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Aloor LJ, Skariyachan S, Raghavamenon AC, Kumar KM, Narayanappa R, Uttarkar A, Niranjan V, Cherian T. BRCA1/TP53 tumor proteins inhibited by novel analogues of curcumin - Insight from computational modelling, dynamic simulation and experimental validation. Int J Biol Macromol 2023; 253:126989. [PMID: 37739292 DOI: 10.1016/j.ijbiomac.2023.126989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/06/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
The current study aimed to design novel curcumin analogue inhibitors with antiproliferative and antitumor activity towards BRCA1 and TP53 tumor proteins and to study their therapeutic potential by computer-aided molecular designing and experimental investigations. Four curcumin analogues were computationally designed and their drug-likeness and pharmacokinetic properties were predicted. The binding of these analogues against six protein targets belonging to BRCA1 and TP53 tumor proteins were modelled by molecular docking and their binding energies were compared with that of curcumin and the standard drug cyclophosphamide and its validated target. The stabilities of selected docked complexes were confirmed by molecular dynamic simulation (MDS) and MMGBSA calculations. The best-docked analogue was chemically synthesized, characterized, and used for in vitro cytotoxic screening using DLA, EAC, and C127I cell lines. In vivo antitumor studies were carried out in Swiss Albino Mice. The study revealed that the designed analogues satisfied drug-likeness and pharmacokinetic properties and demonstrated better binding affinity to the selected targets than curcumin. Among the analogues, NLH demonstrated significant interaction with the BRCA1-BRCT-c domain (TG3; binding energy -8.3 kcal/mol) when compared to the interaction of curcumin (binding energy -6.19 kcal) and cyclophosphamide (binding energy -3.8 kcal/mol) and its usual substrate (TG7). The MDS and MM/GBSA studies revealed that the binding free energy of the NLH-TG3 complex (-61.24 kcal/mol) was better when compared to that of the cyclophosphamide-TG7 complex (-21.67 kcal/mol). In vitro, cytotoxic studies showed that NLH demonstrated significant antiproliferative activities against tumor cell lines. The in vivo study depicted NLH possesses the potential for tumor inhibition. Thus, the newly synthesized curcumin analogue is probably used to develop novel therapeutic agents against breast cancer.
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Affiliation(s)
- Lovely Jacob Aloor
- Department of Chemistry, Little Flower College, Guruvayoor, Kerala, India; Post Graduate & Research Department of Chemistry, Christ College (Autonomous), Irinjalakuda, Kerala, India
| | - Sinosh Skariyachan
- Department of Microbiology, St. Pius X College, Rajapuram, Kerala, India.
| | | | - Kalavathi Murugan Kumar
- Department of Bioinformatics, Pondicherry University, Chinna Kalapet, Kalapet, Puducherry, Tamil Nadu, India
| | - Rajeswari Narayanappa
- Department of Biotechnology, Dayananda Sagar College of Engineering, Bengaluru, Karnataka, India
| | - Akshay Uttarkar
- Department of Biotechnology, RV College of Engineering, Bengaluru, Karnataka, India
| | - Vidya Niranjan
- Department of Biotechnology, RV College of Engineering, Bengaluru, Karnataka, India
| | - Tom Cherian
- Post Graduate & Research Department of Chemistry, Christ College (Autonomous), Irinjalakuda, Kerala, India.
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Athanassiou P, Athanassiou L. Current Treatment Approach, Emerging Therapies and New Horizons in Systemic Lupus Erythematosus. Life (Basel) 2023; 13:1496. [PMID: 37511872 PMCID: PMC10381582 DOI: 10.3390/life13071496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/18/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Systemic lupus erythematosus (SLE), the prototype of systemic autoimmune diseases is characterized by extreme heterogeneity with a variable clinical course. Renal involvement may be observed and affects the outcome. Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement. Conventional immunosuppressive therapy includes corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus. However, despite conventional immunosuppressive treatment, flares occur and broad immunosuppression is accompanied by multiple side effects. Flare occurrence, target organ involvement, side effects of broad immunosuppression and increased knowledge of the pathogenetic mechanisms involved in SLE pathogenesis as well as the availability of biologic agents has led to the application of biologic agents in SLE management. Biologic agents targeting various pathogenetic paths have been applied. B cell targeting agents have been used successfully. Belimumab, a B cell targeting agent, has been approved for the treatment of SLE. Rituximab, an anti-CD20 targeting agent is also used in SLE. Anifrolumab, an interferon I receptor-targeting agent has beneficial effects on SLE. In conclusion, biologic treatment is applied in SLE and should be further evaluated with the aim of a good treatment response and a significant improvement in quality of life.
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Affiliation(s)
| | - Lambros Athanassiou
- Department of Rheumatology, Asclepeion Hospital, Voula, GR16673 Athens, Greece
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3
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Kate A, Shanbhag SS, Donthineni PR, Amescua G, Quinones VLP, Basu S. Role of topical and systemic immunosuppression in aqueous-deficient dry eye disease. Indian J Ophthalmol 2023; 71:1176-1189. [PMID: 37026249 PMCID: PMC10276741 DOI: 10.4103/ijo.ijo_2818_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/19/2022] [Accepted: 01/27/2023] [Indexed: 04/08/2023] Open
Abstract
Immunosuppression in aqueous-deficient dry eye disease (ADDE) is required not only to improve the symptoms and signs but also to prevent further progression of the disease and its sight-threatening sequelae. This immunomodulation can be achieved through topical and/or systemic medications, and the choice of one drug over the other is determined by the underlying systemic disease. These immunosuppressive agents require a minimum of 6-8 weeks to achieve their beneficial effect, and during this time, the patient is usually placed on topical corticosteroids. Antimetabolites such as methotrexate, azathioprine, and mycophenolate mofetil, along with calcineurin inhibitors, are commonly used as first-line medications. The latter have a pivotal role in immunomodulation since T cells contribute significantly to the pathogenesis of ocular surface inflammation in dry eye disease. Alkylating agents are largely limited to controlling acute exacerbations with pulse doses of cyclophosphamide. Biologic agents, such as rituximab, are particularly useful in patients with refractory disease. Each group of drugs has its own side-effect profiles and requires a stringent monitoring schedule that must be followed to prevent systemic morbidity. A customized combination of topical and systemic medications is usually required to achieve adequate control, and this review aims to help the clinician choose the most appropriate modality and monitoring regimen for a given case of ADDE.
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Affiliation(s)
- Anahita Kate
- Shantilal Shanghvi Cornea Institue, LV Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | - Swapna S Shanbhag
- Shantilal Shanghvi Cornea Institue, LV Prasad Eye Institute, Hyderabad, Telengana, India
| | - Pragnya R Donthineni
- Shantilal Shanghvi Cornea Institue, LV Prasad Eye Institute, Hyderabad, Telengana, India
| | - Guillermo Amescua
- Department of Ophthalmology, Duke Eye Center, Duke University School of Medicine, Durham 27705, NC, USA
| | - Victor L Perez Quinones
- Foster Center for Ocular Immunology, Department of Ophthalmology, Duke Eye Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sayan Basu
- Shantilal Shanghvi Cornea Institue, LV Prasad Eye Institute, Hyderabad, Telengana, India
- Center for Ocular Regeneration (CORE), L. V. Prasad Eye Institute, Hyderabad, Telangana, India
- Brien Holden Eye Research Centre, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
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Stratman S, Golpanian RS, Fayne R, Kirsner RS, Maderal AD. Malignancy Risk of Non‐Biologic Immunosuppressive Therapies: A Review of the Literature with Evidence‐Based Treatment Recommendations. Exp Dermatol 2022; 31:1656-1664. [DOI: 10.1111/exd.14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Affiliation(s)
- S. Stratman
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Florida USA
| | - R. S. Golpanian
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Florida USA
| | - R. Fayne
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Florida USA
| | - R. S. Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Florida USA
| | - A. D. Maderal
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Florida USA
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Upregulation of Nrf2/HO-1 Signaling and Attenuation of Oxidative Stress, Inflammation, and Cell Death Mediate the Protective Effect of Apigenin against Cyclophosphamide Hepatotoxicity. Metabolites 2022; 12:metabo12070648. [PMID: 35888772 PMCID: PMC9322057 DOI: 10.3390/metabo12070648] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/04/2022] Open
Abstract
Liver injury is among the adverse effects of the chemotherapeutic agent cyclophosphamide (CP). This study investigated the protective role of the flavone apigenin (API) against CP-induced liver damage, pointing to the involvement of Nrf2/HO-1 signaling. Rats were treated with API (20 and 40 mg/kg) for 15 days and received CP (150 mg/kg) on day 16. CP caused liver damage manifested by an elevation of transaminases, alkaline phosphatase (ALP), and lactate dehydrogenase (LDH), and histological alterations, including granular vacuolation, mononuclear cell infiltration, and hydropic changes. Hepatic reactive oxygen species (ROS), malondialdehyde (MDA), and nitric oxide (NO) were increased and glutathione (GSH) and antioxidant enzymes were decreased in CP-administered rats. CP upregulated the inflammatory markers NF-κB p65, TNF-α, IL-6, and iNOS, along with the pro-apoptotic Bax and caspase-3. Pre-treatment with API ameliorated circulating transaminases, ALP, and LDH, and prevented histopathological changes in CP-intoxicated rats. API suppressed ROS, MDA, NO, NF-κB p65, iNOS, inflammatory cytokines, oxidative DNA damage, Bax, and caspase-3 in CP-intoxicated rats. In addition, API enhanced hepatic antioxidants and Bcl-2 and boosted the Nrf2 and HO-1 mRNA abundance and protein. In conclusion, API is effective in preventing CP hepatotoxicity by attenuating oxidative stress, the inflammatory response, and apoptosis. The hepatoprotective efficacy of API was associated with the upregulation of Nrf2/HO-1 signaling.
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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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Weilbeer C, Jay D, Donnelly JC, Gentile F, Karimi-Busheri F, Yang X, Mani RS, Yu Y, Elmenoufy AH, Barakat KH, Tuszynski JA, Weinfeld M, West FG. Modulation of ERCC1-XPF Heterodimerization Inhibition via Structural Modification of Small Molecule Inhibitor Side-Chains. Front Oncol 2022; 12:819172. [PMID: 35372043 PMCID: PMC8968952 DOI: 10.3389/fonc.2022.819172] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/28/2022] [Indexed: 12/02/2022] Open
Abstract
Inhibition of DNA repair enzymes is an attractive target for increasing the efficacy of DNA damaging chemotherapies. The ERCC1-XPF heterodimer is a key endonuclease in numerous single and double strand break repair processes, and inhibition of the heterodimerization has previously been shown to sensitize cancer cells to DNA damage. In this work, the previously reported ERCC1-XPF inhibitor 4 was used as the starting point for an in silico study of further modifications of the piperazine side-chain. A selection of the best scoring hits from the in silico screen were synthesized using a late stage functionalization strategy which should allow for further iterations of this class of inhibitors to be readily synthesized. Of the synthesized compounds, compound 6 performed the best in the in vitro fluorescence based endonuclease assay. The success of compound 6 in inhibiting ERCC1-XPF endonuclease activity in vitro translated well to cell-based assays investigating the inhibition of nucleotide excision repair and disruption of heterodimerization. Subsequently compound 6 was shown to sensitize HCT-116 cancer cells to treatment with UVC, cyclophosphamide, and ionizing radiation. This work serves as an important step towards the synergistic use of DNA repair inhibitors with chemotherapeutic drugs.
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Affiliation(s)
- Claudia Weilbeer
- Department of Chemistry, University of Alberta, Edmonton, AB, Canada
| | - David Jay
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - James C. Donnelly
- Department of Chemistry, University of Alberta, Edmonton, AB, Canada
| | | | | | - Xiaoyan Yang
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Rajam S. Mani
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Yaping Yu
- Centre for Genome Engineering, University of Calgary, Calgary, AB, Canada
| | - Ahmed H. Elmenoufy
- Department of Chemistry, University of Alberta, Edmonton, AB, Canada
- Department of Pharmaceutical Chemistry, College of Pharmacy, Misr University for Science and Technology, 6th of October City, Egypt
| | - Khaled H. Barakat
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB, Canada
| | - Jack A. Tuszynski
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
- Department of Physics, University of Alberta, Edmonton, AB, Canada
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB, Canada
| | - Michael Weinfeld
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Michael Weinfeld, ; Frederick G. West,
| | - Frederick G. West
- Department of Chemistry, University of Alberta, Edmonton, AB, Canada
- Cancer Research Institute of Northern Alberta, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Michael Weinfeld, ; Frederick G. West,
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8
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Conway R, Nikiphorou E. Efficacy and safety of conventional synthetic, biologic and targeted synthetic DMARDs in RA-ILD: A narrative review. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_157_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Takei S, Igarashi T, Kubota T, Tanaka E, Yamaguchi K, Yamazaki K, Itoh Y, Arai S, Okamoto K, Mori M. Clinical practice guidance for childhood-onset systemic lupus erythematosus-secondary publication. Mod Rheumatol 2021; 32:239-247. [PMID: 34910196 DOI: 10.1093/mr/roab002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 11/12/2022]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) has been recognised as a more acute and severe autoimmune disease than adult-onset SLE. With the development of medications for the disease and supportive therapy, the mortality rate associated with cSLE has drastically improved; the 10-year survival rate among patients with cSLE between 1995 and 2006 in Japan was 98.3%. However, the 10-year survival rate without any permanent functional impairment remained low at 66.1%. Therefore, the current treatment goal for cSLE is to ensure that they can perform normal daily activities throughout their lives by preventing the occurrence and/or progression of organ damage. For this purpose, appropriate treatments and evaluations are required according to the severity and risk of organ damage; however, there are no established guidelines for cSLE. Therefore, the Pediatric Rheumatology Association of Japan and the Pediatric Rheumatology Subcommittee in the Japan College of Rheumatology developed a comprehensive guidance for clinical practice based on cSLE-related data collected from Japanese national surveys and relevant articles from both domestic and international sources. However, due to the lack of indications for defined and objective evidence quality levels, this guidance should be used on the basis of the judgement of the attending physicians for individual patients.
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Affiliation(s)
- Syuji Takei
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Toru Igarashi
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Tomohiro Kubota
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Eriko Tanaka
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | - Kenichi Yamaguchi
- Immune Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuko Yamazaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuhiko Itoh
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Satoru Arai
- Department of Dermatology, St. Luke's International Hospital, Tokyo, Japan
| | - Keisuke Okamoto
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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10
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Ungprasert P, Koster MJ, Cheungpasitporn W, Wijarnpreecha K, Thongprayoon C, Kroner PT. Inpatient epidemiology and economic burden of granulomatosis with polyangiitis: a 10-year study of the national inpatient sample. Rheumatology (Oxford) 2021; 59:3685-3689. [PMID: 32129858 DOI: 10.1093/rheumatology/keaa069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/25/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To characterize inpatient epidemiology and economic burden of granulomatosis with polyangiitis (GPA). METHODS Patients with GPA were identified from the Nationwide Inpatient Sample (NIS), the largest inpatient database in the USA consisting of over 4000 non-federal acute care hospitals, using the ICD-9 CM code. A cohort of comparators without GPA was also constructed from the same database. Data on demographics, procedures, length of stay, mortality, morbidity and total hospitalization charges were extracted. All analysed data were extracted from the database for the years 2005-2014. RESULTS The inpatient prevalence of GPA was 32.6 cases per 100 000 admissions. GPA itself (38.3%), pneumonia (13.7%) and sepsis (8.4%) were the most common reasons for admission. After adjusting for potential confounders, the all-cause mortality adjusted odds ratio (aOR) of patients with GPA was significantly higher than that of patients without GPA (aOR 1.20; 95% CI: 1.41, 1.61). This was also true for several morbidities, including acute kidney injury, multi-organ failure, shock and need for intensive care unit admission. Hospitalizations of patients with GPA were associated with higher cost as demonstrated by an adjusted additional mean of $5125 (95% CI: $4719, $5531) for total hospital cost and an adjusted additional mean of $16 841 (95% CI: $15 280, $18 403) for total hospitalization charges when compared with patients without GPA. CONCLUSION Inpatient prevalence of GPA was higher than what would be expected from prevalence in the general population. Hospitalizations of patients with GPA were associated with higher morbidity, mortality and cost.
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Affiliation(s)
- Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH
| | - Matthew J Koster
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul T Kroner
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
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Alhendi FJ, Werth VP, Sollecito TP, Stoopler ET. Systemic sclerosis: Update for oral health care providers. SPECIAL CARE IN DENTISTRY 2021; 40:418-430. [PMID: 33448431 DOI: 10.1111/scd.12492] [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] [Received: 04/28/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022]
Abstract
Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune disease of unknown origin characterized by an uncontrolled inflammatory process resulting in fibrosis of the skin, internal organs and vasculopathy. Manifestations of SSc are heterogenous and can include pulmonary, cardiac, neural, renal, muscular, cutaneous and orofacial complications. Recent scientific advances have led to a better understanding of disease etiopathogenesis and the development of a new classification system. Therapeutic management is often multidisciplinary and targeted toward the affected organs. Oral health care providers (OHCPs) should be familiar with SSc, particularly as it relates to its impact on the orofacial region and modifications to delivery of oral health care for patients with this condition.
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Affiliation(s)
- Fatmah J Alhendi
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Dermatology, Philadelphia V.A. Hospital, Hospital of the University of Pennsylvania and the Veteran's Administration Medical Center, Philadelphia, Pennsylvania
| | - Thomas P Sollecito
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Eric T Stoopler
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
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Lopalco G, Rigante D, Lopalco A, Emmi G, Venerito V, Vitale A, Capozio G, Denora N, Cantarini L, Iannone F. Safety of systemic treatments for Behçet's syndrome. Expert Opin Drug Saf 2020; 19:1269-1301. [PMID: 32883123 DOI: 10.1080/14740338.2020.1817379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Treatment of Behçet's syndrome (BS) is aimed at controlling all symptoms of such a complex disorder, ensuring a good quality of life and preventing life-threatening complications. A better understanding of the pathogenic role of different chemokines has improved our knowledge of BS and elicited a more specific use of therapies currently available, minimizing the burden of potential side-effects related to treatment. AREAS COVERED This work aims to provide a detailed overview of the safety profile for current therapies available in the treatment of BS, focusing on the main side-effects, toxicity and contraindications. EXPERT OPINION The greatest experience in the management of BS has been achieved with the employment of monoclonal anti-tumor necrosis factor antibodies which have been advocated for BS refractory manifestations. Moreover, interleukin-1 inhibitors have proven to be effective as well as safe, despite escalation of their dosage, especially to manage the most severe and difficult-to-treat ocular manifestations. However, general treatment of BS patients remains awkward as protean clinical features may respond differently to the same treatment or even worsen. Therefore, patients' safety for therapies used in BS promotes the implementation of precision medicine, which could help targeting accurately the pathogenetic mechanisms concealed behind specific clinical phenotypes.
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Affiliation(s)
- Giuseppe Lopalco
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy.,Università Cattolica Sacro Cuore , Rome, Italy
| | - Antonio Lopalco
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence , Florence, Italy
| | - Vincenzo Venerito
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Antonio Vitale
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Giovanna Capozio
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy
| | - Nunzio Denora
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Luca Cantarini
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
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13
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Inpatient burden and association with comorbidities of polyarteritis nodosa: National Inpatient Sample 2014. Semin Arthritis Rheum 2019; 50:66-70. [PMID: 31362895 DOI: 10.1016/j.semarthrit.2019.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To characterize inpatient burden, expenditures and association with comorbidities of polyarteritis nodosa (PAN). METHODS Patients with PAN were identified from the Nationwide Inpatient Sample (NIS) database for the year 2014 using ICD-9 diagnostic codes. The primary outcome was determining the inpatient prevalence of PAN in hospitalized patients in the US. Secondary outcomes included determining inpatient mortality, morbidity, comorbidities, hospital length of stay (LOS) and total hospital costs and charges. A cohort of patients without PAN was also identified from the same database to serve as comparators for analysis of comorbidities. Multivariate regression analysis was used to adjust for age, gender, ethnicity, comorbidities and hospital characteristics. RESULTS A total of 4,110 patients with PAN were included in the study. The mean age was 59.5 years and 61% were female. The inpatient prevalence of PAN was 11.6 cases per 100,000 discharges. Patients with PAN displayed increased adjusted odds of mortality (OR:1.35, p = 0.13), shock (OR:1.75, p<0.01), ICU admission (OR:1.88, p<0.01) and multiorgan failure (OR:3.12, p<0.01) compared to patients without PAN. Patients with PAN also displayed significantly higher hospital costs (additional adjusted mean [aAM]: $9,693, p<0.01), hospitalization charges (aAM: $34,273, p<0.01) and LOS (aAM: 4.1 days, p<0.01) compared to patients without PAN. Analysis of comorbidities found a significant association between PAN and venous thromboembolism, renal injury and sepsis. The main limitation of this study was reliance on accuracy of diagnostic coding. The high inpatient prevalence of PAN might have been inflated and we cannot be certain that the higher risk of comorbidities and expenditures were entirely attributable to PAN as some patients in this cohort may have other vasculitides. CONCLUSIONS The inpatient prevalence of PAN is higher than what would be expected from the overall general prevalence. Hospitalizations of patients with PAN are associated with significantly higher rates of morbidity and expenditures.
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Mühlig AK, Lee JY, Kemper MJ, Kronbichler A, Yang JW, Lee JM, Shin JI, Oh J. Levamisole in Children with Idiopathic Nephrotic Syndrome: Clinical Efficacy and Pathophysiological Aspects. J Clin Med 2019; 8:E860. [PMID: 31208104 PMCID: PMC6617114 DOI: 10.3390/jcm8060860] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/28/2022] Open
Abstract
Steroid sensitive nephrotic syndrome is one of the most common pediatric glomerular diseases. Unfortunately, it follows a relapsing and remitting course in the majority of cases, with 50% of all cases relapsing once or even more often. Most children with idiopathic nephrotic syndrome respond initially to steroid therapy, nevertheless repeated courses for patients with relapses induce significant steroid toxicity. Patients with frequent relapses or steroid dependency thus require alternative treatment, such as cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, levamisole, or rituximab. To reduce the relapse rate, several drugs have been used. Among these, levamisole has been considered the least toxic and least expensive therapy. Several randomized controlled trials (RCT) showed that levamisole is effective in reducing the relapse risk in steroid sensitive forms of nephrotic syndrome with a low frequency of side effects. Levamisole is a synthetic imidazothiazole derivative with immune-modulatory properties. In this article, we review recent data from randomized trials and observational studies to assess the efficacy of levamisole in frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome.
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Affiliation(s)
- Anne K Mühlig
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klink Nord-Heidberg, 22417 Hamburg, Germany.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck 6020, Austria.
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Jiwon M Lee
- Department of Pediatric Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea.
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jun Oh
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
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Ponticelli C, Glassock RJ. Prevention of complications from use of conventional immunosuppressants: a critical review. J Nephrol 2019; 32:851-870. [PMID: 30927190 DOI: 10.1007/s40620-019-00602-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/21/2019] [Indexed: 01/08/2023]
Abstract
Synthetic immunosuppressive drugs are largely used in immune-related renal diseases and in kidney transplantation. Most of these drugs have a low therapeutic index (the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective), which means that the drug should be dosed carefully and the patient monitored frequently. In this review, we consider the categories of synthetic immunosuppressive agents more frequently and conventionally used in clinical nephrology: glucocorticoids, Aalkylating agents (cyclophosphamide, chlorambucil), purine synthesis inhibitors (azathioprine, mycophenolate salts) and calcineurin inhibitors (cyclosporine, tacrolimus). For each category the possible side effects will be reviewed, the general and specific measures to prevent or treat the adverse events will be suggested, and the more common mistakes that may increase the risk of toxicity will be described. However, the efficacy and safety of immunosuppressive agents depend not only on the pharmacologic characteristics of single drugs but can be influenced also by the clinical condition and genetic characteristics of the patient, by the typology and severity of the underlying disease and by the interaction with other concomitantly used drugs.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Istituto Scientifico Ospedale Maggiore, Milan, Italy.
- , Via Ampere 126, 20131, Milan, Italy.
| | - Richard J Glassock
- The David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Hong JH, Kim HJ, Park KS, Ku BJ. Paradigm shift in the management of type B insulin resistance. ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S98. [PMID: 30740419 DOI: 10.21037/atm.2018.11.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jun Hwa Hong
- Department of Internal Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Kang Seo Park
- Department of Internal Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea
| | - Bon Jeong Ku
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
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17
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Ghorbani A, Masoumi K, Forouzan A, Rahmani A, Rahim F, Taeybi BT, Feli M. Effect of Pulse Therapy with Glucocorticoids and Cyclophosphamide in Patients with Paraquat Poisoning. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction Paraquat (PQ) is a widely used herbicide with a high mortality rate when ingested. The aim of the present study was to assess the effectiveness of repeated cyclosphosphamide (CP) and methylprednisolone (MP) combination in the treatment of PQ poisoning. Design Randomised, double-blinded, placebo-controlled trial. Methods Eligible participants were 47 patients with moderate to severe PQ poisoning within 24 hours of hospitalisation. Patients were allocated in a random fashion, 24 as the intervention and 23 as the control group. All patients received two cycles of eight hours of haemoperfusion with charcoal, and underwent emergency haemodialysis. After the dialysis, the intervention group received 15 mg/kg CP for two days and 1g MP for three days. The control group received routine supportive care. Outcome parameters, including mortality, incidence of hypoxia, hepatitis and renal failure were compared between the two groups. Results There were no significant differences between the two groups with regard to age, sex, baseline liver function test, creatinine, time from poisoning to dialysis, and time from poisoning to the hospitalisation. Although the incidence of hepatitis and acute renal failure did not differ significantly between the two groups, the incidence of hypoxia and mortality rate was lower in the intervention group. The number need-to-treat to reduce one mortality was 2.8. Conclusion The results suggest that CP and MP repeated treatment can reduce the mortality rate in moderate to severe PQ intoxication.
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Affiliation(s)
- A Ghorbani
- Razi Hospital, Department of Forensic Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
| | - K Masoumi
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - A Forouzan
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ah Rahmani
- Razi Hospital, Department of Forensic Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
| | - F Rahim
- Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - B Taherinezhad Taeybi
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - M Feli
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Abstract
The majority of rheumatic diseases are chronic and require long-term use of disease-modifying agents to confer the best chance of controlling the disease. A significant proportion of these drugs have a risk, albeit small, of potentially serious side effects, such as neutropenia; therefore, there has been an understandable concern over the use of potentially toxic rheumatic drugs in the elderly. Factors that may contribute to this concern include age, pre-existing co-morbidities, polypharmacy, difficulty in monitoring side effects, and patient perception. The risk of using such medication needs to be balanced with their benefits in controlling chronic disease. This review discusses how rheumatic disease and anti-rheumatic medication are associated with neutropenia in an older age group. Of the rheumatic diseases, we give special focus to rheumatoid arthritis and the use of methotrexate, as well as touching on management considerations in neutropenia.
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Banerjee S, Biehl A, Ghaderi-Yeganeh M, Manna Z, Hasni S. Low incidence of opportunistic Infections in Lupus Patients treated with Cyclophosphamide and Steroids in a Tertiary care setting. ACTA ACUST UNITED AC 2017; 5. [PMID: 29276769 DOI: 10.18103/mra.v5i3.1084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Infection is common cause of morbidity and mortality in systemic lupus erythematosus (SLE). Our objective was to determine incidence and types of infections, particularly opportunistic infections, in SLE patients receiving cyclophosphamide, and to identify contribution of variables like demographics, steroid, other immunosuppressives, white blood cell and absolute neutrophil count to infection risk. Patients and Methods We did retrospective chart review of SLE patients in our institute over last 10 years, who received minimum six cyclophosphamide infusions. Types of infection, cumulative steroid dose, and maintenance medications were recorded. Statistical analyses were done using SAS software. Results 87.1% of the 31 patients were female. Mean age was 37.9 years, 48.4% Hispanic, 25.8% African American, 6.4% Asian and 19.4% were Caucasian. No one was on pneumocystis jirovecii pneumonia (PJP) prophylaxis. There were 42 episodes of infection in 31 patients. Different infections were urinary tract infections (UTI), upper respiratory infections (URI), line sepsis, bacterial pneumonia, PJP, mucocutaneous infections and viral gastroenteritis. Infection frequency was significantly higher among Asians compared to Caucasians (p =0.0152). Infection rate was significantly higher during cyclophosphosphamide induction phase (65.9%) compared to maintenance phase (34.1%) (p value=0.0041). Infection rate was higher with higher cumulative steroid dose and in patients on quarterly cyclophosphamide infusion compared to those on oral azathioprine or mycophenolate mofetil. No association found among baseline white blood cell (WBC) or absolute neutrophil count (ANC) and infection rate. Conclusion We found higher infection rates among Asians and in patients with higher cumulative steroid dose. Single incidence of PJP noted despite absence of prophylaxis. Quarterly cyclophosphamide was associated with higher infection rates. Larger prospective studies are needed to confirm our results.
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Affiliation(s)
- Shubhasree Banerjee
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ann Biehl
- National Institutes of Health Clinical Center Department of Pharmacy, National Institutes of Health, Bethesda, Maryland
| | - Maryam Ghaderi-Yeganeh
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Zerai Manna
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sarfaraz Hasni
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
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Venkatesh P, Gogia V, Gupta S, Tayade A, Shilpy N, Shah BM, Guleria R. Pulse cyclophosphamide therapy in the management of patients with macular serpiginous choroidopathy. Indian J Ophthalmol 2016; 63:318-22. [PMID: 26044470 PMCID: PMC4463555 DOI: 10.4103/0301-4738.158070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: To evaluate safety and efficacy of intravenous pulse cyclophosphamide (CyP) in acute macular serpiginous choroiditis (SC). Methods: Patients with acute macular SC with lesions threatening and/or involving fovea were enrolled. All patients received CyP (1 g/m2 ) for 3 days followed by high-dose oral steroids (1.5 mg/kg) tapered over 6 months and monitored for visual acuity, response to treatment and systemic side effects. Results: Eight patients (seven unilateral and one bilateral) with median age of 27 years (range: 13–40 years) were recruited. Mean visual acuity at presentation was 0.71 ± 0.35 logarithm of the minimum angle of resolution while postpulse visual acuity was 0.40 ± 0.32. Final mean visual acuity at 1-year was 0.31 ± 0.23 (P ≤ 0.05). Three eyes had recurrence and 3 patients developed transient hair loss with no other adverse effect. Conclusion: Intravenous CyP provides rapid resolution of lesion activity and thereby helps in maintaining good functional acuity.
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Affiliation(s)
| | - Varun Gogia
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol 2016; 61:702-717. [DOI: 10.1016/j.survophthal.2016.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/12/2022]
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Schupp JC, Köhler T, Müller-Quernheim J. Usefulness of Cyclophosphamide Pulse Therapy in Interstitial Lung Diseases. Respiration 2016; 91:296-301. [PMID: 27082957 DOI: 10.1159/000445031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Interstitial lung diseases (ILDs) are a group of disorders characterised by progressive lung function decline. Stabilisation of lung function under intermittent i.v. cyclophosphamide was shown in patients suffering from systemic sclerosis, yet data in ILD patients are scarce. OBJECTIVES To retrospectively evaluate the usefulness of cyclophosphamide pulse therapy in ILD. METHODS We retrospectively analysed all patients who received i.v. cyclophosphamide in our centre from 2002 to 2012. Lung function, survival status, and bronchoalveolar lavage cytology were recorded during a follow-up period of 18 months. RESULTS Twenty-six patients with idiopathic pulmonary fibrosis, 6 with lymphocytic interstitial pneumonia (LIP), 8 with idiopathic non-specific interstitial pneumonia (NSIP), 7 with rheumatoid arthritis-associated ILD, and 7 with perinuclear anti-neutrophil cytoplasmic antibody-positive ILD (pANCA+ ILD) were included. Patients with LIP and NSIP had the best survival outcome, those with pANCA+ ILD the worst. In the total cohort, we found a significantly higher total lung capacity decline in the year before treatment compared to the year after treatment. CONCLUSIONS This retrospective analysis of cyclophosphamide treatment shows a stabilisation of lung function in most patients with fibrotic ILDs, yet prospective studies in clearly defined diagnoses are urgently needed.
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Affiliation(s)
- Jonas Christian Schupp
- Department of Pneumology, University Medical Centre, Albert Ludwig University, Freiburg, Germany
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Lee WJ, Lee ST, Byun JI, Sunwoo JS, Kim TJ, Lim JA, Moon J, Lee HS, Shin YW, Lee KJ, Kim S, Jung KH, Jung KY, Chu K, Lee SK. Rituximab treatment for autoimmune limbic encephalitis in an institutional cohort. Neurology 2016; 86:1683-91. [PMID: 27037228 DOI: 10.1212/wnl.0000000000002635] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/04/2016] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine efficacy and safety of rituximab treatment as a second-line immunotherapy treatment for autoimmune limbic encephalitis (ALE) and to determine factors associated with functional improvement and favorable outcome following rituximab treatment. METHODS We recruited 80 patients with ALE who were treated with rituximab as a second-line immunotherapy from the Korea Autoimmune Synaptic and Paraneoplastic Encephalitis Registry and reviewed 81 patients without rituximab as a control. We grouped patients according to the detection or type of antibodies; in addition, we evaluated clinical, laboratory, first-line immunotherapy, and rituximab treatment profiles and defined main outcomes as improvements on the modified Rankin Scale (mRS) score and a favorable mRS score (0-2) at the last follow-up. RESULTS Functional improvement occurred more frequently in the rituximab group compared to the control group. In the rituximab group, 30 (37.5%) patients had synaptic autoantibodies, 15 (18.8%) in the paraneoplastic autoantibodies, and 35 (43.8%) were antibody-negative. The effect of rituximab was the same regardless of autoantibody status. Additional monthly rituximab therapy and partial response to first-line immunotherapies were associated with mRS score improvements, as well as favorable mRS scores. mRS scores of 4-6 as the worst neurologic status predicted an unfavorable mRS score. There were no reported serious infusion-related or infectious adverse effects of rituximab. CONCLUSIONS Rituximab is effective and safe as a second-line immunotherapy for ALE, regardless of autoantibody status. Additional monthly rituximab therapy might potentiate the efficacy of rituximab. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that rituximab improves mRS scores for patients with autoimmune limbic encephalitis who fail first-line therapy.
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Affiliation(s)
- Woo-Jin Lee
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Soon-Tae Lee
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Jung-Ick Byun
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Jun-Sang Sunwoo
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Tae-Joon Kim
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Jung-Ah Lim
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Jangsup Moon
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Han Sang Lee
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Yong-Won Shin
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Keon-Joo Lee
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Soyun Kim
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Keun-Hwa Jung
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Ki-Young Jung
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea
| | - Kon Chu
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea.
| | - Sang Kun Lee
- From the Department of Neurology (W.-J.L., S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., S.K., K.-H.J., K.-Y.J., K.C., S.K.L.), Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital; and Program in Neuroscience (S.-T.L., J.-I.B., J.-S.S., T.-J.K., J.-A.L., J.M., H.S.L., Y.-W.S., K.-J.L., K.-H.J., K.-Y.J., K.C., S.K.L.), Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Soonchunhyang University School of Medicine (J.-S.S.), Seoul, South Korea.
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Kim J, Chan JJ. Cyclophosphamide in dermatology. Australas J Dermatol 2016; 58:5-17. [PMID: 26806212 DOI: 10.1111/ajd.12406] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 09/02/2015] [Indexed: 01/19/2023]
Abstract
Cyclophosphamide is a chemotherapeutic agent which was first discovered in experimental tumours in rats, and it has since been widely used to treat malignancies and severe manifestations of various auto-immune diseases. High-dose chemotherapy and continuous daily oral regimens are associated with significant toxicity profiles, but i.v. pulsed regimens have lowered the rates of adverse effects in rheumatological studies. Cyclophosphamide has been shown to be useful in the treatment of severe autoimmune conditions due to its powerful immunosuppressive ability; however, it remains a relatively underused modality in dermatology. This article reviews the current literature on cyclophosphamide and its clinical applications in dermatology.
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Affiliation(s)
- Janet Kim
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan J Chan
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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25
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Knickelbein JE, Armbrust KR, Kim M, Sen HN, Nussenblatt RB. Pharmacologic Treatment of Noninfectious Uveitis. Handb Exp Pharmacol 2016; 242:231-268. [PMID: 27848029 DOI: 10.1007/164_2016_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Uveitis encompasses a spectrum of diseases whose common feature is intraocular inflammation, which may be infectious or noninfectious in etiology (Nussenblatt and Whitcup 2010). Infectious causes of uveitis are typically treated with appropriate antimicrobial therapy and will not be discussed in this chapter. Noninfectious uveitides are thought have an autoimmune component to their etiology and are thus treated with anti-inflammatory agents.
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Affiliation(s)
- Jared E Knickelbein
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Karen R Armbrust
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Meredith Kim
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA.
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26
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Yilmaz N, Emmungil H, Gucenmez S, Ozen G, Yildiz F, Balkarli A, Kimyon G, Coskun BN, Dogan I, Pamuk ON, Yasar S, Cetin GY, Yazici A, Ergulu Esmen S, Cagatay Y, Yilmaz S, Cefle A, Sayarlioglu M, Kasifoglu T, Karadag O, Pehlivan Y, Dalkilic E, Kisacik B, Cobankara V, Erken E, Direskeneli H, Aksu K, Yavuz S. Incidence of Cyclophosphamide-induced Urotoxicity and Protective Effect of Mesna in Rheumatic Diseases. J Rheumatol 2015; 42:1661-6. [DOI: 10.3899/jrheum.150065] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
Objective.To assess bladder toxicity of cyclophosphamide (CYC) and uroprotective effect of mesna in rheumatic diseases.Methods.Data of 1018 patients (725 women/293 men) treated with CYC were evaluated in this retrospective study. All of the following information was obtained: the cumulative CYC dose, route of CYC administration, duration of therapy, concomitant mesna usage, and hemorrhagic cystitis. Cox proportional hazard model was used for statistics.Results.We identified 17 patients (1.67%) with hemorrhagic cystitis and 2 patients (0.19%) with bladder cancer in 4224 patient-years. The median time for diagnosis to hemorrhagic cystitis was 10 months (4–48) and bladder cancer was 8 years (6–10.9). There were 583 patients (57.2%) who received mesna with intravenous CYC therapy. We observed similar incidence rate for hemorrhagic cystitis in both patient groups concomitantly treated with or without mesna [9/583 (1.5%) vs 8/425 (1.8%) respectively, p = 0.08]. Cumulative CYC dose (HR for 10-g increments 1.24, p < 0.001) was associated with hemorrhagic cystitis.Conclusion.Cumulative dose was the only risk factor for hemorrhagic cystitis in patients treated with CYC. No proof was obtained for the uroprotective effect of mesna in our cohort.
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Abstract
Uveitis is a group of inflammatory ocular conditions that cause significant visual morbidity around the world. Many of the cases of blindness secondary to uveitis can be avoided with adequate and aggressive management of the intraocular inflammation. Steroids have been utilized in the treatment of noninfectious uveitis for more than 60 years, but their chronic use is associated with severe ocular and systemic side-effects. Ophthalmologists are often not familiar with the systemic steroid-sparing agents available for the management of ocular inflammation and depend primarily on the use of corticosteroids. In this article, we review the most common agents utilized in the treatment of uveitis and their side-effect profiles.
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Affiliation(s)
- Eduardo Uchiyama
- Department of Ophthalmology , Massachusetts Eye and Ear Infirmary, Boston, Massachusetts , USA and
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28
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Abe Y, Shima T, Izumi Y, Kitamura M, Yamashita H, Tsuji Y, Sasaki O, Maeda C, Kawahara C, Torisu A, Kawaguchi Y, Kurohama H, Ito M, Iwanaga N, Kawakami A, Nakayama T, Taguchi T, Migita K. Successful Management of Lupus Nephritis with High Titers of Myeloperoxidase Anti-Neutrophil Cytoplasmic Antibodies Using Tacrolimus. Intern Med 2015; 54:2929-33. [PMID: 26568012 DOI: 10.2169/internalmedicine.54.4343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 63-year-old Japanese woman with a 30-year history of systemic lupus erythematosus developed macrohematuria and massive proteinuria after seroconversion of myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA). A renal biopsy indicated focal proliferative lupus nephritis (class III A/C) with a fibrous crescent formation. Methylprednisolone pulse therapy (500 mg, 3 successive days) was administered because of progressive proteinuria. Steroid therapy did not suppress the progressive proteinuria; therefore, tacrolimus was added as an alternative immunosuppressive therapy, resulting in the improvement of proteinuria and renal impairment. This case report suggests that MPO-ANCA might play a pathogenic role in the exacerbation of immune-complex-type lupus nephritis.
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Affiliation(s)
- Yoshikazu Abe
- Department of General Internal Medicine and Rheumatology, Nagasaki Medical Center, Japan
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29
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Severe infections in patients with autoimmune diseases treated with cyclophosphamide. ACTA ACUST UNITED AC 2014; 11:221-3. [PMID: 25455720 DOI: 10.1016/j.reuma.2014.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/24/2014] [Accepted: 09/19/2014] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Infectious diseases are a significant cause of morbidity and mortality in patients with connective tissue diseases. Corticosteroids and immunosuppressive drugs, such as cyclophosphamide (CYC), increases the risk of infections. The objective of this study was to estimate the incidence rates of severe infections in patients who received treatment with CYC. PATIENTS AND METHODS The records of 60 patients with systemic autoimmune diseases who received treatment with CYC were retrospectively reviewed. We evaluated the rate of severe infections that occurred during CYC therapy and the 3 subsequent months. RESULTS Systemic lupus erythematosus was the most common disease, and diffuse proliferative glomerulonephritis the most frequent indication. Severe infection occurred in 9 patients (15%). Community acquired pneumonia was the most frequent infection with 3 cases (33%) followed by Herpes Zoster with 2 reports (22%). The cumulative dose of corticosteroid was the only significant risk factor for infection 32.8±16.7 vs. 20.1±15.3 P=.007. CONCLUSION The use of lower doses of corticosteroids and an aggressive management of infectious complications, allows for an acceptable safety profile in patients treated with CYC.
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Vinet É, Bernatsky S, Hudson M, Pineau CA, Baron M. Effect of menopause on the modified Rodnan skin score in systemic sclerosis. Arthritis Res Ther 2014; 16:R130. [PMID: 24957704 PMCID: PMC4095602 DOI: 10.1186/ar4587] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 06/05/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction We aimed to evaluate the effect of menopause on skin thickening, as measured by the modified Rodnan skin score (mRSS), in women with systemic sclerosis (SSc). Methods We identified women with either limited or diffuse SSc, aged ≥ 18 years, enrolled within the Canadian Scleroderma Research Group (CSRG) cohort, between 2004 and 2011. As part of the CSRG cohort, subjects undergo annual assessments with standardized questionnaires and physical examinations. We performed multivariate regression analyses using generalized estimating equation (GEE) to determine the effect of menopause on the mRSS, adjusting for relevant covariates including notably age, follow-up time, and disease duration. Results We identified 1070 women with SSc, contributing a total of 3546 observations over the study period. Of these women, at baseline, 65% had limited disease and 35% diffuse disease. In multivariate analyses, we observed a substantial effect of postmenopausal status on the mean mRSS in women with diffuse disease subtype [−2.62 units, 95% confidence interval (CI) -4.44, −0.80] and significant interaction between menopausal status and disease subtype (2.04 units, 95% CI 0.20, 3.88). The effect of postmenopausal status on the mean mRSS was smaller in women with limited SSc (−0.58, 95% CI −1.50, 0.34). Conclusions Our results suggest that menopause has a substantial effect on skin thickening in diffuse SSc, with postmenopausal status being associated with a lower mean mRSS compared to premenopausal status.
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Patel MP, Kute VB, Vanikar AV, Trivedi HL. Cyclophosphamide-induced toxic epidermal necrolysis: vigilance needed. Clin Kidney J 2014; 7:323-4. [PMID: 25852901 PMCID: PMC4377749 DOI: 10.1093/ckj/sfu027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 02/26/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mohan P Patel
- Department of Nephrology and Clinical Transplantation , Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS] , Ahmedabad , India
| | - Vivek B Kute
- Department of Nephrology and Clinical Transplantation , Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS] , Ahmedabad , India
| | - Aruna V Vanikar
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology , IKDRC-ITS , Ahmedabad , India
| | - Hargovind L Trivedi
- Department of Nephrology and Clinical Transplantation , Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences [IKDRC-ITS] , Ahmedabad , India
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Sharma VK, Khandpur S. Evaluation of cyclophosphamide pulse therapy as an adjuvant to oral corticosteroid in the management of pemphigus vulgaris. Clin Exp Dermatol 2013; 38:659-64. [DOI: 10.1111/ced.12073] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2012] [Indexed: 11/28/2022]
Affiliation(s)
- V. K. Sharma
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi; India
| | - S. Khandpur
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi; India
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Stankiewicz JM, Kolb H, Karni A, Weiner HL. Role of immunosuppressive therapy for the treatment of multiple sclerosis. Neurotherapeutics 2013; 10:77-88. [PMID: 23271506 PMCID: PMC3557368 DOI: 10.1007/s13311-012-0172-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Immunosuppressives have been used in multiple sclerosis (MS) since 1966. Today, we have many treatments for the relapsing forms of the disease, including 8 US Food and Drug Administration-approved therapies, with more soon to be introduced. Given the current treatment landscape what place do immunosuppressants have in combating MS? Trial work and our experience suggest that immunosuppressives still have an important role in treating MS. Cyclophosphamide finds use in treating patients with severe, inflammatory relapsing remitting MS or those suffering from a fulminant attack. We tend to employ mycophenolate mofetil as an add-on to injectable therapy for patients experiencing breakthrough activity. Some progressive (primary progressive multiple sclerosis or secondary progressive multiple sclerosis) patients may stabilize after treatment with either cyclophosphamide or mycophenolate. We rarely employ mitoxantrone because of potential cardiac or carcinogenic effects. We prefer to use cyclophosphamide or mycophenolate mofetil in preference to methotrexate because evidence of efficacy is limited for this drug. We have less experience with azathioprine, but it may be an alternative for patients with limited options who are unable to tolerate conventional therapies.
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Affiliation(s)
- James M. Stankiewicz
- />Department of Neurology, Brigham and Women’s Hospital, Center for Neurologic Disease and Partners MS Center, Harvard Medical School, Boston, MA USA
| | - Hadar Kolb
- />Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler’s Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Karni
- />Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler’s Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Howard L. Weiner
- />Department of Neurology, Brigham and Women’s Hospital, Center for Neurologic Disease and Partners MS Center, Harvard Medical School, Boston, MA USA
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Alantar A, Cabane J, Hachulla E, Princ G, Ginisty D, Hassin M, Sorel M, Maman L, Pilat A, Mouthon L. Recommendations for the care of oral involvement in patients with systemic sclerosis. Arthritis Care Res (Hoboken) 2011; 63:1126-33. [PMID: 21485023 DOI: 10.1002/acr.20480] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To review the literature and collect expert advice for proposing preventive and curative treatments of mouth and dental involvement in patients with systemic sclerosis (SSc; scleroderma). METHODS The literature pertaining to mouth and/or dental involvement related to SSc was reviewed, and recommendations were developed according to the suggestions of a French multidisciplinary working group of experts and validated by a lecture committee. RESULTS Dentists face 3 main issues in caring for SSc patients: oral mucosa involvement, manducatory apparatus and mouth involvement responsible for limitations in mouth opening, and treatment-related adverse events. An increased risk of tongue carcinoma has been noted. In patients with severe limitation in mouth opening (<30 mm), recommended treatments are a specific mouth-opening rehabilitation program, flexible sectional dentures, and splint therapy. Indications for dental implants depend on the severity of SSc, comorbidities, and/or ongoing bisphosphonate treatment. Prevention of mouth infections and caries implies patient education and teaching about mouth and dental hygiene, periodontal maintenance, and treatment of sicca syndrome. Cessation of tobacco use is mandatory. Patient-tailored rehabilitation may improve limitations in mouth opening. Systematic dental panoramic radiography allows for the early detection of dental caries. CONCLUSION Prevention of oral and dental complications is a major issue in patients with SSc. Dental treatment should be tailored to limitations in mouth opening, disease severity, and ongoing treatments.
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Affiliation(s)
- Alp Alantar
- Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HOP, 27 Rue du Faubourg Saint-Jacques, Paris Cedex 14, France
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Hirshfeld-Cytron J, Gracia C, Woodruff TK. Nonmalignant diseases and treatments associated with primary ovarian failure: an expanded role for fertility preservation. J Womens Health (Larchmt) 2011; 20:1467-77. [PMID: 21827325 DOI: 10.1089/jwh.2010.2625] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cancer treatments can be detrimental to fertility; recent literature has focused on the efforts of fertility preservation for this patient population. It should be recognized, however, that several nonmalignant medical conditions and therapeutic interventions could be similarly hazardous to fertility. Some of these nonmalignant diseases and their treatments that can adversely impact the reproductive axis are gastrointestinal diseases, rheumatologic disorders, nonmalignant hematologic conditions, neurologic disorders, renal disorders, gynecologic conditions, and metabolic diseases. Their negative effects on reproductive function are only now being appreciated and include impaired ovarian function, endocrine function, or sexual function and inability to carry a pregnancy to term. Complications and comorbidities associated with certain diseases may limit the success of established fertility preservation options. Recent advances in fertility preservation techniques may provide these patients with new options for childbearing. Here, we review several fertility-threatening conditions and treatments, describe current established and experimental fertility preservation options, and present three initiatives that may help minimize the adverse reproductive effects of these medical conditions and treatments by raising awareness of the issues and options: (1) increase awareness among practitioners about the reproductive consequences of specific diseases and treatments, (2) facilitate referral of patients to fertility-sparing or restorative programs, and (3) provide patient education about the risk of infertility at the time of diagnosis before initiation of treatment.
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Affiliation(s)
- Jennifer Hirshfeld-Cytron
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Stummvoll GH, Schmaldienst S, Smolen JS, Derfler K, Biesenbach P. Lupus nephritis: prolonged immunoadsorption (IAS) reduces proteinuria and stabilizes global disease activity. Nephrol Dial Transplant 2011; 27:618-26. [DOI: 10.1093/ndt/gfr239] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Meyer KC, Decker C, Baughman R. Toxicity and monitoring of immunosuppressive therapy used in systemic autoimmune diseases. Clin Chest Med 2011; 31:565-88. [PMID: 20692548 DOI: 10.1016/j.ccm.2010.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Systemic autoimmune diseases may be progressive and lead to organ system dysfunction and premature death. Current treatment paradigms are usually predominantly based on the administration of immunosuppressive and/or immunomodulatory drug therapy. Such therapy can stabilize systemic manifestations of connective tissue disease (CTD) and may put the disease into remission, and many of these agents are commonly used to treat CTD-associated interstitial lung disease (ILD). Although these agents have largely revolutionized the treatment of the systemic autoimmune diseases, adverse reactions, which can be serious and life threatening, to the various immunosuppressive agents used in the treatment of CTD can occur. Treating physicians must be aware of mechanisms of action of various immunosuppressive agents and be able to recognize the potential adverse reactions that may occur with therapy as well as potentially harmful effects on fetal development. Appropriate monitoring may prevent or limit toxicity from these agents, and knowledge of drug-drug interactions is essential when these agents are prescribed.
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Affiliation(s)
- Keith C Meyer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Abstract
Immunoadsorption (IAS) is used as a rescue therapy in severely ill SLE patients who are refractory to conventional therapies. This extracorporeal method aims at the rapid and extensive removal of pathogenic immunocomplexes (ICs) and (auto-)antibodies (Abs). Although past data have shown short- to mid-term efficacy and biocompatibility of IAS in (renal) SLE, it is still an experimental and rather expensive procedure – and evidence from randomized controlled trials (RCTs) is lacking. Nevertheless, IAS is successfully used in life-threatening situations because of its fast mode of action and its acceptable safety profile.
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Affiliation(s)
- GH Stummvoll
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Austria
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Methylprednisolone pulse plus mizoribine in children with Henoch-Schoenlein purpura nephritis. Clin Rheumatol 2010; 30:529-35. [PMID: 20844911 DOI: 10.1007/s10067-010-1572-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 08/26/2010] [Accepted: 09/06/2010] [Indexed: 10/19/2022]
Abstract
We evaluated whether methylprednisolone and urokinase pulse therapy combined with mizoribine (MUPM) was effective in children with severe Henoch-Schoenlein purpura nephritis (HSPN). We studied 12 patients who had been diagnosed with HSPN of at least ISKDC type III. All patients were treated with MUPM. Clinical features, pathological findings, and prognosis were prospectively investigated. Ten patients (responders; nine with ISKDC grade IIIb and one with grade IVb) were treated with MUPM, whereas MUPM was discontinued due to the lack of response in two patients (non-responders; two with grade IVb). Among responders, urinary protein excretion had decreased significantly from 99.7 ± 37.8 to 25.9 ± 33.4 mg/m(2) per hour after 3 months of therapy. The acute index and tubulointerstitial scores decreased significantly from 5.8 ± 1.5 and 3.8 ± 0.6 at the first biopsy to 2.3 ± 1.3 and 1.0 ± 0.8 at the second biopsy, respectively. At the most recent follow-up, eight of the responders had normal urine, and two had minor urinary abnormalities. Non-responders demonstrated continued high levels of urinary protein excretion after 3 months of therapy, and MUPM was discontinued. Our study suggests that MUPM is effective in ameliorating the proteinuria and the histological severity of HSPN in patients with <50% crescents but is not so effective for HSPN in patients with >50% crescents.
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Monach PA, Arnold LM, Merkel PA. Incidence and prevention of bladder toxicity from cyclophosphamide in the treatment of rheumatic diseases: a data-driven review. ACTA ACUST UNITED AC 2010; 62:9-21. [PMID: 20039416 DOI: 10.1002/art.25061] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Paul A Monach
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts 02118, USA.
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Pujari SS, Kempen JH, Newcomb CW, Gangaputra S, Daniel E, Suhler EB, Thorne JE, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Foster CS. Cyclophosphamide for ocular inflammatory diseases. Ophthalmology 2009; 117:356-65. [PMID: 19969366 DOI: 10.1016/j.ophtha.2009.06.060] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 05/22/2009] [Accepted: 06/24/2009] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To evaluate the outcomes of cyclophosphamide therapy for noninfectious ocular inflammation. DESIGN Retrospective cohort study. PARTICIPANTS Two hundred fifteen patients with noninfectious ocular inflammation observed from initiation of cyclophosphamide. METHODS Patients initiating cyclophosphamide, without other immunosuppressive drugs (other than corticosteroids), were identified at 4 centers. Dose of cyclophosphamide, response to therapy, corticosteroid-sparing effects, frequency of discontinuation, and reasons for discontinuation were obtained by medical record review of every visit. MAIN OUTCOME MEASURES Control of inflammation, corticosteroid-sparing effects, and discontinuation of therapy. RESULTS The 215 patients (381 involved eyes) meeting eligibility criteria carried diagnoses of uveitis (20.4%), scleritis (22.3%), ocular mucous membrane pemphigoid (45.6%), or other forms of ocular inflammation (11.6%). Overall, approximately 49.2% (95% confidence interval [CI], 41.7%-57.2%) gained sustained control of inflammation (for at least 28 days) within 6 months, and 76% (95% CI, 68.3%-83.7%) gained sustained control of inflammation within 12 months. Corticosteroid-sparing success (sustained control of inflammation while tapering prednisone to 10 mg or less among those not meeting success criteria initially) was gained by 30.0% and 61.2% by 6 and 12 months, respectively. Disease remission leading to discontinuation of cyclophosphamide occurred at the rate of 0.32/person-year (95% CI, 0.24-0.41), and the estimated proportion with remission at or before 2 years was 63.1% (95% CI, 51.5%-74.8%). Cyclophosphamide was discontinued by 33.5% of patients within 1 year because of side effects, usually of a reversible nature. CONCLUSIONS The data suggest that cyclophosphamide is effective for most patients for controlling inflammation and allowing tapering of systemic corticosteroids to 10 mg prednisone or less, although 1 year of therapy may be needed to achieve these goals. Unlike with most other immunosuppressive drugs, disease remission was induced by treatment in most patients who were able to tolerate therapy. To titrate therapy properly and to minimize the risk of serious potential side effects, a systematic program of laboratory monitoring is required. Judicious use of cyclophosphamide seems to be beneficial for severe ocular inflammation cases where the potentially vision-saving benefits outweigh the substantial potential side effects of therapy, or when indicated for associated systemic inflammatory diseases.
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Affiliation(s)
- Siddharth S Pujari
- The Massachusetts Eye Research and Surgery Institution, Cambridge, Massachusetts, USA
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Abstract
Acquired myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction in which patients experience fluctuating skeletal muscle weakness that often affects selected muscle groups preferentially. The target of the autoimmune attack in most cases is the skeletal muscle acetylcholine receptor (AChR), but in others, non-AChR components of the neuromuscular junction, such as the muscle-specific receptor tyrosine kinase, are targeted. The pathophysiological result is muscle endplate dysfunction and consequent fatigable muscle weakness. Clinical presentations vary substantially, both for anti-AChR positive and negative MG, and accurate diagnosis and selection of effective treatment depends on recognition of less typical as well as classic disease phenotypes. Accumulating evidence suggests that clinical MG subgroups might respond differently to treatment. In this Review, we provide current information about the epidemiology, immunopathogenesis, clinical presentations, diagnosis, and treatment of MG, including emerging therapeutic strategies.
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Affiliation(s)
- Matthew N Meriggioli
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Smith P, Stalin C, Shaw D, Granger N, Jeffery N. Comparison of Two Regimens for the Treatment of Meningoencephalomyelitis of Unknown Etiology. J Vet Intern Med 2009; 23:520-6. [DOI: 10.1111/j.1939-1676.2009.0299.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Appenzeller S, Blatyta PF, Costallat LTL. Ovarian failure in SLE patients using pulse cyclophosphamide: comparison of different regimes. Rheumatol Int 2007; 28:567-71. [PMID: 17968551 DOI: 10.1007/s00296-007-0478-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 10/14/2007] [Indexed: 10/22/2022]
Abstract
The objective of this study was to determine the frequency and risk factors of early ovarian failure in systemic lupus erythematosus (SLE) women treated with cyclophosphamide (CY). We further tried to determine if there was a reduction of ovarian failure in recent years, due to reduction in the CY dose. We reviewed the charts of all women below 40 years of age who received intravenous CY pulse therapy. In order to be included, the patients must have finished CY treatment before completing 40 years. Patients were divided into two groups: Group A (57 patients), patients who were treated with 0.75 mg/body surface; Group B (50 patients), patients treated with 0.5 mg/body surface. Fifty patients with similar age distribution who never received CY were selected from the database as a control group (Group C). The Chi-square test was applied to compare the categorical variables of the groups and whenever needed, the Fisher's Exact test was used. We observed similar age distribution and disease duration at disease onset between groups. Also, no differences regarding the age at menarche, total prednisone dose, and SLICC-ACR/DI scores were observed at disease onset between the three groups. In group A, ten (17.5%) patients refereed sustained amenorrhea, independently associated with treatment duration (P = 0.001), total intravenous cyclophosphamide (IV-CF) dose (P = 0.02), older age at disease onset (P = 0.04). Seven (12.3%) patients referred transient amenorrhea. Transient amenorrhea was related to CY treatment duration (P = 0.017). In group B, no patient reported sustained amenorrhea and 10 of 50 (20%) patients referred transient amenorrhea, related to CY treatment duration (P = 0.017). The most important risk factors for menstrual abnormalities were duration of treatment and cumulative dose of CY. Lower CY dose reduced the number of premature ovarian failures significantly in this cohort.
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Effect of lower dose intravenous cyclophosphamide on remission induction in Korean patients with lupus nephritis. Rheumatol Int 2007; 28:453-8. [PMID: 17924111 DOI: 10.1007/s00296-007-0464-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Accepted: 09/07/2007] [Indexed: 10/22/2022]
Abstract
This study retrospectively investigated the efficacy and adverse events of applying a lower dose (0.5 g/m(2)) of monthly intravenous (IV) cyclophosphamide (CYC) for lupus nephritis in Korean patients. Adverse events occurred in 64 patients (61.5%) of 104 lupus nephritis patients who were treated with IV CYC, with the most common being those related to the gastrointestinal system, followed by infection, symptoms related to the hematopoietic system, skin and its appendages, reproductive system, and urinary system. Lower-dose IV CYC therapy resulted in renal remission or response in 76 patients (73.1%), which was as effective as the reported outcomes of higher-dose (0.75-1.0 g/m(2)) IV CYC regimens. Adverse events were more likely (with borderline statistical significance, p = 0.055) in those who achieved renal remission or response than in nonresponders.
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Perini P, Calabrese M, Rinaldi L, Gallo P. The safety profile of cyclophosphamide in multiple sclerosis therapy. Expert Opin Drug Saf 2007; 6:183-90. [PMID: 17367264 DOI: 10.1517/14740338.6.2.183] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cyclophosphamide (Cyc) is an alkylating agent used to treat malignancies and autoimmune diseases, such as lupus nephritis, rheumatoid arthritis and immune-mediated neuropathies. Over the past 40 years, Cyc has also been applied to treat multiple sclerosis (MS) and the effective stabilisation of rapidly progressive forms of MS has been demonstrated in several studies. Cyc has a dose-dependent bimodal effect on the immune system. High doses have been demonstrated to induce an anti-inflammatory immune deviation (i.e., suppression of T helper 1 and enhancement of T helper 2 activity), affect CD4CD25(high) regulatory T cells and establish a state of marked immunosuppression. Data from the literature suggest that Cyc is particularly indicated in the treatment of young MS patients, suffering from a very active inflammatory disease characterised by frequent relapses and rapid accumulation of disability and displaying gadolinium-enhancing lesions on brain magnetic resonance. The most common Cyc-based therapeutic protocol applied in MS consists of monthly intravenous pulses for 1 year followed by bimonthly pulses for the second year, with or without prior infusion of corticosteroids. This protocol is usually well tolerated by the patients. Indeed, most of the side effects (mild alopecia, nausea and vomiting, cystitis) are dose dependent, transient and completely reversible. Definitive amenorrhoea is observed only in older female patients (aged > 40 years). Cyc has a safety and efficacy profile similar to that of mitoxantrone and can be used in patients whose disease is not controlled by IFN-beta or glatiramer acetate. Short course (6-12 months) of Cyc therapy can precede the initiation of immunomodulatory treatment in selected patients with an aggressive MS onset.
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Affiliation(s)
- Paola Perini
- Multiple Sclerosis Centre Veneto Region, First Neurology Clinic, University Hospital, Padova, Italy.
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Schmidt C, Wittig BM, Moser C, Zeitz M, Stallmach A. Cyclophosphamide pulse therapy followed by azathioprine or methotrexate induces long-term remission in patients with steroid-refractory Crohn's disease. Aliment Pharmacol Ther 2006; 24:343-50. [PMID: 16842461 DOI: 10.1111/j.1365-2036.2006.02988.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND In patients with steroid-refractory Crohn's disease, the therapeutic goal is to achieve both rapid remission and maintenance of clinical response. AIM To evaluate the long-term benefit in patients treated with cyclophosphamide pulse therapy and azathioprine or methotrexate, a combination shown to be effective in a recent pilot study. METHODS Sixteen patients with acute steroid-refractory Crohn's disease participated in a prospective open-labelled uncontrolled pilot study between December 1998 and June 2003. All had a median number of 4 monthly pulses of intravenous cyclophosphamide (750 mg) and were followed until relapse of the disease. RESULTS Thirteen of 16 patients (81%) achieved remission within 8 weeks after two pulses of cyclophosphamide in combination with azathioprine or methotrexate, with a Crohn's Disease Activity Index decrease from 294 to 111 (median). Remission sustained for 19 months (median, range: 1-45). Moreover, eight patients with pyoderma gangrenosum and erythema nodosum who responded to cyclophosphamide have maintained their remission for up to 30 months. CONCLUSIONS In steroid refractory patients with Crohn's disease, cyclophosphamide is highly effective to induce remission. This uncontrolled study indicates that cyclophosphamide-induced remission is long-lasting under standard immunosuppressive therapy.
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Affiliation(s)
- C Schmidt
- Department of Internal Medicine II, Saarland University Hospital Homburg, Homburg, Germany
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Opastirakul S, Chartapisak W. Infection in children with lupus nephritis receiving pulse and oral cyclophosphamide therapy. Pediatr Nephrol 2005; 20:1750-5. [PMID: 16133037 DOI: 10.1007/s00467-005-2032-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Revised: 06/13/2005] [Accepted: 06/13/2005] [Indexed: 10/25/2022]
Abstract
Infection is the major complication of cyclophosphamide therapy in patients with lupus nephritis. The objectives of this study were to report and compare the rate of infection between children with lupus nephritis who had received intravenous pulse cyclophosphamide (IVCY) and those who had received oral cyclophosphamide (OCY) and to determine the risk factors for infection during treatment with cyclophosphamide in these groups. Records of nine patients who had received IVCY from the beginning [pure intravenous cyclophosphamide (PIVCY) group], 11 patients who had received prior oral cyclophosphamide and later switched to IVCY [combined intravenous cyclophosphamide (CIVCY) group] and 41 patients who had received OCY were reviewed. Infection occurred in 21 of 61 patients (34%). In the PIVCY group, four episodes of infection occurred in three of nine patients (33%). In the CIVCY group, six episodes of infection occurred in four of 11 patients (36%). In the OCY group, 18 episodes of infection occurred in 14 of 41 patients (34%). The rate of infection between these groups was not different (P=0.99). None of the following parameters were risk factors for infection: cumulative dose of cyclophosphamide, leukopenia and neutropenia. On the contrary, white blood cell (WBC) count and polymorphonuclear cell (PMN) count were significantly less in the no-infection group (P=<0.001, P<0.001, respectively), with odds ratios for leukopenia (WBCs <4,000 mm(3)) and neutropenia (PMNs <1,500 mm(3)) between the infection and the no-infection group equal to 0.18 (95%CI 0.05-0.63) and 0 (95%CI 0-0.19), respectively. Most of the patients who had infection received prednisolone at a dosage of more than 0.5 mg/kg per day (67% of the PIVCY group, 50% of the CIVCY group and 83% of the OCY group). Fatal infections occurred in two patients who had concomitant active systemic lupus erythematosus (SLE). Although lymphopenia (lymphocyte count <1,500/mm(3)) was not the risk factor for infection, it was observed that six of seven patients with herpes zoster had lymphopenia. Herpes zoster seemed to occur more frequently in the OCY group (15%) than in the whole IVCY group (5%), but there was no statistical difference (P=0.41). We conclude that the rate of infection in the IVCY and OCY group was not different. Infection is likely to occur in patients receiving a concomitant high dose of prednisolone. The occurrence of fatal infection in patients with active disease should be noted. No single risk factor was detected in this study.
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Affiliation(s)
- Sauwalak Opastirakul
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand.
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Chiu SJ, Ou LS, Tsai TL, Hung IJ, Huang JL. Sequential evaluation of clinical and laboratory changes amongst children suffering from lupus nephritis during intermittent intravenous cyclophosphamide therapy. Clin Rheumatol 2005; 25:515-9. [PMID: 16283418 DOI: 10.1007/s10067-005-0081-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2004] [Revised: 09/01/2005] [Accepted: 09/01/2005] [Indexed: 10/25/2022]
Abstract
We prospectively evaluated the efficacy and safety of a 24-month course of intermittent intravenous cyclophosphamide (IC) therapy for children suffering from lupus nephritis soon after the diagnosis of systemic lupus erythematosus (SLE) was made. Eight children with severe lupus nephritis were treated with IC monthly for 6 months and then every 3 months, totaling 24 months. The repeated measurements of sequential serological parameters of lupus nephritis, monitored over the course of the study, were analyzed statistically. The urine creatinine clearance rate (Ccr), the 24-h urine protein excretion, and the serum creatinine level significantly improved (p<0.05) after 6, 9 and 12 months of treatment, respectively. The serum C3, C4, albumin, and triglyceride level, the hemoglobin level, and the erythrocyte sedimentation rate significantly improved (p<0.05) 1 month after treatment. The IC appeared to elicit a significant effect (p<0.05) upon the mean leukocyte and neutrophil counts but had no effect (p>0.05) on the platelet count. The lymphocyte count decreased (p<0.05) during the first six monthly IC, whereas the lymphocyte count returned to the baseline level during the quarterly IC events. From a total of 96 IC doses given to those SLE patients, severe myelotoxicity occurred in one patient when lymphocyte count declined to 98 mm(-3); however, no sign of clinical infection was observed. The daily steroid dosage can be tapered rapidly, and the SLE-associated hyperlipidemia resolved parallel to the resolution of the acute lupus nephritis. We concluded that the efficacy of a 24-month IC course for a child suffering from lupus nephritis is significant.
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Affiliation(s)
- Shih-Jung Chiu
- Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University, Taoyuan, Taiwan
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Nakajima S, Umebayashi H, Kurosawa R, Imagawa T, Katakura S, Mori M, Aihara Y, Yokota S. [Three cases of childhood-onset male systemic lupus erythematosus (SLE) successfully treated with a combination of pulse methylprednisolone and pulse cyclophosphamide]. NIHON RINSHO MEN'EKI GAKKAI KAISHI = JAPANESE JOURNAL OF CLINICAL IMMUNOLOGY 2005; 28:343-8. [PMID: 16276048 DOI: 10.2177/jsci.28.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We reported three cases of childhood-onset male systemic lupus erythematosus (SLE), all of whom successfully treated with a combination of pulse methylprednisolone (mPSL) and pulse cyclophosphamide (IVCY). All of them had severe lupus nephritis and were complicated with other collagen diseases. Two cases were complicated with Sjögren syndrome (SS) and the other was complicated with both SS and anti-phospholipid syndrome (APS). After a combination of pulse mPSL and IVCY for a year, followed by oral predonisolone (PSL) and azathioprine (AZA), following up renal biopsy were performed in all cases, which showed histological improvement in glomerulonephritis. One case had flares a year later, but no flares were observed either in clinical symptoms or in laboratory examinations in the others. Their autoantibodies except anti-nuclear antibody (ANA) were eliminated. We suggest a combination of pulse mPSL and IVCY is effective for the patients who are suffering with severe lupus nephritis complicated with the other collagen diseases.
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Affiliation(s)
- Shoko Nakajima
- Department of Pediatrics, Yokohama City University School of Medicine
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