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Koczanowski S, Morrisroe K, Fairley J, Nikpour M, Oon S, Brown Z. Role of intravenous immunoglobulins in systemic sclerosis (SSc): A systematic literature review. Semin Arthritis Rheum 2024; 68:152471. [PMID: 38954999 DOI: 10.1016/j.semarthrit.2024.152471] [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: 02/19/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Systemic sclerosis (SSc) is a heterogenous, multi-system autoimmune disease that causes progressive fibrosis of the skin and internal organs, resulting in high morbidity and mortality. Intravenous Immunoglobulin (IVIG) is a therapeutic option for SSc; however, reports of its efficacy have been variable, and its use across multiple organ manifestations of SSc has not been comprehensively reviewed. AIM The aim of this study was to systematically assess the existing literature on the role of IVIG use across a range of SSc manifestations. METHODS Medline, Embase, Cochrane, Web of Science and Scopus were searched from 01/01/2003-15/04/2024 using terms related to SSc and IVIG. Included studies were English-language full texts, where ≥5 adults with SSc received IVIG, and where a reportable outcome was documented. RESULTS Of 418 potentially relevant records, 12 were included in this review, comprising 266 patients across one randomised control trial, two pilot studies, one open label study, seven retrospective studies and one case control study. Eighteen outcomes were documented across five different organ systems: cutaneous, respiratory, musculoskeletal, gastrointestinal, and other (clinical improvement and corticosteroid sparing benefit). Results showed a favourable effect of IVIG in reducing the extent of skin thickening, muscle and joint pain, gastrointestinal symptoms, steroid dosing and improving patient/physician reported quality of life. Whilst IVIG may appear to be less beneficial for respiratory disease, the stabilisation in pulmonary function tests and radiological features may be considered a positive outcome in itself. Limitations included a lack of high-quality studies, and the use of concomitant therapies in many studies, rendering the efficacy of IVIG alone difficult to ascertain. CONCLUSION IVIG showed benefit in treating some manifestations of SSc, however there was a lack of convincing evidence for the efficacy in others. The lack of high-quality data highlights the need for further well-designed clinical trials to confirm these findings and inform guidelines for IVIG use.
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Affiliation(s)
| | - Kathleen Morrisroe
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Jessica Fairley
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Shereen Oon
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Zoe Brown
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
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Tandaipan J, Guillén-Del-Castillo A, Simeón-Aznar CP, Carreira PE, De la Puente C, Narváez J, Lluch J, Rubio-Rivas M, Alegre-Sancho JJ, Bonilla G, Moriano C, Casafont-Sole I, García-Vicuña R, Ortiz-Santamaría V, Riera E, Atienza-Mateo B, Blanco R, Galisteo C, Gonzalez-Martin JJ, Pego-Reigosa JM, Pros A, Heredia S, Castellví I. Immunoglobulins in systemic sclerosis management. A large multicenter experience. Autoimmun Rev 2023; 22:103441. [PMID: 37708984 DOI: 10.1016/j.autrev.2023.103441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To analyze the effectiveness and safety of intravenous immunoglobulin (IVIG) given in routine care to patients with systemic sclerosis (SSc). METHODS A retrospective multicenter observational study was conducted in SSc patients treated with IVIG. We collected data on epidemiological parameters and clinical outcomes. Firstly, we assessed changes in organ manifestations during IVIG treatment. Secondly, we analyzed the frequency of adverse effects. The following parameters were collected from baseline to the last follow-up: the patient's weight, modified Rodnan Skin Score (mRSS), modified manual muscle strength scale (MRC), laboratory test(creatine kinase(CK), hemoglobin and protein levels), The University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA GIT 2.0) questionnaire, pulmonary function tests, and echocardiography. RESULTS Data were collected on 78 patients (82% females; 59% with diffuse SSc). Inflammatory idiopathic myopathy was the most frequent concomitant overlap disease (41%). The time since Raynaud's phenomenon and SSc onset were 8.8 ± 18 and 6.2 ± 6.7 years respectively. The most frequent IVIG indication was myositis (38/78), followed by gastrointestinal (27/78) and cutaneous (17/78) involvement. The median number of cycles given were 5. 54, 53 and 9 patients have been treated previously with glucocorticoids, synthetic disease-modifying antirheumatic drugs and biologic therapies respectively. After IVIG use we found significant improvements in muscular involvement (MRC ≥ 3/5 92% IVIG, p = 0.001 and CK levels from 1149 ± 2026 UI to 217 ± 224 UI, p = 0.02), mRSS (15 ± 12.4 to 13 ± 12.5, p = 0.015) and improvement in total score of UCLA GIT 2.0 (p = 0.05). None Anti-RNA polymerase III patients showed an adequate response in gastrointestinal involvement (0/7) in comparison with other antibodies (0 vs. 25, p = 0,039). Cardiorespiratory involvement remained stable. A total of 12 adverse events were reported with only one withdrawn due to serious adverse effect. CONCLUSIONS this study suggest that IVIG may improve myositis, gastrointestinal and skin involvement in SSc patients treated in routine care and seems to have a good safety profile.
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Affiliation(s)
- J Tandaipan
- Department of Rheumatology and Systemic Autoinmune Diseases, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A Guillén-Del-Castillo
- Unit of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - C P Simeón-Aznar
- Unit of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - P E Carreira
- Department of Rheumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - C De la Puente
- Department of Rheumatology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - J Narváez
- Department of Rheumatology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - J Lluch
- Department of Rheumatology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - M Rubio-Rivas
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - J J Alegre-Sancho
- Department of Rheumatology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - G Bonilla
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
| | - C Moriano
- Department of Rheumatology, Complejo Asistencial Universitario de León, León, Spain
| | - I Casafont-Sole
- Department of Rheumatology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - R García-Vicuña
- Department of Rheumatology, Hospital Universitario de La Princesa, Madrid, Spain
| | - V Ortiz-Santamaría
- Department of Rheumatology, Hospital General de Granollers, Granollers, Spain
| | - E Riera
- Department of Rheumatology, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - B Atienza-Mateo
- Department of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - R Blanco
- Department of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - C Galisteo
- Department of Rheumatology, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J J Gonzalez-Martin
- Department of Rheumatology, Hospital Universitario HM San Chinarro, Madrid, Spain
| | - J M Pego-Reigosa
- Department of Rheumatology, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute (IISGS), Vigo, Spain
| | - A Pros
- Department of Rheumatology, Hospital del Mar, Barcelona, Spain
| | - S Heredia
- Department of Rheumatology, Hospital Sant Joan Despí Moisès Broggi, Sant Joan Despí, Spain
| | - I Castellví
- Department of Rheumatology and Systemic Autoinmune Diseases, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Medicine, Universitat Autonoma de Barcelona, Spain.
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Cacciapaglia F, Stano S, Fornaro M, Iannone F. Subcutaneous immunoglobulin therapy for refractory skin thickening in rapidly progressive systemic sclerosis: A case report and literature review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:101-106. [PMID: 37287951 PMCID: PMC10242697 DOI: 10.1177/23971983221124180] [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: 07/11/2022] [Accepted: 08/17/2022] [Indexed: 06/04/2024]
Abstract
The use of immunoglobulin is a therapeutic option with increasing evidence of efficacy for different rheumatologic autoimmune systemic diseases. Some studies concerning immunoglobulin use in systemic sclerosis have been published with encouraging results. We present the case of a young woman diagnosed with rapidly progressive diffuse cutaneous systemic sclerosis, refractory to therapy with methotrexate and rituximab, which presented a relevant skin improvement after one year of subcutaneous immunoglobulin (2 g/kg cumulative monthly dose, refracted in weekly administrations). Furthermore, a narrative literature review of the evidence for alternative treatments with a focus on immunoglobulin use for systemic sclerosis skin involvement was carried out.
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Affiliation(s)
- Fabio Cacciapaglia
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Stefano Stano
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Marco Fornaro
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
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Velikova T, Sekulovski M, Bogdanova S, Vasilev G, Peshevska-Sekulovska M, Miteva D, Georgiev T. Intravenous Immunoglobulins as Immunomodulators in Autoimmune Diseases and Reproductive Medicine. Antibodies (Basel) 2023; 12:antib12010020. [PMID: 36975367 PMCID: PMC10045256 DOI: 10.3390/antib12010020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Intravenous administration of immunoglobulins has been routinely used for more than 60 years in clinical practice, developed initially as replacement therapy in immunodeficiency disorders. Today, the use of intravenous immunoglobulins (IVIGs) is embedded in the modern algorithms for the management of a few diseases, while in most cases, their application is off-label and thus different from their registered therapeutic indications according to the summary of product characteristics. In this review, we present the state-of-the-art use of IVIGs in various autoimmune conditions and immune-mediated disorders associated with reproductive failure, as approved therapy, based on indications or off-label. IVIGs are often an alternative to other treatments, and the administration of IVIGs continues to expand as data accumulate. Additionally, new insights into the pathophysiology of immune-mediated disorders have been gained. Therefore, the need for immunomodulation has increased, where IVIG therapy represents an option for stimulating, inhibiting and regulating various immune processes.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Correspondence:
| | - Metodija Sekulovski
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Anesthesiology and Intensive Care, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Simona Bogdanova
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
| | - Georgi Vasilev
- Clinic of Neurology, UMHAT “Sv. Georgi”, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
| | - Monika Peshevska-Sekulovska
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Gastroenterology, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Dimitrina Miteva
- Department of Genetics, Faculty of Biology, Sofia University St. Kliment Ohridski, 8 Dragan Tzankov Str., 1164 Sofia, Bulgaria
| | - Tsvetoslav Georgiev
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
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Kayser C, Victória de Oliveira Martins L. Treatment of Inflammatory Arthritis in Systemic Sclerosis. Rheum Dis Clin North Am 2023; 49:337-343. [PMID: 37028838 DOI: 10.1016/j.rdc.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Joint involvement, including arthralgia, inflammatory arthritis, joint contractures and overlapping with rheumatoid arthritis, is a common manifestation and is associated with impared quality of life in systemic sclerosis (SSc). Few studies have evaluated the treatment of arthritis in SSc. Pharmacological approach includes low-dose corticosteroids, methotrexate, and hydroxychloroquine. Non-tumor necrosis factor biologics, especially rituximab and tocilizumab, may be a promising option for refractory cases.
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Affiliation(s)
- Cristiane Kayser
- Rheumatology Division, Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP), Rua Botucatu 740, 3 andar, São Paulo, São Paulo 04023-062, Brazil.
| | - Lucas Victória de Oliveira Martins
- Rheumatology Division, Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP), Rua Botucatu 740, 3 andar, São Paulo, São Paulo 04023-062, Brazil
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Pedraza-Sánchez S, Cruz-González A, Palmeros-Rojas O, Gálvez-Romero JL, Bellanti JA, Torres M. Polyvalent human immunoglobulin for infectious diseases: Potential to circumvent antimicrobial resistance. Front Immunol 2023; 13:987231. [PMID: 36713426 PMCID: PMC9880058 DOI: 10.3389/fimmu.2022.987231] [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: 07/05/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023] Open
Abstract
Antimicrobial resistance (AMR) is a global health problem that causes more than 1.27 million deaths annually; therefore, it is urgent to focus efforts on solving or reducing this problem. The major causes of AMR are the misuse of antibiotics and antimicrobials in agriculture, veterinary medicine, and human medicine, which favors the selection of drug-resistant microbes. One of the strategies proposed to overcome the problem of AMR is to use polyvalent human immunoglobulin or IVIG. The main advantage of this classic form of passive immunization is its capacity to enhance natural immunity mechanisms to eliminate bacteria, viruses, or fungi safely and physiologically. Experimental data suggest that, for some infections, local administration of IVIG may produce better results with a lower dose than intravenous application. This review presents evidence supporting the use of polyvalent human immunoglobulin in AMR, and the potential and challenges associated with its proposed usage.
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Affiliation(s)
- Sigifredo Pedraza-Sánchez
- Unidad de Bioquímica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico,*Correspondence: Martha Torres, ; Sigifredo Pedraza-Sánchez,
| | - Adrián Cruz-González
- Facultad de Ciencias, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico
| | - Oscar Palmeros-Rojas
- Área de matemáticas, preparatoria agrícola, Universidad Autónoma Chapingo, Texcoco, Mexico
| | | | | | - Martha Torres
- Subdirección de Investigación Biomédica, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico,*Correspondence: Martha Torres, ; Sigifredo Pedraza-Sánchez,
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Elahmar H, Feldman BM, Johnson SR. Management of calcinosis cutis in rheumatic diseases. J Rheumatol Suppl 2022; 49:980-989. [PMID: 35569832 DOI: 10.3899/jrheum.211393] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/22/2022]
Abstract
Calcinosis (hydroxyapatite and calcium phosphate crystal deposition) within the extracellular matrix of the dermis and subcutaneous tissue is a frequent manifestation of adult and pediatric systemic autoimmune rheumatic diseases, specifically systemic sclerosis, dermatomyositis, mixed connective tissue disease and systemic lupus erythematosus. In this article, we review classification of calcinosis, highlight mechanisms that may contribute to the pathogenesis of calcinosis and summarize the evidence evaluating non-pharmacologic and pharmacologic interventions for the treatment of calcinosis.
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Affiliation(s)
- Hadiya Elahmar
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Brian M Feldman
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Sindhu R Johnson
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
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Agostini E, De Luca G, Bruni C, Bartoli F, Tofani L, Campochiaro C, Pacini G, Moggi-Pignone A, Guiducci S, Bellando-Randone S, Shoenfeld Y, Dagna L, Matucci-Cerinic M. Intravenous immunoglobulins reduce skin thickness in systemic sclerosis: evidence from Systematic Literature Review and from real life experience. Autoimmun Rev 2021; 20:102981. [PMID: 34718166 DOI: 10.1016/j.autrev.2021.102981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intravenous immunoglobulins (IVIG) are a new therapeutic approach in systemic sclerosis SSc. An immunomodulatory and antifibrotic activity has been postulated. IVIG are generally well tolerated and have only rare side effects. Our retrospective study focused its attention on SSc, an autoimmune connective tissue disease, characterized by several complications which has a significant impact on patient's quality of life. The pathophysiology comprises fibrotic, vascular and immunological aspects. AIM The aim of this study was to verify the effectiveness of IVIG on SSc skin involvement. Moreover, a systematic review of the literature (SLR) of the results obtained to date on the use of Intravenous immunoglobulin (IVIG) in SSc has been also performed. PATIENTS AND METHODS The data of 24 patients (21 women, 3 male) with refractory diffuse SSc skin involvement were evaluated (mean age was 52.13 years). IVIG infusion at a dosage of 2 g/Kg body weight for 4 consecutive days/month, was started between 2002 and 2019. Skin involvement was evaluated with the modified Rodnan Skin Score (mRSS) before therapy and then again after 6 and 12 months. To perform the SLR, the PubMed, Medline, Embase, and Web of Science database were searched from 1990 to 2020 (keywords: IVIG, systemic sclerosis). Three assessors (E.A., C.B. & M.M.C) identified the criteria to scan all papers. RESULTS From the total SLR (106 results), 17 papers were identified after the separation of the clinical cases from the studies (total number of treated patients 183). The studies were classified according to the organ involvement considered in each study, as well as the prescribed dose (high or low doses), and the therapeutic regimens. In the selected papers, the organs mainly involved were the skin, the gastrointestinal, the joint and the cardiovascular systems. Only in one case, plasmapheresis was associated to IVIG. All papers reported significant reduction of the skin involvement, although generally the strength of the works was limited the lack of control cases or by the low number of patients involved. From the real life experience, a statistically significant reduction of mRSS was obtained at 6 months follow-up (average value of -6.61 ± 5.2, p < 0.001), and it was further maintained with a significant stabilization after 12-months (-11.45 ± 9.63, p < 0.002). DISCUSSION This SLR and the data of the retrospective study suggest that IVIG may improve skin involvement reducing mRSS in particular in those patients that were refractory to other standard of care therapies and represents a therapeutic option in patients with concomitant myositis. The literature review revealed encouraging perspectives on the use of this therapy, given the effectiveness found in the selected works.
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Affiliation(s)
- Elana Agostini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Cosimo Bruni
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Bartoli
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Lorenzo Tofani
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Pacini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Alberto Moggi-Pignone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Internal Medicine, AOUC, Florence, Italy
| | - Serena Guiducci
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Silvia Bellando-Randone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Yehuda Shoenfeld
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Saint Petersburg State University, Saint-Petersburg, Russia
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Marco Matucci-Cerinic
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Division of Rheumatology, AOUC, Florence, Italy.
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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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Ruaro B, Confalonieri M, Matucci-Cerinic M, Salton F, Confalonieri P, Santagiuliana M, Citton GM, Baratella E, Bruni C. The Treatment of Lung Involvement in Systemic Sclerosis. Pharmaceuticals (Basel) 2021; 14:154. [PMID: 33668530 PMCID: PMC7918752 DOI: 10.3390/ph14020154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022] Open
Abstract
Systemic sclerosis (SSc) patients are often affected by interstitial lung disease (ILD) and, although there have been recent treatment advances, it remains the leading cause of death among SSc, with a 10-year mortality up to 40%. African Americans and subjects with diffuse cutaneous SSc or anti-topoisomerase 1 antibodies are most commonly affected. Currently, early ILD diagnosis can be made, and it is pivotal to improve the prognosis. The diagnostic mainstay test for SSc-ILD is high-resolution computed tomography for the morphology and pulmonary function tests for the functional aspects. Treatment planning and intensity are guided by the disease severity and risk of progression. Traditionally, therapy has depended on combinations of immunosuppressants, particularly cyclophosphamide and mycophenolate mofetil, which can be supplemented by targeted biological and antifibrotic therapies. Benefits have been observed in trials on hematopoietic autologous stem cell transplantation for patients with progressive SSc, whilst lung transplantation is reserved for refractory SSc-ILD cases. Herein, recent advances in SSc-ILD treatment will be explored.
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Affiliation(s)
- Barbara Ruaro
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Marco Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, 50121 Firenze FI, Italy; (M.M.-C.); (C.B.)
| | - Francesco Salton
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Paola Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Mario Santagiuliana
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Gloria Maria Citton
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste TS, Italy; (M.C.); (F.S.); (P.C.); (M.S.); (G.M.C.)
| | - Elisa Baratella
- Department of Radiology, Cattinara Hospital, University of Trieste, 34127 Trieste TS, Italy;
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, 50121 Firenze FI, Italy; (M.M.-C.); (C.B.)
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11
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Perković D, Petrić M, Božić I, Borić K, Marasović Krstulović D, Radić M, Martinović Kaliterna D. Low dose intravenous immunoglobulin in addition to cyclophosphamide in systemic sclerosis : Single centre experience. Wien Klin Wochenschr 2020; 133:1070-1075. [PMID: 32451820 DOI: 10.1007/s00508-020-01669-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/29/2020] [Indexed: 11/26/2022]
Abstract
AIM Systemic sclerosis (SSc) is a rare chronic disease characterized by pathologic collagen deposits in the skin and internal organs. Although it is considered to be an autoimmune disease, immunosuppressants have a limited effect on severe SSc. Intravenous immunoglobulins (IVIG) have shown favorable effects in patients with SSc by suppressing the action of profibrotic cytokines, so they could have additional effect on standard treatment such as cyclophosphamide (CYC). This article presents the immunomodulatory effect of low-dose IVIG in addition to CYC in the treatment of severe SSc in this center during the last 9 years. METHODS This retrospective observational study analyzed the medical documentation of nine patients with SSc treated with low-dose IVIG (0.4 g/kg and month) together with intravenous CYC (600 mg/m2 and month). The therapeutic effect on lung and skin manifestations was assessed. RESULTS Of the patients one had interstitial lung diseases (ILD), two had progressive skin diseases, and six had a combination of skin and lung involvement. The best results were achieved in skin changes, where complete healing of digital ulcers (DU) was recorded in every reported case. A decrease in the modified Rodnan skin score (mRSS) was noted in three patients and increased diffusion capacity of the lungs for carbon monoxide in another three patients. CONCLUSION The results of the study suggest that IVIG may be an additional treatment option together with CYC for patients for whom other therapies have failed, but further studies on the exact role of IVIG in the treatment of severe SSc are required.
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Affiliation(s)
- Dijana Perković
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Marin Petrić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia.
| | - Ivona Božić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Katarina Borić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Daniela Marasović Krstulović
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Mislav Radić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Dušanka Martinović Kaliterna
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
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12
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Corticosteroid-sparing benefit of intravenous immunoglobulin in systemic sclerosis-associated myopathy: A comparative study in 52 patients. Autoimmun Rev 2020; 19:102431. [DOI: 10.1016/j.autrev.2019.102431] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 11/22/2022]
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13
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Arese V, Murabito P, Ribero S, Panzone M, Tonella L, Fierro MT, Papini M, Quaglino P. Autoimmune connective tissue diseases and pregnancy. GIORN ITAL DERMAT V 2019; 154:263-276. [PMID: 30650958 DOI: 10.23736/s0392-0488.18.06252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune connective tissue-diseases are more frequent in women and deserve a multidisciplinary approach in which the dermatologist play a major role together with other physicians. Pregnancy in these patients has to be considered a high-risk situation, because of possible worsening of the mother's disease and increased morbility and mortality for the fetus; also, therapies have to be chosen carefully because some drugs cannot be used during pregnancy. For all these reasons, the decision to become pregnant needs to consider the type of disease, stage of disease, age and clinical condition, and requires a multidisciplinary approach. A correct counselling, a close monitoring, a specific approach based on the risks involved and the use of appropriate therapies are the keys to obtain optimal pregnancy outcomes.
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Affiliation(s)
- Veronica Arese
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pierangela Murabito
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Michele Panzone
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Luca Tonella
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Maria T Fierro
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Manuela Papini
- Department of Surgical and Biomedical Sciences, Dermatologic Clinic of Terni, University of Perugia, Perugia, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
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14
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Katsiari CG, Simopoulou T, Alexiou I, Sakkas LI. Immunotherapy of systemic sclerosis. Hum Vaccin Immunother 2018; 14:2559-2567. [PMID: 29985736 DOI: 10.1080/21645515.2018.1491508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Systemic sclerosis (SSc) is a chronic systemic disease characterized by microvasculopathy, immune activation, and extensive collagen deposition. Microvasculopathy and immune activation occur very early in the disease process. Evidence from animal models and in vitro studies indicate that T-cells and B-cells activate fibroblasts to produce collagen. Traditional immunosuppressants, cyclophosphamide(CyP), methotrexate(MTX), and more recently mycophenolate mofetil(MMF), may prove more effective if used very early in the disease course. These drugs showed some benefit in skin (MTX, CyP, MMF) and lung function (CyP, MMF). Biologicals, such as intravenous immunoglobulin (IVIg), belimumab(Beli), tocilizumab(TCZ), abatacept(Aba), rituximab(RTX) and fresolimumab(Fresu) appear promising as they exhibited some benefit in skin (IVIg, Beli, TCZ, Aba, RTX, Fresu), hand function (IVIg), and joints (IVIg, TCZ, Aba). Autologous stem cell transplantation showed the best therapeutic efficacy on skin and internal organs, and looks very promising, as modification of transplantation immunosuppression is decreasing the early high mortality.
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Affiliation(s)
- Christina G Katsiari
- a Department of Rheumatology and clinical Immunology, Faculty of Medicine, School of Health Sciences , University of Thessaly , Larissa , Greece
| | - Theodora Simopoulou
- a Department of Rheumatology and clinical Immunology, Faculty of Medicine, School of Health Sciences , University of Thessaly , Larissa , Greece
| | - Ioannis Alexiou
- a Department of Rheumatology and clinical Immunology, Faculty of Medicine, School of Health Sciences , University of Thessaly , Larissa , Greece
| | - Lazaros I Sakkas
- a Department of Rheumatology and clinical Immunology, Faculty of Medicine, School of Health Sciences , University of Thessaly , Larissa , Greece
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15
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Blank RB, Nwawka OK, Yusov AA, Gordon JK. Inflammatory arthritis in systemic sclerosis: What to do? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 4:3-16. [DOI: 10.1177/2397198318779532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/08/2018] [Indexed: 01/16/2023]
Abstract
Musculoskeletal involvement, including arthritis and tendinopathy, is a common and important determinant of disability and impaired quality of life in systemic sclerosis. However, the treatment of arthritis in systemic sclerosis has not been studied as a primary outcome in randomized controlled trials, and arthritis-specific outcome measures for systemic sclerosis have not been sufficiently validated to date. Rheumatologists caring for patients with systemic sclerosis must address these complaints regularly despite the fact that the level of evidence for the treatment of systemic sclerosis–related inflammatory arthritis is limited. Consensus statements, based on treatments for related musculoskeletal aspects of rheumatoid arthritis, systemic lupus erythematosus, and other autoimmune diseases, support the use of methotrexate and hydroxychloroquine. Newer biologics, which have efficacy in the treatment of other autoimmune conditions, may show promise in the treatment of arthritis in systemic sclerosis. In this article, we review the current literature on the assessment and treatment of systemic sclerosis arthritis in order to address management considerations.
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Affiliation(s)
- Rebecca B Blank
- NewYork-Presbyterian/Weill Cornell Medicine Center, New York, NY, USA
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16
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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17
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Clements P, Allanore Y, Furst DE, Khanna D. Points to consider for designing trials in systemic sclerosis patients with arthritic involvement. Rheumatology (Oxford) 2017; 56:v23-v26. [PMID: 28992165 DOI: 10.1093/rheumatology/kex194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Indexed: 11/14/2022] Open
Abstract
Although musculoskeletal involvement is quite common in SSc (arthritic in particular), there have been few trials and even fewer controlled trials of therapeutic agents in arthritis in SSc. In addition, there have been only three outcome measures that have been validated for use in trials of SSc arthritis: the HAQ Disability Index, the Cochin Hand Function Scale and the Hand Mobility in SSc scale. The purpose of this article is to present evidence-based points to consider for the design of trials in SSc patients with musculoskeletal involvement (joints in particular). In addition, we make an argument for including outcome variables that can be validated within a given trial for use in future trials.
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Affiliation(s)
- Philip Clements
- Department of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Yannick Allanore
- Department of Rheumatology A, Cochin Hospital and Cochin Institute, AP-HP, Paris-Descartes University, Paris, France
| | - Daniel E Furst
- Department of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Dinesh Khanna
- Michigan Scleroderma Program, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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18
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Sanges S, Rivière S, Mekinian A, Martin T, Le Quellec A, Chatelus E, Lescoat A, Jego P, Cazalets C, Quéméneur T, Le Gouellec N, Senet P, Francès C, Deroux A, Imbert B, Fain O, Boukari L, Sené T, Deligny C, Mathian A, Agard C, Pugnet G, Speca S, Dubucquoi S, Hatron PY, Hachulla É, Launay D. Intravenous immunoglobulins in systemic sclerosis: Data from a French nationwide cohort of 46 patients and review of the literature. Autoimmun Rev 2017; 16:377-384. [PMID: 28232167 DOI: 10.1016/j.autrev.2017.02.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/26/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND As intravenous immunoglobulins (IVIG) exhibit immunomodulatory and antifibrotic properties, they may be a relevant treatment for systemic sclerosis (SSc). The objectives of this work were thus to report on the efficacy and safety of IVIG in a population of SSc patients and to review the available literature. METHODS 46 patients from 19 French centers were retrospectively recruited. They were included if they had a diagnosis of SSc and received at least 1 IVIG infusion at a dosage >1g/kg/cycle. Relevant data collected at IVIG discontinuation were compared to those collected at IVIG initiation. A comprehensive literature review was performed. RESULTS We observed a significant improvement of muscle pain (74% vs. 20%, p<0.0001), muscle weakness (45% vs. 21%, p=0.01), joint pain (44% vs. 19%, p=0.02), CK levels (1069±1552UI vs. 288±449UI, p<0.0001) and CRP levels (13.1±17.6mg/L vs. 9.2±16.6mg/L, p=0.001). We also noted a trend for an improvement of gastro-esophageal reflux disease (68% vs. 53%, p=0.06) and bowel symptoms (42% vs. 27%, p=0.06). Skin and cardiorespiratory involvements remained stable. Finally, corticosteroid daily dose was significantly lower by the end of treatment (13.0±11.6mg/day vs. 8.9±10.4mg/day, p=0.01). Only two severe adverse events were reported (one case of deep vein thrombosis and one case of diffuse edematous syndrome). CONCLUSION Our work suggests that IVIG are a safe therapeutic option that may be effective in improving musculoskeletal involvement, systemic inflammation, digestive tract symptoms and could be corticosteroid sparing.
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Affiliation(s)
- Sébastien Sanges
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - Sébastien Rivière
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Arsène Mekinian
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Thierry Martin
- Service d'Immunologie Clinique, Hôpitaux universitaires de Strasbourg, UPR CNRS 3572, Strasbourg, France
| | - Alain Le Quellec
- Service de Médecine Interne et Maladies Multi-Organiques de l'Adulte, Hôpital Saint-Éloi, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Emmanuel Chatelus
- Hôpitaux Universitaires de Strasbourg, CHU Hautepierre, Service de Rhumatologie, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg, INSERM UMR 1109, Strasbourg, France
| | - Alain Lescoat
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Patrick Jego
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Claire Cazalets
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Thomas Quéméneur
- Service de Médecine Interne, Néphrologie et Médecine Vasculaire, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Noémie Le Gouellec
- Service de Médecine Interne, Néphrologie et Médecine Vasculaire, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Patricia Senet
- Service de Dermatologie, Hôpital Tenon, AP-HP, UPMC, Paris, France
| | - Camille Francès
- Service de Dermatologie, Hôpital Tenon, AP-HP, UPMC, Paris, France
| | - Alban Deroux
- Service de Médecine Interne, Université Grenoble Alpes, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Bernard Imbert
- Service de Médecine Interne, Université Grenoble Alpes, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Olivier Fain
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Latifatou Boukari
- Service de Médecine Interne, Hôpital Jean-Verdier, AP-HP, Université Paris-13, Bondy, France
| | - Thomas Sené
- Service de Médecine Interne et Rhumatologie, GH Diaconesses Croix Saint Simon, Paris, France
| | - Christophe Deligny
- Service de Médecine Interne et Rhumatologie 3C/5D, Centre Hospitalier Universitaire Pierre Zobda-Quitman, Fort-de-France, Martinique
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National pour le Lupus et le Syndrome des Antiphospholipides, institut E3M, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Sorbonne universités, UPMC université Paris 06, 75013 Paris, France
| | - Christian Agard
- Service de Médecine interne, Hôtel-Dieu, CHU de Nantes, Université de Nantes, Nantes, France
| | - Grégory Pugnet
- CHU, Université de Toulouse, Faculté de Médecine, Service de Médecine Interne, Toulouse, France; INSERM, UMR 1027, Toulouse, France
| | - Silvia Speca
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France
| | - Sylvain Dubucquoi
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France
| | - Pierre-Yves Hatron
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - Éric Hachulla
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - David Launay
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET).
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Shoenfeld Y, Zandman-Goddard G, Levy Y. Comment on published article in Lupus: Autoimmune myelofibrosis with pancytopenia as a presenting manifestation of systemic lupus erythematosus responsive to mycophenolate mofetil; IVIG in myelofibrosis in SLE. Lupus 2017; 26:224. [DOI: 10.1177/0961203316662725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Y Shoenfeld
- Chaim Sheba Medical Center, Zabludowicz Center for Autoimmune Diseases, Tel-Hashomer, Israel
| | | | - Y Levy
- Meir Medical Center – Internal Medicine W, Kfar-Saba, Israel
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20
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Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016. [DOI: 10.5301/jsrd.5000228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy. Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs. The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.
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Hand Impairment in Systemic Sclerosis: Various Manifestations and Currently Available Treatment. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [PMID: 28018840 DOI: 10.1007/s40674-016-0052-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
Systemic sclerosis (SSc) is an autoimmune disease initially recognized by hand involvement due to characteristic Raynaud's phenomenon (RP), puffy hands, skin thickening, and contractures resembling claw deformities. SSc contributes to hand impairment through inflammatory arthritis, joint contractures, tendon friction rubs (TFRs), RP, digital ulcers (DU), puffy hands, skin sclerosis, acro-osteolysis, and calcinosis. These manifestations, which often co-exist, can contribute to difficulty with occupational activities and activities of daily living (ADL), which can result in impaired quality of life. However, despite this knowledge, most diagnostic and treatment principles in SSc are focused on visceral manifestations due to known associations with morbidity and mortality. Treatment of inflammatory arthritis is symptom based and involves corticosteroids ≤10mg daily, methotrexate, tumor necrosis factor inhibitors, tocilizumab, and abatacept. Small joint contractures are managed by principles of occupational hand therapy and rarely surgical procedures. TFRs may be treated similar to inflammatory arthritis with corticosteroids. All patients with RP and DU should keep digits covered and warm and avoid vasoconstrictive agents. Pharmacologic management of RP begins with use of calcium channel blockers, but additional agents that may be considered are fluoxetine and phosphodiesterase 5 (PDE5) inhibitors. DU management also involves vasodilators including calcium channel blockers and PDE5 inhibitors; bosentan has also been shown to prevent DU. In patients with severe RP and active DU, intravenous epoprostenol or iloprost can be used and surgical procedures, such as botulinum injections and digital sympathectomies, may be considered. For those with early diffuse cutaneous SSc needing immunosuppression for skin sclerosis, methotrexate or mycophenolate mofetil can be used, but the agent of choice depends on co-existing manifestations, such as inflammatory arthritis and/or lung involvement. Various pharmacologic agents for calcinosis have been considered but are generally ineffective; however, surgical options, including excision of areas of calcinosis, can be considered. Overall management of hand impairment for all patients with SSc should include occupational hand therapy techniques such as range of motion exercises, paraffin wax, and devices to assist in ADL. Thus, treatment options for the various manifestations contributing to hand impairment in SSc are limited and often modestly efficacious at best. Robust studies are needed to address the manifestations of SSc that contribute to hand impairment.
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Bruni C, Praino E, Allanore Y, Distler O, Gabrielli A, Iannone F, Matucci-Cerinic M. Use of biologics and other novel therapies for the treatment of systemic sclerosis. Expert Rev Clin Immunol 2016; 13:469-482. [PMID: 27899043 DOI: 10.1080/1744666x.2017.1263153] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by vasculopathy, inflammation and fibrosis. These three main disease-determining pathways are the target of the currently available treatments used to possibly modify the progression of disease-related manifestations, although this synergy has not been fully applied on SSc joint, skin or lung involvement yet. Areas covered: we describe the current status of SSc treatment/therapy performing a literature search in MEDLINE/Pubmed and Thomson Reuter's Web of Science for articles published until March 2016. Moreover, ongoing registered clinical trials (RCTs) on SSc were searched through clinicaltrials.gov website. Expert commentary: presently, promising drugs are under evaluation to target the different pathogenic pathways of systemic sclerosis: Tocilizumab and Abatacept for skin and lung fibrosis; Riociguat and Selexipag are approved for pulmonary arterial hypertension but promising anti-fibrotic effects are now being studied. Finally, several anti-fibrotic molecules are currently involved in RCTs, such as Nintedanib, IVA-337, Terguride.
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Affiliation(s)
- Cosimo Bruni
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
| | - Emanuela Praino
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy.,b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Yannick Allanore
- c Department of Rheumatology A and INSERM U1016 , Paris Descartes University, Cochin Hospital , Paris , France
| | - Oliver Distler
- d Department of Rheumatology , University Hospital Zurich , Zurich , Switzerland
| | - Armando Gabrielli
- e Department Of Clinical and Molecular Sciences, Clinica Medica , University 'Politecnica delle Marche' , Ancona , Italy
| | - Florenzo Iannone
- b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Marco Matucci-Cerinic
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
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Young A, Namas R, Dodge C, Khanna D. Hand Impairment in Systemic Sclerosis: Various Manifestations and Currently Available Treatment. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016; 2:252-269. [PMID: 28018840 DOI: 10.1007/s40674-016-0052-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Systemic sclerosis (SSc) is an autoimmune disease initially recognized by hand involvement due to characteristic Raynaud's phenomenon (RP), puffy hands, skin thickening, and contractures resembling claw deformities. SSc contributes to hand impairment through inflammatory arthritis, joint contractures, tendon friction rubs (TFRs), RP, digital ulcers (DU), puffy hands, skin sclerosis, acro-osteolysis, and calcinosis. These manifestations, which often co-exist, can contribute to difficulty with occupational activities and activities of daily living (ADL), which can result in impaired quality of life. However, despite this knowledge, most diagnostic and treatment principles in SSc are focused on visceral manifestations due to known associations with morbidity and mortality. Treatment of inflammatory arthritis is symptom based and involves corticosteroids ≤10mg daily, methotrexate, tumor necrosis factor inhibitors, tocilizumab, and abatacept. Small joint contractures are managed by principles of occupational hand therapy and rarely surgical procedures. TFRs may be treated similar to inflammatory arthritis with corticosteroids. All patients with RP and DU should keep digits covered and warm and avoid vasoconstrictive agents. Pharmacologic management of RP begins with use of calcium channel blockers, but additional agents that may be considered are fluoxetine and phosphodiesterase 5 (PDE5) inhibitors. DU management also involves vasodilators including calcium channel blockers and PDE5 inhibitors; bosentan has also been shown to prevent DU. In patients with severe RP and active DU, intravenous epoprostenol or iloprost can be used and surgical procedures, such as botulinum injections and digital sympathectomies, may be considered. For those with early diffuse cutaneous SSc needing immunosuppression for skin sclerosis, methotrexate or mycophenolate mofetil can be used, but the agent of choice depends on co-existing manifestations, such as inflammatory arthritis and/or lung involvement. Various pharmacologic agents for calcinosis have been considered but are generally ineffective; however, surgical options, including excision of areas of calcinosis, can be considered. Overall management of hand impairment for all patients with SSc should include occupational hand therapy techniques such as range of motion exercises, paraffin wax, and devices to assist in ADL. Thus, treatment options for the various manifestations contributing to hand impairment in SSc are limited and often modestly efficacious at best. Robust studies are needed to address the manifestations of SSc that contribute to hand impairment.
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Affiliation(s)
- Amber Young
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; University of Michigan Scleroderma Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rajaie Namas
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; University of Michigan Scleroderma Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carole Dodge
- Division of Occupational and Physical Therapy, University of Michigan, Ann Arbor, MI, USA
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; University of Michigan Scleroderma Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Lóránd V, Bálint Z, Komjáti D, Németh B, Minier T, Kumánovics G, Farkas N, Czirják L, Varjú C. Validation of disease activity indices using the 28 joint counts in systemic sclerosis. Rheumatology (Oxford) 2016; 55:1849-58. [DOI: 10.1093/rheumatology/kew246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Indexed: 01/23/2023] Open
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Cappelli S, Bellando Randone S, Camiciottoli G, De Paulis A, Guiducci S, Matucci-Cerinic M. Interstitial lung disease in systemic sclerosis: where do we stand? Eur Respir Rev 2016; 24:411-9. [PMID: 26324802 DOI: 10.1183/16000617.00002915] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Interstitial lung disease (ILD) is common in systemic sclerosis (SSc) patients and despite recent advances in the treatment is, at present, the major cause of death. Today, an early diagnosis of ILD is possible, and is mandatory to improve the prognosis of the disease. Pulmonary function tests and high-resolution computed tomography remain the mainstay for the diagnosis of SSc-ILD, but there is a growing interest in lung ultrasound. Recently, the correlation between severity of fibrosis and some peripheral blood biomarkers has been described. Nonselective immunosuppressors are still the main treatment for ILD, with cyclophosphamide (CYC) most widely used to obtain remission. Novel therapies towards specific molecular and cellular targets have been suggested; in particular, rituximab (RTX) has shown promising results, but further research is needed. It is of paramount importance to define the severity of the disease and the risk of progression in order to define the need for treatment and the treatment intensity. We propose the division of the treatment strategies at our disposal to induce remission into three categories: high intensity (haematopoietic stem cell transplantation), medium intensity (CYC and RTX) and low intensity (azathioprine (AZA) and mycophenolate mofetil (MMF)). After obtaining remission, maintenance treatment with AZA or MMF should be started. In this review we explore new advances in the pathogenesis, diagnosis and treatment of SSc-ILD.
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Affiliation(s)
- Susanna Cappelli
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Silvia Bellando Randone
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Gianna Camiciottoli
- Dept of Experimental and Clinical Medicine, Division of Pneumology and Lung Physiopathology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Amato De Paulis
- Dept of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Serena Guiducci
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Marco Matucci-Cerinic
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
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Cantarini L, Rigante D, Vitale A, Napodano S, Sakkas LI, Bogdanos DP, Shoenfeld Y. Intravenous immunoglobulins (IVIG) in systemic sclerosis: a challenging yet promising future. Immunol Res 2015; 61:326-37. [PMID: 25550086 DOI: 10.1007/s12026-014-8615-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The etiology and pathogenesis of systemic sclerosis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena have been documented. In addition, the rarity of the disease, the broad spectrum of clinical manifestations, and the relevant risk of severe complications as well as the highly variable disease course render its management a major challenge. Some immunomodulatory agents have been used, but no single agent has given a convincing proof of effectiveness, and treatment has remained largely symptomatic through recent years. Novel therapies are currently being tested and may have the potential of modifying the disease process and overall clinical outcome. Efficacy of intravenous immunoglobulins (IVIG) in different regimens (1-2 g/kg of body weight, administered over 2-5 consecutive days) has been described in a limited number of trials and small case series, showing benefits in skin, articular, and lung interstitial disease symptoms. However, studies on IVIG in systemic sclerosis still remain few, and further randomized controlled trials should be undertaken to assess their clinical effectiveness or define the optimal dosage and times of administration.
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Affiliation(s)
- Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy,
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Morrisroe KB, Nikpour M, Proudman SM. Musculoskeletal Manifestations of Systemic Sclerosis. Rheum Dis Clin North Am 2015. [DOI: 10.1016/j.rdc.2015.04.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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28
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Rueda de León Aguirre A, Ramírez Calvo JA, Rodríguez Reyna TS. Manejo integral de las pacientes con esclerosis sistémica durante el embarazo. ACTA ACUST UNITED AC 2015; 11:99-107. [DOI: 10.1016/j.reuma.2014.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/27/2014] [Accepted: 06/03/2014] [Indexed: 02/02/2023]
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29
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Rueda de León Aguirre A, Ramírez Calvo JA, Rodríguez Reyna TS. Comprehensive Approach to Systemic Sclerosis Patients During Pregnancy. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.reumae.2014.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Poelman CL, Hummers LK, Wigley FM, Anderson C, Boin F, Shah AA. Intravenous immunoglobulin may be an effective therapy for refractory, active diffuse cutaneous systemic sclerosis. J Rheumatol 2014; 42:236-42. [PMID: 25433527 DOI: 10.3899/jrheum.140833] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We sought to retrospectively review a single-center experience using intravenous immunoglobulin (IVIG) for the treatment of refractory, active diffuse cutaneous systemic sclerosis (dcSSc). METHODS The mean modified Rodnan Skin score (mRSS) at baseline was compared to the mRSS at 6, 12, 18, and 24 months post-IVIG initiation by the paired Student t test. Changes in mRSS at 6 and 12 months were also compared to data from historical controls of 3 large, negative, multicenter, randomized clinical trials of other medications [D-penicillamine (D-pen), recombinant human relaxin (relaxin), and oral bovine type I collagen (collagen)] and to patients treated with mycophenolate mofetil (MMF) alone using the Student t test. RESULTS Thirty patients were treated with adjunctive IVIG (2 g/kg/mo) for refractory, active dcSSc. The mean baseline mRSS of our cohort was 29.6 ± 7.2, and this significantly decreased to 24.1 ± 9.6 (n = 29, p = 0.0011) at 6 months, 22.5 ± 10.0 (n = 25, p = 0.0001) at 12 months, 20.6 ± 11.8 (n = 23, p = 0.0001) at 18 months, and 15.3 ± 6.4 (n = 15, p < 0.0001) at 24 months. The mean change in mRSS at 6 months was not significantly different in the IVIG group (-5.3 ± 7.9) compared to the relaxin trial (-4.8 ± 6.99, p = 0.74) or MMF group (-3.4 ± 7.4, p = 0.26); however, at 12 months, the mean change in mRSS was significantly better in the IVIG group (-8 ± 8.3) than in the D-pen (-2.47 ± 8.6, p = 0.005) and collagen (-3.4 ± 7.12, p = 0.005) groups, and was comparable to the group of primary MMF responders (-7.1 ± 9, p = 0.67). CONCLUSION Our observational study suggests that IVIG may be an effective adjunctive therapy for active dcSSc in patients failing other therapies.
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Affiliation(s)
- Corrie L Poelman
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine
| | - Laura K Hummers
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine
| | - Fredrick M Wigley
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine
| | - Cynthia Anderson
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine
| | - Francesco Boin
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine
| | - Ami A Shah
- From the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.C.L. Poelman, BA; L.K. Hummers, MD, ScM, Associate Professor of Medicine; F.M. Wigley, MD, Professor of Medicine; C. Anderson, MS; F. Boin, MD, Assistant Professor of Medicine; A.A. Shah, MD, MHS, Assistant Professor of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine.
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Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
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Lóránd V, Czirják L, Minier T. Musculoskeletal involvement in systemic sclerosis. Presse Med 2014; 43:e315-28. [PMID: 25179276 DOI: 10.1016/j.lpm.2014.03.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/18/2014] [Indexed: 12/26/2022] Open
Abstract
Musculoskeletal (MSK) involvement is a very frequent manifestation of patients with systemic sclerosis (SSc). There are several reports about clinical trials assessing musculoskeletal involvement in SSc. However, only few controlled studies have been conducted. The prevalence of musculoskeletal symptoms, clinical and radiographic findings has been assessed. The most important articular (arthralgia, synovitis, contractures), tendon (tendon friction rubs, tenosynovitis) and muscular manifestations (myalgia, muscle weakness, myositis) should be carefully evaluated during the assessment of SSc patients, because these are not only common, but substantially influence the quality of life and some of them also have predictive value concerning disease activity and severity.
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Affiliation(s)
- Veronika Lóránd
- University of Pécs, Faculty of Medicine, Department of Rheumatology and Immunology, 7632 Pécs, Hungary
| | - László Czirják
- University of Pécs, Faculty of Medicine, Department of Rheumatology and Immunology, 7632 Pécs, Hungary
| | - Tünde Minier
- University of Pécs, Faculty of Medicine, Department of Rheumatology and Immunology, 7632 Pécs, Hungary.
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Mauhin W, Rivière S, Cabane J, Tiev KP. Improvement in lung fibrosis using intravenous immunoglobulin in systemic sclerosis with myositis. Scand J Rheumatol 2014; 43:170-1. [PMID: 24588337 DOI: 10.3109/03009742.2013.868510] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- W Mauhin
- Department of Internal Medicine, Saint-Antoine Hospital, Paris VI University. The Public Assistance Hospitals of Paris (AH-HP) , Paris
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Németh A, Szamosi S, Horváth A, Schönherr J, Nicksch E, Szekanecz Z, Szűcs G. [Systemic sclerosis and pregnancy. A review of the current literature]. Z Rheumatol 2013; 73:175-9. [PMID: 24306839 DOI: 10.1007/s00393-013-1267-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pregnancy in women diagnosed with systemic sclerosis generally has a favorable outcome according to most recent studies. Women with systemic sclerosis who wish to become pregnant should achieve low disease activity for at least 6 months prior to conception. Regular follow-up of pregnant scleroderma patients by an interdisciplinary medical team including gynaecologists and rheumatologists is necessary to control disease activity and avoid possible complications. Severe organ involvement, early diffuse systemic sclerosis with rapid onset, and pulmonary hypertension ought to discourage patients from pregnancy, as these situations are at high risk of complications for both mother and fetus during pregnancy.
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Affiliation(s)
- A Németh
- Department of Rheumatology, University of Debrecen Medical and Health Sciences Center, Debrecen, Hungary,
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37
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McMahan ZH, Wigley FM. Novel investigational agents for the treatment of scleroderma. Expert Opin Investig Drugs 2013; 23:183-98. [PMID: 24261610 DOI: 10.1517/13543784.2014.848852] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The purpose of this article is to highlight novel therapies that are being used in scleroderma (SSc). Therapeutic interventions in SSc generally target at least one of three ongoing biological processes characteristic of the disease: vasculopathy, autoimmunity and tissue fibrosis. Treatment decisions in SSc are determined by the level of disease activity and the degree of specific organ involvement. Traditional therapy has primarily focused on organ-specific management without clear evidence of overall disease modification. AREAS COVERED The authors provide a review of a variety of agents, which are already used for other autoimmune diseases, that are now being used to treat active SSc skin or lung disease, including rituximab, tocilizumab and IVIG. Several agents studied in vitro and in animal models of fibrosis have shown promise, including bortezomib, LPA-1 antagonists, anti-CCN2 therapy, anti-IL-13 and thrombin antagonists. The authors also provide details on targeting intracellular molecular pathways and matricellular proteins, which is another novel area of investigation. EXPERT OPINION Combination therapy may be necessary to control the complex biological network active in SSc. Most of the current evidence that suggest benefit of these agents is based on small population studies. Ultimately well-designed clinical trials are required to define the role of these agents in treating SSc.
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Affiliation(s)
- Zsuzsanna Hortobagyi McMahan
- Johns Hopkins University, Medicine/Rheumatology , 55200 Eastern Avenue, MFL Center Tower, Suite 5300, Baltimore, MD 21224 , USA
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Bellando-Randone S, Cappelli S, Guiducci S, Cometi L, Matucci-Cerinic M. Treatment options in systemic sclerosis. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.849195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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39
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Tissue Doppler assessment of right ventricular function in female patients with limited form of systemic sclerosis. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2013.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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40
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Viswanath V, Phiske MM, Gopalani VV. Systemic sclerosis: current concepts in pathogenesis and therapeutic aspects of dermatological manifestations. Indian J Dermatol 2013; 58:255-68. [PMID: 23918994 PMCID: PMC3726870 DOI: 10.4103/0019-5154.113930] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem connective tissue disease with protean clinical manifestations. Recent advances in understanding the pathogenic mechanisms have led to development of target-oriented and vasomodulatory drugs which play a pivotal role in treating various dermatological manifestations. An exhaustive literature search was done using Medline, Embase, and Cochrane library to review the recent concepts regarding pathogenesis and evidence-based treatment of salient dermatological manifestations. The concept of shared genetic risk factors for the development of autoimmune diseases is seen in SSc. It is divided into fibroproliferative and inflammatory groups based on genome-wide molecular profiling. Genetic, infectious, and environmental factors play a key role; vascular injury, fibrosis, and immune activation are the chief pathogenic factors. Vitamin D deficiency has been documented in SSc and correlates with the severity of skin involvement. Skin sclerosis, Raynaud's phenomenon (RP) with digital vasculopathies, pigmentation, calcinosis, and leg ulcers affect the patient's quality of life. Immunosuppressives, biologicals, and hematopoietic stem cell transplantation are efficacious in skin sclerosis. Endothelin A receptor antagonists, calcium-channel blockers, angiotensin receptor inhibitors, prostacyclin analogs, and phosphodiesterase type 5 (PDE-5) inhibitors are the mainstay in RP and digital vasculopathies. Pigmentation in SSc has been attributed to melanogenic potential of endothelin-1 (ET-1); the role of ET 1 antagonists and vitamin D analogs needs to be investigated. Sexual dysfunction in both male and female patients has been attributed to vasculopathy and fibrosis, wherein PDE-5 inhibitors are found to be useful. The future concepts of treating SSc may be based on the gene expression signature.
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Affiliation(s)
- Vishalakshi Viswanath
- Department of Dermatology, Rajiv Gandhi Medical College and CSM Hospital, Kalwa, Thane Municipal Corporation, India
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Shah AA, Wigley FM. My approach to the treatment of scleroderma. Mayo Clin Proc 2013; 88:377-93. [PMID: 23541012 PMCID: PMC3666163 DOI: 10.1016/j.mayocp.2013.01.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
Systemic sclerosis (scleroderma) is unique among the rheumatic diseases because it presents the challenge of managing a chronic multisystem autoimmune disease with a widespread obliterative vasculopathy of small arteries that is associated with varying degrees of tissue fibrosis. The hallmark of scleroderma is clinical heterogeneity with subsets that vary in the degree of disease expression, organ involvement, and ultimate prognosis. Thus, the term scleroderma is used to describe patients who have common manifestations that link them together, whereas a highly variable clinical course exists that spans from mild and subtle findings to aggressive, life-threatening multisystem disease. The physician needs to carefully characterize each patient to understand the specific manifestations and level of disease activity to decide appropriate treatment. This is particularly important in treating a patient with scleroderma because there is no treatment that has been proven to modify the overall disease course, although therapy that targets specific organ involvement early before irreversible damage occurs improves both quality of life and survival. This review describes our approach as defined by evidence, expert opinion, and our experience treating patients. Scleroderma is a multisystem disease with variable expression; thus, any treatment plan must be holistic, yet at the same time focus on the dominant organ disease. The goal of therapy is to improve quality of life by minimizing specific organ involvement and subsequent life-threatening disease. At the same time the many factors that alter daily function need to be addressed, including nutrition, pain, deconditioning, musculoskeletal disuse, comorbid conditions, and the emotional aspects of the disease, such as fear, depression, and the social withdrawal caused by disfigurement.
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Affiliation(s)
- Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Frech TM, Shanmugam VK, Shah AA, Assassi S, Gordon JK, Hant FN, Hinchcliff ME, Steen V, Khanna D, Kayser C, Domsic RT. Treatment of early diffuse systemic sclerosis skin disease. Clin Exp Rheumatol 2013; 31:166-171. [PMID: 23910619 PMCID: PMC3889109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/06/2013] [Indexed: 06/02/2023]
Abstract
Diffuse systemic sclerosis carries a high morbidity and mortality. The Prospective Registry of Early Systemic Sclerosis (PRESS), a multicentre incident cohort study of patients with early diffuse cutaneous systemic sclerosis, has the goal of advancing the understanding of disease pathogenesis and identifying novel biomarkers. In this review, PRESS investigators discuss the evidence pertaining to the more commonly used treatments for early diffuse SSc skin disease including methotrexate, mycophenolate, cyclophosphamide, azathioprine, and intravenous immunoglobulin. This review highlights the unmet need for effective treatment in early diffuse SSc as well as its more rigorous study. Nonetheless, the PRESS investigators aim to decrease intra- and inter-institutional variability in prescribing in order to improve the understanding of the clinical course of early diffuse SSc skin disease.
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Affiliation(s)
- Tracy M Frech
- University of Utah and Veterans Affair Medical Center, Salt Lake City, USA.
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Topal AA, Dhurat RS. Scleroderma therapy: clinical overview of current trends and future perspective. Rheumatol Int 2012; 33:1-18. [PMID: 23011088 DOI: 10.1007/s00296-012-2486-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 07/07/2012] [Indexed: 12/20/2022]
Abstract
Systemic sclerosis is a chronic autoimmune condition with a complex pathogenesis and a high rate of mortality and morbidity. Internal organ involvement requires interdisciplinary approach in individual patient management. New discoveries in the pathogenesis of scleroderma herald a drastic change in the traditional outlook to therapy and have led to the development of the target-based approach in management. The challenge at present is to translate these advances in molecular mechanisms into well-designed clinical trials that will recognize potential disease-modifying therapies. This article is an evidence-based review of prevailing treatment options and future therapeutic targets in systemic sclerosis.
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Affiliation(s)
- Afsha A Topal
- T.N.M.C & BYL Nair Hospital, OPD 16, OPD building, Mumbai Central, Mumbai 400 008, India.
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Avouac J, Clements PJ, Khanna D, Furst DE, Allanore Y. Articular involvement in systemic sclerosis. Rheumatology (Oxford) 2012; 51:1347-56. [DOI: 10.1093/rheumatology/kes041] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Daoussis D, Antonopoulos I, Liossis SNC, Yiannopoulos G, Andonopoulos AP. Treatment of systemic sclerosis-associated calcinosis: a case report of rituximab-induced regression of CREST-related calcinosis and review of the literature. Semin Arthritis Rheum 2012; 41:822-9. [PMID: 22221908 DOI: 10.1016/j.semarthrit.2011.11.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 11/07/2011] [Accepted: 11/15/2011] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Calcinosis is frequently encountered in patients with systemic sclerosis (SSc) and may be associated with significant morbidity. No treatment has shown so far an unequivocal beneficial effect. METHODS We performed an extensive internet search (MEDLINE) using the keywords calcinosis, calcification, scleroderma, systemic sclerosis, and treatment. RESULTS Our patient had extensive Calcinosis, Raynaud, Esophagitis, Sclerodactyly, telangiectasia (CREST)-related calcinosis, frequently ulcerating and painful. Following 2 rituximab courses (consisting of 4 weekly infusions, 375 mg/m(2) each), calcinosis significantly improved and pain disappeared. Pharmacologic agents used in the treatment of SSc-associated calcinosis include diltiazem, minocycline, warfarin, biphosphonates, and intravenous immunoglobulin. Other therapeutic approaches include surgical excision, laser vaporization, and extracorporeal shock wave lithotripsy. CONCLUSIONS Evidence for all existing therapies is weak and therefore larger scale controlled studies are needed. Rituximab appears as a promising treatment especially in view of recent evidence that this therapy may be also effective in the underlying disease.
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Affiliation(s)
- Dimitrios Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Patras, Greece.
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Clements PJ, Allanore Y, Khanna D, Singh M, Furst DE. Arthritis in systemic sclerosis: systematic review of the literature and suggestions for the performance of future clinical trials in systemic sclerosis arthritis. Semin Arthritis Rheum 2011; 41:801-14. [PMID: 22177105 DOI: 10.1016/j.semarthrit.2011.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 08/22/2011] [Accepted: 10/04/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Musculoskeletal (MSK) pain is a frequent (between 40-80%) complaint of patients with systemic sclerosis (SSc). Unfortunately, there are virtually no systematic studies of the causes or the management of MSK involvement in SSc and with few exceptions there have been no controlled trials to determine what are and should be the best strategies for managing MSK pain and synovitis in patients with SSc. METHODS A literature search was conducted for published reports that have addressed the clinical assessment of "arthritis" and "musculoskeletal" involvement in SSc. The literature search was a prelude to developing recommendations/suggestions for performing clinical trials (preferably randomized) in the future in SSc-related arthritis. RESULTS The search netted a number of articles that reported clinical assessments of arthritis in SSc, but very few reported results of controlled clinical trials. Nevertheless, a prevalence of clinical arthritis and tools used to assess the involvement (clinical examination, functional assessments and assessments of quality of life, and radiographic imaging) was found. CONCLUSIONS Most of the tools used to assess arthritis in SSc patients have not been validated and additional work is needed to develop a "core set" of variables for assessment of arthritis in SSc and its response to treatment. This report furnishes the background information that can help provide the building blocks for the development of a "core set" that can be used to chart the efficacy of new treatments for SSc-related arthritis in the future.
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Affiliation(s)
- Philip J Clements
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1670, USA.
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The role of intravenous immunoglobulin preparations in the treatment of systemic sclerosis. Int J Rheumatol 2011; 2011:829751. [PMID: 22121376 PMCID: PMC3216365 DOI: 10.1155/2011/829751] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 08/28/2011] [Accepted: 08/28/2011] [Indexed: 11/18/2022] Open
Abstract
Scleroderma is progressive autoimmune disease associated with severe disability. The major underlying pathological process in scleroderma is progressive development of fibrous tissue and obliteration of the microvasculature. Currently, there are no medical products for the treatment of scleroderma that provide both sufficient immunosuppression and low-risk side safety profile with negligible side effects. There are a large number of experimental data showing that intravenous immunoglobulin (IVIG) has multiple clinical and morphological effects. On the other hand, some authors report good effect of intravenous immune globulins in patients with scleroderma. The less frequent side effects of IVIG in doses below or equal to 2 g/kg/month divided in 5 consecutive days make IVIG a promising treatment of choice in scleroderma.
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Bayry J, Negi VS, Kaveri SV. Intravenous immunoglobulin therapy in rheumatic diseases. Nat Rev Rheumatol 2011; 7:349-59. [PMID: 21556030 DOI: 10.1038/nrrheum.2011.61] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Prepared from the collective plasma of several thousand people, therapeutic intravenous immunoglobulin (IVIg) consists mostly of human polyspecific IgG. In addition to its use in primary and secondary immune deficiencies, IVIg is used in the treatment of several rheumatic conditions, including Kawasaki disease, dermatomyositis and antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis. In these diseases, IVIg therapy generally involves the use of 2 g/kg administered over either 2 or 5 consecutive days. However, dosage regimens have not been thoroughly explored, and indications for IVIg in most rheumatic diseases, such as systemic lupus erythematosus, polymyositis and catastrophic antiphospholipid syndrome, derive from its off-label usage. Randomized clinical trials are warranted to support the evidence-based use of IVIg, and to identify the ideal administration protocols to maximize the benefits of what is a limited resource. Further research to improve the therapeutic application of IVIg relies essentially on the conception of next-generation immunoglobulin preparations and optimization of combined therapies with immunomodulatory drugs and biologic agents.
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Affiliation(s)
- Jagadeesh Bayry
- Institut National de Santé et de Recherche Médicale Unité 872 (INSERM U872), Université Pierre et Marie Curie and Université René Descartes, 15 rue de l'Ecole de Médicine, Paris, F-75006, France
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Steen VD. Management of systemic sclerosis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00140-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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50
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Skare TL, Toebe BL, Boros C. Hand dysfunction in scleroderma patients. SAO PAULO MED J 2011; 129:357-60. [PMID: 22069136 PMCID: PMC10868939 DOI: 10.1590/s1516-31802011000500012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 01/24/2011] [Accepted: 04/20/2011] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thelma Larocca Skare
- MD, PhD. Head of Rheumatology Service, Hospital Universitário Evangélico de Curitiba, Curitiba, Paraná, Brazil.
| | - Bruna Leticia Toebe
- MD. Rheumatology Service, Hospital Universitário Evangélico de Curitiba, Curitiba, Paraná, Brazil.
| | - Carla Boros
- MD. Rheumatology Service, Hospital Universitário Evangélico de Curitiba, Curitiba, Paraná, Brazil.
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