1
|
An observational study of clinical recurrence in patients with interstitial lung disease related to the antisynthetase syndrome. Clin Rheumatol 2023; 42:711-720. [PMID: 36334174 DOI: 10.1007/s10067-022-06424-4] [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: 08/01/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the clinical characteristics and risk factors of clinical recurrence in interstitial lung disease related to antisynthetase syndrome (ARS-ILD). METHODS Patients diagnosed as ARS-ILD in Nanjing Drum Tower Hospital between January 2015 and November 2020 were retrospectively analyzed. Clinical information and treatment course were reviewed. The primary endpoint was the disease recurrence, and the secondary point was mortality. Univariate and multivariable Cox regression analyses were performed to identify risk factors for recurrence. RESULTS Totally, 132 patients with ARS-ILD received immunomodulation treatment from diagnosis. During follow-ups, sixty-nine patients showed recurrence, with a recurrency rate yielding 52.3%. The median duration from treatment initiation to recurrence was 11 (5-18) months. The median tapering course in the recurrence group was 8 (3-12.5) months, which was significantly shorter than the 16 (10-32) months in the no-recurrence group (p < 0.001). Fifty-eight patients experienced recurrence when the glucocorticoids (GC) dose dropped to 10 (9.375-15) mg/day. Twelve patients discontinued GC with a median treatment course of 11.5 (8-16.75) months, and 11 patients developed recurrence after discontinuing GC for 3 (1-4) months. Twelve patients died, with a mortality rate of 9.1%, and recurrence was not associated with increased mortality. The adjusted multivariate analysis showed that age, increased serum lactate dehydrogenase (LDH) level, relatively shorter tapering duration, and inappropriate GC discontinuation were associated with recurrence. CONCLUSION Recurrence of ARS-ILD was common during medication intensity reduction. Age, LDH, medication tapering duration, and discontinuation were risk factors for recurrence. Further efforts to reduce recurrence should take into consideration of these factors. Key Points • Recurrence is observed commonly with a recurrency rate 52.3% in patients with interstitial lung disease related to antisynthetase syndrome (ARS-ILD) when glucocorticoids (GC) tapering or discontinuation. • Age, increased serum lactate dehydrogenase (LDH) level, medication tapering duration, and GC discontinuation were identified to be significantly associated with the recurrence of ARS-ILD.
Collapse
|
2
|
Anderle K, Machold K, Kiener HP, Bormann D, Hoetzenecker K, Geleff S, Prosch H, Laccone F, Heil PM, Petzelbauer P, Aletaha D, Blüml S, Kastrati K. COVID-19 as a putative trigger of anti-MDA5-associated dermatomyositis with acute respiratory distress syndrome (ARDS) requiring lung transplantation, a case report. BMC Rheumatol 2022; 6:42. [PMID: 35821079 PMCID: PMC9277832 DOI: 10.1186/s41927-022-00271-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Autoimmune disease following COVID-19 has been studied intensely since the beginning of the pandemic. Growing evidence indicates that SARS-CoV-2 infection, by virtue of molecular mimicry can lead to an antigen-mediated cross-reaction promoting the development of a plethora of autoimmune spectrum diseases involving lungs and extrapulmonary tissues alike. In both COVID-19 and autoimmune disease, the immune self-tolerance breaks, leading to an overreaction of the immune system with production of a variety of autoantibodies, sharing similarities in clinical manifestation, laboratory, imaging, and pathology findings. Anti-Melanoma Differentiation-Associated gene 5 dermatomyositis (anti-MDA5 DM) comprises a rare subtype of systemic inflammatory myopathies associated with characteristic cutaneous features and life-threatening rapidly progressive interstitial lung disease (RP-ILD). The production of anti-MDA5 autoantibodies was proposed to be triggered by viral infections. Case presentation A 20-year-old male patient with polyarthritis, fatigue and exertional dyspnea was referred to our department. An elevated anti-MDA5 autoantibody titer, myositis on MRI, ground glass opacifications on lung CT and histological features of Wong-type dermatomyositis were confirmed, suggesting the diagnosis of an anti-MDA5 DM. Amid further diagnostic procedures, a serologic proof of a recent SARS-CoV-2 infection emerged. Subsequently, the patient deteriorated into a fulminant respiratory failure and an urgent lung transplantation was performed, leading to remission ever since (i.e. 12 months as of now). Conclusions We report a unique case of a patient with a new-onset anti-MDA5 DM with fulminant ARDS emerging in a post-infectious stage of COVID-19, who underwent a successful lung transplantation and achieved remission. Given the high mortality of anti-MDA5 DM associated RP-ILD, we would like to highlight that the timely recognition of this condition and urgent therapy initiation are of utmost importance. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00271-1.
Collapse
Affiliation(s)
- Karolina Anderle
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.,Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Klaus Machold
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Hans P Kiener
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniel Bormann
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.,Department of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Silvana Geleff
- Clinical Institute of Pathology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 109, Vienna, Austria
| | - Franco Laccone
- Institute of Medical Genetics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Peter M Heil
- Department of Dermatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Peter Petzelbauer
- Department of Dermatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stephan Blüml
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Kastriot Kastrati
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| |
Collapse
|
3
|
Kuwana M, Wakasugi N, Furuya T, Uno S, Suda T. Tacrolimus in Patients With Interstitial Pneumonia Associated With Polymyositis or Dermatomyositis: Interim Report of Postmarketing Surveillance in Japan. J Rheumatol 2022; 49:707-718. [PMID: 35428708 DOI: 10.3899/jrheum.210322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The calcineurin inhibitor tacrolimus has been approved in Japan for the treatment of interstitial pneumonia (IP) in patients with polymyositis (PM) and dermatomyositis (DM). Postmarketing surveillance was initiated to examine long-term outcomes of immunosuppressive regimens containing tacrolimus in real-world settings. METHODS Observational, prospective, postmarketing surveillance is ongoing in 179 patients with PM/DM-associated IP initiating treatment with tacrolimus. We report interim findings after 2 years of follow-up. Cumulative overall survival was assessed using Kaplan-Meier analysis. Potential prognostic factors for mortality were assessed by univariate Cox proportional hazards analysis. RESULTS A total of 170 patients were included in this analysis. At the time of starting treatment with tacrolimus, almost all patients were receiving corticosteroids (98.8%), and cyclophosphamide was additionally used in 42 patients (24.7%). Forty-nine patients (28.8%) discontinued tacrolimus during follow-up, mainly due to loss to follow-up, patient death, and adverse events. Mean (SD) oral corticosteroid dose decreased from 32.4 (21.6) mg/day at baseline to 7.6 (4.2) mg/day at 2 years. Overall survival at 2 years was 90.3%; corresponding progression-free survival was 62.5%. Factors found to be associated with all-cause mortality included diagnosis of clinically amyopathic DM (hazard ratio [HR] 9.04, 95% CI 1.18-69.51 vs PM), ferritin level 500 to < 1500 ng/mL (HR 8.61, 95% CI 2.51-29.45 vs < 500 ng/mL), and presence of antimelanoma differentiation-associated gene 5 antibodies (HR 8.16, 95% CI 1.03-64.47 vs absence). CONCLUSION Immunosuppressive regimens containing tacrolimus appear useful for the management of IP in patients with PM/DM. [ClinicalTrials.gov: NCT02159651].
Collapse
Affiliation(s)
- Masataka Kuwana
- M. Kuwana, MD, PhD, Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo;
| | - Naoko Wakasugi
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Toshinori Furuya
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Satoshi Uno
- N. Wakasugi, MSc, T. Furuya, MSc, S. Uno, MSc, Astellas Pharma Inc., Tokyo
| | - Takafumi Suda
- T. Suda, MD, Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
4
|
Ando H, Suzuki K, Yanagihara T. Insights into Potential Pathogenesis and Treatment Options for Immune-Checkpoint Inhibitor-Related Pneumonitis. Biomedicines 2021; 9:1484. [PMID: 34680601 PMCID: PMC8533467 DOI: 10.3390/biomedicines9101484] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/14/2022] Open
Abstract
Immune-checkpoint inhibitors (ICIs) targeting cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death-1 (PD-1), and programmed cell death-1-ligand 1 (PD-L1) have become new treatment options for various malignancies. ICIs bind to immune-checkpoint inhibitory receptors or to the foregoing ligands and block inhibitory signals to release the brakes on the immune system, thereby enhancing immune anti-tumor responses. On the other hand, unlike conventional chemotherapies, ICIs can cause specific side effects, called immune-related adverse events (irAEs). These toxicities may affect various organs, including the lungs. ICI-related pneumonitis (ICI-pneumonitis) is not the most frequent adverse event, but it is serious and can be fatal. In this review, we summarize recent findings regarding ICI-pneumonitis, with a focus on potential pathogenesis and treatment.
Collapse
Affiliation(s)
- Hiroyuki Ando
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; (H.A.); (K.S.)
| | - Kunihiro Suzuki
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; (H.A.); (K.S.)
| | - Toyoshi Yanagihara
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; (H.A.); (K.S.)
- A Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka 810-8539, Japan
| |
Collapse
|
5
|
Lee S, Lee JH. Current advances in the treatment of autoimmune-associated interstitial lung diseases. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.4.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Autoimmune-associated interstitial lung disease (ILD) is a widespread and clinically significant form of autoimmune diseases. ILD can be present in most type of autoimmune diseases. Scleroderma, Sjogren syndrome, rheumatoid arthritis, inflammatory myositis, systemic lupus erythematosus, and mixed connective tissue disease are all examples of autoimmune disorders that can cause ILD. Treatment and prognosis vary from that of other forms of ILD depending on the etiology and pathogenesis of the autoimmune disease. As a result, glucocorticoids and immunosuppressive agents are the mainstays of treatment for autoimmune-associated ILD, despite the fact that there is little high-level evidence to guide the treatment owing to limited data from randomized controlled trials. Immunosuppressive agents including cyclophosphamide, tacrolimus, azathioprine, and mycophenolate mofetil can be used to reduce the dose of glucocorticoids and the inflammatory cascade and inhibit various pro-inflammatory cytokines. Studies have also started alternative therapeutic approaches, such as biological and antifibrotic agents, and traditional immunosuppressive agents. In this review, we summarize available treatment options and recent advances in therapeutic strategies for patients with autoimmune-associated ILD.
Collapse
|
6
|
Santhanam S, Mohanasundaram K, Krishnan S. Interstitial pneumonia with autoimmune features. J R Coll Physicians Edinb 2020; 50:247-255. [PMID: 32936097 DOI: 10.4997/jrcpe.2020.307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Interstitial lung disease (ILD) is an umbrella term for lung disease characterised by inflammation and fibrosis of the interstitium. ILD can be idiopathic or secondary to connective tissue disorders, drugs or environmental exposures. Before labelling it as idiopathic we have to rule out secondary causes. ILD is one of the most common extra-articular manifestations of connective tissue diseases (CTDs), causing significant morbidity and mortality. Patients with pre-existing CTD can develop ILD; some patients develop ILD against the background of either one or two clinical features of a CTD or isolated auto-antibody positivity. The current terminology for such an entity is interstitial pneumonia with autoimmune features (IPAF). The current criterion is based on three domains: clinical, serologic and morphologic. To satisfy the IPAF classification criteria, one needs to satisfy the mandatory criterion with one feature from two of the three domains. Classifying patients with this criterion helps in early initiation of immunosuppression and in monitoring them closely for development of features of a well defined CTD. There are a few limitations like the clinical domain being more skewed towards systemic sclerosis and in˜flammatory myositis, exclusion of antineutrophilic cytoplasmic antibody (ANCA) and cytoplasmic pattern in antinuclear antibody (ANA). There are no clear protocols for treatment of IPAF and most of the data has been extrapolated from the management of systemic sclerosis (SSc) ILD and idiopathic non-specific c interstitial pneumonia (NSIP). Progressive disease in spite of treatment demands stronger immunosuppressive agents. Studies on the role of antifibrotics in IPAF are underway, with few small studies showing positive outcomes. There are con˜flicting reports on the survival and outcome of the IPAF cohort. Certain studies suggest that they have better survival compared with idiopathic pulmonary fibrosis (IPF) though other studies contradict this statement.
Collapse
Affiliation(s)
- Sham Santhanam
- Gleneagles Global Health City, Chennai,Tamil Nadu, India,
| | | | | |
Collapse
|
7
|
Stager K, Wise L. MDA-5 dermatomyositis complicated by interstitial lung disease and cutaneous ulcers: successful treatment with corticosteroids, mycophenolate mofetil and intravenous immunoglobulin. BMJ Case Rep 2020; 13:13/9/e236431. [DOI: 10.1136/bcr-2020-236431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antimelanoma differentiation-associated gene 5 (MDA-5) dermatomyositis is a subtype of dermatomyositis that is associated with rapidly progressive interstitial lung disease (RP-ILD), as well as with a variety of cutaneous manifestations. Patients with MDA-5 dermatomyositis tend to have a poor prognosis that is often attributed to the high rates of concurrent RP-ILD. Given the severity of disease, early diagnosis and aggressive management is pivotal. We present a case of a 40-year-old woman diagnosed with MDA-5 dermatomyositis who presented with weakness, painful cutaneous ulcerations and interstitial lung disease. She was treated with monthly intravenous Ig (IVIg), weight-based prednisone and mycophenolate mofetil (MMF). After approximately 2 years of treatment, her interstitial lung disease remains stable and she has had significant improvement in weakness and cutaneous ulcerations. Our case provides evidence for early and aggressive treatment of MDA-5 dermatomyositis with a combination of weight-based prednisone, MMF and IVIg.
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW Lung involvement is a distinctive feature of antisynthetase syndrome (ASS) and it is considered a basic disease-classifying criterion. In this review, we go over clinical features, radiological patterns, prognostic factors, pathogenesis and treatment of lung involvement in ASS patients, focusing on the clinical differences linked to the different antibody specificities known so far. RECENT FINDINGS The lung is the most common extramuscular organ involved in ASS and has the greatest impact on patient prognosis. The pulmonary disease-defining manifestation in ASS is interstitial lung disease (ILD), yet a proportion of patients also develop pulmonary arterial hypertension and, less frequently, obstructive bronchiolitis or acute respiratory failure according to drivers not yet fully understood but likely associated with the underlying autoantibody pattern. Clinical presentation of pulmonary involvement can range from milder forms to a rapidly progressive disease which may lead to chronic lung damage if misdiagnosed and not properly treated. SUMMARY The knowledge of risk factors associated with progressive or refractory lung damage is important to identify and properly treat patients with the poorest prognosis. For those with a disease not responsive to conventional therapy the efficacy of other therapeutic option is under evaluation.
Collapse
|
9
|
Successful treatment of steroid-refractory immune checkpoint inhibitor-related pneumonitis with triple combination therapy: a case report. Cancer Immunol Immunother 2020; 69:2033-2039. [PMID: 32415507 DOI: 10.1007/s00262-020-02600-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/29/2020] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibitor (ICI)-related pneumonitis is a relatively rare but clinically serious and potentially life-threatening adverse event. The majority of cases can be managed by drug discontinuation, with the administration of corticosteroids added in severe cases. However, worsening of pneumonitis can develop in a subset of patients despite treatment with high doses of corticosteroids. We herein report a case of steroid-refractory ICI-related pneumonitis in a recurrent non-small cell lung cancer (NSCLC) patient treated with pembrolizumab that was successfully improved by triple combination therapy (high-dose corticosteroids, tacrolimus, and cyclophosphamide). After 3 weeks of initial pembrolizumab administration, the patient was diagnosed with ICI-related pneumonitis. Chest computed tomography (CT) showed patchy distributed bilateral consolidation and ground-glass opacities (GGOs) with traction bronchiectasis and bronchiolectasis resembling the diffuse alveolar damage (DAD) radiographic pattern. Although methylprednisolone pulse therapy was initiated, worsening of respiratory failure resulted in the patient being transferred to the intensive care unit. Because of an insufficient therapeutic response to high-dose corticosteroids, tacrolimus and cyclophosphamide pulse therapy were additively performed as triple combination therapy according to the treatment strategy for pulmonary complications of clinically amyopathic dermatomyositis (CADM). In response to this triple combination therapy, the patient's respiratory condition gradually improved, and chest CT showed the marked amelioration of pulmonary opacities. This is the first report suggesting the efficacy of triple combination therapy (high-dose corticosteroids, tacrolimus, and cyclophosphamide) for steroid-refractory ICI-related pneumonitis complicated with respiratory failure.
Collapse
|
10
|
Current and Emerging Drug Therapies for Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD). Drugs 2020; 79:1511-1528. [PMID: 31399860 DOI: 10.1007/s40265-019-01178-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Interstitial lung disease (ILD) can be associated with all connective tissue diseases and is an important cause of morbidity and mortality. The management of connective tissue disease-interstitial lung disease (CTD-ILD) is challenging due substantial heterogeneity in disease behaviour and paucity of controlled clinical trials to guide treating clinicians. Not all patients require treatment, and the decision to treat needs to be individualised based on a patient's observed disease behaviour, baseline and longitudinal lung function measurements, extent of lung involvement on radiology and patient factors including age, co-morbidities and personal preference. If indicated, treatment of the CTD-ILD is largely with immunomodulation, with the aim to prevent progression of the ILD before further irreversible lung injury and disability occurs. Corticosteroids, cyclophosphamide, mycophenolate mofetil and azathioprine are the most common immunosuppressive agents currently used to treat CTD-ILD, demonstrating stability of lung function in case series and a small number of randomised controlled trials in ILD associated with systemic sclerosis. Biological and non-biological disease-modifying anti-rheumatic drugs, and the anti-fibrotics nintedanib and pirfenidone, have revolutionised the treatment of connective tissue diseases and idiopathic ILD, respectively. Furthermore, anti-fibrotics have recently demonstrated safety and efficacy in ILD associated with systemic sclerosis. There remains a critical unmet need to clarify when and in whom to initiate treatment, and which agent(s) to utilise to achieve optimal outcomes for CTD-ILD patients whilst minimising harms through prospective multicentre trials. This review highlights the challenges faced when treating patients with CTD-ILD and summarises available evidence for current, emerging and novel therapies.
Collapse
|
11
|
Vacchi C, Sebastiani M, Cassone G, Cerri S, Della Casa G, Salvarani C, Manfredi A. Therapeutic Options for the Treatment of Interstitial Lung Disease Related to Connective Tissue Diseases. A Narrative Review. J Clin Med 2020; 9:jcm9020407. [PMID: 32028635 PMCID: PMC7073957 DOI: 10.3390/jcm9020407] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022] Open
Abstract
Interstitial lung disease (ILD) is one of the most serious pulmonary complications of connective tissue diseases (CTDs) and it is characterized by a deep impact on morbidity and mortality. Due to the poor knowledge of CTD-ILD’s natural history and due to the difficulties related to design of randomized control trials, there is a lack of prospective data about the prevalence, follow-up, and therapeutic efficacy. For these reasons, the choice of therapy for CTD-ILD is currently very challenging and still largely based on experts’ opinion. Treatment is often based on steroids and conventional immunosuppressive drugs, but the recent publication of the encouraging results of the INBUILD trial has highlighted a possible effective and safe use of antifibrotic drugs as a new therapeutic option for these subjects. Aim of this review is to summarize the available data and recent advances about therapeutic strategies for ILD in the context of various CTD, such as systemic sclerosis, idiopathic inflammatory myopathy and Sjogren syndrome, systemic lupus erythematosus, mixed connective tissue disease and undifferentiated connective tissue disease, and interstitial pneumonia with autoimmune features, focusing also on ongoing clinical trials.
Collapse
Affiliation(s)
- Caterina Vacchi
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Giulia Cassone
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Stefania Cerri
- Respiratory Disease Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Giovanni Della Casa
- Radiology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Carlo Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Andreina Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
- Correspondence:
| |
Collapse
|
12
|
Koo SM, Kim SY, Choi SM, Lee HK. Korean Guidelines for Diagnosis and Management of Interstitial Lung Diseases: Part 5. Connective Tissue Disease Associated Interstitial Lung Disease. Tuberc Respir Dis (Seoul) 2019; 82:285-297. [PMID: 31172701 PMCID: PMC6778739 DOI: 10.4046/trd.2019.0009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
Connective tissue disease (CTD) is a collection of disorders characterized by various signs and symptoms such as circulation of autoantibodies in the entire system causing damage to internal organs. Interstitial lung disease (ILD) which is associated with CTD is referred to as CTD-ILD. Patients diagnosed with ILD should be thoroughly examined for the co-occurrence of CTD, since the treatment procedures and prognosis of CTD-ILD are vary from those of idiopathic interstitial pneumonia. The representative types of CTD which may accompany ILD include rheumatoid arthritis, systemic sclerosis (SSc), Sjögren's syndrome, mixed CTD, idiopathic inflammatory myopathies, and systemic lupus erythematous. Of these, ILD most frequently co-exists with SSc. If an ILD is observed in the chest, high resolution computed tomography and specific diagnostic criteria for any type of CTD are met, then a diagnosis of CTD-ILD is made. It is challenging to conduct a properly designed randomized study on CTD-ILD, due to low incidence. Therefore, CTD-ILD treatment approach is yet to been established in absence of randomized controlled clinical trials, with the exception of SSc-ILD. When a patient is presented with acute CTD-ILD or if symptoms occur due to progression of the disease, steroid and immunosuppressive therapy are generally considered.
Collapse
Affiliation(s)
- So My Koo
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Meidicine, Seoul National University Hospital, Seoul, Korea.
| | - Hyun Kyung Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | | |
Collapse
|
13
|
Schulze AB, Evers G, Kümmel A, Rosenow F, Sackarnd J, Hering JP, Schülke C, Engelbertz JA, Görlich D, Barth PJ, Lenz G, Becker H, Mohr M, Schmidt LH. Cyclophosphamide pulse therapy as treatment for severe interstitial lung diseases. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2019; 36:157-166. [PMID: 32476949 DOI: 10.36141/svdld.v36i2.7636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/24/2019] [Indexed: 11/02/2022]
Abstract
Introduction Besides invasive or non-invasive ventilation, treatment of severe forms of interstitial lung diseases (ILD) includes immunosuppressive medication. In case of refractory organ- or life-threatening courses of disease, cyclophosphamide pulse therapy can serve as a rescue treatment option. Objectives To investigate therapeutic and prognostic effects of cyclophosphamide for the treatment of severe forms of ILD on intensive care unit (ICU) we performed this analysis. Methods Between 2009 and 2017 we identified 14 patients, who were treated on intensive care unit (ICU) with severe forms of ILD. Retrospectively, clinical, radiologic and prognostic data were collected and evaluated. Results Our analysis demonstrated a prognostic impact of cyclophosphamide on the ILD in general. Whereas pulmonary manifestations of both systemic sclerosis (SSc) and ANCA-associated vasculitis had an improved outcome, a reduced overall survival was found for Goodpasture syndrome (GPS), dermatomyositis (DM), cryptogenic organizing pneumonia (COP) and drug reaction with eosinophilia and systemic symptoms (DRESS; p=0.040, logrank test). Besides, additional plasmapheresis and initiation of cyclophosphamide within ten days following initial diagnosis of ILD were associated with improved prognosis. Conclusion Positive prognostic effects of cyclophosphamide pulse therapy in ICU treated patients suffering from severe respiratory failure due to pulmonary manifestations of both SSc and ANCA-associated-vasculitis were observed. Further prognostic and therapeutic data are needed for cyclophosphamide for this indication in order to prevent patients from its toxic side-effects, who most likely will not benefit from its application.
Collapse
Affiliation(s)
- Arik Bernard Schulze
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany.,these authors are contributed equally to this work as first authors
| | - Georg Evers
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany.,these authors are contributed equally to this work as first authors
| | - Andreas Kümmel
- Department of Hematology, Medical Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Felix Rosenow
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Muenster, Muenster, Germany
| | - Jan Sackarnd
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Muenster, Muenster, Germany
| | - Jan Philipp Hering
- Department of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Christoph Schülke
- Department of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Jonas Andreas Engelbertz
- Unit of Cytostatic Reconstitution, Hospital pharmacy, University Hospital Muenster, Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, Westfaelische Wilhelms-Universitaet Muenster, Muenster, Germany
| | - Peter J Barth
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | - Georg Lenz
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany.,Cluster of Excellence EXC 1003, Cells in Motion, Muenster, Germany
| | - Heidemarie Becker
- Department of Medicine D, Nephrology, Rheumatology and Hypertensiology, University Hospital Muenster, Muenster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany.,these authors are contributed equally to this work as senior authors
| | - Lars Henning Schmidt
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Muenster, Muenster, Germany.,these authors are contributed equally to this work as senior authors
| |
Collapse
|
14
|
Takei R, Arita M, Tokioka F, Tachibana H, Tokumasu H, Ishida T. Cyclosporin A in idiopathic chronic fibrosing interstitial pneumonia without idiopathic pulmonary fibrosis. J Thorac Dis 2019; 10:6695-6701. [PMID: 30746214 DOI: 10.21037/jtd.2018.11.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We have sometimes observed interstitial pneumonia which had chronic course and unknown causes but not diagnosed as idiopathic pulmonary fibrosis (IPF). However, the treatment strategy was not established definitely. To clarify the usefulness of cyclosporin A (CsA) in idiopathic chronic fibrosing interstitial pneumonia (iCFIP) without IPF, we examined longitudinal changes in pulmonary physiology. Methods Japanese patients with iCFIP without IPF treated with CsA were identified retrospectively. Linear mixed-effects models were used to evaluate changes in pulmonary physiology after adjusting for age, sex, and smoking history. Primary outcomes were longitudinal trajectories of the percent predicted forced vital capacity (%FVC), percent predicted diffusing capacity for carbon monoxide (%DLco), and composite physiologic index (CPI) before and after CsA. Results Thirty-three patients were included. Before CsA initiation, %FVC, %DLco, and CPI declined at rates of 9.1%, 8.6% and -7.1 per 1 year, respectively. After CsA initiation, the gradient of %FVC showed significant improvements in 0-1 years (6.2%±3.0%; P<0.01) and in 1-2 years (10.0%±3.6%; P<0.01); %DLco improved in 0-1 year (4.0%±4.6%; P=0.09) and in 1-2 years (7.0%±5.6%; P=0.02); and CPI improved in 0-1 year (3.2%±3.3%; P=0.06) and in 1-2 years (4.6%±4.1%; P=0.03). Conclusions CsA for iCFIP without IPF may be associated with improvements in pulmonary physiology in 2 years. Further studies are needed to determine the role of CsA in iCFIP without IPF.
Collapse
Affiliation(s)
- Reoto Takei
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Machiko Arita
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Fumiaki Tokioka
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiromasa Tachibana
- Department of Respiratory Medicine, National Hospital Organization Minami Kyoto Hospital, Joyo, Japan
| | - Hironobu Tokumasu
- Department of Management, Clinical Research Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| |
Collapse
|
15
|
Yashiro M, Asano T, Sato S, Kobayashi H, Watanabe H, Miyata M, Migita K. Anti-MDA5 antibody-positive hypomyopathic dermatomyositis complicated with pneumomediastinum. Fukushima J Med Sci 2018; 64:89-94. [PMID: 30158335 DOI: 10.5387/fms.2018-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive clinically amyopathic dermatomyositis (CADM) is frequently associated with rapidly progressive interstitial lung disease (RP-ILD) resulting in high mortality. Here we report a 51-year-old Japanese woman with anti-MDA5 antibody-positive hypomyopathic dermatomyositis (DM) who developed RP-ILD. She developed respiratory failure and pneumomediastinum, however her RP-ILD responded favorably to the combined immunosuppressive treatments consisting of steroids, intravenous cyclophosphamide and tacrolimus. She was complicated with severe infections, which were successfully managed by combined modality therapy including artificial ventilation and antibiotics in addition to immunosuppressive treatments in parallel to the decline of anti-MDA5 antibody titer (>150 Index to 75 Index). She was discharged after 6 months of treatment without any respiratory sequelae. Hypomyopathic DM patients with high titers of anti-MDA5 antibody should be treated with aggressive immunosuppressive therapies and closely monitored to prevent various infections.
Collapse
Affiliation(s)
- Makiko Yashiro
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Masayuki Miyata
- Department of Internal Medicine and Gastroenterology, Japanese Red Cross Fukushima Hospital
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| |
Collapse
|
16
|
Treatment of Interstitial Lung Disease Associated With Myositis and the Anti-Synthetase Syndrome. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0111-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Long-term pulmonary outcomes and mortality in idiopathic inflammatory myopathies associated with interstitial lung disease. Clin Rheumatol 2018; 38:803-815. [DOI: 10.1007/s10067-018-4353-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/30/2018] [Accepted: 10/26/2018] [Indexed: 01/04/2023]
|
18
|
Ishikawa Y, Iwata S, Hanami K, Nawata A, Zhang M, Yamagata K, Hirata S, Sakata K, Todoroki Y, Nakano K, Nakayamada S, Satoh M, Tanaka Y. Relevance of interferon-gamma in pathogenesis of life-threatening rapidly progressive interstitial lung disease in patients with dermatomyositis. Arthritis Res Ther 2018; 20:240. [PMID: 30367666 PMCID: PMC6235206 DOI: 10.1186/s13075-018-1737-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dermatomyositis (DM) with rapidly progressive interstitial lung disease (DM RP-ILD) is a life-threatening condition. Serum cytokine levels are potentially suitable biomarkers for DM RP-ILD. However, the relationships among cytokine levels, lung imaging findings, and lung pathology have not been investigated. The aim of the present retrospective study was to determine the association between hypercytokinemia and lung inflammation in patients with DM RP-ILD. METHODS The study subjects were nine patients with life-threatening DM RP-ILD and severe hypoxemia (partial arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio ≤ 200) before receiving intensive care management, who were admitted to our hospital between 2006 and 2015. The controls included 10 patients with DM without RP-ILD and 19 healthy subjects. We assessed the association between serum cytokine levels and computed tomography (CT) scores of the lung (ground glass opacity-score, G-score; fibrosis-score, F-score). Lung, hilar lymph nodes, and spleen from two autopsies were examined by hematoxylin-eosin (H&E) staining and immunostaining. RESULTS Serum interferon (IFN)-γ, interleukin (IL)-1β and IL-12 levels were significantly higher in patients with DM RP-ILD than in the other two groups, whereas serum IL-6 levels were elevated in the two patient groups but not in the healthy subjects. Serum levels of IL-2, IL-4, IL-8, IL-10, IFN-α, and TNF (tumor necrosis factor)-α were not characteristically elevated in the DM RP-ILD group. Serum IFN-γ levels correlated with G-scores in patients with DM RP-ILD, while IL-1β was negatively correlation with F-scores. Immunohistochemical staining showed infiltration of numerous IFN-γ-positive histiocytes in the lung and hilar lymph nodes; but not in the spleen. Serum IL-6 levels did not correlate with the CT scores. Numerous IL-6-positive plasma cells were found in hilar lymph nodes, but not in the lungs or spleen. CONCLUSIONS Our results suggest strong IFN-γ-related immune reaction in the lungs and hilar lymph nodes of patients with life-threatening DM RP-ILD, and potential IFN-γ involvement in the pathogenesis of DM, specifically in the pulmonary lesions of RP-ILD.
Collapse
Affiliation(s)
- Yuichi Ishikawa
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Shigeru Iwata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Kentaro Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Aya Nawata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan.,Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu City, Japan
| | - Mingzeng Zhang
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Kaoru Yamagata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Shintaro Hirata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan.,Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kei Sakata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan.,Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Yasuyuki Todoroki
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan
| | - Minoru Satoh
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu City, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu City, 807-8555, Japan.
| |
Collapse
|
19
|
Ward IM, Knott A. Practical Pearls About Current Rheumatic Medications. Prim Care 2018; 45:193-212. [PMID: 29759120 DOI: 10.1016/j.pop.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
New and existing rheumatic disease is frequently encountered in the primary care setting. The number of medications used to treat various rheumatic conditions continues to increase. Some medications have very specific indications, whereas others have increasing off-label uses. Regardless of the indication, the medications used in rheumatology have variable dosing recommendations, significant side effects, recommended monitoring parameters, and potential medication interactions. Clinicians need to be aware of the potential uses as well as possible pitfalls associated with medications used in rheumatology.
Collapse
Affiliation(s)
- Ian M Ward
- Rheumatology Service, Department of Medicine, Landstuhl Regional Medical Center, Landstuhl, Germany.
| | - Amanda Knott
- Department of Pharmacy, Landstuhl Regional Medical Center, Landstuhl, Germany
| |
Collapse
|
20
|
Abstract
Idiopathic inflammatory myopathies (IIMs) are heterogeneous disorders that affect the skeletal muscles. Polymyositis, dermatomyositis, and inclusion body myositis are major IIM subsets. Immune-mediated necrotizing myopathy became recognized as a potentially new IIM subset. Since the new classification criteria published by the International Myositis Classification Criteria Project have higher sensitivity and specificity for IIM classification and subclassification than the previous criteria, they should help precise diagnosis. It should be noted that several tests available in current clinical practice, such as electromyography, magnetic resonance imaging, and other myositis-specific autoantibodies than anti-Jo-1 antibodies, were not included in the new criteria. As for treatment, glucocorticoids are used empirically as the first-line treatment despite their various adverse effects. Concomitant treatment with steroid-sparing immunosuppressive agents, including methotrexate, azathioprine, calcineurin inhibitors, mycophenolate mofetil, and cyclophosphamide, reduces successfully initial glucocorticoid doses for the remission induction, the relapse risk during glucocorticoid tapering, and adverse effects of glucocorticoids. Treatment with biologics, including rituximab and abatacept, seems promising in some IIM patients. Multi-target treatment with glucocorticoids and several steroid-sparing immunosuppressive agents is effective in refractory IIM patients. Considering proven steroid-sparing efficacy and tolerability of multi-target treatment in patients with other autoimmune diseases, it should be a good therapeutic option for IIMs.
Collapse
Affiliation(s)
- Hirokazu Sasaki
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
| | - Hitoshi Kohsaka
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
| |
Collapse
|
21
|
Abstract
The treatment of rheumatoid arthritis (RA) has undergone considerable changes over the last 15–20 years. With an expansion in the armamentarium of therapies available for RA comes a wider choice in selecting the best treatment in terms of comparative safety in the presence of comorbidities. Clinicians frequently encounter patients with RA-associated interstitial lung disease with uncontrolled joint disease and have to make decisions about the safest treatments in this context with the eventual goal of joint remission. In this chapter, available evidence is reviewed on the comparative pulmonary safety of non-biologic disease-modifying antirheumatic drugs (nbDMARDs), biologic DMARDs, biosimilars and targeted synthetic DMARDs in RA-ILD. In addition, the potential role for additional immunosuppression in RA-ILD is reviewed as well as overarching recommendations proposed for patient assessment to guide treatment decisions and management.
Collapse
|
22
|
Effective Administration of Rituximab in Anti-MDA5 Antibody-Positive Dermatomyositis with Rapidly Progressive Interstitial Lung Disease and Refractory Cutaneous Involvement: A Case Report and Literature Review. Case Rep Rheumatol 2017; 2017:5386797. [PMID: 29225988 PMCID: PMC5684540 DOI: 10.1155/2017/5386797] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/24/2017] [Indexed: 12/27/2022] Open
Abstract
We describe the case of a 48-year-old man with dermatomyositis (DM) who demonstrated rapidly progressive interstitial lung disease (RP-ILD) and refractory cutaneous involvement together with high levels of anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5-Ab). Even after combination immunosuppressive therapy including a corticosteroid, cyclosporine A, and intravenous cyclophosphamide, his respiratory insufficiency and cutaneous involvement progressively worsened. However, the administration of rituximab (RTX) resulted in clinical remission as well as a visible reduction in anti-MDA5-Ab levels, suggesting that RTX could be a useful remedy in cases refractory to conventional immunosuppressive agents, especially those of RP-ILD related to anti-MDA5-Ab–positive DM.
Collapse
|
23
|
Koo SM, Uh ST. Treatment of connective tissue disease-associated interstitial lung disease: the pulmonologist's point of view. Korean J Intern Med 2017; 32:600-610. [PMID: 28704913 PMCID: PMC5511941 DOI: 10.3904/kjim.2016.212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 06/16/2017] [Indexed: 01/21/2023] Open
Abstract
Interstitial lung disease (ILD) occurs in 15% of patients with collagen vascular disease (CVD), referred to as connective tissue disease (CTD). Despite advances in management strategies, ILD continues to be a significant cause of mortality in patients with CVD-associated ILD (CTD-ILD). There is a lack of randomized, clinical trials assessing pharmacological agents for CTD-ILD, except in cases of ILD-associated systemic sclerosis (SSc). This may be due to the lack of CTD cases available, the difficulty of histological confirmation of ILD, and the various types of CTD and ILD. As a result, evidence-based pharmacological treatment of CTD-ILD is not yet well established. CTD-ILD presents with varying degrees of histology, from inflammation to fibrosis, and a wide spectrum of clinical manifestations, from minimal symptoms to respiratory failure. This renders it difficult for clinicians to make decisions regarding treatment options, observational strategies, optimal timing for interventions, and the appropriateness of pharmacological agents for treatment. There is no specific treatment for reversing fibrosis-like idiopathic pulmonary fibrosis in a clinical setting. This review describes pharmacological interventions for SSc-ILD described in randomized control trials, and presents an overview of recent advances of CTD-ILD-dependent treatments based on the types of CTD.
Collapse
Affiliation(s)
| | - Soo-Taek Uh
- Correspondence to Soo-Taek Uh, M.D. Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soon Chun Hyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel: +82-2-709-9482 Fax: +82-2-793-9965 E-mail:
| |
Collapse
|
24
|
Suzuki A, Kondoh Y, Fischer A. Recent advances in connective tissue disease related interstitial lung disease. Expert Rev Respir Med 2017; 11:591-603. [PMID: 28544856 DOI: 10.1080/17476348.2017.1335600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Interstitial lung disease (ILD) is a common manifestation of connective tissue disease (CTD). Although the majority of patients with CTD-ILD are stable or slowly progressive, a significant group exhibits a more severe and progressive decline. Interstitial pneumonia with autoimmune features (IPAF) describes the subset of patients with interstitial pneumonia who have features suggesting underlying autoimmunity, but whose features fall short of a clear diagnosis of CTD. Areas covered: In this focused review, we discuss recent advances in early detection, prognostic evaluation, and management of autoimmune forms of ILD. Expert commentary: Early detection of ILD and a better understanding of factors that impact prognostication may be helpful when making decisions regarding therapeutic interventions. The treatment of CTD-ILD should be comprehensive, is often fraught with challenges and can be complicated by comorbid conditions and extra-thoracic disease activities. Several large randomized studies have examined the impact of immunosuppressive therapy for CTD-ILD, however, additional studies are needed to determine the optimal treatment strategies. Future studies may provide additional information about the best treatments in patients with IPAF.
Collapse
Affiliation(s)
- Atsushi Suzuki
- a Department of Respiratory Medicine and Allergy , Tosei General Hospital , Seto , Japan
| | - Yasuhiro Kondoh
- a Department of Respiratory Medicine and Allergy , Tosei General Hospital , Seto , Japan
| | - Aryeh Fischer
- b Department of Medicine, Divisions of Rheumatology, Pulmonary Sciences and Critical Care Medicine , University of Colorado , Aurora , CO , USA
| |
Collapse
|
25
|
Management of connective tissue diseases associated interstitial lung disease: a review of the published literature. Curr Opin Rheumatol 2016; 28:236-45. [PMID: 27027811 DOI: 10.1097/bor.0000000000000270] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Interstitial lung disease (ILD), though a common and often a severe manifestation of many connective tissue diseases (CTD), is challenging to manage because of its variable presentation and the relative lack of guidelines to assist the clinician. In this review, we discuss the approach to diagnosis, treatment, and monitoring patients with CTD-associated ILD, with a focus on systemic sclerosis (SSc), rheumatoid arthritis (RA), and idiopathic inflammatory myopathy (IIM). RECENT FINDINGS High-resolution computed tomography scan and pulmonary function testing can be reliably used to diagnose ILD and monitor progression, and often to determine its likely histologic subtype and severity. In SSc-ILD, randomized controlled trials show ILD stabilization with cyclophosphamide treatment; preliminary data from another randomized controlled trial demonstrates similar findings with mycophenolate. There are no robust clinical trials supporting specific treatments for RA-ILD or IIM-ILD, but rituximab in RA-ILD, and cyclophosphamide, mycophenolate and calcineurin inhibitors in IIM-ILD show promise. SUMMARY Though ILD contributes substantially to morbidity and mortality in patients with CTD, there are minimal data to guide its management except in SSc-ILD.
Collapse
|
26
|
Management of Myositis-Related Interstitial Lung Disease. Chest 2016; 150:1118-1128. [DOI: 10.1016/j.chest.2016.04.007] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 12/15/2022] Open
|
27
|
|
28
|
Ikeda S, Sekine A, Baba T, Okudela K, Iwasawa T, Sakai F, Notohara K, Ohashi K, Takemura T, Ogura T. Abundant immunoglobulin (Ig)G4-positive plasma cells in interstitial pneumonia without extrathoracic lesions of IgG4-related disease: is this finding specific to IgG4-related lung disease? Histopathology 2016; 70:242-252. [DOI: 10.1111/his.13053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/30/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Satoshi Ikeda
- Department of Respiratory Medicine; Kanagawa Cardiovascular and Respiratory Center; Yokohama Japan
- Department of Pathology; Yokohama-city Graduate University School of Medicine; Yokohama Japan
| | - Akimasa Sekine
- Department of Respiratory Medicine; Kanagawa Cardiovascular and Respiratory Center; Yokohama Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine; Kanagawa Cardiovascular and Respiratory Center; Yokohama Japan
| | - Koji Okudela
- Department of Pathology; Yokohama-city Graduate University School of Medicine; Yokohama Japan
| | - Tae Iwasawa
- Department of Radiology; Kanagawa Cardiovascular and Respiratory Center; Yokohama Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology; Saitama International Medical Center; Saitama Medical University; Saitama Japan
| | - Kenji Notohara
- Department of Anatomic Pathology; Kurashiki Central Hospital; Kurashiki Japan
| | - Kenichi Ohashi
- Department of Pathology; Yokohama-city Graduate University School of Medicine; Yokohama Japan
| | - Tamiko Takemura
- Department of Pathology; Japanese Red Cross Medical Center; Shibuya Japan
| | - Takashi Ogura
- Department of Respiratory Medicine; Kanagawa Cardiovascular and Respiratory Center; Yokohama Japan
| |
Collapse
|
29
|
Yeboah MM, Hye Khan MA, Chesnik MA, Sharma A, Paudyal MP, Falck JR, Imig JD. The epoxyeicosatrienoic acid analog PVPA ameliorates cyclosporine-induced hypertension and renal injury in rats. Am J Physiol Renal Physiol 2016; 311:F576-85. [PMID: 27358055 DOI: 10.1152/ajprenal.00288.2016] [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: 05/06/2016] [Accepted: 06/28/2016] [Indexed: 01/05/2023] Open
Abstract
The introduction of calcineurin inhibitors (CNI) into clinical practice in the late 1970s transformed organ transplantation and led to significant improvement in acute rejection episodes. However, despite their significant clinical utility, the use of these agents is hampered by the development of hypertension and nephrotoxicity, which ultimately lead to end-stage kidney disease and overt cardiovascular outcomes. There are currently no effective agents to treat or prevent these complications. Importantly, CNI-free immunosuppressive regimens lack the overall efficacy of CNI-based treatments and put patients at risk of allograft rejection. Cytochrome P-450 epoxygenase metabolites of arachidonic acid, epoxyeicosatrienoic acids (EETs), have potent vasodilator and antihypertensive properties in addition to many cytoprotective effects, but their effects on CNI-induced nephrotoxicity have not been explored. Here, we show that PVPA, a novel, orally active analog of 14,15-EET, effectively prevents the development of hypertension and ameliorates kidney injury in cyclosporine-treated rats. PVPA treatment reduced proteinuria and renal dysfunction induced by cyclosporine. PVPA inhibited inflammatory cell infiltration into the kidney and decreased renal fibrosis. PVPA also reduced tubular epithelial cell apoptosis, attenuated the generation of reactive oxygen species, and modulated the unfolded protein response that is associated with endoplasmic reticulum stress. Consistent with the in vivo data, PVPA attenuated cyclosporine-induced apoptosis of NRK-52E cells in vitro. These data indicate that the cytochrome P-450/EET system offers a novel therapeutic strategy to treat or prevent CNI-induced nephrotoxicity.
Collapse
Affiliation(s)
- Michael M Yeboah
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin;
| | - Md Abdul Hye Khan
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Marla A Chesnik
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amit Sharma
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Mahesh P Paudyal
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John R Falck
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John D Imig
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| |
Collapse
|
30
|
Abstract
The lung is a common site of complications of systemic connective tissue disease (CTD), and lung involvement can present in several ways. Interstitial lung disease (ILD) and pulmonary hypertension are the most common lung manifestations in CTD. Although it is generally thought that interstitial lung disease develops later on in CTD it is often the initial presentation ("lung dominant" CTD). ILD can be present in most types of CTD, including rheumatoid arthritis, scleroderma, systemic lupus erythematosus, polymyositis or dermatomyositis, Sjögren's syndrome, and mixed connective tissue disease. Despite similarities in clinical and pathologic presentation, the prognosis and treatment of CTD associated ILD (CTD-ILD) can differ greatly from that of other forms of ILD, such as idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) can present as a primary vasculopathy in pulmonary arterial hypertension or in association with ILD (PH-ILD). Therefore, detailed history, physical examination, targeted serologic testing, and, occasionally, lung biopsy are needed to diagnose CTD-ILD, whereas both non-invasive and invasive assessments of pulmonary hemodynamics are needed to diagnose pulmonary hypertension. Immunosuppression is the mainstay of treatment for ILD, although data from randomized controlled trials (RCTs) to support specific treatments are lacking. Furthermore, treatment strategies vary according to the clinical situation-for example, the treatment of a patient newly diagnosed as having CTD-ILD differs from that of someone with an acute exacerbation of the disease. Immunosuppression is indicated only in select cases of pulmonary arterial hypertension related to CTD; more commonly, selective pulmonary vasodilators are used. For both diseases, comorbidities such as sleep disordered breathing, symptoms of dyspnea, and cough should be evaluated and treated. Lung transplantation should be considered in patients with advanced disease but is not always feasible because of other manifestations of CTD and comorbidities. Clinical trials of novel therapies including immunosuppressive therapies are needed to inform best treatment strategies.
Collapse
Affiliation(s)
- Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sonye K Danoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
31
|
Fasano S, Alves SC, Isenberg DA. Current pharmacological treatment of idiopathic inflammatory myopathies. Expert Rev Clin Pharmacol 2016; 9:547-558. [PMID: 26708717 DOI: 10.1586/17512433.2016.1136561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The idiopathic inflammatory myopathies are uncommon and heterogeneous disorders. Their classification is based on distinct clinicopathologic features. Although idiopathic inflammatory myopathies share some similarities, different subtypes may have variable responses to therapy, so it is very important to distinguish the correct subtype. There are few randomised, double blind placebo controlled studies to support the current treatment. High dose corticosteroids continue to be the first-line therapy and other immunosupressive drugs are used in refractory cases, as well as steroid-sparing agents. Some novel therapeutic approaches have emerged as potential treatment including tacrolimus, intravenous immunoglobulin and rituximab, following good outcomes reported in case studies. However, more randomised controlled trials are needed. This review considers the current and the potential future therapies for inflammatory myopathies.
Collapse
Affiliation(s)
- Serena Fasano
- a Rheumatology Unit, Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Sara Custódio Alves
- b Internal Medicine Unit, Department of Medicine , Hospital de Cascais , Cascais , Portugal
| | - David A Isenberg
- c Centre for Rheumatology, Department of Medicine , University College London , London , UK
| |
Collapse
|
32
|
|