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Nishikawa S, Takahashi N, Nishikawa Y, Yokoi S, Morita S, Shimamoto Y, Sakashita S, Nishimori K, Kobayashi M, Fukushima S, Mikami D, Kimura H, Kasuno K, Naiki H, Iwano M. Fanconi syndrome in an elderly patient with membranous nephropathy during treatment with the immunosuppressant mizoribine. CEN Case Rep 2023; 12:32-38. [PMID: 35749014 PMCID: PMC9243880 DOI: 10.1007/s13730-022-00715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/03/2022] [Indexed: 02/04/2023] Open
Abstract
We report on an 80-year-old man diagnosed with Fanconi syndrome induced by mizoribine after 4 weeks of administration to treat membranous nephropathy. Mizoribine is an oral immunosuppressant that inhibits inosine monophosphate dehydrogenase and is widely used in Japan for the treatment of autoimmune diseases and nephrotic syndrome, as well as after renal transplantation. Acquired Fanconi syndrome is often caused by drugs (antibacterial, antiviral, anticancer, and anticonvulsant drugs) and is sometimes caused by autoimmune diseases, monoclonal light chain-associated diseases, or heavy metal poisoning. In our patient, hypokalemia, hypophosphatemia, glucosuria, hypouricemia, and severe proteinuria resolved gradually after discontinuation of mizoribine administration, despite oral administration of prednisolone followed by a single intravenous injection of rituximab. The patient was ultimately diagnosed with Fanconi syndrome induced by mizoribine based on his clinical course and his typical laboratory data with the absence of proximal tubular acidosis. To our knowledge, this is the first report of Fanconi syndrome possibly induced by mizoribine. Although the precise mechanism by which mizoribine induces proximal tubular dysfunction is unknown, we suggest that nephrologists should be aware of the onset of Fanconi syndrome, a rare complication during mizoribine treatment.
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Affiliation(s)
- Sho Nishikawa
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Yudai Nishikawa
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Seiji Yokoi
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Sayu Morita
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Yuki Shimamoto
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Sayumi Sakashita
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kazuhisa Nishimori
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Mamiko Kobayashi
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Sachiko Fukushima
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Daisuke Mikami
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hideki Kimura
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kenji Kasuno
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hironobu Naiki
- Department of Molecular Pathology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
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Nakai T, Fukui S, Kidoguchi G, Ikeda Y, Kitada A, Nomura A, Tamaki H, Kishimoto M, Okada M. Effect and safety profile of belimumab and tacrolimus combination therapy in thirty-three patients with systemic lupus erythematosus. Clin Rheumatol 2022; 41:3735-3745. [PMID: 35939162 DOI: 10.1007/s10067-022-06325-6] [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: 05/10/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION/OBJECTIVES Belimumab combined with mycophenolate mofetil has been proven to be effective for treating systemic lupus erythematosus (SLE) in several randomized controlled trials. Calcineurin inhibitors are also useful in controlling the activity of SLE. However, the safety and effectiveness of belimumab-calcineurin inhibitor combination therapy have not been addressed. Therefore, the current single-center retrospective study aimed to analyze the safety/efficacy profile of belimumab-tacrolimus (B-T) combination therapy in patients with SLE. METHOD Patients with SLE administered tacrolimus and belimumab during treatment were included in the study. Samples were analyzed for the drug retention rate, SLE flare rate, infection incidence rate, and glucocorticoid-sparing effect of the B-T combination therapy. RESULTS Thirty-three patients with SLE were treated with B-T combination therapy at our institution. Four patients discontinued treatment due to insufficient response or adverse events. The drug retention rate was over 90% at week 52 and approximately 80% at day 1000. Only one patient developed serious infection. The lupus low disease activity state (LLDAS) achievement ratio was 9.1% on the day of initiation and improved to 64.0% at 52 weeks after initiation. SLE flares were observed in three patients (9.1%) in the first 52 weeks after initiation, and in five patients (15.2%) throughout the study period. A glucocorticoid-reducing effect was also observed in patients treated with B-T combination therapy. CONCLUSIONS In most patients with SLE, B-T combination therapy is well tolerated with a good efficacy profile and glucocorticoid-reducing effect. Thus, B-T combination therapy represents a feasible option for patients with refractory lupus. Key Points • The safety and effectiveness of belimumab-calcineurin inhibitor combination therapy have not been addressed. • The drug retention rate of belimumab-tacrolimus combination therapy was over 90% at week 52 and around 80% on day 1000 • Almost none of the patients suffered from severe infection after the initiation of belimumab-tacrolimus combination therapy. • Belimumab-tacrolimus combination therapy is efficacious in suppressing lupus activity and achieving LLDAS.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.,Center for Clinical Epidemiology, St. Luke's International University, Tokyo, Japan.,Department of Emergency and General Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Genki Kidoguchi
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.,Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
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Nakai T, Fukui S, Ikeda Y, Suda M, Tamaki H, Okada M. Glucocorticoid discontinuation in patients with SLE with prior severe organ involvement: a single-center retrospective analysis. Lupus Sci Med 2022; 9:9/1/e000682. [PMID: 35654482 PMCID: PMC9163542 DOI: 10.1136/lupus-2022-000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/19/2022] [Indexed: 12/13/2022]
Abstract
Objective Long-term glucocorticoid use in SLE may have significant side effects; however, glucocorticoid discontinuation is occasionally associated with disease flare-ups. Therefore, we evaluated the risk factors for disease flares and the flare rate on glucocorticoid tapering in patients with prior severe organ involvement. Methods Data of patients with SLE with glucocorticoid tapering at our institution were retrospectively analysed. We divided the patients by the presence of prior severe organ involvement and compared flare rates after glucocorticoid discontinuation. Furthermore, we determined risk factors for flares after glucocorticoid discontinuation. Results In total, 309 patients with SLE were screened, 73 of whom met the inclusion criteria; 49 were classified as SLE with prior severe organ involvement. No significant differences were noted in the 52-week flare rate after glucocorticoid discontinuation between patients with and without prior severe organ involvement (16.7% vs 18.2%, p=1.0). Hypocomplementaemia, elevated anti-dsDNA antibody titres more than twice the upper limit of the laboratory reference range, positive anti-Smith/anti-ribonucleoprotein antibody, and use of any immunosuppressant on the day of glucocorticoid discontinuation were negatively associated with flare-free remission. Conclusions Glucocorticoid discontinuation after gradual tapering can often be achieved in patients with SLE, even with prior severe organ involvement, especially when the disease is clinically and serologically stable.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Center for Clinical Epidemiology, St Luke's International University, Chuo-ku, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masei Suda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Department of Rheumatology, Suwa Central Hospital, Nagano, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
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4
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Ayano M, Kimoto Y, Mitoma H, Akahoshi M, Ono N, Arinobu Y, Akashi K, Horiuchi T, Niiro H. Comparative efficacy and safety of mizoribine and mycophenolate mofetil for treating systemic lupus erythematosus: a retrospective cohort study. Ther Adv Musculoskelet Dis 2022; 14:1759720X221096367. [PMID: 35586513 PMCID: PMC9109492 DOI: 10.1177/1759720x221096367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/01/2022] [Indexed: 12/11/2022] Open
Abstract
Background Mizoribine (MZR) is an immunosuppressive agent that selectively inhibits inosine monophosphate dehydrogenase; its actions are considerably similar to those of mycophenolate mofetil (MMF). This study aimed to clarify whether MZR can be a good treatment option for systemic lupus erythematosus (SLE) and to compare the efficacy and safety of MZR and MMF in patients with active SLE. Methods We retrospectively compared the efficacy, continuation rate, and safety of MZR (52 patients) and MMF (31 patients) after adjusting for stabilized inverse probability of treatment weighting based on propensity scores. The efficacy endpoints were as follows: cumulative incidence of lupus low disease activity state (LLDAS) or remission attainment and flares and change in prednisolone dose over 2 years. Drug continuation rates were defined as the time from drug initiation to discontinuation for any cause, owing to the lack of efficacy, or owing to adverse events. The safety endpoint was the frequency of adverse events. Results Overall, 25 (48.1%) and 13 (25.0%) patients in the MZR group and 18 (58.1%) and 15 (48.3%) in the MMF group achieved LLDAS and remission during the follow-up period, respectively; thus, the cumulative incidence of LLDAS and remission attainment of the two groups was similar after adjustment. Prednisolone dose was steadily reduced in both the groups, and the change in prednisolone dose was nearly identical between the two groups. Drug discontinuation rate due to adverse events and the frequency of all adverse events and infections were higher in the MMF group than in the MZR group, albeit without significance after adjustment. Conclusion MZR is as effective as MMF in controlling SLE activity. The adverse events of MZR, whose profile differs from MMF, are comparable to or less than those of MMF. MZR may be a valuable option as an immunosuppressive agent for SLE, as well as MMF.
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Affiliation(s)
- Masahiro Ayano
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi,
Higashi-ku, Fukuoka 812-8582, Japan
- Department of Cancer Stem Cell Research, Kyushu
University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu
University Beppu Hospital, Beppu, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
- Department of Rheumatology, Saga University
Hospital, Saga, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu
University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu
University Graduate School of Medical Sciences, Fukuoka, Japan
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5
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Kashiwado Y, Kimoto Y, Sawabe T, Irino K, Nakano S, Hiura J, Wang Q, Kawano S, Ayano M, Mitoma H, Ono N, Arinobu Y, Niiro H, Hotta T, Kang D, Akashi K, Ohshima S, Takeuchi T, Horiuchi T. Antibody response to SARS-CoV-2 mRNA vaccines in patients with rheumatic diseases in Japan: Interim analysis of a multicentre cohort study. Mod Rheumatol 2022; 33:367-372. [PMID: 35411376 PMCID: PMC9047194 DOI: 10.1093/mr/roac030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/13/2022] [Accepted: 03/25/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the impact of medication on antibody response to severe acute respiratory syndrome coronavirus-2 mRNA vaccines in Japanese patients with rheumatic diseases. METHODS This prospective multicentre cohort study evaluated the humoral response in 12 different medication groups. Antibody levels before the first vaccination and 3-6 weeks after the second vaccination were measured using the Elecsys Anti-SARS-CoV-2 S assay. Statistical analysis included comparing antibody titres among the different medication groups using the Kruskal-Wallis test followed by the Bonferroni-Dunn test and multiple linear regression analysis. RESULTS 295 patients were analysed. The seroconversion rate was 92.2% and the median antibody titre was 255 U/ml (interquartile range, 34.1-685) after the second mRNA vaccination. Antibody levels were significantly lower in the groups treated with Tumour necrosis factor inhibitor with methotrexate, abatacept, mycophenolate mofetil (MMF), MMF or mizoribine combined with calcineurin inhibitor, and rituximab or cyclophosphamide compared with those treated with sulfasalazine and/or bucillamine or calcineurin inhibitor (p < 0.01). The correlation between antibody titre and treatment was significant after adjusting for age, gender, and glucocorticoid dose (p < 0.01). CONCLUSIONS Additional early vaccination is required in patients treated with Tumour necrosis factor inhibitor and methotrexate, abatacept, MMF, MMF or mizoribine combined with calcineurin inhibitor and rituximab or cyclophosphamide.
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Affiliation(s)
- Yusuke Kashiwado
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Kensuke Irino
- Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Shota Nakano
- Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Junki Hiura
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Qiaolei Wang
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Taeko Hotta
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Dongchon Kang
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shiro Ohshima
- Department of Clinical Research, Rheumatology and Allergology, Osaka Minami Medical Center, Osaka, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takahiko Horiuchi
- *Correspondence: Takahiko Horiuchi; ; Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumibaru, Beppu, Oita 874-0838, Japan
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Choi CB, Won S, Bae SC. Outcomes of multitarget therapy using mycophenolate mofetil and tacrolimus for refractory or relapsing lupus nephritis. Lupus 2018; 27:1007-1011. [DOI: 10.1177/0961203318758505] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- C-B Choi
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - S Won
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - S-C Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
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Mizoribine is as Effective as Methotrexate for the Treatment of Polymyalgia Rheumatica: A Retrospective Case Series Analysis. Arch Rheumatol 2018; 33:302-308. [PMID: 30632539 DOI: 10.5606/archrheumatol.2018.6418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 10/23/2017] [Indexed: 01/31/2023] Open
Abstract
Objectives This study aims to evaluate the efficacy and safety of mizoribine (MZR) as a steroid-sparing agent compared to methotrexate (MTX) in the treatment of polymyalgia rheumatica in elderly patients. Patients and methods Twenty-four patients (9 males, 15 females; mean age 71.7 years; range 50 to 86 years) diagnosed with polymyalgia rheumatica between April 1998 and August 2014, who received prednisone in combination with either MTX or MZR, were included. We collected the data on the cumulative prednisone dose that patients received within 48 weeks after MTX or MZR and its side effect profile. Results There were 10 patients in the MTX group and 14 in the MZR group. The cumulative prednisone dose over 0-48 weeks was 2272±396 mg in the MTX group and 1907±241 mg in the MZR group, which was not significantly different (p=0.41). In terms of side effects, in the MTX group, three patients experienced a transient elevation in liver enzymes, and one patient developed gastrointestinal symptoms that led to MTX withdrawal. In the MZR group, one patient was hospitalized due to pneumonia that led to MZR withdrawal. Conclusion Mizoribine was non-inferior to MTX in terms of steroid-sparing effects on polymyalgia rheumatica. Also, MZR tended to have fewer side effects than MTX.
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Mok CC. Calcineurin inhibitors in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2017; 31:429-438. [PMID: 29224682 DOI: 10.1016/j.berh.2017.09.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/06/2017] [Accepted: 09/02/2017] [Indexed: 01/14/2023]
Abstract
The calcineurin inhibitors (CNIs) belong to a group of immunosuppressive agents that block T-cell activation through the suppression of the calcium/calcimodulin-dependent phosphatase calcineurin. Agents such as cyclosporine A (CSA) and tacrolimus (TAC) have long been used in patients with systemic lupus erythematosus (SLE). TAC is preferred to CSA in SLE because of the lower frequency of cosmetic, hypertensive and dyslipidemic adverse effects. Recent randomised controlled trials have demonstrated noninferiority of TAC to mycophenolate mofetil (MMF) or cyclophosphamide (CYC) for induction therapy of lupus nephritis. Low-dose combination of TAC and MMF has also been shown to outperform CYC pulses in inducing remission of lupus nephritis in Chinese patients. TAC does not affect fertility and is relatively safe in pregnancy. In SLE patients who are intolerant or refractory to conventional immunosuppressives, or where contraindications to other immunosuppressive agents exist, TAC is an alternative option. However, the therapeutic window of TAC is narrow, and drug level monitoring is required to ensure drug exposure and minimise toxicities. Current evidence of TAC in lupus nephritis is limited to 6 months, and its long-term safety as maintenance therapy of SLE is yet to be determined. Newer chemical analogues of CNIs, such as voclosporin, with less variable plasma concentration are being tested in lupus nephritis.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, New Territories, Hong Kong, China.
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9
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Takeuchi T, Okada K, Yoshida H, Yagi N. Post-marketing surveillance study of the long-term use of mizoribine for the treatment of lupus nephritis: 2-Year results. Mod Rheumatol 2017; 28:85-94. [PMID: 28722500 DOI: 10.1080/14397595.2017.1349573] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To understand the status of mizoribine use in patients with lupus nephritis (LN) and to collect safety- and efficacy-related data on 2-year treatment with mizoribine. METHODS A continuous survey was conducted between March 2010 and July 2015. RESULTS The analysis set included 559 patients (mean age 39.5 years, females 82.6%, mean duration of systemic lupus erythematosus (SLE) 8.4 years, mean duration of LN 5.9 years). Renal function was satisfactory for 6 months, but worsened from 12 months, with significant worsening at 24 months. By the ACR 2006 remission criteria (eGFR >60), at 24 months, 26.5% of patients achieved complete remission, and 63.3% achieved complete or partial remission. The urine protein to creatinine ratio decreased significantly. The SLE Disease Activity Index 2000 score decreased significantly at 12 and 24 months. Overall, 98 (17.5%) patients experienced 124 adverse drug reactions (ADRs); 3.6% experienced serious ADRs. Mizoribine was used with a steroid in 99.3% and an immunosuppressant in 51.2%; tacrolimus was used in 43.8%. The oral steroid dosage decreased from baseline to 24 months. The incidence of ADRs was not significantly different with concomitant tacrolimus use. CONCLUSIONS The results suggest that long-term mizoribine is safe and effective, even when used with tacrolimus.
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Affiliation(s)
- Tsutomu Takeuchi
- a Division of Rheumatology, Department of Internal Medicine , Keio University School of Medicine , Tokyo , Japan
| | - Kenya Okada
- b Post-Marketing Surveillance Department , Regulatory Affairs and Reliability Assurance Center, Asahi Kasei Pharma Corporation , Tokyo , Japan
| | - Hisao Yoshida
- b Post-Marketing Surveillance Department , Regulatory Affairs and Reliability Assurance Center, Asahi Kasei Pharma Corporation , Tokyo , Japan
| | - Nobuyuki Yagi
- c Pharmaceuticals Marketing Division, Pharmaceuticals Sales Division , Asahi Kasei Pharma Corporation , Tokyo , Japan
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10
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Sakai R, Kurasawa T, Nishi E, Kondo T, Okada Y, Shibata A, Nishimura K, Chino K, Okuyama A, Takei H, Nagasawa H, Amano K. Efficacy and safety of multitarget therapy with cyclophosphamide and tacrolimus for lupus nephritis: a prospective, single-arm, single-centre, open label pilot study in Japan. Lupus 2017; 27:273-282. [DOI: 10.1177/0961203317719148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Sakai
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Department of Microbiology and Immunology, Keio University, Tokyo, Japan
| | - T Kurasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - E Nishi
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - T Kondo
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - Y Okada
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Shibata
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - K Nishimura
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Division of Rheumatology, Japan Community Health Care Organization, Saitama, Japan
| | - K Chino
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Okuyama
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Takei
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Nagasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Nagasawa Clinic, Saitama, Japan
| | - K Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
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11
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Suda M, Kataoka Y, Tomishima Y, Jinta T, Rokutanda R, Kishimoto M, Okada M. Effectiveness of multi-target therapy in anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis with early-stage interstitial lung disease. Scand J Rheumatol 2017. [PMID: 28649889 DOI: 10.1080/03009742.2017.1314004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- M Suda
- a Immuno-Rheumatology Center , St Luke's International Hospital , Tokyo , Japan
| | - Y Kataoka
- a Immuno-Rheumatology Center , St Luke's International Hospital , Tokyo , Japan
| | - Y Tomishima
- b Division of Pulmonary Medicine , St Luke's International Hospital , Tokyo , Japan
| | - T Jinta
- b Division of Pulmonary Medicine , St Luke's International Hospital , Tokyo , Japan
| | - R Rokutanda
- a Immuno-Rheumatology Center , St Luke's International Hospital , Tokyo , Japan
| | - M Kishimoto
- a Immuno-Rheumatology Center , St Luke's International Hospital , Tokyo , Japan
| | - M Okada
- a Immuno-Rheumatology Center , St Luke's International Hospital , Tokyo , Japan
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12
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Ikeda K, Watanabe K, Hirai T, Tanji K, Miyashita T, Nakajima S, Uomori K, Morimoto S, Takamori K, Ogawa H, Takasaki Y, Sekigawa I. Mizoribine Synchronized Methotrexate Therapy should be Considered when Treating Rheumatoid Arthritis Patients with an Inadequate Response to Various Combination Therapies. Intern Med 2017; 56:1147-1152. [PMID: 28502927 PMCID: PMC5491807 DOI: 10.2169/internalmedicine.56.7886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The objective of this study was to confirm the efficacy of low-dose mizoribine (MZR), an inhibitor of inosine monophosphate dehydrogenase, as part of synchronized methotrexate (MTX) therapy for rheumatoid arthritis (RA) patients with an inadequate response to various combination therapies of MTX, other synthetic disease-modifying anti-rheumatic drugs (DMARDs) and biological DMARDs. Methods Low-dose MZR was administered to 56 uncontrolled RA patients being treated with MTX and various biological DMARDs. The observation period was 12 months, and the disease activity was evaluated based on the Disease Activity Score in 28 joints (DAS28)-ESR, Simplified Disease Activity Index (SDAI) and serum MMP-3 level. Results All of the disease activity indices were significantly improved within three months, and the serum MMP-3 levels were also significantly decreased around four months after starting low-dose MZR therapy. No patients experienced any adverse effects. Conclusion The present preliminary findings suggest that low-dose MZR therapy with MTX should be considered for the treatment of RA patients with an inadequate response to various combination therapies including MTX, other synthetic DMARDs and biological DMARDs or in whom increasing the dose of MTX is difficult for reasons such as adverse effects and complications.
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Affiliation(s)
- Keigo Ikeda
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kozo Watanabe
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Takuya Hirai
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kana Tanji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Tomoko Miyashita
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
| | - Shihoko Nakajima
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Kaori Uomori
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Shinji Morimoto
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Kenji Takamori
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Hideoki Ogawa
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshinari Takasaki
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Japan
| | - Iwao Sekigawa
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Japan
- Institutes for Environmental and Gender Specific Medicine, Juntendo University Graduate School of Medicine, Japan
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13
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Mok CC. Pro: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1561-6. [PMID: 27591327 DOI: 10.1093/ndt/gfw289] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 03/19/2016] [Indexed: 12/11/2022] Open
Abstract
Renal disease in systemic lupus erythematosus (SLE) carries significant morbidity and mortality. Cyclophosphamide (CYC)- and mycophenolate mofetil (MMF)-based induction regimens are not ideal in terms of efficacy and toxicity. The adverse effects of CYC, such as infection risk, infertility, urotoxicity and oncogenicity, limit its use in lupus nephritis. Although MMF is non-inferior to CYC as induction therapy and has reduced gonadal toxicity and oncogenic potential, meta-analyses of clinical trials do not show a lower rate of infective and gastrointestinal complications. Tacrolimus (TAC) has recently been shown to have equal efficacy to either MMF or CYC for inducing remission of lupus nephritis. A low-dose combination of MMF and TAC appears to be more effective than intravenous CYC pulses in Chinese patients, and has potential to replace the more toxic CYC regimens in high-risk subgroups. TAC may be considered as another non-CYC alternative for induction therapy of lupus nephritis and in those with refractory disease or intolerance to CYC or MMF. TAC has no negative effect on fertility in younger women, and unlike MMF and CYC, it is safe in pregnancy. However, TAC has a narrow therapeutic window and drug level monitoring is required to ensure drug exposure and minimize acute toxicities. Current evidence for the efficacy of TAC in lupus nephritis is limited to 6 months and the incidence of renal flare after discontinuation of therapy or switching to azathioprine appears to be higher than other induction agents. Long-term data and the incidence of chronic nephrotoxicity of TAC as maintenance therapy in lupus nephritis are currently lacking and further prospective trials are needed to address these issues.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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14
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Suyama Y, Okada M, Rokutanda R, Min C, Sassé B, Kobayashi D, Takahashi O, Deshpande GA, Matsui K, Kawaguchi Y, Kishimoto M. Safety and efficacy of upfront graded administration of trimethoprim–sulfamethoxazole in systemic lupus erythematosus: A retrospective cohort study. Mod Rheumatol 2016; 26:557-61. [DOI: 10.3109/14397595.2015.1112467] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Yasuhiro Suyama
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
| | - Ryo Rokutanda
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
| | - Chisun Min
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
| | - Belinda Sassé
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
| | - Daiki Kobayashi
- Center for Clinical Epidemiology, St Luke’s Life Science Institute, Tokyo, Japan,
| | - Osamu Takahashi
- Center for Clinical Epidemiology, St Luke’s Life Science Institute, Tokyo, Japan,
| | - Gautam A. Deshpande
- Center for Clinical Epidemiology, St Luke’s Life Science Institute, Tokyo, Japan,
| | - Kazuo Matsui
- Department of Rheumatology, Kameda Medical Center, Kamogawa City, Chiba, Japan, and
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women’s Medical University, Shinjuku-Ku, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke’s International Hospital, St. Luke’s International University, Tokyo, Japan,
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15
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Tanaka H, Aizawa T, Watanabe S, Oki E, Tsuruga K, Imaizumi T. Efficacy of mizoribine-tacrolimus-based induction therapy for pediatric lupus nephritis. Lupus 2014; 23:813-8. [PMID: 24651669 DOI: 10.1177/0961203314528553] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 02/26/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recent advances in the management of lupus nephritis (LN) have also contributed to a favorable outcome in patients with pediatric-onset LN. Nevertheless, we believe that a more effective and less toxic treatment is needed to attain optimal control of pediatric-onset LN. METHODS Seven consecutive children with biopsy-proven LN (four with class III/IV and three with class V) received multitarget induction therapy consisting of mizoribine (MZR), tacrolimus (Tac), and prednisolone (PDN). They were prospectively evaluated at three, six, and 12 months, and at the latest observation point after a mean period of 32 months. Post-treatment renal biopsy was performed in two patients with class III/IV. RESULTS Despite gradually tapering the dose of concomitantly administered PDN, a significant improvement compared with baseline values was observed in the urinary, serological, and clinical assessment measures even at three months of treatment, and the favorable changes persisted throughout the treatment period in most of the study participants except for one. In two patients who underwent post-treatment renal biopsy, a marked histologic improvement was confirmed. No serious adverse events were observed. CONCLUSIONS Multitarget therapy may be an attractive option for the treatment of pediatric-onset LN. Further studies involving a larger number of patients are needed.
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Affiliation(s)
- H Tanaka
- Department of Pediatrics, Hirosaki University Hospital Department of School Health Science, Faculty of Education, Hirosaki University
| | - T Aizawa
- Department of Pediatrics, Hirosaki University Hospital
| | - S Watanabe
- Department of Pediatrics, Hirosaki University Hospital
| | - E Oki
- Department of Pediatrics, Hirosaki University Hospital
| | - K Tsuruga
- Department of Pediatrics, Hirosaki University Hospital
| | - T Imaizumi
- Department of Vascular Biology, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
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16
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Ikeuchi H, Hiromura K, Takahashi S, Mishima K, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Kuroiwa T, Nojima Y. Efficacy and safety of multi-target therapy using a combination of tacrolimus, mycophenolate mofetil and a steroid in patients with active lupus nephritis. Mod Rheumatol 2013; 24:618-25. [DOI: 10.3109/14397595.2013.844397] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hidekazu Ikeuchi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Keiju Hiromura
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Satoshi Takahashi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Keiichiro Mishima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Noriyuki Sakurai
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Toru Sakairi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Yoriaki Kaneko
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Akito Maeshima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Takashi Kuroiwa
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
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17
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Kurasawa T, Nagasawa H, Nishi E, Takei H, Okuyama A, Kondo T, Nishimura K, Sakai R, Shibata A, Chino K, Ogawa H, Ito T, Amano K, Kato H. Successful treatment of class IV+V lupus nephritis with combination therapy of high-dose corticosteroids, tacrolimus and intravenous cyclophosphamide. Intern Med 2013; 52:1125-30. [PMID: 23676603 DOI: 10.2169/internalmedicine.52.9366] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A substantial number of patients with lupus nephritis (LN) are refractory to conventional glucocorticoid (GC) treatment. Although many of these patients respond to immunosuppressive drugs such as intravenous cyclophosphamide (IVCY), azathioprine (AZA), mizoribine, tacrolimus, cyclosporine A (CSA) and mycofenolate mofetil (MMF), some remain refractory to such therapies. Recent studies of multi-target therapies have reported effective outcomes for immunosuppression following renal transplantation and refractory LN when therapy consists of two or more immunosuppressive drugs with different mechanisms of action. We herein report a case of LN unresponsive to IVCY that was successfully treated with the addition of tacrolimus and discuss the usefulness of multi-target therapy for LN.
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Affiliation(s)
- Takahiko Kurasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Japan
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