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Lee YH, Song GG. Relative efficacy and safety of calcineurin inhibitor, mycophenolate mofetil, and azathioprine as maintenance therapies for lupus nephritis: a network meta-analysis. Z Rheumatol 2024; 83:140-147. [PMID: 37278824 DOI: 10.1007/s00393-023-01374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE This study aimed to assess the relative efficacy and safety of calcineurin inhibitor (CNI), mycophenolate mofetil (MMF), and azathioprine (AZA) as maintenance therapies for lupus nephritis. METHODS Randomized controlled trials (RCTs) examining the efficacy and safety of CNI, MMF, and AZA as maintenance therapies in patients with lupus nephritis were included. We performed a Bayesian random-effects network meta-analysis to combine the direct and indirect evidence from RCTs. RESULTS Ten RCTs comprising 884 patients were included in the study. Although the difference was not statistically significant, MMF showed a trend toward a lower relapse rate compared with AZA (odds ratio [OR] 0.72, 95% credible interval [CrI] 0.45-1.22). Similarly, tacrolimus showed a trend toward a lower relapse rate compared with AZA (OR 0.85, 95% CrI 0.34-2.00). Ranking probability based on the surface under the cumulative ranking curve (SUCRA) indicated that MMF had the highest probability of being the best treatment based on the relapse rate, followed by CNI and AZA. The incidence of leukopenia in the MMF and CNI groups was significantly lower than that in the AZA group (OR 0.12, 95% CrI 0.04-0.34; OR 0.16, 95% CrI 0.04-0.50; respectively). Fewer patients with infections were observed in the MMF group than in the AZA group, although the difference was not statistically significant. The analysis of withdrawals due to adverse events showed a similar pattern. CONCLUSION Lower relapse rates combined with a more favorable safety profile suggest that CNI and MMF are superior to AZA as maintenance treatments in lupus nephritis patients.
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Affiliation(s)
- Young Ho Lee
- Department of Rheumatology, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, 136-705, Seoul, Seongbuk-gu, Korea (Republic of).
| | - Gwan Gyu Song
- Department of Rheumatology, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, 136-705, Seoul, Seongbuk-gu, Korea (Republic of)
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Guo Q, Zhang X, Sun S, Tang X, Shen W, Liang J, Yao G, Geng L, Ding S, Chen H, Wang H, Hua B, Zhang H, Wang D, Feng X, Sun L, Jin Z. Association Between Mycophenolate Mofetil Use and Subsequent Infections Among Hospitalized Patients with Systemic Lupus Erythematosus: A Nested Case-Control Study. Rheumatol Ther 2023; 10:1535-1554. [PMID: 37742321 PMCID: PMC10654301 DOI: 10.1007/s40744-023-00595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION The association between mycophenolate mofetil (MMF) and infection in patients with systemic lupus erythematosus (SLE) has not been clarified. This study evaluated the degree and factors in effect of MMF use on infection in patients with SLE. METHODS A hospitalized-based observational study was conducted to collect medical records on patients with SLE during 2010-2021. A nested case-control study was performed among 3339 patients with SLE, including 1577 cases and 1762 controls by whether they developed any type of infection. The exposure of MMF use was determined within 1 year before diagnosed infection or the end of follow-up. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for association between MMF and subsequent infection. RESULTS MMF was significantly associated with the risk of overall infection (adjusted OR 1.90, 95% CI 1.48-2.44) and different types of infections, including bacterial infection (adjusted OR 2.07, 95% CI 1.55-2.75), viral infection (adjusted OR 1.92, 95% CI 1.23-3.01), and opportunistic infection (adjusted OR 2.13, 95% CI 1.31-3.46). The top three risks of specific types of infections were bacteremia/septicemia, urinary tract infection/pyelonephritis, and herpes zoster. Stratification analysis showed risk of overall infection increased especially in MMF users with age over 55 years, diabetes, central nervous system involvement, and thrombocytopenia. Moreover, the risk of infection increased with increasing dosage and duration of MMF use. Additionally, the combination of MMF with CYC and other immunosuppressants significantly increases the risk of infections compared to using a single one. CONCLUSIONS MMF use is associated with various type of infections in patients with SLE, particularly in those with longer use, older age, complications with comorbidities, and concomitant use of CYC or other immunosuppressants.
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Affiliation(s)
- Qingqing Guo
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xueyi Zhang
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Siqin Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xiaojun Tang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Wei Shen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Jun Liang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Genhong Yao
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Linyu Geng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Shuai Ding
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hongwei Chen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hong Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Bingzhu Hua
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Huayong Zhang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Dandan Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China.
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
| | - Ziyi Jin
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Revisited Cyclophosphamide in the Treatment of Lupus Nephritis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8345737. [PMID: 35707391 PMCID: PMC9192236 DOI: 10.1155/2022/8345737] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
Lupus nephritis (LN) is the most common serious complication of systemic lupus erythematosus (SLE). The pathogenesis of LN is complex, and the majority causes of LN are the renal deposition of circulating or/and in situ-formed immune complexes. These immune complexes trigger glomerular and tubulointerstitial inflammation, which finally leads to proteinuria and loss of renal function. Despite the emergence of new biological agents, cyclophosphamide (CY), an alkylating agent, is still the first-line drug widely used to treat patients with severe LN. In this review, we outline the application history, molecular structure, and pharmacokinetics of CY in the treatment of LN. We also detail its latest known immunopharmacological mechanisms, with a focus on supplemental regulation and inhibition of CD4 and CD8 positive T cells, differences in the use of various guidelines, and the combination with other drugs. The side effects of CY are also mentioned in this review.
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Li K, Yu Y, Gao Y, Zhao F, Liang Z, Gao J. Comparative Effectiveness of Rituximab and Common Induction Therapies for Lupus Nephritis: A Systematic Review and Network Meta-Analysis. Front Immunol 2022; 13:859380. [PMID: 35444666 PMCID: PMC9013779 DOI: 10.3389/fimmu.2022.859380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study aimed to compare the efficacy and safety (infection events) between rituximab (RTX), tacrolimus (TAC), mycophenolate mofetil (MMF), and cyclophosphamide (CYC) as induction therapies in lupus nephritis (LN). Methods Electronic databases, including PubMed, EMBASE, and the Cochrane Library, were searched from inception up to December 9, 2021. Bayesian network meta-analysis was used to combine the direct and indirect evidence of different drugs for LN patients. The pooled relative effects were shown using odds ratios (ORs) and 95% credible intervals (CrIs). Results Nineteen studies (1,566 patients) met the inclusion criteria and were selected in the present study. The network meta-analysis reported that no statistically significant differences were found in partial remission (PR) and infection among the four drugs. RTX showed a significantly higher complete remission (CR) than MMF (OR = 2.60, 95% CrI = 1.00–7.10) and seemed to be more effective than CYC (OR = 4.20, 95% CrI = 1.70–14.00). MMF had a better CR than CYC (OR = 1.60, 95% CrI = 1.00–3.20). TAC presented a better overall response than CYC (OR = 3.70, 95% CrI = 1.20–12.00). Regarding CR and overall response, the maximum surface under the cumulative ranking curve (SUCRA) values were 96.94% for RTX and 80.15% for TAC. The maximum SUCRA value of infection reaction was 74.98% for RTX and the minimum value was 30.17% for TAC, respectively. Conclusions RTX and TAC were the most effective drugs for induction remission in LN. Among the four drugs, TAC had the lowest probability of infection, and RTX showed the highest probability of experiencing an infection. This meta-analysis could not conclude about other adverse events.
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Shin JI, Li H, Park S, Yang JW, Lee KH, Jo Y, Park S, Oh J, Kim H, An HJ, Jeong G, Jung H, Lee HJ, Kim JS, Nam SW, Koyanagi A, Jacob L, Hwang J, Yon DK, Lee SW, Tizaoui K, Kronbichler A, Kim JH, Smith L. Induction and Maintenance Treatment of Lupus Nephritis: A Comprehensive Review of Meta-Analyses. J Clin Med 2022; 11:jcm11020343. [PMID: 35054037 PMCID: PMC8780781 DOI: 10.3390/jcm11020343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lupus nephritis (LN) is present in over 50% of patients with systemic lupus erythematosus (SLE) which is managed with immunosuppressive and immunomodulatory therapies. However, several novel therapeutic approaches for LN are under investigation due to the adverse effects spectrum of conventional therapy; Methods: We performed a comprehensive review of meta-analyses aggregating the comparative efficacies of various pharmacotherapies for LN. We conducted a literature search and retrieved a total of 23 meta-analyses and network meta-analyses for summarization. Pharmacotherapies were evaluated across six major outcomes: remission, relapse, mortality, end stage kidney disease (ESKD) progression, infection, and malignancy. RESULT Calcineurin inhibitors (CNI), particularly tacrolimus (TAC), in combination with glucocorticoids (GC) outperformed cyclophosphamide (CPA) with GC in the rate of remission, either complete or partial remission, and in terms of infectious complications. In maintenance therapy, MMF was superior to azathioprine (AZA) as the MMF-treated patients had lower relapse rate. INTERPRETATION This review aggregates evidence of therapy for clinicians and sheds light on comparative efficacies of alternative LN treatments. As more promising agents are entering the market, such as voclosporin, belimumab, and obinutuzumab, LN management might undergo significant changes during the next years.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Han Li
- University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Yongsuk Jo
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Seongeun Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jungmin Oh
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hansol Kim
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hyo Jin An
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Gahee Jeong
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Haerang Jung
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Hyun Jung Lee
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Seoung Wan Nam
- Department of Rheumatology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Catalan Institution for Research and Advanced Studies, Pg. Lluis Companys 23, 08010 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
| | - Louis Jacob
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, 78000 Montigny-le-Bretonneux, France
| | - Jimin Hwang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Dong Keon Yon
- Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul 02447, Korea;
| | - Seung-Won Lee
- Department of Data Science, Sejong University College of Software Convergence, Sungkyunkwan University School of Medicine, Seoul 05006, Korea;
| | - Kalthoum Tizaoui
- Laboratory of Microorganisms and Active Biomolecules, Sciences Faculty of Tunis, University Tunis El Manar, Tunis 1068, Tunisia;
| | | | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Korea
- Correspondence:
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge CB1 1PT, UK;
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Alamilla-Sanchez ME, Alcala-Salgado MA, Alonso-Bello CD, Fonseca-Gonzalez GT. Mechanism of Action and Efficacy of Immunosupressors in Lupus Nephritis. Int J Nephrol Renovasc Dis 2021; 14:441-458. [PMID: 34924767 PMCID: PMC8675090 DOI: 10.2147/ijnrd.s335371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Approximately 70% of the patients with systemic lupus erythematosus will have clinical evidence of kidney damage during their evolution. Patients with impaired renal function at onset and those with recurrent flares have a poor prognosis. Understanding the mechanism of action of immunosuppressants is essential for proper prescription. Steroids inhibit the DNA sequence that promotes the release of inflammatory cytokines. Phosphoramide mustard, metabolite of cyclophosphamide, cross-link with the DNA, causing the aggregation of an alkyl group, causing cell death. Mycophenolate inhibits inosine monophosphate dehydrogenase, prevents de novo synthesis of guanine, inducing cell arrest in S phase. Azathioprine blocks the synthesis of purines and induces apoptosis. Calcineurin inhibitors prevent the dephosphorylation of NFAT and reduce the production of interleukin 2. Antimalarials alter the enzymatic release of lysosomes by increasing intravesicular pH. The mechanism of action of rituximab is related to complement-dependent cytotoxicity and the elimination of anti-CD20-labeled B cells. Progress in the knowledge and management of low doses of steroids may change the current paradigm and reduce the frequency of related adverse events. Mycophenolate seems to be a better choice than cyclophosphamide for induction, it is also preferred over azathioprine as a maintenance immunosuppressive agent, although azathioprine is preferred in women with a desire for conception, those pregnant, or with low resources. For treatment-resistant cases, tacrolimus, rituximab or belimumab may be effective. Ongoing clinical trials with new drugs offer promising results.
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Affiliation(s)
| | | | - Cesar D Alonso-Bello
- Department of Immunology, Centro Medico Nacional "20 de Noviembre", Mexico City, Mexico
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Ponticelli C, Reggiani F, Moroni G. Old and New Calcineurin Inhibitors in Lupus Nephritis. J Clin Med 2021; 10:jcm10214832. [PMID: 34768354 PMCID: PMC8584552 DOI: 10.3390/jcm10214832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/27/2022] Open
Abstract
Calcineurin inhibitors (CNIs) are drugs that inhibit calcineurin, a key phosphatase that dephosphorylates a transcription factor called the nuclear factor of activated T cells (NFAT), allowing its translocation into the nucleus of quiescent T cells. In the nucleus, NFAT activates interleukin 2, which stimulates the proliferation and differentiation of T-cells. CNIs can also stabilize the actin cytoskeleton of podocytes reducing proteinuria. Thanks to these characteristics, CNIs have been often used in the treatment of autoimmune diseases. However, the therapeutic index of CNIs is narrow, and their interactions with other drugs can increase toxicity or reduce efficacy. In lupus nephritis, cyclosporine and tacrolimus have been used both in induction and maintenance therapies. Observational studies and randomized controlled trials showed that both cyclosporine and tacrolimus can increase efficacy. Tolerance is satisfactory if low doses are used and the patient is carefully monitored. More recently, a new CNI, called voclosporin (VCS), has been approved by the Food and Drug Administration for use in lupus nephritis. VCS offers potential advantages over other CNIs. In two large multiethnic trials, VCS was not associated with adverse renal and metabolic events and obtained positive results despite a novel and rapid corticosteroid tapering regime.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology Division, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Francesco Reggiani
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
| | - Gabriella Moroni
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
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Desai Y, Jaki T, Beresford MW, Burnett T, Eleftheriou D, Jacobe H, Leone V, Li S, Mozgunov P, Ramanan AV, Torok KS, Anderson ME, Anton J, Avcin T, Felton J, Foeldvari I, Laguda B, McErlane F, Shaw L, Zulian F, Pain CE. Prior elicitation of the efficacy and tolerability of Methotrexate and Mycophenolate Mofetil in Juvenile Localised Scleroderma. AMRC OPEN RESEARCH 2021; 3:20. [PMID: 38708070 PMCID: PMC11064983 DOI: 10.12688/amrcopenres.13008.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 05/07/2024]
Abstract
Background Evidence is lacking for safe and effective treatments for juvenile localised scleroderma (JLS). Methotrexate (MTX) is commonly used first line and mycophenolate mofetil (MMF) second line, despite a limited evidence base. A head to head trial of these two medications would provide data on relative efficacy and tolerability. However, a frequentist approach is difficult to deliver in JLS, because of the numbers needed to sufficiently power a trial. A Bayesian approach could be considered. Methods An international consensus meeting was convened including an elicitation exercise where opinion was sought on the relative efficacy and tolerability of MTX compared to MMF to produce prior distributions for a future Bayesian trial. Secondary aims were to achieve consensus agreement on critical aspects of a future trial. Results An international group of 12 clinical experts participated. Opinion suggested superior efficacy and tolerability of MMF compared to MTX; where most likely value of efficacy of MMF was 0.70 (95% confidence interval (CI) 0.34-0.90) and of MTX was 0.68 (95% CI 0.41-0.8). The most likely value of tolerability of MMF was 0.77 (95% CI 0.3-0.94) and of MTX was 0.62 (95% CI 0.32-0.84). The wider CI for MMF highlights that experts were less sure about relative efficacy and tolerability of MMF compared to MTX. Despite using a Bayesian approach, power calculations still produced a total sample size of 240 participants, reflecting the uncertainty amongst experts about the performance of MMF. Conclusions Key factors have been defined regarding the design of a future Bayesian approach clinical trial including elicitation of prior opinion of the efficacy and tolerability of MTX and MMF in JLS. Combining further efficacy data on MTX and MMF with prior opinion could potentially reduce the pre-trial uncertainty so that, when combined with smaller trial sample sizes a compelling evidence base is available.
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Affiliation(s)
- Yasin Desai
- MPS Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, LA1 4YF, UK
| | - Thomas Jaki
- MPS Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, LA1 4YF, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L69 3BX, UK
| | - Thomas Burnett
- MPS Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, LA1 4YF, UK
| | - Despina Eleftheriou
- University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Paediatric Rheumatology, Great Ormond St Hospital NHS Foundation Trust, London, WC1N 3JH, UK
| | - Heidi Jacobe
- UT Southwestern Medical Center, Dallas, Texas, TX 75390, USA
| | - Valentina Leone
- Paediatric Rheumatology Department, Leeds Children Hospital (Leeds Teaching Hospitals) and University of Leeds, Leeds, LS1 3EX, UK
| | - Suzanne Li
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital, Hackensack University Medical Center & Hackensack Meridian School of Medicine, Hackensack, New Jersey, NJ 07601, USA
| | - Pavel Mozgunov
- MPS Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, LA1 4YF, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, Bristol, BS1 3NU, UK
| | - Kathryn S Torok
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Marina E Anderson
- Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
- Lancaster Medical School, Lancaster University, Lancaster, LA1 4YF, UK
| | - Jordi Anton
- Pediatric Rheumatology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Barcelona, 08007, UK
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre, Ljubljana, 1000 Ljubljana, Slovenia
| | - Jessie Felton
- Department of Dermatology, Brighton and Sussex University Hospitals & Royal Alexandra Children’s Hospital, Brighton, BN2 1DH, UK
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, 22081 Hamburg, Germany
| | - Bisola Laguda
- Department of Paediatric Dermatology, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Flora McErlane
- Department of Paediatric Rheumatology, Great North Children's Hospital, Newcastle, NE1 4LP, UK
| | - Lindsay Shaw
- Department of Paediatric Rheumatology, Great Ormond St Hospital NHS Foundation Trust, London, WC1N 3JH, UK
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, Bristol, BS1 3NU, UK
| | - Francesco Zulian
- Department of Woman's and Child's Health, University of Padova, Padua, 35122 Padua, Italy
| | - Clare E Pain
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UK
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Comparative efficacy and safety of mycophenolate mofetil versus cyclophosphamide in patients with active antineutrophil cytoplasmic antibody-associated vasculitis: a meta-analysis of randomized trials. Z Rheumatol 2021; 80:425-431. [PMID: 32337635 DOI: 10.1007/s00393-020-00803-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to assess the efficacy and safety of mycophenolate mofetil (MMF) versus cyclophosphamide (CYC) in patients with active antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS We performed a meta-analysis of four randomized clinical trials (RCTs; 300 patients) to examine the relative efficacy and safety of MMF compared to CYC in patients with active AAV. RESULTS There was no significant difference in remission at 6 months between MMF and CYC (odds ratio [OR] 1.311, 95% confidence interval [CI] 0.570-3.017, P = 0.524). Additionally, the relapse rate did not differ between the MMF and CYC groups (OR 1.331, 95% CI 0.497-3.568, P = 0.570). There was no significant difference in serious adverse event (SAE; OR 1.232, 95% CI 0.754-2.014, P = 0.404) and infection rates (OR 0.958, 95% CI 0.561-1.634, P = 0.873) between the MMF and CYC groups. Some heterogeneity was found in the meta-analysis of remission and relapse rates (I2 = 57.4%, 63.4%), but no between-study heterogeneity was found during the meta-analysis of SAE and infection rate. Egger's regression test showed no evidence of publication bias (Egger's regression test P-values >0.1). CONCLUSION MMF was an equally effective alternative treatment to CYC and MMF was comparable to CYC in patients with active AAV in terms of safety, suggesting that MMF can be used as an alternative to CYC for remission induction in AAV.
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Khanna PP, Khanna D, Cutter G, Foster J, Melnick J, Jaafar S, Biggers S, Rahman AKMF, Kuo HC, Feese M, Kivitz A, King C, Shergy W, Kent J, Peloso PM, Danila MI, Saag KG. Reducing Immunogenicity of Pegloticase With Concomitant Use of Mycophenolate Mofetil in Patients With Refractory Gout: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Arthritis Rheumatol 2021; 73:1523-1532. [PMID: 33750034 DOI: 10.1002/art.41731] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/18/2021] [Accepted: 03/09/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pegloticase is used for the treatment of severe gout, but its use is limited by immunogenicity. This study was undertaken to evaluate whether mycophenolate mofetil (MMF) prolongs the efficacy of pegloticase. METHODS Participants were randomized 3:1 to receive 1,000 mg MMF twice daily or placebo for 14 weeks, starting 2 weeks before receiving pegloticase and continuing while receiving intravenous pegloticase 8 mg biweekly for 12 weeks. Participants then received pegloticase alone from week 12 to week 24. The primary end points were the proportion of patients who sustained a serum urate level of ≤6 mg/dl at 12 weeks and the rate of adverse events (AEs). Secondary end points included 24-week durability of serum urate level ≤6 mg/dl. Fisher's exact test and Wilcoxon's 2-sample test were used for analyses, along with Kaplan-Meier estimates and log rank tests. RESULTS A total of 32 participants received ≥1 dose of pegloticase. Participants were predominantly men (88%), with a mean age of 55.2 years, mean gout duration of 13.4 years, and mean baseline serum urate level of 9.2 mg/dl. At 12 weeks, a serum urate level of ≤6 mg/dl was achieved in 19 (86%) of 22 participants in the MMF arm compared to 4 (40%) of 10 in the placebo arm (P = 0.01). At week 24, the serum urate level was ≤6 mg/dl in 68% of MMF-treated patients versus 30% of placebo-treated patients (P = 0.06), and rates of AEs were similar between groups, with more infusion reactions occurring in the placebo arm (30% versus 0%). CONCLUSION Our findings indicate that MMF therapy with pegloticase is well tolerated and shows a clinically meaningful improvement in targeted serum urate level of ≤6 mg/dl at 12 and 24 weeks. This study suggests an innovative approach to pegloticase therapy in gout.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania, USA
| | | | | | - Jeff Kent
- Horizon Therapeutics, Lake Forest, Illinois, USA
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11
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Huang X, Huang Q, He Y, Chen S, Li T. Mycophenolic acid enhanced lipopolysaccharide-induced interleukin-18 release in THP-1 cells via activation of the NLRP3 inflammasome. Immunopharmacol Immunotoxicol 2019; 41:521-526. [PMID: 31429348 DOI: 10.1080/08923973.2019.1652913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Interleukin (IL)-18 is a pro-inflammatory cytokine that has important functions in host defense. The maturation and secretion of IL-18 has been shown to be regulated by the NOD-like receptor (NLR) family pyrin domain-containing 3 (NLRP3) inflammasome. Mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), in association with lipopolysaccharide (LPS), is able to promote the secretion of IL-18, but the mechanism remains unknown. This study aims to explore the mechanism by which MPA synergizes with LPS to induced IL-18 release. Methods: THP-1 cells were stimulated with LPS and MPA and treated with or without the inhibitors of caspase-1, Ac-YVAD-cmk or KCl; IL-18 in the supernatants was measured by ELISA. The intracellular protein levels of NF-κB p-p65, pro-IL-18, NLRP3, and cleaved caspase-1(p20) were measured by Western blot. Results: We found that MPA alone failed to induce IL-18, whereas MPA enhanced LPS-mediated IL-18 release. MPA did not affect the intracellular protein levels of NF-κB p-p65 or pro-IL-18 but activated the NLRP3 inflammasome. Ac-YVAD-cmk or increasing extracellular K+ blocked the activation of caspase-1 and attenuated the release of IL-18. Conclusions: Taken together, MPA synergized with LPS to induce the release of IL-18 via activating the NLRP3 inflammasome and increasing the degradation of pro-IL-18, rather than by enhancing the production of pro-IL-18.
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Affiliation(s)
- Xuechan Huang
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital , Guangzhou , PR China.,The Second School of Clinical Medicine, Southern Medical University , Guangzhou , PR China
| | - Qidang Huang
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital , Guangzhou , PR China.,The Second School of Clinical Medicine, Southern Medical University , Guangzhou , PR China
| | - Yi He
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University , Guangzhou , PR China.,Institute of Clinical Immunology, Academy of Orthopedics , Guangzhou , PR China
| | - Shuyang Chen
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital , Guangzhou , PR China.,The Second School of Clinical Medicine, Southern Medical University , Guangzhou , PR China
| | - Tianwang Li
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital , Guangzhou , PR China.,The Second School of Clinical Medicine, Southern Medical University , Guangzhou , PR China
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12
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Dörner T, Furie R. Novel paradigms in systemic lupus erythematosus. Lancet 2019; 393:2344-2358. [PMID: 31180031 DOI: 10.1016/s0140-6736(19)30546-x] [Citation(s) in RCA: 308] [Impact Index Per Article: 61.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/19/2019] [Accepted: 03/05/2019] [Indexed: 12/22/2022]
Abstract
The heterogeneity of systemic lupus erythematosus (SLE), long recognised by clinicians, is now challenging the entire lupus community, from geneticists to clinical investigators. Although the outlook for patients with SLE has greatly improved, many unmet needs remain, chief of which is the development of safer and more efficacious therapies. To develop innovative therapies, a far better understanding of SLE pathogenesis as it relates to the array of clinical phenotypes is needed. Additionally, to efficiently achieve these goals, the lupus community needs to refine existing clinical research tools and better adapt them to overcome the obstacles created by the heterogeneity of manifestations. Here, we review progress towards the ultimate goal of safely reducing disease activity and preventing damage accrual and death. We discuss the new classification criteria from the European League Against Rheumatism and American College of Rheumatology, novel definitions of remission and low lupus disease activity, and new proposals for the histological classification of lupus nephritis. Recommendations for the treatment of SLE and novel approaches to drug development hold much promise to further enhance SLE outcomes.
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Affiliation(s)
- Thomas Dörner
- Department of Medicine and Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; German Rheumatism Research Center (DRFZ), Berlin, Germany.
| | - Richard Furie
- Division of Rheumatology Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
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13
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Thong KM, Chan TM. Infectious complications in lupus nephritis treatment: a systematic review and meta-analysis. Lupus 2019; 28:334-346. [PMID: 30744523 DOI: 10.1177/0961203319829817] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Infection is an important concern in lupus nephritis treatment, but few studies have focused on this complication. Available data suggest marked variation in occurrence and outcome. This meta-analysis and review aims to provide an overview of infective complications, focusing on the risk factors and outcomes. METHODS Original articles on lupus nephritis Class III/IV/V published in the period January 1980 to December 2016 were identified from the Pubmed/Medline electronic database. Meta-analysis of randomized controlled trials was performed to investigate total and serious infections at different phases of treatment and their associated factors. A descriptive review that included all studies was also performed, providing details on the types of infection, infection-related mortality, and potential impact of different eras on infection rates. RESULTS A total of 56 studies (32 randomized controlled trials) were included. The incidence rates of overall and serious infections were higher during the induction than maintenance phase of therapy, with serious infections occurring at 8.2-50 and 3.5 per 100 patient-years, respectively. Recent data, predominantly from Asia, suggested lower rates of overall infections with induction regimens that included tacrolimus compared with mycophenolate (risk ratio 0.50, 95% confidence interval 0.33-0.76, p = 0.001). Mycophenolate as induction treatment was associated with lower overall infection risks than cyclophosphamide in non-Asians (risk ratio 0.60, 95% confidence interval 0.48-0.75, p < 0.001). The rates of serious infections were 4.1-25% in Asian and 4.4-8.5% in non-Asian countries; with infection-related mortality rates of 0-6.7% in Asian, compared to 0-2.1% in non-Asian locations. CONCLUSIONS Infection remains a serious complication during treatment of lupus nephritis, but the reported rates and outcomes varied markedly. Mycophenolate was associated with lower infection risk than cyclophosphamide in non-Asians. Infection-related deaths appeared more common in Asian patients.
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Affiliation(s)
- K M Thong
- 1 Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China.,2 Nephrology Unit, Department of Medicine, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
| | - T M Chan
- 1 Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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14
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Tunnicliffe DJ, Palmer SC, Henderson L, Masson P, Craig JC, Tong A, Singh‐Grewal D, Flanc RS, Roberts MA, Webster AC, Strippoli GFM. Immunosuppressive treatment for proliferative lupus nephritis. Cochrane Database Syst Rev 2018; 6:CD002922. [PMID: 29957821 PMCID: PMC6513226 DOI: 10.1002/14651858.cd002922.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids, has been first-line treatment for inducing disease remission for proliferative lupus nephritis, reducing death at five years from over 50% in the 1950s and 1960s to less than 10% in recent years. Several treatment strategies designed to improve remission rates and minimise toxicity have become available. Treatments, including mycophenolate mofetil (MMF) and calcineurin inhibitors, alone and in combination, may have equivalent or improved rates of remission, lower toxicity (less alopecia and ovarian failure) and uncertain effects on death, end-stage kidney disease (ESKD) and infection. This is an update of a Cochrane review first published in 2004 and updated in 2012. OBJECTIVES Our objective was to assess the evidence and evaluate the benefits and harms of different immunosuppressive treatments in people with biopsy-proven lupus nephritis. The following questions relating to management of proliferative lupus nephritis were addressed: 1) Are new immunosuppressive agents superior to or as effective as cyclophosphamide plus corticosteroids? 2) Which agents, dosages, routes of administration and duration of therapy should be used? 3) Which toxicities occur with the different treatment regimens? SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 2 March 2018 with support from the Cochrane Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any immunosuppressive treatment for biopsy-proven class III, IV, V+III and V+VI lupus nephritis in adult or paediatric patients were included. DATA COLLECTION AND ANALYSIS Data were abstracted and the risks of bias were assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) and measures on continuous scales calculated as mean differences (MD) with 95% confidence intervals (CI). The primary outcomes were death (all causes) and complete disease remission for induction therapy and disease relapse for maintenance therapy. Evidence certainty was determined using GRADE. MAIN RESULTS In this review update, 26 new studies were identified, to include 74 studies involving 5175 participants overall. Twenty-nine studies included children under the age of 18 years with lupus nephritis, however only two studies exclusively examined the treatment of lupus nephritis in patients less than 18 years of age.Induction therapy Sixty-seven studies (4791 participants; median 12 months duration (range 2.5 to 48 months)) reported induction therapy. The effects of all treatment strategies on death (all causes) and ESKD were uncertain (very low certainty evidence) as this outcome occurred very infrequently. Compared with intravenous (IV) cyclophosphamide, MMF may have increased complete disease remission (RR 1.17, 95% CI 0.97 to 1.42; low certainty evidence), although the range of effects includes the possibility of little or no difference.Compared to IV cyclophosphamide, MMF is probably associated with decreased alopecia (RR 0.29, 95% CI 0.19 to 0.46; 170 less (129 less to 194 less) per 1000 people) (moderate certainty evidence), increased diarrhoea (RR 2.42, 95% CI 1.64 to 3.58; 142 more (64 more to 257 more) per 1000 people) (moderate certainty evidence) and may have made little or no difference to major infection (RR 1.02, 95% CI 0.67 to 1.54; 2 less (38 less to 62 more) per 1000 people) (low certainty evidence). It is uncertain if MMF decreased ovarian failure compared to IV cyclophosphamide because the certainty of the evidence was very low (RR 0.36, 95% CI 0.06 to 2.18; 26 less (39 less to 49 more) per 1000 people). Studies were not generally designed to measure ESKD.MMF combined with tacrolimus may have increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 336 more (17 to 1048 more) per 1000 people (low certainty evidence) compared with IV cyclophosphamide, however the effects on alopecia, diarrhoea, ovarian failure, and major infection remain uncertain. Compared to standard of care, the effects of biologics on most outcomes were uncertain because of low to very low certainty of evidence.Maintenance therapyNine studies (767 participants; median 30 months duration (range 6 to 63 months)) reported maintenance therapy. In maintenance therapy, disease relapse is probably increased with azathioprine compared with MMF (RR 1.75, 95% CI 1.20 to 2.55; 114 more (30 to 236 more) per 1000 people (moderate certainty evidence). Multiple other interventions were compared as maintenance therapy, but patient-outcome data were sparse leading to imprecise estimates. AUTHORS' CONCLUSIONS In this review update, studies assessing treatment for proliferative lupus nephritis were not designed to assess death (all causes) or ESKD. MMF may lead to increased complete disease remission compared with IV cyclophosphamide, with an acceptable adverse event profile, although evidence certainty was low and included the possibility of no difference. Calcineurin combined with lower dose MMF may improve induction of disease remission compared with IV cyclophosphamide, but the comparative safety profile of these therapies is uncertain. Azathioprine may increase disease relapse as maintenance therapy compared with MMF.
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Affiliation(s)
- David J Tunnicliffe
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Lorna Henderson
- NHS LothianRenal DepartmentRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Philip Masson
- Royal Free London NHS Foundation TrustDepartment of Renal MedicineLondonUK
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Allison Tong
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Davinder Singh‐Grewal
- The Sydney Children's Hospitals NetworkDepartment Paediatric RheumatologyThe Children's Hospital at WestmeadCnr Hainsworth and Hawkesbury RoadsWestmeadNSWAustralia2145
| | - Robert S Flanc
- Monash Medical CentreDepartment of NephrologyClayton RdClaytonVICAustralia3168
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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15
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Ichinose K, Sato S, Kitajima Y, Horai Y, Fujikawa K, Umeda M, Fukui S, Nishino A, Koga T, Kawashiri SY, Iwamoto N, Tamai M, Nakamura H, Origuchi T, Yasuhi I, Masuzaki H, Kawakami A. The efficacy of adjunct tacrolimus treatment in pregnancy outcomes in patients with systemic lupus erythematosus. Lupus 2018; 27:1312-1320. [PMID: 29665758 DOI: 10.1177/0961203318770536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Systemic lupus erythematosus (SLE) involves multiple organ systems and primarily affects women during their reproductive years. Pregnancy in a woman with SLE may lead to higher rates of disease flares. Little is known regarding which medications are safe to maintain remission and/or treat flares throughout such pregnancies. Here we retrospectively analyzed the efficacy of tacrolimus (TAC) in the pregnancy outcomes of SLE patients. We studied the 54 deliveries of 40 SLE patients over an eight-year period from 2008 to 2016. We used analyses of covariance with adjustments for the propensity score and inverse probability of treatment weights to compare the patient backgrounds between the TAC users and non-TAC users. TAC was administered to the patient in 15 of the 54 (27.8%) pregnancies, and these patients had a significantly higher dose of prednisolone, hypocomplementemia, lower estimated glomerular filtration rate, past history of lupus nephritis, and complication with antiphospholipid syndrome. In the adjusted background of the TAC deliveries, the risks of decreased fetal body weight, low birth weight infant, non-reassuring fetal status (NRFS), and preterm birth were not increased compared to the non-TAC deliveries. Thrombocytopenia and hypertension during the pregnancy were extracted as independent predictive risk factors for decreased fetal body weight and NRFS, respectively. We had anticipated that the maternal and fetal outcomes in the TAC-use deliveries would be poor before the analysis; however, the TAC-use group showed no significant difference in risks contributing to outcomes compared to the non-TAC group, suggesting that adjunct TAC treatment corrected various risk factors during the lupus pregnancies.
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Affiliation(s)
- K Ichinose
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Sato
- 2 Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Y Kitajima
- 3 Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Y Horai
- 4 Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Omura, Japan
| | - K Fujikawa
- 5 Department of Rheumatology, JCHO Isahaya General Hospital, Isahaya, Japan
| | - M Umeda
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Fukui
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - A Nishino
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Koga
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Y Kawashiri
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - N Iwamoto
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - M Tamai
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - H Nakamura
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Origuchi
- 6 Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - I Yasuhi
- 7 Department of Obstetrics and Gynecology, NHO Nagasaki Medical Center, Omura, Japan
| | - H Masuzaki
- 3 Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - A Kawakami
- 1 Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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16
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Kamanamool N, Ingsathit A, Rattanasiri S, Ngamjanyaporn P, Kasitanont N, Chawanasuntorapoj R, Pichaiwong W, Anutrakulchai S, Sangthawan P, Ophascharoensuk V, Avihingsanon Y, Sumethkul V. Comparison of disease activity between tacrolimus and mycophenolate mofetil in lupus nephritis: a randomized controlled trial. Lupus 2018; 27:647-656. [PMID: 29105558 DOI: 10.1177/0961203317739131] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We conducted a prospective multicenter, opened-label, parallel, randomized, controlled trial to compare tacrolimus (TAC) and mycophenolate mofetil (MMF) for induction and maintenance therapy in lupus nephritis (LN). Adult patients with biopsy-proven LN International Society of Nephrology/Renal Pathology Society classes III-V and active nephritis were to receive prednisolone (0.7-1.0 mg/kg/day for four weeks of run-in period and tapered) and randomly assigned to receive TAC (0.1 mg/kg/day) or MMF (1.5-2 g/day) as induction therapy for six months. All patients who had remission received azathioprine (AZA) 1-2 mg/kg/day as standard treatment in the maintenance phase. The primary outcome was Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) at six and 12 months, and the secondary outcomes included renal SLEDAI, non-renal SLEDAI, modified SLEDAI-2K, immunity SLEDAI, and disease activity remission. Eighty-four patients were randomized. One patient who was randomized to the TAC group withdrew from the study immediately after randomization. Therefore, 42 patients received MMF and 41 patients received TAC. Disease activity remission rate and time to disease activity remission were similar in both groups. Twelve patients (28.57%) in the MMF group and 10 patients (24.39%) in the TAC group achieved disease activity remission. For disease activity scores, both regimens significantly improved SLEDAI-2K during induction and maintenance therapy. Overall, SLEDAI-2K score in the MMF group decreased more compared with the TAC group. In the MMF group, mean SLEDAI-2K decreased from 11.6 ± 4.8 to 6.3 ± 3.9 after induction therapy and to 5.4 ± 4.4 after maintenance therapy. In the TAC group, mean SLEDAI-2K decreased from 9.0 ± 3.7 to 6.3 ± 5.1 after induction therapy and to 7.1 ± 5.4 after maintenance therapy. Renal SLEDAI and modified SLEDAI-2K showed a similar pattern with SLEDAI-2K. In non-renal SLEDAI and immunity SLEDAI, both regimens also resulted in decreased disease activity scores during the first two months. After that the scores were slightly increased. In the MMF group, the scores were still lower than baseline but in the TAC group were not. In conclusion, disease activity remission rate was similar in the MMF and TAC groups. For disease activity score as measured by SLEDAI-2K, TAC was comparable with MMF during induction but MMF was more effective on disease activity of active LN classes III and IV at 12 months, especially in the renal system.
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Affiliation(s)
- N Kamanamool
- 1 Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- 2 Department of Preventive and Social Medicine, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - A Ingsathit
- 1 Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Rattanasiri
- 1 Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - P Ngamjanyaporn
- 3 Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - N Kasitanont
- 4 Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - R Chawanasuntorapoj
- 5 Department of Medicine, 65106 Faculty of Medicine, Siriraj Hospital, Mahidol University , Bangkok, Thailand
| | - W Pichaiwong
- 6 Department of Internal Medicine, 54781 Rajavithi Hospital , Bangkok, Thailand
| | - S Anutrakulchai
- 7 Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - P Sangthawan
- 8 Department of Medicine, 37689 Faculty of Medicine, Prince of Songkla University , Hat Yai, Thailand
| | - V Ophascharoensuk
- 4 Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Y Avihingsanon
- 9 37690 Division of Nephrology , Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - V Sumethkul
- 3 Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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17
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Chen Y, Sun J, Zou K, Yang Y, Liu G. Treatment for lupus nephritis: an overview of systematic reviews and meta-analyses. Rheumatol Int 2017; 37:1089-1099. [DOI: 10.1007/s00296-017-3733-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/04/2017] [Indexed: 12/29/2022]
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Palmer SC, Tunnicliffe DJ, Singh-Grewal D, Mavridis D, Tonelli M, Johnson DW, Craig JC, Tong A, Strippoli GFM. Induction and Maintenance Immunosuppression Treatment of Proliferative Lupus Nephritis: A Network Meta-analysis of Randomized Trials. Am J Kidney Dis 2017; 70:324-336. [PMID: 28233655 DOI: 10.1053/j.ajkd.2016.12.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 12/01/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intravenous (IV) cyclophosphamide has been first-line treatment for inducing disease remission in lupus nephritis. The comparative efficacy and toxicity of newer agents such as mycophenolate mofetil (MMF) and calcineurin inhibitors are uncertain. STUDY DESIGN Network meta-analysis. SETTING & POPULATION Patients with proliferative lupus nephritis. SELECTION CRITERIA FOR STUDIES Randomized trials of immunosuppression to induce or maintain disease remission. INTERVENTIONS IV cyclophosphamide, oral cyclophosphamide, MMF, calcineurin inhibitor, plasma exchange, rituximab, or azathioprine, alone or in combination. OUTCOMES Complete remission, end-stage kidney disease, all-cause mortality, doubling of serum creatinine level, relapse, and adverse events. RESULTS 53 studies involving 4,222 participants were eligible. Induction and maintenance treatments were administered for 12 (IQR, 6-84) and 25 (IQR, 12-48) months, respectively. There was no evidence of different effects between therapies on all-cause mortality, doubling of serum creatinine level, or end-stage kidney disease. Compared to IV cyclophosphamide, the most effective treatments to induce remission in moderate- to high-quality evidence were combined MMF and calcineurin inhibitor therapy, calcineurin inhibitors, and MMF (ORs were 2.69 [95% CI, 1.74-4.16], 1.86 [95% CI, 1.05-3.30], and 1.54 [95% CI, 1.04-2.30], respectively). MMF was significantly less likely than IV cyclophosphamide to cause alopecia (OR, 0.21; 95% CI, 0.12-0.36), and MMF combined with calcineurin inhibitor therapy was less likely to cause ovarian failure (OR, 0.25; 95% CI, 0.07-0.93). Regimens generally had similar odds of major infection. MMF was the most effective strategy to maintain remission. LIMITATIONS Outcome definitions not standardized, short duration of follow-up, and possible confounding by previous or subsequent therapy. CONCLUSIONS Evidence for induction therapy for lupus nephritis is inconclusive based on treatment effects on all-cause mortality, doubling of serum creatinine level, and end-stage kidney disease. MMF, calcineurin inhibitors, or their combination were most effective for inducing remission compared to IV cyclophosphamide, while conferring similar or lower treatment toxicity. MMF was the most effective maintenance therapy.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - David J Tunnicliffe
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Davinder Singh-Grewal
- School of Paediatrics and Child Health, The University of Sydney, Sydney, NSW, Australia; Department of Rheumatology, The Sydney Children's Hospitals Network Westmead and Randwick, NSW, Australia
| | - Dimitris Mavridis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David W Johnson
- Division of Medicine, Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia; Translational Research Institute, Brisbane, QLD, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Diaverum Medical Scientific Office and Diaverum Academy, Lund, Sweden; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
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Ramos F, Seragioli F, Quintão G, Barbalho Junior P, Giorgi R, Araújo N. TACROLIMUS INDUZINDO REMISSÃO EM NEFRITE LÚPICA REFRATÁRIA: RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Kraaij T, Bredewold OW, Trompet S, Huizinga TWJ, Rabelink TJ, de Craen AJM, Teng YKO. TAC-TIC use of tacrolimus-based regimens in lupus nephritis. Lupus Sci Med 2016; 3:e000169. [PMID: 28123768 PMCID: PMC5237713 DOI: 10.1136/lupus-2016-000169] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 12/01/2016] [Accepted: 12/03/2016] [Indexed: 01/22/2023]
Abstract
Current guidelines do not mention tacrolimus (TAC) as a treatment option and no consensus has been reported on the role of TAC in lupus nephritis (LN). The present study aimed to guide clinical judgement on the use of TAC in patients with LN. A meta-analysis was performed for clinical studies investigating TAC regimens in LN on the basis of treatment target (induction or maintenance), concomitant immunosuppression and quality of the data. 23 clinical studies performed in patients with LN were identified: 6 case series, 9 cohort studies, 2 case-control studies and 6 randomised controlled trials (RCTs). Of the 6 RCTs, 5 RCTs investigated TAC regimens as induction treatment and 1 RCT as maintenance treatment. Five RCTs investigated TAC in combination with steroids and 2 TAC with mycophenolate plus steroids. All RCTs were performed in patients of Asian ethnicity. In a meta-analysis, TAC regimens achieved a significantly higher total response (relative risk (RR) 1.23, 95% CI 1.12 to 1.34, p<0.05) and significantly higher complete response (RR 1.48, 95% CI 1.23 to 1.77, p<0.05). The positive outcome was predominantly defined by the largest RCT investigating TAC with mycophenolate plus steroids. Regarding safety, the occurrence of leucopoenia was significantly lower, while the occurrence of increased creatine was higher. Clinical studies on TAC regimens for LN are limited to patients of Asian ethnicity and hampered by significant heterogeneity. The positive results on clinical efficacy of TAC as induction treatment in LN cannot be extrapolated beyond Asian patients with LN. Therefore, further confirmation in multiethnic, randomised trials is mandatory. Until then, TAC can be considered in selected patients with LN.
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Affiliation(s)
- Tineke Kraaij
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands; Clinic for Lupus-, Vasculitis and Complement-Mediated Systemic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Obbo W Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands; Clinic for Lupus-, Vasculitis and Complement-Mediated Systemic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Stella Trompet
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom W J Huizinga
- Clinic for Lupus-, Vasculitis and Complement-Mediated Systemic Diseases, Leiden University Medical Center, Leiden, The Netherlands; Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands; Clinic for Lupus-, Vasculitis and Complement-Mediated Systemic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Anton J M de Craen
- Department of Gerontology and Geriatrics , Leiden University Medical Center , Leiden , The Netherlands
| | - Y K Onno Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands; Clinic for Lupus-, Vasculitis and Complement-Mediated Systemic Diseases, Leiden University Medical Center, Leiden, The Netherlands
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Lee YH, Song GG. Comparative efficacy and safety of tacrolimus, mycophenolate mofetil, azathioprine, and cyclophosphamide as maintenance therapy for lupus nephritis. Z Rheumatol 2016; 76:904-912. [DOI: 10.1007/s00393-016-0186-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fernandez Nieto M, Jayne DR. Con: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1567-71. [PMID: 27591328 DOI: 10.1093/ndt/gfw291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 01/30/2023] Open
Abstract
Lupus nephritis (LN) therapy has limited efficacy due to its toxicity, and LN patients suffer high risks of renal and cardiovascular morbidity and mortality. Calcineurin inhibitors (CNIs) have been used for over >30 years in LN treatment and are an established alternative therapy for Class V nephritis, but uncertainty remains about their role in proliferative disease or in the maintenance of remission. More recently, the combination of CNIs with mycophenolate mofetil (MMF) and glucocorticoid combination therapy, 'multitarget' therapy and the use of tacrolimus as opposed to ciclosporin has received attention. Is the evidence now sufficient to support the routine use of regimens including CNIs in LN? Although CNIs appear to have similar efficacy to MMF-based regimens as induction therapy, and are comparable with azathioprine as maintenance treatment, CNI toxicities, such as new-onset hypertension, hyperglycaemia and nephrotoxicity, have been problematic. Multitarget therapy improves the rate of complete remission in short-term studies, but whether this benefit is maintained over the longer term is uncertain. However, patient tolerability is lower and the frequency of serious events is higher in multitarget versus cyclophosphamide-based regimens, and there is a paucity of evidence from non-Asian ethnic groups. CNI-based therapy is also complicated by the absence of standardized dosing and the need for drug level monitoring, as well as by pharmacogenetic differences. Also, multitarget therapy increases the complexity and the cost of treatment. There is insufficient evidence to support the routine use of CNI-based or multitarget therapy for proliferative LN. Further data on long-term renal and cardiovascular outcomes and strategies to improve tolerability and safety are required.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Schur PH. Laboratory testing for the diagnosis, evaluation, and management of systemic lupus erythematosus: Still more questions for the next generations: A Tribute and Thanks and in Memory of my mentor: Henry G. Kunkel. Clin Immunol 2016; 172:117-121. [PMID: 27506962 DOI: 10.1016/j.clim.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/02/2016] [Accepted: 08/03/2016] [Indexed: 12/01/2022]
Abstract
This paper is a review, personal memoir, a tribute to Henry Kunkel, and a critique regarding laboratory tests used for the evaluation, diagnosis, and understanding Autoimmune Rheumatic Diseases, in particular systemic lupus erythematosus (SLE).
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Affiliation(s)
- Peter H Schur
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
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Riedl M, Kuhn A, Krämer I, Kolbe E, Kahaly GJ. Prospective, systematically recorded mycophenolate safety data in Graves' orbitopathy. J Endocrinol Invest 2016; 39:687-94. [PMID: 26886940 DOI: 10.1007/s40618-016-0441-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 12/17/2022]
Abstract
CONTEXT The antiproliferative mechanism of mycophenolate acid (MPA) suggests a beneficial effect in patients with Graves' orbitopathy (GO). OBJECTIVE To systematically analyze for the first time adverse events (AEs) during MPA treatment in GO. DESIGN Prospective longitudinal study. SETTING Academic tertiary referral center with a joint thyroid-eye clinic. PATIENTS Fifty-three consecutive, unselected patients with clinically active and moderate-to-severe GO. METHODS MPA 0.720 g was given once daily for 24-weeks in GO patients. AEs were documented and coded according to the standardized medical dictionary for regulatory activities (MedDRA). AE were followed up and seriousness as defined by ICH-guideline E6 was documented. All AEs were analyzed regarding a possible underlying cause and if not, graded as side effect (SE). RESULTS Fifty GO patients (93 %) had Graves' disease, 37 (70 %) and 29 (54.7 %) were female and smoker, respectively. Thirty-six patients (68 %) reported at least one AE. A total of 88 AEs were documented, most frequent AEs were insomnia (N = 6), fatigue (N = 5) and optic neuropathy (N = 5), while other AEs occurred in up to three patients (5.6 %), only. In 12 (23 %) patients, at least one SE occurred. All 17 reported SE, i.e. mild infections and gastrointestinal intolerance were within the known safety profile of MPA. No patient dropped MPA medication because of drug-induced SE. Most AEs showed a recovered (76 %) or recovering (16 %) outcome. Seven (13 %) patients were hospitalized, five (62 %) due to optic neuropathy, none of these events was graded as SE. CONCLUSIONS MedDRA-coded data documented the good tolerance of a moderate MPA dose in GO patients.
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Affiliation(s)
- M Riedl
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
- Interdisciplinary Center for Clinical Trials, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - A Kuhn
- Interdisciplinary Center for Clinical Trials, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - I Krämer
- Pharmacy Department, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - E Kolbe
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - G J Kahaly
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany.
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