Sc) is a rare connective tissue disease classified as an autoimmune disorder. The pathogenesis of this disease is not fully understood. (2) Methods: This article reviews the literature on systemic scleroderma (SSc). A review of available scientific articles was conducted using the PubMed database with a time range of January 1985 to December 2021. (3) Results and Conclusions: The article is a review of information on epidemiology, criteria for diagnosis, pathogenesis, a variety of clinical pictures and the possibility of laboratory diagnostic in the diagnosis and monitoring of systemic scleroderma.
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15
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Herrick AL, Assassi S, Denton CP. Skin involvement in early diffuse cutaneous systemic sclerosis: an unmet clinical need. Nat Rev Rheumatol 2022; 18:276-285. [PMID: 35292731 PMCID: PMC8922394 DOI: 10.1038/s41584-022-00765-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 12/23/2022]
Abstract
Diffuse cutaneous systemic sclerosis (dcSSc) is associated with high mortality resulting from early internal-organ involvement. Clinicians therefore tend to focus on early diagnosis and treatment of potentially life-threatening cardiorespiratory and renal disease. However, the rapidly progressive painful, itchy skin tightening that characterizes dcSSc is the symptom that has the greatest effect on patients' quality of life, and there is currently no effective disease-modifying treatment for it. Considerable advances have been made in predicting the extent and rate of skin-disease progression (which vary between patients), including the development of techniques such as molecular analysis of skin biopsy samples. Risk stratification for progressive skin disease is especially relevant now that haematopoietic stem-cell transplantation is a treatment option, because stratification will inform the balance of risk versus benefit for each patient. Measurement of skin disease is a major challenge. Results from clinical trials have highlighted limitations of the modified Rodnan skin score (the current gold standard). Alternative patient-reported and other potential outcome measures have been and are being developed. Patients with early dcSSc should be referred to specialist centres to ensure best-practice management, including the management of their skin disease, and to maximize opportunities for inclusion in clinical trials.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Shervin Assassi
- McGovern Medical School, The University of Texas, Houston, TX, USA
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16
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Blank N, Schmalzing M, Moinzadeh P, Oberste M, Siegert E, Müller-Ladner U, Riemekasten G, Günther C, Kötter I, Zeidler G, Pfeiffer C, Juche A, Jandova I, Ehrchen J, Susok L, Schmeiser T, Sunderkötter C, Distler JHW, Worm M, Kreuter A, Keyßer G, Lorenz HM, Krieg T, Hunzelmann N, Henes J. Autologous hematopoietic stem cell transplantation improves long-term survival-data from a national registry. Arthritis Res Ther 2022; 24:258. [PMID: 36424638 PMCID: PMC9685870 DOI: 10.1186/s13075-022-02948-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Current recommendations on the management of systemic sclerosis (SSc) suggest that autologous hematopoietic stem cell therapy (HSCT) can be a rescue therapy for patients with rapidly progressive SSc. OBJECTIVES To assess the safety and efficacy of HSCT for patients with SSc and to compare these with non-HSCT patients in a control cohort with adjusted risk factors. METHODS A retrospective analysis of data from the multicentric German network for systemic scleroderma (DNSS) with 5000 patients with SSc. Control groups consisted of all patients with diffuse cutaneous (dc)-SSc (group A) and an adjusted high-risk cohort of male patients with Scl70-positive dc-SSc (group B). RESULTS Eighty SSc patients received an HSCT 4.1 ± 4.8 years after SSc diagnosis. Among them, 86.3% had dc-SSc, 43.5% were males, and 71.3% were positive for Scl70 antibodies. The control group A (n=1513) showed a significant underrepresentation of these risk factors for mortality. When the survival of the control group B (n=240) was compared with the HSCT group, a lower mortality of the latter was observed instead. Within 5 years after HSCT, we observed an improvement of the mRSS from 17.6 ± 11.5 to 11.0 ± 8.5 (p=0.001) and a stabilization of the DLCO. We did not see differences in transplant-related mortality between patients who received HSCT within 3 years after SSc diagnosis or later. CONCLUSION Our analysis of real-life data show that the distribution of risk factors for mortality is critical when HSCT cohorts are compared with non-HSCT control groups.
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Affiliation(s)
- Norbert Blank
- grid.5253.10000 0001 0328 4908Internal Medicine 5, Division of Hematology, Oncology and Rheumatology, Department of Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Marc Schmalzing
- grid.411760.50000 0001 1378 7891Department of Rheumatology/Clinical Immunology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Pia Moinzadeh
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Max Oberste
- grid.6190.e0000 0000 8580 3777Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Elise Siegert
- grid.6363.00000 0001 2218 4662Department of Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Müller-Ladner
- grid.8664.c0000 0001 2165 8627Campus Kerckhoff, Department of Rheumatology and Clinical Immunology, Justus Liebig University Giessen, Bad Nauheim, Germany
| | | | - Claudia Günther
- grid.412282.f0000 0001 1091 2917Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ina Kötter
- Department of Rheumatology and Immunology, University Hospital, Hamburg-Eppendorf and Rheumatology Hospital Bad Bramstedt, Bad Bramstedt, Germany
| | - Gabriele Zeidler
- Department of Rheumatology, Johanniter-Krankenhaus im Flaeming Treuenbrietzen, Treuenbrietzen, Germany
| | - Christiane Pfeiffer
- grid.411095.80000 0004 0477 2585Department of Dermatology, University Hospital Munich, Munich, Germany
| | - Aaron Juche
- grid.473656.50000 0004 0415 8446Department of Rheumatology, Immanuel Krankenhaus Berlin-Buch, Berlin, Germany
| | - Ilona Jandova
- grid.7708.80000 0000 9428 7911Department of Rheumatology, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Jan Ehrchen
- grid.16149.3b0000 0004 0551 4246Department of Dermatology and Venerology, University Hospital Muenster, Muenster, Germany
| | - Laura Susok
- grid.5570.70000 0004 0490 981XDepartment of Dermatology and Venereology, Ruhr-University-Bochum, Bochum, Germany
| | - Tim Schmeiser
- grid.416438.cDepartment of Dermatology, St. Josef Hospital Wuppertal, Wuppertal, Germany
| | - Cord Sunderkötter
- grid.461820.90000 0004 0390 1701Dermatology, University Hospital Halle, Halle, Germany
| | - Jörg H. W. Distler
- grid.411668.c0000 0000 9935 6525Department of Rheumatology, University Hospital Erlangen, Erlangen, Germany
| | - Margitta Worm
- grid.6363.00000 0001 2218 4662Department of Dermatology and Allergology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Kreuter
- grid.412581.b0000 0000 9024 6397Allergology, HELIOS St. Elisabeth Hospital Oberhausen, University Witten-Herdecke, Witten, Germany
| | - Gernot Keyßer
- grid.461820.90000 0004 0390 1701Rheumatology, University Hospital Halle, Halle, Germany
| | - Hanns-Martin Lorenz
- grid.5253.10000 0001 0328 4908Internal Medicine 5, Division of Hematology, Oncology and Rheumatology, Department of Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Thomas Krieg
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Nicolas Hunzelmann
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Jörg Henes
- grid.411544.10000 0001 0196 8249Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Hematology, Immunology, Rheumatology), University Hospital Tuebingen, Tuebingen, Germany
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17
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Herrick AL. Advances in the Treatment of Systemic Sclerosis. Rheumatology (Oxford) 2022. [DOI: 10.17925/rmd.2022.1.2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Although systemic sclerosis (SSc) is currently incurable, there have been recent advances in treatment. This review article begins by providing a brief background to SSc in terms of disease subtyping and autoantibodies, because both predict disease trajectory and help clinicians to select appropriate monitoring and treatment protocols. Broad principles of management are then described: ‘disease-modifying’ therapies and therapies directed at reducing disease burden and/or progression of SSc-related digital vascular disease and of internal organ involvement. Next, advances in the management of digital vasculopathy, pulmonary arterial hypertension (PAH), interstitial lung disease (ILD) and early diffuse cutaneous SSc are discussed in turn, for example: (a) increased use of phosphodiesterase inhibitors and endothelin receptor antagonists for digital vasculopathy; (b) early recognition and treatment of PAH, including with combination therapies; (c) increased use of mycophenolate mofetil and of nintedanib in ILD; and (d) immunosuppression now as standard practice in early diffuse cutaneous SSc, and autologous haematopoietic stem cell transplantation for highly selected patients with progressive diffuse disease. Finally, future challenges are discussed, including ensuring that all patients with SSc are monitored and treated according to best practice guidelines, and whenever possible giving patients the opportunity to participate in clinical trials.
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18
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Skaug B, Lyons MA, Swindell WR, Salazar GA, Wu M, Tran TM, Charles J, Vershel CP, Mayes MD, Assassi S. Large-scale analysis of longitudinal skin gene expression in systemic sclerosis reveals relationships of immune cell and fibroblast activity with skin thickness and a trend towards normalisation over time. Ann Rheum Dis 2021; 81:516-523. [PMID: 34937693 DOI: 10.1136/annrheumdis-2021-221352] [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] [Received: 08/13/2021] [Accepted: 11/29/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Determine relationships between skin gene expression and systemic sclerosis (SSc) clinical disease features, and changes in skin gene expression over time. METHODS A total of 339 forearm skin biopsies were obtained from 113 SSc patients and 44 matched healthy controls. 105 SSc patients had a second biopsy, and 76 had a third biopsy. Global gene expression profiling was performed, and differentially expressed genes and cell type-specific signatures in SSc were evaluated for relationships to modified Rodnan Skin Score (mRSS) and other clinical variables. Changes in skin gene expression over time were analysed by mixed effects models and principal component analysis. Immunohistochemical staining was performed to validate conclusions. RESULTS Gene expression dysregulation was greater in SSc patients with affected skin than in those with unaffected skin. Immune cell and fibroblast signatures positively correlated with mRSS. High baseline immune cell and fibroblast signatures predicted higher mRSS over time, but were not independently predictive of longitudinal mRSS after adjustment for baseline mRSS. In early diffuse cutaneous SSc, immune cell and fibroblast signatures declined over time, and overall skin gene expression trended towards normalisation. On immunohistochemical staining, most early diffuse cutaneous SSc patients with high baseline T cell and macrophage numbers had declines in these numbers at follow-up. CONCLUSIONS Skin thickness in SSc is related to dysregulated immune cell and fibroblast gene expression. Skin gene expression changes over time in early diffuse SSc, with a tendency towards normalisation. These observations are relevant for understanding SSc pathogenesis and could inform treatment strategies and clinical trial design.
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Affiliation(s)
- Brian Skaug
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Marka A Lyons
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - William R Swindell
- Department of Internal Medicine, The Jewish Hospital, Cincinnati, Ohio, USA
| | - Gloria A Salazar
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Minghua Wu
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Tuan M Tran
- Department of Genetics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julio Charles
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Connor P Vershel
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Maureen D Mayes
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
| | - Shervin Assassi
- Division of Rheumatology, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
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Domsic RT, Gao S, Laffoon M, Wisniewski S, Zhang Y, Steen V, Lafyatis R, Medsger TA. Defining the optimal disease duration of early diffuse systemic sclerosis for clinical trial design. Rheumatology (Oxford) 2021; 60:4662-4670. [PMID: 33506859 PMCID: PMC8677444 DOI: 10.1093/rheumatology/keab075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Clinical trials in early diffuse cutaneous systemic sclerosis (SSc) using the modified Rodnan skin score (mRSS) as the primary outcome measure have most often been negative. We wanted to assess how the definition of disease onset (first SSc manifestation vs first non-Raynaud manifestation) and varying lengths of disease duration at trial entry as an inclusion criteria functioned. Our objective was to optimize trial inclusion criteria. METHODS We used the prospective, observational University of Pittsburgh Scleroderma Cohort to identify early diffuse SSc patients first evaluated between 1980 and 2015. All had <3 years from first SSc (n = 481) or first non-Raynaud manifestation (n = 514) and three or more mRSS scores. We used descriptive, survival and group-based trajectory analyses to compare the different definitions of disease onset and disease duration as inclusion criteria for clinical trials. RESULTS There was no appreciable difference between using first SSc manifestation compared with first non-Raynaud manifestation as the definition of disease onset. Compared with other disease durations, <18 months of disease had >70% of patients fitting into trajectories with worsening cutaneous disease over 6 months of follow-up. Longer disease durations demonstrated the majority of patients with trajectories showing an improvement in mRSS (regression to the mean) over 6 months. CONCLUSIONS Regardless of whether the first SSc or first non-Raynaud manifestation is used to define disease onset, duration of <18 months at enrolment is preferable. A longer disease duration criterion more frequently results in regression to the mean of the mRSS score, and likely contributes to negative trial outcomes.
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Affiliation(s)
- Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine
| | - Shiyao Gao
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Maureen Laffoon
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine
| | - Steven Wisniewski
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine
| | - Yuqing Zhang
- Division of Epidemiology, Massachusetts General Hospital, Boston, MA
| | - Virginia Steen
- Division of Rheumatology, Georgetown University, Washington, DC, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine
| | - Thomas A Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine
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20
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You H, Xu D, Hou Y, Zhou J, Wang Q, Li M, Zeng X. Tofacitinib as a possible treatment for skin thickening in diffuse cutaneous systemic sclerosis. Rheumatology (Oxford) 2021; 60:2472-2477. [PMID: 33188425 DOI: 10.1093/rheumatology/keaa613] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 08/23/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To analyse the effectiveness of tofacitinib for the treatment of refractory skin thickening in dcSSc. METHODS Data from 10 patients with dcSSc treated with tofacitinib (5 mg twice daily) were analysed. A total of 12 dcSSc patients treated with intensive conventional immunosuppressants were selected as the historical comparator group. A clinically relevant response was defined as a decrease in the modified Rodnan skin score (mRSS) of >5 points and ≥25% from baseline. Clinical indicators were compared between the two groups to evaluate the effect of tofacitinib. RESULTS The mRSS significantly improved the first month after tofacitinib treatment, with a mean change in the mRSS of -3.7 (95% CI -5.52, -1.88; P = 0.001) and greater than the comparators at 6 months [-10.0 (95% CI -14.74, -5.26) vs -4.1 (95% CI -7.49, -0.73), P = 0.026]. Tofacitinib-treated patients had a significantly shorter response time than the comparators (P = 0.015 by log-rank test), with overall response rates of 20% (2/10) vs 0% (0/12) and 60% (6/10) vs 16.7% (2/12) at 1 and 3 months, respectively. CONCLUSION Our results indicate that tofacitinib may be as effective as or even better than intensive conventional immunosuppressants, with a quicker and higher response rate in refractory dcSSc patients with progressive skin thickness.
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Affiliation(s)
- Hanxiao You
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Yong Hou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
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Jaafar S, Lescoat A, Huang S, Gordon J, Hinchcliff M, Shah AA, Assassi S, Domsic R, Bernstein EJ, Steen V, Elliott S, Hant F, Castelino FV, Shanmugam VK, Correia C, Varga J, Nagaraja V, Roofeh D, Frech T, Khanna D. Clinical characteristics, visceral involvement, and mortality in at-risk or early diffuse systemic sclerosis: a longitudinal analysis of an observational prospective multicenter US cohort. Arthritis Res Ther 2021; 23:170. [PMID: 34127049 PMCID: PMC8201684 DOI: 10.1186/s13075-021-02548-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/24/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Early diffuse cutaneous systemic sclerosis (dcSSc) has the highest case fatality among rheumatic diseases. We report baseline characteristics, current immunosuppressive therapies, progression of skin and internal organ involvement, and mortality in a multicenter prospective cohort from the United States (US) of America. METHODS We performed a longitudinal analysis of participants from 12 US centers, from April 2012 to July 2020. All participants had early dcSSc or were at-risk for dcSSc, with ≤2 years since the first non-Raynaud's phenomenon (RP) symptom. RESULTS Three hundred one patients were included with a baseline median disease duration of 1.2 years since RP and a mean modified skin score of 21.1 units. At baseline, 263 (87.3%) had definite dcSSc and 38 (12.7%) were classified as at-risk; 112 (49.6%) patients were positive for anti-RNA polymerase III antibodies. The median follow-up duration was 24.5 months (IQR = 10.3-40.7 months). One hundred ninety (63.1%) participants were treated with an immunosuppressive therapy, of which mycophenolate mofetil was most used at baseline and follow-up. Of 38 who were classified as at-risk at baseline, 27 (71%) went on to develop dcSSc; these patients were characterized by higher baseline mean HAQ-DI (0.8 versus 0.4, p = 0.05) and higher baseline mRSS (8.8 versus 4.4, p < 0.01) in comparison with those who remained as limited cutaneous SSc. In the overall cohort, 48 participants (21.1%) had clinically significant worsening of skin fibrosis, mainly occurring in the first year of follow-up; 41 (23.3%) had an absolute forced vital capacity decline of ≥10%. Twenty participants (6.6%) died, of which 18 died in the first 3 years of follow-up. Cardiac involvement (33.3%), gastrointestinal dysmotility (22.2%), and progressive interstitial lung disease (ILD) (16.7%) were the main causes of death. CONCLUSION This US cohort highlights the management of early SSc in the current era, demonstrating progression of skin and lung involvement despite immunosuppressive therapy and high mortality due to cardiac involvement.
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Affiliation(s)
- Sara Jaafar
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Alain Lescoat
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine and Clinical Immunology, CHU Rennes, Univ Rennes, Rennes, France
- University of Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail, Rennes, France
| | - Suiyuan Huang
- School of Public Health, University of Michigan, Ann Arbor, USA
| | - Jessica Gordon
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | | | - Ami A Shah
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Shervin Assassi
- Department of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Robyn Domsic
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Elana J Bernstein
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Virginia Steen
- Department of Medicine, Georgetown University, Washington, DC, USA
| | - Sabrina Elliott
- Department of Medicine, Georgetown University, Washington, DC, USA
| | - Faye Hant
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Chase Correia
- Department of Medicine, Northwestern University, Chicago, IL, USA
| | - John Varga
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Vivek Nagaraja
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - David Roofeh
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Tracy Frech
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Dinesh Khanna
- Division of Rheumatology and Scleroderma Program, Department of Internal Medicine, University of Michigan, Suite 7C27 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA.
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22
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Menkü Özdemir FD, Üstün GG, Vargel İ, Özgür FF. "Treatment of En Coup de Sabre Deformity with Fat Grafting and Demineralized Bone Matrix: A Case Series". J Plast Reconstr Aesthet Surg 2021; 74:3353-3360. [PMID: 34417126 DOI: 10.1016/j.bjps.2021.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/28/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022]
Abstract
En coup de sabre deformity (ECDS) is a form of localized scleroderma in the frontoparietal region caused by progressive subcutaneous tissue atrophy and bony defect. Although ECDS involves two layers, skin/subcutaneous tissue and bone, the existing literature mainly focuses only on treating the skin/subcutaneous tissue layer. In this case series, we aimed to propose a novel approach that includes the combined use of fat grafting and demineralized bone matrix (DBM). Four patients with ECDS deformity, operated between February 2016 and October 2018, were retrospectively evaluated. All the patients were treated with the novel approach. Patients were evaluated with localized scleroderma scale and computed tomography (CT) scan in the preoperative period and at the annual follow-up. We observed remarkable improvement in the localized scleroderma scale including appearance, palpation, and size scores in all patients at the annual follow-up. CT scans at the annual follow-up revealed new callus formation at the bony defect area in all patients. Reinforcing fat grafting with DBM could promote healing of the bony and skin/subcutaneous tissue defects associated with ECDS.
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Affiliation(s)
- Fethiye Damla Menkü Özdemir
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Research and Application Center for the Treatment of Cleft Lip and Palate and Craniomaxillofacial Deformities, Ankara, Turkey
| | - Galip Gencay Üstün
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Research and Application Center for the Treatment of Cleft Lip and Palate and Craniomaxillofacial Deformities, Ankara, Turkey
| | - İbrahim Vargel
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Research and Application Center for the Treatment of Cleft Lip and Palate and Craniomaxillofacial Deformities, Ankara, Turkey.
| | - Fatma Figen Özgür
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Research and Application Center for the Treatment of Cleft Lip and Palate and Craniomaxillofacial Deformities, Ankara, Turkey
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Lescoat A, Varga J, Matucci-Cerinic M, Khanna D. New promising drugs for the treatment of systemic sclerosis: pathogenic considerations, enhanced classifications, and personalized medicine. Expert Opin Investig Drugs 2021; 30:635-652. [PMID: 33909517 PMCID: PMC8292968 DOI: 10.1080/13543784.2021.1923693] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023]
Abstract
Introduction: Systemic sclerosis (SSc), also known as scleroderma, is a complex orphan disease characterized by early inflammatory features, vascular hyper-reactivity, and fibrosis of the skin and internal organs. Although substantial progress has been made in the understanding of the pathogenesis of SSc, there is still no disease-modifying drug that could significantly impact the natural history of the disease.Areas covered: This review discusses the rationale, preclinical evidence, first clinical eevidence,and pending issues concerning new promising therapeutic options that are under investigation in SSc. The search strategy was based on PubMed database and clinical trial.gov, highlighting recent key pathogenic aspects and phase I or II trials of investigational drugs in SSc.Expert opinion: The identification of new molecular entities that potentially impact inflammation and fibrosis may constitute promising options for a disease modifying-agent in SSc. The early combinations of antifibrotic drugs (such as pirfenidone) with immunomodulatory agents (such as mycophenolate mofetil) may also participate to achieve such a goal. A more refined stratification of patients, based on clinical features, molecular signatures, and identification of subpopulations with distinct clinical trajectories, may also improve management strategies in the future.
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Affiliation(s)
- Alain Lescoat
- Department of internal medicine, Division of rheumatology and Michigan Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of internal medicine, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut De Recherche En Santé, Environnement Et Travail) - UMR_S 1085, Rennes, France
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - John Varga
- Department of internal medicine, Division of rheumatology and Michigan Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Dinesh Khanna
- Department of internal medicine, Division of rheumatology and Michigan Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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24
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Leodori G, Pellicano C, Gigante A, Rosato E. Estimated glomerular filtration rate and renal resistive index as possible predictive markers of mortality in systemic sclerosis. Eur J Intern Med 2021; 87:83-89. [PMID: 33593660 DOI: 10.1016/j.ejim.2021.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/14/2021] [Accepted: 01/24/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Subclinical nephropathy is underestimated in systemic sclerosis (SSc). Study aim is to evaluate the role of renal resistance indices (RRI) and estimated glomerular filtration rate (eGFR) assessed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) as predictive markers of mortality during 10 years of follow-up in SSc patients. METHODS 181 SSc patients (60 years, 152 females) were enrolled. At baseline, the GFR was estimated in 181 SSc patients and RRI was measured in 122 SSc patients. During a follow-up of 10 years we recorded the main complications of disease, date and causes of death. RESULTS eGFR shows a linear negative correlation with RRI. RRI showed a correlation with systolic pulmonary artery pressure (sPAP). Overall survival is lower in SSc patients with eGFR<60 ml/min and RRI ≥0.70 than in SSc patients with eGFR≥60 ml/min (p<0.0001) and with RRI<0.70 (p<0.01) both for mortality due to SSc and all causes. In multivariate analysis, eGFR<60 ml/min [HR 6.429, 95%CI (1.006-41.08), p<0.05] and forced vital capacity (FVC) [HR 0.954, 95%CI (0.911-1), p<0.05] are predictive markers of mortality due to SSc, while eGFR [HR 3.617, 95%CI (1.370-9.554), p<0.01], RRI [HR 0.210, 95% CI (0.068-0.649), p<0.01], age [HR 1.062, 95%CI (1.023-1.103), p<0.01], FVC [HR 0.967, 95%CI (0.946-0.989), p<0.01] and disease activity index (DAI) [HR 1.663, 95%CI (1.262-2.191), p<0.0001] are predictive markers of mortality due to all causes. CONCLUSION We demonstrate that eGFR is a predictive marker of mortality due to SSc and to all causes, conversely RRI is predictive marker of mortality due to all causes.
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Affiliation(s)
- Giorgia Leodori
- Department of Translational and Precision Medicine, Sapienza University of Rome.
| | - Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University of Rome
| | - Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome
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25
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The Autoantigen Repertoire and the Microbial RNP World. Trends Mol Med 2021; 27:422-435. [PMID: 33722441 DOI: 10.1016/j.molmed.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/30/2021] [Accepted: 02/13/2021] [Indexed: 02/08/2023]
Abstract
Although autoimmunity and autoimmune disease (AID) are relatively common, the repertoire of autoantigens is paradoxically very limited. Highly enriched in this autoantigen repertoire are nucleic acids and their binding proteins, which together form large macromolecular structures. Most of these complexes are of ancient evolutionary origin, with homologs throughout multiple kingdoms of life. Why and if these nucleic acid-protein particles drive the development of autoimmunity remains unresolved. Recent advances in our understanding of the microbiome may provide clues about the origins of autoimmunity - and the particular puzzle of why the autoantigen repertoire is so particularly enriched in ribonucleoprotein particles (RNPs). We discuss the possibility that autoimmunity to some RNPs may arise from molecular mimicry to microbial orthologs.
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26
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Bering J, Griffing WL, Crowell M, Umar SB. Progression of gastrointestinal symptoms over time in patients with systemic sclerosis. Rheumatol Int 2021; 41:1281-1287. [PMID: 33630144 DOI: 10.1007/s00296-021-04806-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Up to 90% of patients with systemic sclerosis (SSc) develop gastrointestinal (GI) symptoms. To evaluate whether GI symptoms and quality of life in patients with SSc demonstrate longitudinal stability. Consecutive patients with SSc (n = 100) completed the validated university of California at Los Angeles scleroderma clinical trial consortium gastrointestinal tract 2.0 (GIT) instrument and completed the same instrument approximately 5 years later. Comparison was made between patients with diffuse (dcSSc) and limited (lcSSc) subtypes and duration of disease of less than or greater than 5 years. GIT scores were calculated and analyzed for differences. 37 patients with dcSSc and 63 patients with lcSSc were included. Social functioning score significantly improved over time [0.44 (0.59)-0.31 (0.47); P = 0.003]. Total GIT scores were lower in patients with diffuse [0.51 (0.41)] compared with limited [(0.72 (0.53); P = 0.029] disease at both baseline and follow-up. Social functioning improved similarly in both dcSSc and lcSSc over time (P = 0.004). GIT Total scores increased in 27% (27/100) of patients and did not change or improved in 73% (73/100). Patients with worsening GI status had significantly increased scores on all GIT subscales. A lower body-mass index at baseline was significantly associated with worsening GIT Total score (OR 1.22; 95% CI 1.07-1.39; P < 0.001). Patients with SSc generally demonstrate longitudinal stability or improvement in their GI symptoms, but a subset of patients experience worsening of GI symptoms and negative impacts on GI-related quality of life.
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Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - W Leroy Griffing
- Division of Rheumatology Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Michael Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Sarah B Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
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27
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Henes J, Oliveira MC, Labopin M, Badoglio M, Scherer HU, Del Papa N, Daikeler T, Schmalzing M, Schroers R, Martin T, Pugnet G, Simoes B, Michonneau D, Marijt EWA, Lioure B, Olivier Bay J, Snowden JA, Rovira M, Huynh A, Onida F, Kanz L, Marjanovic Z, Farge D. Autologous stem cell transplantation for progressive systemic sclerosis: a prospective non-interventional study from the European Society for Blood and Marrow Transplantation Autoimmune Disease Working Party. Haematologica 2021; 106:375-383. [PMID: 31949011 PMCID: PMC7849556 DOI: 10.3324/haematol.2019.230128] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 01/09/2020] [Indexed: 12/29/2022] Open
Abstract
Three randomized controlled trials in early severe systemic sclerosis demonstrated that autologous hematopoietic stem cell transplantation was superior to standard cyclophosphamide therapy. This European Society for Blood and Marrow Transplantation multicenter, prospective, non-interventional study was designed to further decipher efficacy and safety of this procedure for severe systemic sclerosis patients in real-life practice and to search for prognostic factors. All consecutive adult patients with systemic sclerosis undergoing a first autologous hematopoietic stem cell transplant between December 2012 and February 2016 were prospectively included in the study. The primary endpoint was progression-free survival. Secondary endpoints were overall survival, non-relapse mortality, response and incidence of progression. Eighty patients with systemic sclerosis were included. The median duration of the follow-up was 24 (range, 6-57) months after stem cell transplantation using cyclophosphamide plus antithymocyte globulin conditioning for all, with CD34+ selection in 35 patients. At 2 years, the progression- free survival rate was 81.8%, the overall survival rate was 90%, the response rate was 88.7% and the incidence of progression was 11.9%. The 100-day non-relapse mortality rate was 6.25% (n=5) with four deaths from cardiac events, including three due to cyclophosphamide toxicity. Modified Rodnan skin score and forced vital capacity improved with time (P<0.001). By multivariate analysis, baseline skin score >24 and older age at transplantation were associated with lower progression-free survival (hazard ratios 3.32 and 1.77, respectively). CD34+-cell selection was associated with better response (hazard ratio 0.46). This study confirms the efficacy of autologous stem cell transplantation, using nonmyeloablative conditioning, in real-life practice for severe systemic sclerosis. Careful cardio-pulmonary assessment to identify organ involvement at the time of the patient’s referral, reduced cyclophosphamide doses and CD34+-cell selection may improve outcomes. The study was registered at ClinicalTrials.gov: NCT02516124.
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Affiliation(s)
- Joerg Henes
- University Hospital Tuebingen; Intenal Medicine II, Tuebingen, Germany
| | | | - Myriam Labopin
- Saint Antoine Hospital, Université Pierre et Marie Curie, Paris, France
| | | | - Hans Ulrich Scherer
- Leiden University Medical Center, Department of Rheumatology; Leiden, Netherlands
| | - Nicoletta Del Papa
- Scleroderma Clinic, Osp. G. Pini, Department of Rheumatology, Milan, Italy
| | - Thomas Daikeler
- University and University Hospital of Basel, Department of Rheumatology, Basel, Switzerland
| | - Marc Schmalzing
- University Hospital of Wuerzburg, Department of Rheumatology/Immunology, Wuerzburg, Germany
| | | | - Thierry Martin
- Service de Medecine Interne et Immunologie Clinique, Hopitaux Universitaires de Strasbourg, France
| | - Gregory Pugnet
- CHU de Toulouse, Hopital Purpan, Service de Medecine Interne, Toulouse, France
| | - Belinda Simoes
- Dept. of Hematology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - David Michonneau
- Dept. of Hematology, Hopital Saint Louis and Université Paris 7, Denis Diderot, Paris, France
| | - Erik W A Marijt
- Leiden University Medical Center, Department of Hematology, Leiden, Netherlands
| | - Bruno Lioure
- Strasbourg University Hospital, Department of Hematology, Strasbourg, France
| | | | - John A Snowden
- Dept. of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Montserrat Rovira
- Department of Hematology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Anne Huynh
- UCT Oncopole, Department of Haematology, Toulouse, France
| | - Francesco Onida
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano Italy
| | - Lothar Kanz
- University Hospital Tuebingen, Department of Internal Medicine II, Tuebingen, Germany
| | - Zora Marjanovic
- Saint Antoine Hospital, Department of Haematology, Paris, France
| | - Dominique Farge
- Assistance Publique-Hopitaux de Paris, Saint-Louis Hospital, Paris, France
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28
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Herrick AL, Shukla R, Watson REB. Frontiers in translational systemic sclerosis research: A focus on the unmet 'cutaneous' clinical needs (Viewpoint). Exp Dermatol 2020; 29:1144-1153. [DOI: 10.1111/exd.14179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Ariane L. Herrick
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
| | | | - Rachel E. B. Watson
- Division of Musculoskeletal and Dermatological Sciences Salford Royal NHS Foundation Trust Manchester Academic Health Science Centre The University of Manchester Manchester UK
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29
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Azuma A, Chung L, Behera D, Chung M, Kondoh Y, Ogura T, Okamoto M, Swarnakar R, Zeng X, Zou H, Meng X, Gahlemann M, Alves M, Kuwana M. Efficacy and safety of nintedanib in Asian patients with systemic sclerosis-associated interstitial lung disease: Subgroup analysis of the SENSCIS trial. Respir Investig 2020; 59:252-259. [PMID: 33223487 DOI: 10.1016/j.resinv.2020.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE In the SENSCIS trial in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD), nintedanib reduced the rate of decline in forced vital capacity (FVC) (mL/year) over 52 weeks by 44% in comparison with placebo, with manageable adverse events in most patients. We analyzed the efficacy and safety of nintedanib in patients of Asian race. METHODS Patients with SSc-ILD were randomized to receive nintedanib or placebo. The outcomes over 52 weeks were analyzed in Asian versus non-Asian patients. RESULTS Of the 288 patients in each treatment group, 62 (21.5%) in the nintedanib group and 81 (28.1%) in the placebo group were Asian; 90.2% of the Asian patients were enrolled in Asian countries. In the placebo group, the rate of FVC decline over 52 weeks was consistent between Asian and non-Asian patients (-99.9 and -90.6 mL/year, respectively). The effect of nintedanib on reducing the rate of FVC decline over 52 weeks was consistent between Asian (difference, 44.3 mL/year [95% CI: -32.8, 121.4]) and non-Asian patients (difference, 39.0 mL/year [95% CI: -5.1, 83.1]) (treatment-by-time-by-subgroup interaction, p = 0.91). Diarrhea was the most frequent adverse event and was reported in similar proportions of Asian and non-Asian patients in the nintedanib group (80.6% and 74.3%, respectively) and placebo group (28.4% and 32.9%, respectively). CONCLUSIONS In patients with SSc-ILD, nintedanib had a consistent benefit on slowing the progression of SSc-ILD in Asian and non-Asian patients, with a similar adverse event profile. TRIAL REGISTRATION ClinicalTrials.gov NCT02597933.
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Affiliation(s)
- Arata Azuma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Lorinda Chung
- Departments of Medicine and Dermatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Melody Chung
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Centre, Yokohama, Japan
| | - Masaki Okamoto
- Department of Internal Medicine, Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Japan
| | - Rajesh Swarnakar
- Department of Respiratory Medicine, Getwell Hospital and Research Institute, Nagpur, Maharashtra, India
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - Heijan Zou
- Division of Rheumatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xianhua Meng
- Boehringer Ingelheim (China) Investment Co., Ltd, Shanghai, China
| | | | | | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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30
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Rimar D, Rosner I, Slobodin G. Upfront Combination Therapy With Rituximab and Mycophenolate Mofetil for Progressive Systemic Sclerosis. J Rheumatol 2020; 48:304-305. [PMID: 33060315 DOI: 10.3899/jrheum.200484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Doron Rimar
- Rheumatology Unit, Bnai-Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel.
| | - Itzhak Rosner
- Rheumatology Unit, Bnai-Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai-Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
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31
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Vonk MC. Is there still a role for cyclophosphamide in the treatment of systemic sclerosis? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 6:117-122. [PMID: 35382095 PMCID: PMC8892929 DOI: 10.1177/2397198320961673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/27/2022]
Abstract
Cyclophosphamide has been the cornerstone of treatment of systemic sclerosis for
a long time and is the first-choice therapy for treating systemic
sclerosis–associated interstitial lung disease according to the European League
Against Rheumatism recommendations on treatment of systemic sclerosis. However,
new therapeutic options are emerging, and treatment with cyclophosphamide is
hampered by its toxicity and restricted possible treatment duration. This review
has a focus on the evidence of efficacy of cyclophosphamide in different aspects
of systemic sclerosis and its organ involvements, reviews its toxicity, and will
answer the question whether there is still a role for cyclophosphamide in the
treatment of systemic sclerosis, taking the evidence and current therapeutic
options into account.
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Affiliation(s)
- Madelon C Vonk
- Department of the Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Mihai C, Dobrota R, Assassi S, Mayes MD, Distler O. Enrichment Strategy for Systemic Sclerosis Clinical Trials Targeting Skin Fibrosis: A Prospective, Multiethnic Cohort Study. ACR Open Rheumatol 2020; 2:496-502. [PMID: 32720753 PMCID: PMC7437132 DOI: 10.1002/acr2.11165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/03/2020] [Indexed: 12/27/2022] Open
Abstract
Objective The modified Rodnan skin score (mRSS) is often used as a primary outcome measure in systemic sclerosis (SSc) randomized clinical trials (RCTs). Previous cohort studies with predominantly European Caucasian patients showed that setting an upper limit of mRSS as a selection criterion for RCTs leads effectively to enrichment with progressive patients. This study aimed to demonstrate this effect in an ethnically diverse cohort, rich in patients positive for anti‐RNA polymerase III antibodies (Pol3). Methods We selected from the Genetics versus Environment in Scleroderma Outcomes Study (GENISOS) cohort patients with diffuse cutaneous SSc (dcSSc), who had mRSS of 7 or more at inclusion and a documented mRSS after 12 ± 2 months. Progression of skin fibrosis was defined as an increase in mRSS greater than 5 points and 25% or more from baseline. To identify the optimal cutoff for the baseline mRSS yielding the highest sensitivity for progressive skin fibrosis, we developed ROC curves and logistic regression models with “progression” as the outcome variable and a binary variable of baseline mRSS cutoff point as predictor. Results We included 152 patients (age and disease duration [mean ± SD, years]: 48.7 ± 13.0 and 2.4 ± 1.5 respectively, 22.4% males, 34.2% Pol3‐positive). Seventeen patients (11.2%) had skin fibrosis progression after 12 ± 2 months. An mRSS cutoff of 27 or less had the highest probability of progression (odds ratio, 9.12; 95% confidence interval: 1.173‐70.851; P = 0.035; area under the curve, 0.652; sensitivity, 94%). Conclusion We demonstrated in an ethnically diverse cohort of patients with early dcSSc and with a high proportion of patients who are Pol3‐positive that setting an upper limit of the mRSS as a selection criterion leads effectively to cohort enrichment with progressors.
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Affiliation(s)
- Carina Mihai
- University Hospital Zurich, Zurich, Switzerland, and Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Kuwana M, Hasegawa M, Fukue R, Shirai Y, Ishikawa O, Endo H, Ogawa F, Goto D, Kawaguchi Y, Sato S, Ihn H, Takehara K. Initial predictors of skin thickness progression in patients with diffuse cutaneous systemic sclerosis: Results from a multicentre prospective cohort in Japan. Mod Rheumatol 2020; 31:386-393. [PMID: 32552202 DOI: 10.1080/14397595.2020.1784548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To identify initial parameters that predict worsening of skin thickening in patients with diffuse cutaneous systemic sclerosis (dcSSc) using a multicentre, prospective, observational cohort in Japan. METHODS A total of 171 patients with dcSSc were selected from a prospective cohort database based on the following criteria: dcSSc, modified Rodnan total skin thickness score (mRSS) ≥7, disease duration <60 months, and valid mRSS data at one year. Worsening of skin thickness was defined as an increase in mRSS ≥3 points and an increase ≥25% from baseline to one year. Initial demographic and clinical parameters useful for predicting the progression of skin thickness were identified using univariate and multivariable analysis, and prediction models of skin thickening progression were built based on combinations of independent predictive parameters. RESULTS Only 23 patients (13.5%) experienced worsening mRSSs at one year. Short disease duration, low mRSS, absence of nailfold bleeding, arthritis, and a high erythrocyte sedimentation rate at diagnosis were identified as predictors of subsequent worsening of the mRSS even after adjusting for the treatment. Assessment of the best predictive model revealed that patients with a disease duration ≤12 months and mRSS ≤19 had a risk of mRSS worsening within one year, with a sensitivity of 73.9% and specificity of 81.1%. CONCLUSION Identification of predictors of subsequent worsening of skin thickness in dcSSc patients is useful for identifying patients who require intensive treatment with potential disease-modifying agents and for improving clinical trial design by characterizing eligible progressors in the Japanese population.
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Affiliation(s)
- Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ryosuke Fukue
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yuichiro Shirai
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hirahito Endo
- Department of Rheumatology, Southern Tohoku General Hospital, Fukushima, Japan
| | - Fumihide Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Daisuke Goto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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Khanna D, Allanore Y, Denton CP, Kuwana M, Matucci-Cerinic M, Pope JE, Atsumi T, Bečvář R, Czirják L, Hachulla E, Ishii T, Ishikawa O, Johnson SR, De Langhe E, Stagnaro C, Riccieri V, Schiopu E, Silver RM, Smith V, Steen V, Stevens W, Szücs G, Truchetet ME, Wosnitza M, Laapas K, de Oliveira Pena J, Yao Z, Kramer F, Distler O. Riociguat in patients with early diffuse cutaneous systemic sclerosis (RISE-SSc): randomised, double-blind, placebo-controlled multicentre trial. Ann Rheum Dis 2020; 79:618-625. [PMID: 32299845 PMCID: PMC7213318 DOI: 10.1136/annrheumdis-2019-216823] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/19/2020] [Accepted: 03/09/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Riociguat is approved for pulmonary arterial hypertension and has antiproliferative, anti-inflammatory and antifibrotic effects in animal models of tissue fibrosis. We evaluated the efficacy and safety of riociguat in patients with early diffuse cutaneous systemic sclerosis (dcSSc) at high risk of skin fibrosis progression. METHODS In this randomised, double-blind, placebo-controlled, phase IIb trial, adults with dcSSc of <18 months' duration and a modified Rodnan skin score (mRSS) 10-22 units received riociguat 0.5 mg to 2.5 mg orally three times daily (n=60) or placebo (n=61). The primary endpoint was change in mRSS from baseline to week 52. RESULTS At week 52, change from baseline in mRSS units was -2.09±5.66 (n=57) with riociguat and -0.77±8.24 (n=52) with placebo (difference of least squares means -2.34 (95% CI -4.99 to 0.30; p=0.08)). In patients with interstitial lung disease, forced vital capacity declined by 2.7% with riociguat and 7.6% with placebo. At week 14, average Raynaud's condition score had improved ≥50% in 19 (41.3%)/46 patients with riociguat and 13 (26.0%)/50 patients with placebo. Safety assessments showed no new signals with riociguat and no treatment-related deaths. CONCLUSIONS Riociguat did not significantly benefit mRSS versus placebo at the predefined p<0.05. Secondary and exploratory analyses showed potential efficacy signals that should be tested in further trials. Riociguat was well tolerated.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yannick Allanore
- Rheumatology A department, Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | - Christopher P Denton
- Division of Medicine, Centre for Rheumatology, University College London, London, UK
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Janet E Pope
- Schulich School of Medicine, Division of Rheumatology, The University of Western Ontario, London, Ontario, Canada
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Radim Bečvář
- Institute of Rheumatology, Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Claude Huriez Hospital, Lille University School of Medicine, Lille, France
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Gunma University Postgraduate School of Medicine, Maebashi, Japan
| | - Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University Health Network, Mount Sinai Hospital, University of Toronto, Toronto Scleroderma Research Program, Toronto, Ontario, Canada
| | - Ellen De Langhe
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Chiara Stagnaro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Riccieri
- Department of Clinical Medicine and Therapy, University of Rome La Sapienza, Rome, Italy
| | - Elena Schiopu
- Division of Rheumatology, Department of Internal Medicine, Michigan Medicine University Hospitals, Ann Arbor, Michigan, USA
| | - Richard M Silver
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vanessa Smith
- Department of Rheumatology and Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Virginia Steen
- Division of Rheumatology, Georgetown University Medical Center, Washington, DC, USA
| | - Wendy Stevens
- Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Gabriella Szücs
- Division of Rheumatology, Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | - Zhen Yao
- Bayer Healthcare, Beijing, China
| | - Frank Kramer
- Research & Development, Bayer AG, Wuppertal, Germany
| | - Oliver Distler
- Department of Rheumatology, University Hospital, Zurich, Switzerland
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Kersten BE, den Broeder N, van den Hoogen FHJ, Knaapen-Hans HAK, van den Ende CHM, Vonk MC. Treatment with cyclophosphamide i.v. pulse therapy is an option for effective treatment of skin fibrosis in patients with early systemic sclerosis. Rheumatology (Oxford) 2020; 59:1550-1555. [PMID: 31628802 PMCID: PMC7310100 DOI: 10.1093/rheumatology/kez487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/18/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives SSc is a autoimmune disease characterized by fibrosis of the skin and internal organs. There is a lack of evidence for the efficacy of i.v. CYC pulse therapy on skin thickening. We aimed to examine the response of i.v. CYC pulse therapy on skin thickening in our cohort of SSc patients and analysed factors that predict this response. Methods We retrospectively evaluated the data for 143 patients with SSc from baseline to 12, 24 and 36 months. All patients were treated with at least 6 i.v. CYC pulses (750 mg/m2/month). We applied the modified Rodnan Skin Score (mRSS) to assess skin thickening. A clinically relevant response was defined as a decrease in mRSS of 5 points and 25% from baseline. Different baseline variables for predicting response on month 12 were tested in logistic regression analyses. Results Baseline characteristics of the patients with dcSSc and lcSSc were collected. Forty-three percent (n = 42) of dcSSc patients had a clinically relevant response on month 12. Non-responding on month 6 predicts non-response on month 12 (odds ratio 37.1; 95% CI 4.5, 306.4). Conclusion We concluded that i.v. CYC pulse therapy should be considered as an effective treatment option for skin thickening in dcSSc patients, because 43% of this group of patients were found to have a clinically relevant response. Of the dcSSC patients who did not respond by month 6, only 29% had a response by month 12. This finding can help the physician and patient in shared decision making about whether or not to continue therapy.
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Affiliation(s)
- Brigit E Kersten
- Department of Rheumatic Diseases, Radboud University Medical Center
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | | | | | - Madelon C Vonk
- Department of Rheumatic Diseases, Radboud University Medical Center
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Abstract
PURPOSE OF REVIEW To discuss recent advances in identification of biomarkers in systemic sclerosis for disease severity, prognosis, and treatment response. RECENT FINDINGS Recent reports describe novel circulating markers of disease severity, autoantibody associations with specific manifestations including cancer, and skin gene expression-based predictors of modified Rodnan skin score progression and treatment response. Moreover, there is converging evidence that C-reactive protein and pneumoproteins such as Krebs von den Lungen-6 and chemokine ligand 18 could serve as prognostic biomarkers in systemic sclerosis-associated interstitial lung disease. SUMMARY Several novel biomarkers show promise in improving the assessment of systemic sclerosis (SSc) disease severity, prognosis, and treatment response. Their potential utility in prospective selection of patients for clinical trials and in individual patient management require additional research.
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Zheng B, Nevskaya T, Baxter CA, Ramey DR, Pope JE, Baron M. Changes in skin score in early diffuse cutaneous systemic sclerosis are associated with changes in global disease severity. Rheumatology (Oxford) 2020; 59:398-406. [PMID: 31359048 DOI: 10.1093/rheumatology/kez299] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/30/2019] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To determine whether skin score changes are associated with changes in overall disease severity, function and quality of life in early dcSSc patients. METHODS A total of 154 and 128 dcSSc patients from the Canadian Scleroderma Research Group database with 1 and 2 year follow-up and a disease duration ⩽5 years without end-stage organ damage and/or significant comorbidity at the initial visit were included. Skin was assessed using the modified Rodnan skin score (mRSS) and disease severity by the summed Medsger disease severity score (DSS) (without skin domain), physician and patient global assessments, function [HAQ disability index (HAQ-DI)] and quality of life [36-item Short Form Health Survey (SF-36) physical component summary (PCS)]. Analyses were repeated in patients with a disease duration ⩽3 years. RESULTS At 2 years, 64 (50%) patients had improved skin (mRSS decrease of ⩾5 points and/or ⩾25%). Skin improvers had improved summed DSS (P = 0.002); better physician global assessments of disease activity, severity and damage (all P ⩽ 0.003); better HAQ-DI (P = 0.001) and SF-36 PCS (P = 0.005). Changes in the mRSS were positively correlated with changes in summed DSS (P = 0.006) and other disease outcomes. In the 26 (20.3%) patients with worsened skin (mRSS increase of ⩾5 points and/or ⩾25%), the summed DSS and physician global assessments were worse (P = 0.01 and P ⩽ 0.009, respectively). In the subgroup with a disease duration ⩽3 years, similar associations were found. CONCLUSION At 1 and 2 years, overall disease improvement parallels skin improvement in early dcSSc. This is important for prognosis and reflects the value of mRSS as an outcome measure in trials with these patients.
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Affiliation(s)
- Boyang Zheng
- Division of Rheumatology, McGill University, Montreal, QC, Canada
| | | | | | | | - Janet E Pope
- St Joseph Health Care, London, ON, Canada.,Division of Rheumatology, Western University, London, ON, Canada
| | - Murray Baron
- Division of Rheumatology, McGill University, Montreal, QC, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, QC, Canada
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Chung MP, Chung L. Drugs in phase I and phase II clinical trials for systemic sclerosis. Expert Opin Investig Drugs 2020; 29:349-362. [PMID: 32178544 DOI: 10.1080/13543784.2020.1743973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Systemic sclerosis (SSc) is an autoimmune connective tissue disease that is characterized by excessive collagen deposition, vascular dysfunction, and fibrosis of cutaneous and visceral organs. Current therapeutic options are limited and provide only modest benefit.Areas covered: This review summarizes investigational agents in recent Phase I and II clinical trials evaluated for the treatment of SSc with a focus on skin in patients with early diffuse disease and interstitial lung disease. We performed a search on Pubmed and https://clinicaltrials.gov with keywords systemic sclerosis, Phase I clinical trial, and Phase II clinical trial to identify relevant studies from 2015 to 2019.Expert opinion: Therapeutic interventions in SSc should be guided by the level of disease activity and the degree of organ involvement. While most novel agents have failed to meet the primary endpoints of reducing skin thickening as measured by the modified Rodnan skin score, some have shown promise in improving the Composite Response Index for Clinical Trials in Early Diffuse Cutaneous Systemic Sclerosis (CRISS), reducing lung function decline, or improving patient-reported outcomes. However, most of the current evidence is based on small or open-label clinical trials. Well-designed, large, randomized, Phase III clinical trials are necessary to define the roles of investigational agents in treating SSc.
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Affiliation(s)
- Melody P Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Rheumatology, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Mecoli CA, Shah AA. More Than Skin Deep: Bringing Precision Medicine to Systemic Sclerosis. Arthritis Rheumatol 2020; 72:383-385. [PMID: 31677364 PMCID: PMC7050332 DOI: 10.1002/art.41154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/29/2019] [Indexed: 01/16/2023]
Affiliation(s)
| | - Ami A Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Del Galdo F, Hartley C, Allanore Y. Randomised controlled trials in systemic sclerosis: patient selection and endpoints for next generation trials. THE LANCET. RHEUMATOLOGY 2020; 2:e173-e184. [PMID: 38263655 DOI: 10.1016/s2665-9913(20)30007-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 10/24/2022]
Abstract
The heterogeneity in the natural history of systemic sclerosis is a major issue in both clinical management and trial design and is dictated by the complex and multifactorial pathogenesis of the disease. Systemic sclerosis is an autoimmune disease and therefore many trials for the disease have targeted immune activation pathways; however, the phase 3 trials that have been positive have targeted pathways directly linked to tissue damage rather than systemic immune activation. On one hand, these results represent enormous progress that has led to the first approved drugs for this extremely challenging condition. On the other hand, they have revealed a possible selection bias in our current approach to trial design. In this Series paper, we describe randomised controlled trials from the past 4 years we believe to be most relevant to future strategies in systemic sclerosis. Based on advances in our understanding of the pathogenesis and natural history of disease, we will also identify important points to consider in the design of the next generation of systemic sclerosis trials.
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Affiliation(s)
- Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute of Health Research Biomedical Research Centre, Leeds Teaching Hospital Trust, Leeds, UK.
| | - Collette Hartley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute of Health Research Biomedical Research Centre, Leeds Teaching Hospital Trust, Leeds, UK
| | - Yannick Allanore
- Université de Paris, Hôpital Cochin, INSERM U1016, Paris, France
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Ledoult E, Launay D, Béhal H, Mouthon L, Pugnet G, Lega JC, Agard C, Allanore Y, Jego P, Fauchais AL, Harlé JR, Berthier S, Aouba A, Mekinian A, Diot E, Truchetet ME, Boulon C, Duhamel A, Hachulla E, Sobanski V. Early trajectories of skin thickening are associated with severity and mortality in systemic sclerosis. Arthritis Res Ther 2020; 22:30. [PMID: 32070422 PMCID: PMC7029583 DOI: 10.1186/s13075-020-2113-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/31/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a severe and highly heterogeneous disease. The modified Rodnan skin score (mRSS) is a widely used tool for the assessment of the extent and degree of skin thickness. This study aimed to identify the classes of patients with early similar skin thickening trajectories without any a priori assumptions and study their associations with organ involvement and survival. METHODS From the French SSc national cohort, patients with a disease duration of less than 2 years at inclusion and with at least 2 mRSS available within the first 4 years of follow-up were enrolled. Classes of patients with similar mRSS trajectories were identified based on a latent class mixed model. The clinical characteristics and survival rate were compared between the obtained classes. RESULTS A total of 198 patients fulfilled the inclusion criteria, with a total of 641 mRSS available. The median disease duration and follow-up were 0.8 (interquartile range 0.4; 1.2) and 6.3 (3.8; 8.9) years, respectively. Individual trajectories of mRSS were highly heterogeneous between patients. Models with 1-6 latent classes of trajectories were sequentially assessed, and the 5-class model represented the best fit to data. Each class was characterized by a unique global trajectory of mRSS. The median disease duration did not differ significantly between classes. Baseline organ involvement was more frequent in classes with significant change over time (classes 2-5) than in class 1 (low baseline mRSS without significant change over time). Using Cox regression, we observed a progressively increasing risk of death from classes 1 to 5. CONCLUSIONS Early identification of clinical phenotype based on skin thickening trajectories could predict morbi-mortality in SSc. This study suggested that mRSS trajectories characterization might be pivotal for clinical practice and future trial designs.
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Affiliation(s)
- Emmanuel Ledoult
- Univ. Lille, Institute for Translational Research in Inflammation (INFINITE), F-59000, Lille, France.,CHU Lille, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), F-59000, Lille, France.,INSERM, U1286, F-59000, Lille, France
| | - David Launay
- Univ. Lille, Institute for Translational Research in Inflammation (INFINITE), F-59000, Lille, France.,CHU Lille, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), F-59000, Lille, France.,INSERM, U1286, F-59000, Lille, France
| | - Hélène Béhal
- Univ. Lille, CHU Lille, EA 2694-Santé publique, épidémiologie et qualité des soins, Unité de Biostatistiques, F-59000, Lille, France
| | - Luc Mouthon
- Hôpital Cochin-APHP, Service de Médecine Interne, Paris, France
| | - Grégory Pugnet
- CHU Toulouse, Service de Médecine Interne, Toulouse, France
| | | | | | | | - Patrick Jego
- CHU Rennes, Service de Médecine Interne, Rennes, France
| | | | - Jean-Robert Harlé
- Hôpital de la Timone, Service de Médecine Interne, Marseille, France
| | - Sabine Berthier
- CHU Dijon, Service de Médecine Interne et Immunologie Clinique, Dijon, France
| | | | - Arsène Mekinian
- Hôpital Saint-Antoine-APHP, Service de Médecine Interne, Paris, France
| | | | | | - Carine Boulon
- CHU Bordeaux, Service de Médecine vasculaire, Bordeaux, France
| | - Alain Duhamel
- Univ. Lille, CHU Lille, EA 2694-Santé publique, épidémiologie et qualité des soins, Unité de Biostatistiques, F-59000, Lille, France
| | - Eric Hachulla
- Univ. Lille, Institute for Translational Research in Inflammation (INFINITE), F-59000, Lille, France.,CHU Lille, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), F-59000, Lille, France.,INSERM, U1286, F-59000, Lille, France
| | - Vincent Sobanski
- Univ. Lille, Institute for Translational Research in Inflammation (INFINITE), F-59000, Lille, France. .,CHU Lille, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), F-59000, Lille, France. .,INSERM, U1286, F-59000, Lille, France.
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Abstract
Epidemiological studies reporting demographic, clinical and serological factors predictive of various outcomes in systemic sclerosis (SSc) range from the prediction of mortality to the development and progression of disease manifestations. However, predicting the disease trajectory in the individual patient is a challenging but important step towards a stratified approach to disease management. Recent technological advances provide the opportunity for new subgroupings of disease based on risk stratification, through the systematic analysis of high-dimensional clinical data combined with genes, their transcription products and their corresponding translated proteins. In addition, these variables offer a rich vein of research to identify non-invasive biomarkers for predicting organ involvement and to assess disease activity and response to therapy. Selection of patients with a clinical phenotype or molecular signature relevant to the therapy under study combined with recent efforts to standardise outcome measures, show promise for improving clinical trial design and the identification of effective targeted therapies.
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Khanna D, Spino C, Johnson S, Chung L, Whitfield M, Denton CP, Berrocal V, Jennifer F, Mehta B, Molitor J, Steen VD, Lafyatis R, Simms RW, Gill A, Kafaja S, Frech TM, Hsu V, Domsic RT, Pope JE, Gordon JK, Mayes MD, Schiopu E, Young A, Sandorfi N, Park J, Hant FN, Bernstein EJ, Chatterjee S, Castelino FV, Ajam A, Wang Y, Wood T, Allanore Y, Matucci-Cerinic M, Distler O, Singer O, Bush E, Fox D, Furst DE. Abatacept in Early Diffuse Cutaneous Systemic Sclerosis: Results of a Phase II Investigator-Initiated, Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial. Arthritis Rheumatol 2020; 72:125-136. [PMID: 31342624 PMCID: PMC6935399 DOI: 10.1002/art.41055] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE T cells play a key role in the pathogenesis of early systemic sclerosis. This study was undertaken to assess the safety and efficacy of abatacept in patients with diffuse cutaneous systemic sclerosis (dcSSc). METHODS In this 12-month, randomized, double-blind, placebo-controlled trial, participants were randomized 1:1 to receive either subcutaneous abatacept 125 mg or matching placebo, stratified by duration of dcSSc. Escape therapy was allowed at 6 months for worsening disease. The coprimary end points were change in the modified Rodnan skin thickness score (MRSS) compared to baseline and safety over 12 months. Differences in longitudinal outcomes were assessed according to treatment using linear mixed models, with outcomes censored after initiation of escape therapy. Skin tissue obtained from participants at baseline was classified into intrinsic gene expression subsets. RESULTS Among 88 participants, the adjusted mean change in the MRSS at 12 months was -6.24 units for those receiving abatacept and -4.49 units for those receiving placebo, with an adjusted mean treatment difference of -1.75 units (P = 0.28). Outcomes for 2 secondary measures (Health Assessment Questionnaire disability index and a composite measure) were clinically and statistically significantly better with abatacept. The proportion of subjects in whom escape therapy was needed was higher in the placebo group relative to the abatacept group (36% versus 16%). In the inflammatory and normal-like skin gene expression subsets, decline in the MRSS over 12 months was clinically and significantly greater in the abatacept group versus the placebo group (P < 0.001 and P = 0.03, respectively). In the abatacept group, adverse events occurred in 35 participants versus 40 participants in the placebo group, including 2 deaths and 1 death, respectively. CONCLUSION In this phase II trial, abatacept was well-tolerated, but change in the MRSS was not statistically significant. Secondary outcome measures, including gene expression subsets, showed evidence in support of abatacept. These data should be confirmed in a phase III trial.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, MI
| | - Sindhu Johnson
- Rheumatology, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Lorinda Chung
- Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Whitfield
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | | | | | - Franks Jennifer
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Bhaven Mehta
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Jerry Molitor
- Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN
| | - Virginia D. Steen
- Rheumatology, MedStar Georgetown University Hospital, Washington, DC
| | - Robert Lafyatis
- Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA
| | - Robert W. Simms
- Rheumatology, Boston University School of Medicine, Boston, MA
| | - Anna Gill
- UCL Division of Medicine, Royal Free Campus, London, United Kingdom
| | - Suzanne Kafaja
- Department of Internal Medicine, University of California Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA
| | - Tracy M. Frech
- Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Vivien Hsu
- Rheumatology, Robert Wood Johnson University Scleroderma Program, New Brunswick, NJ
| | - Robyn T. Domsic
- Medicine - Rheumatology, University of Pittsburgh, Pittsburgh, PA
| | - Janet E. Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | | | - Maureen D. Mayes
- Rheumatology, University of Texas McGovern Medical School, Houston, TX
| | - Elena Schiopu
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Amber Young
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Nora Sandorfi
- Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA
| | - Jane Park
- Seattle Rheumatology Associates, Seattle, WA
| | - Faye N. Hant
- Medicine/Rheumatology & Immunology, Medical University of South Carolina, Charleston, SC
| | | | | | | | - Ali Ajam
- Division of Rheumatology-Immunology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Yue Wang
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Tammara Wood
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | | | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Ora Singer
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Erica Bush
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - David Fox
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
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Baker Frost D, Wolf B, Peoples C, Fike J, Silver K, Laffoon M, Medsger TA, Feghali-Bostwick C. Estradiol levels are elevated in older men with diffuse cutaneous SSc and are associated with decreased survival. Arthritis Res Ther 2019; 21:85. [PMID: 30940202 PMCID: PMC6444502 DOI: 10.1186/s13075-019-1870-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/18/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a female-predominant disease, characterized by excessive extracellular matrix deposition (ECM) with dermal and internal organ fibrosis. Considering the sex-based disparity in disease incidence, estradiol (E2), an estrogen form with pro-fibrotic effects, may play a role in SSc. We reported that post-menopausal women with diffuse cutaneous (dc)SSc have higher serum E2 levels compared to similar aged, healthy controls. Since males with SSc tend to have more severe disease, we examined serum E2 in dcSSc males in relation to disease characteristics and survival. METHODS We measured serum E2 in 83 dcSSc men > 50 years old from the University of Pittsburgh Scleroderma Center and similar aged healthy controls. Using statistical modeling, we examined the associations between serum E2, internal organ involvement, autoantibody profiles, and survival. RESULTS Male dcSSc patients had significantly higher serum E2 levels compared to healthy males and similar aged dcSSc post-menopausal women. Male dcSSc patients with high serum E2 had significantly more heart involvement, a trend for higher skin thickness progression rate, and worse survival. Using Cox regression modeling, increased serum E2 levels in anti-Scl-70 antibody-positive dcSSc males were associated with an increased risk of death. CONCLUSIONS dcSSc males > 50 years old have higher levels of serum E2 compared to healthy controls and dcSSc post-menopausal women. Elevated serum E2 levels in dcSSc males are associated with heart involvement, trend to progression of dermal fibrosis, and, if anti-Scl-70 antibody positive, worse survival. Our study expands on previous work implicating E2 in dermal fibrosis in SSc and associates E2 levels with internal organ involvement and survival. These data suggest a role for estrogen imbalance in dcSSc.
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Affiliation(s)
- DeAnna Baker Frost
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Bethany Wolf
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.,College of Medicine, Department of Public Health Sciences, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Christine Peoples
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Jessica Fike
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Katherine Silver
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Maureen Laffoon
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Thomas A Medsger
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
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Lazzaroni MG, Airò P. Anti-RNA polymerase III antibodies in patients with suspected and definite systemic sclerosis: Why and how to screen. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:214-220. [DOI: 10.1177/2397198318786158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/08/2018] [Indexed: 01/29/2023]
Abstract
Anti-RNA Polymerase III antibodies are the most frequent anti-nuclear antibodies in systemic sclerosis, after anti-centromere and anti-Topoisomerase I. Considering their specificity for systemic sclerosis, they have been included in 2013 American College of Rheumatology/European League Against Rheumatism classification criteria for systemic sclerosis. They were first identified in 1993 using an immunoprecipitation method; the subsequent diffusion of commercial assays, based on the enzyme-linked immunosorbent assay or multiplex line immunoblot techniques, has allowed an increasing number of systemic sclerosis patients to be tested for this autoantibody; nevertheless, the diffusion of this test in systemic sclerosis patients is probably still sub-optimal. Anti-RNA Polymerase III antibodies have been associated with important clinical manifestations: rapid and diffuse cutaneous involvement, joint contractures, scleroderma renal crisis, gastric antral vascular ectasia and malignancies synchronous to systemic sclerosis onset. Moreover, other possible clinical associations, including pulmonary hypertension, still need confirmation. Since the correct approach for screening for anti- RNA Polymerase III antibodies in patients with suspected or definite systemic sclerosis is still debated, possible strategies are proposed here. Moreover, issues that are still controversial are discussed, including the interpretation of multiple simultaneous positivity for anti-RNA Polymerase III antibodies and other autoantibodies in line immunoassay, and the possible relevance of anti-RNA Polymerase III antibodies titre.
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Affiliation(s)
- Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy
| | - Paolo Airò
- Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy
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Aringer M, Denton CP. Systemic sclerosis phase III clinical trials: Hope on the horizon? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:193-200. [DOI: 10.1177/2397198318775353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/15/2018] [Indexed: 12/19/2022]
Abstract
While significant progress has been made in treating systemic sclerosis, many patients still have an outcome that is far from satisfactory. For the first time in history, several drugs are now in phase III randomized controlled trials. Approaches tested include the anti-B cell antibody rituximab, the anti-interleukin-6 receptor antibody tocilizumab, the antifibrotic drugs nintedanib and pirfenidone, and the cannabinoid receptor mimetic lenabasum. That all these drugs are in advanced clinical trials despite the relatively low incidence of the disease therefore is good news. Not only is there realistic hope that at least some of the approaches will work, this also indicates growing industry interest, for most of the trials are company-sponsored. This review attempts to delineate the ongoing trials and to summarize the underlying evidence of these candidate systemic sclerosis drugs.
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Affiliation(s)
- Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christopher P Denton
- Royal Free Hospital and Centre for Rheumatology and Connective Tissue Diseases, University College London, London, UK
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47
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Didier K, Bolko L, Giusti D, Toquet S, Robbins A, Antonicelli F, Servettaz A. Autoantibodies Associated With Connective Tissue Diseases: What Meaning for Clinicians? Front Immunol 2018; 9:541. [PMID: 29632529 PMCID: PMC5879136 DOI: 10.3389/fimmu.2018.00541] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/02/2018] [Indexed: 02/06/2023] Open
Abstract
Connective tissue diseases (CTDs) such as systemic lupus erythematosus, systemic sclerosis, myositis, Sjögren's syndrome, and rheumatoid arthritis are systemic diseases which are often associated with a challenge in diagnosis. Autoantibodies (AAbs) can be detected in these diseases and help clinicians in their diagnosis. Actually, pathophysiology of these diseases is associated with the presence of antinuclear antibodies. In the last decades, many new antibodies were discovered, but their implication in pathogenesis of CTDs remains unclear. Furthermore, the classification of these AAbs is nowadays misused, as their targets can be localized outside of the nuclear compartment. Interestingly, in most cases, each antibody is associated with a specific phenotype in CTDs and therefore help in better defining either the disease subtypes or diseases activity and outcome. Because of recent progresses in their detection and in the comprehension of their pathogenesis implication in CTD-associated antibodies, clinicians should pay attention to the presence of these different AAbs to improve patient's management. In this review, we propose to focus on the different phenotypes and features associated with each autoantibody used in clinical practice in those CTDs.
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Affiliation(s)
- Kevin Didier
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Robert Debré Hospital, Reims, France
| | - Loïs Bolko
- Rheumatology Department, Maison Blanche Hospital, Reims University Hospitals, Reims, France
| | - Delphine Giusti
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Segolene Toquet
- Department of Internal Medicine, CHU de Reims, Reims, France
| | - Ailsa Robbins
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Robert Debré Hospital, Reims, France
| | - Frank Antonicelli
- Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Amelie Servettaz
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Robert Debré Hospital, Reims, France.,Laboratory of Dermatology, Faculty of Medicine, EA7319, University of Reims Champagne-Ardenne, Reims, France
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