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Perrotta F, Sanduzzi Zamparelli S, D’Agnano V, Montella A, Fomez R, Pagliaro R, Schiattarella A, Cazzola M, Bianco A, Mariniello DF. Genomic Profiling for Predictive Treatment Strategies in Fibrotic Interstitial Lung Disease. Biomedicines 2024; 12:1384. [PMID: 39061958 PMCID: PMC11274143 DOI: 10.3390/biomedicines12071384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/01/2024] [Accepted: 06/18/2024] [Indexed: 07/28/2024] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) has traditionally been considered the archetype of progressive fibrotic interstitial lung diseases (f-ILDs), but several other f-ILDs can also manifest a progressive phenotype. Integrating genomic signatures into clinical practice for f-ILD patients may help to identify patients predisposed to a progressive phenotype. In addition to the risk of progressive pulmonary fibrosis, there is a growing body of literature examining how pharmacogenomics influences treatment response, particularly regarding the efficacy and safety profiles of antifibrotic and immunomodulatory agents. In this narrative review, we discuss current studies in IPF and other forms of pulmonary fibrosis, including systemic autoimmune disorders associated ILDs, sarcoidosis and hypersensitivity pneumonitis. We also provide insights into the future direction of research in this complex field.
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Affiliation(s)
- Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | | | - Vito D’Agnano
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Antonia Montella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Ramona Fomez
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Angela Schiattarella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (V.D.); (A.M.); (R.F.); (R.P.); (A.S.); (A.B.)
- Unit of Respiratory Medicine “L. Vanvitelli”, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
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Dhooria S, Sehgal IS, Agarwal R. Reply: A suggested classification of disease behaviour and treatment response in sarcoidosis trials. Eur Respir J 2024; 63:2302208. [PMID: 38237998 DOI: 10.1183/13993003.02208-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Hayes K, Niewoehner J, Rice JB, Downes N, Hagopian E, Ma I, Wan GJ. Corticosteroid Use and Adherence in Patients Treated with Acthar Gel for Advanced Sarcoidosis. Adv Ther 2023; 40:4999-5015. [PMID: 37728695 PMCID: PMC10567815 DOI: 10.1007/s12325-023-02630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/27/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Long-term corticosteroid use in immune-mediated diseases is associated with increased risk of adverse events (AEs) and worsened health-related quality of life (HRQoL). Previous studies report chronic high-dose corticosteroid therapy results in higher rates of healthcare resource use and AE-related medical costs. Recent studies suggest Acthar® Gel (repository corticotropin injection) is an effective steroid-sparing therapy for sarcoidosis. This study compares the corticosteroid-sparing effect between Acthar Gel and comparators and evaluates the impact of Acthar Gel adherence on reduction of corticosteroid burden. METHODS A retrospective analysis of a large administrative pharmacy and medical claims database (Symphony Health Solutions) was conducted. Patients were included with confirmed ICD-9/10 diagnosis for sarcoidosis in the study period (2014-2020), followed by ≥ 2 Acthar Gel claims or comparators (janus kinase inhibitor (JAKi)/rituximab), ≥ 18 years old, with 12 months coverage pre/post index. Outcomes were compared as change from baseline. Acthar Gel adherence was determined by proportion of days covered in the follow-up period. RESULTS The Acthar Gel (n = 735) and comparator (n = 626) cohorts were mostly female (68-72%) between 55 and 58 years old. Compared to the comparator cohort at baseline, Acthar Gel patients had greater any corticosteroid use (80% vs. 56%, p < 0.001), extended use (61% vs. 32%, p < 0.001), and mean average daily dose (6.72 vs. 3.03, p < 0.001). After treatment, Acthar Gel patients had greater reduction from baseline in any corticosteroid use (- 9.0% vs. - 3.2%) and extended use (- 10.0% vs. - 3.0%). In the Acthar Gel adherence cohorts, patients with above average adherence had greater reduction in both measures (- 11.2% vs. - 6.1%; - 11.6% vs. - 7.6%, respectively) than patients with below average adherence. Acthar Gel patients had greater reduction of extended use at all dose levels. CONCLUSION Acthar Gel is associated with reductions in corticosteroid use compared to alternatives. Better adherence is associated with greater reduction in corticosteroid exposure. Key Summary Points.
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Affiliation(s)
- Kyle Hayes
- Mallinckrodt Pharmaceuticals, Bridgewater, NJ USA
| | | | - J. Bradford Rice
- Analysis Group Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
| | - Nathaniel Downes
- Analysis Group Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
| | - Ella Hagopian
- Analysis Group Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
| | - Izzy Ma
- Analysis Group Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
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Dhooria S, Sehgal IS, Agarwal R, Muthu V, Prasad KT, Dogra P, Debi U, Garg M, Bal A, Gupta N, Aggarwal AN. High-dose (40 mg) versus low-dose (20 mg) prednisolone for treating sarcoidosis: a randomised trial (SARCORT trial). Eur Respir J 2023; 62:2300198. [PMID: 37690784 DOI: 10.1183/13993003.00198-2023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/05/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Current guidelines recommend 20-40 mg·day-1 of oral prednisolone for treating pulmonary sarcoidosis. Whether the higher dose (40 mg·day-1) can improve outcomes remains unknown. METHODS We conducted an investigator-initiated, single-centre, open-label, parallel-group, randomised controlled trial (ClinicalTrials.gov identifier NCT03265405). Consecutive subjects with pulmonary sarcoidosis were randomised (1:1) to receive either high-dose (40 mg·day-1 initial dose) or low-dose (20 mg·day-1 initial dose) oral prednisolone, tapered over 6 months. The primary outcome was the frequency of relapse or treatment failure at 18 months from randomisation. Key secondary outcomes included the time to relapse or treatment failure, overall response, change in forced vital capacity (FVC, in litres) at 6 and 18 months, treatment-related adverse effects and health-related quality of life (HRQoL) scores using the Sarcoidosis Health Questionnaire and Fatigue Assessment Scale. FINDINGS We included 86 subjects (43 in each group). 42 and 43 subjects completed treatment in the high-dose and low-dose groups, respectively, while 37 (86.0%) and 41 (95.3%), respectively, completed the 18-month follow-up. 20 (46.5%) subjects had relapse or treatment failure in the high-dose group and 19 (44.2%) in the low-dose group (p=0.75). The mean time to relapse/treatment failure was similar between the groups (high-dose 307 days versus low-dose 269 days, p=0.27). The overall response, the changes in FVC at 6 and 18 months and the incidence of adverse effects were also similar. Changes in HRQoL scores did not differ between the study groups. INTERPRETATION High-dose prednisolone was not superior to a lower dose in improving outcomes or the HRQoL in sarcoidosis and was associated with similar adverse effects.
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pooja Dogra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Uma Debi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nalini Gupta
- Department of Cytology and Gynecologic Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Obi ON, Saketkoo LA, Russell AM, Baughman RP. Sarcoidosis: Updates on therapeutic drug trials and novel treatment approaches. Front Med (Lausanne) 2022; 9:991783. [PMID: 36314034 PMCID: PMC9596775 DOI: 10.3389/fmed.2022.991783] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous inflammatory disease of unknown etiology. It affects the lungs in over 90% of patients yet extra-pulmonary and multi-organ involvement is common. Spontaneous remission of disease occurs commonly, nonetheless, over 50% of patients will require treatment and up to 30% of patients will develop a chronic progressive non-remitting disease with marked pulmonary fibrosis leading to significant morbidity and death. Guidelines outlining an immunosuppressive treatment approach to sarcoidosis were recently published, however, the strength of evidence behind many of the guideline recommended drugs is weak. None of the drugs currently used for the treatment of sarcoidosis have been rigorously studied and prescription of these drugs is often based on off-label” indications informed by experience with other diseases. Indeed, only two medications [prednisone and repository corticotropin (RCI) injection] currently used in the treatment of sarcoidosis are approved by the United States Food and Drug Administration. This situation results in significant reimbursement challenges especially for the more advanced (and often more effective) drugs that are favored for severe and refractory forms of disease causing an over-reliance on corticosteroids known to be associated with significant dose and duration dependent toxicities. This past decade has seen a renewed interest in developing new drugs and exploring novel therapeutic pathways for the treatment of sarcoidosis. Several of these trials are active randomized controlled trials (RCTs) designed to recruit relatively large numbers of patients with a goal to determine the safety, efficacy, and tolerability of these new molecules and therapeutic approaches. While it is an exciting time, it is also necessary to exercise caution. Resources including research dollars and most importantly, patient populations available for trials are limited and thus necessitate that several of the challenges facing drug trials and drug development in sarcoidosis are addressed. This will ensure that currently available resources are judiciously utilized. Our paper reviews the ongoing and anticipated drug trials in sarcoidosis and addresses the challenges facing these and future trials. We also review several recently completed trials and draw lessons that should be applied in future.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States,*Correspondence: Ogugua Ndili Obi,
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, United States,University Medical Center—Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, United States,Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, United States,Department of Undergraduate Honors, Tulane University School of Medicine, New Orleans, LA, United States
| | - Anne-Marie Russell
- Exeter Respiratory Institute University of Exeter, Exeter, United Kingdom,Royal Devon and Exeter NHS Foundation Trust, Devon, United Kingdom,Faculty of Medicine, Imperial College and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, OH, United States
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Damsky W, Wang A, Kim DJ, Young BD, Singh K, Murphy MJ, Daccache J, Clark A, Ayasun R, Ryu C, McGeary MK, Odell ID, Fazzone-Chettiar R, Pucar D, Homer R, Gulati M, Miller EJ, Bosenberg M, Flavell RA, King B. Inhibition of type 1 immunity with tofacitinib is associated with marked improvement in longstanding sarcoidosis. Nat Commun 2022; 13:3140. [PMID: 35668129 PMCID: PMC9170782 DOI: 10.1038/s41467-022-30615-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/05/2022] [Indexed: 01/05/2023] Open
Abstract
Sarcoidosis is an idiopathic inflammatory disorder that is commonly treated with glucocorticoids. An imprecise understanding of the immunologic changes underlying sarcoidosis has limited therapeutic progress. Here in this open-label trial (NCT03910543), 10 patients with cutaneous sarcoidosis are treated with tofacitinib, a Janus kinase inhibitor. The primary outcome is the change in the cutaneous sarcoidosis activity and morphology instrument (CSAMI) activity score after 6 months of treatment. Secondary outcomes included change in internal organ involvement, molecular parameters, and safety. All patients experience improvement in their skin with 6 patients showing a complete response. Improvement in internal organ involvement is also observed. CD4+ T cell-derived IFN-γ is identified as a central cytokine mediator of macrophage activation in sarcoidosis. Additional type 1 cytokines produced by distinct cell types, including IL-6, IL-12, IL-15 and GM-CSF, also associate with pathogenesis. Suppression of the activity of these cytokines, especially IFN-γ, correlates with clinical improvement. Our results thus show that tofacitinib treatment is associated with improved sarcoidosis symptoms, and predominantly acts by inhibiting type 1 immunity.
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Affiliation(s)
- William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA. .,Department of Pathology, Yale School of Medicine, New Haven, CT, USA.
| | - Alice Wang
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Daniel J. Kim
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Bryan D. Young
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Katelyn Singh
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Michael J. Murphy
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Joseph Daccache
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Abigale Clark
- grid.258405.e0000 0004 0539 5056Kansas City University of Medicine and Biosciences, Kansas City, MO USA
| | - Ruveyda Ayasun
- grid.240324.30000 0001 2109 4251Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY USA
| | - Changwan Ryu
- grid.47100.320000000419368710Seciton of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT USA
| | - Meaghan K. McGeary
- grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA
| | - Ian D. Odell
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA
| | - Ramesh Fazzone-Chettiar
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Darko Pucar
- grid.47100.320000000419368710Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Robert Homer
- grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA
| | - Mridu Gulati
- grid.47100.320000000419368710Seciton of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT USA
| | - Edward J. Miller
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Marcus Bosenberg
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA
| | - Richard A. Flavell
- grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT USA
| | - Brett King
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA.
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Nienhuis WA, Grutters JC. Potential therapeutic targets to prevent organ damage in chronic pulmonary sarcoidosis. Expert Opin Ther Targets 2021; 26:41-55. [PMID: 34949145 DOI: 10.1080/14728222.2022.2022123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Sarcoidosis is a granulomatous inflammatory disease with high chances of reduced quality of life, irreversible organ damage, and reduced life expectancy when vital organs are involved. Any organ system can be affected, and the lungs are most often affected. There is no preventive strategy as the exact etiology is unknown, and complex immunogenetic and environmental factors determine disease susceptibility and phenotype. Present-day treatment options originated from clinical practice and are effective in many patients. However, a substantial percentage of patients suffer from unacceptable side effects or still develop refractory, threatening pulmonary or extrapulmonary disease. AREAS COVERED As non-caseating granulomas, the pathological hallmark of disease, are assigned to divergent activation and regulation of the immune system, targets in relation to the possible triggers of granuloma formation and their sequelae were searched and reviewed. EXPERT OPINION :The immunopathogenesis underlying sarcoidosis has been a dynamic field of study. Several recent new insights give way to promising new therapeutic targets, such as certain antigenic triggers (e.g. from Aspergillus nidulans), mTOR, JAK-STAT and PPARγ pathways, the NRP2 receptor and MMP-12, which await further exploration. Clinical and trigger related phenotyping, and molecular endotyping in sarcoidosis will likely hold the key for precision medicine in the future.
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Affiliation(s)
- W A Nienhuis
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Grutters
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands.,Division of Hearth and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Kahlmann V, Moor CC, Miedema JR, Wijsenbeek MS. Comparison of the treatment guidelines for sarcoidosis: common sense in the search for evidence. Eur Respir J 2021; 59:13993003.03114-2021. [PMID: 34949705 DOI: 10.1183/13993003.03114-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Vivienne Kahlmann
- Academic Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Catharina C Moor
- Academic Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jelle R Miedema
- Academic Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Marlies S Wijsenbeek
- Academic Centre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Simmering J, Stapleton EM, Polgreen PM, Kuntz J, Gerke AK. Patterns of medication use and imaging following initial diagnosis of sarcoidosis. Respir Med 2021; 189:106622. [PMID: 34600163 PMCID: PMC10918686 DOI: 10.1016/j.rmed.2021.106622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/31/2021] [Accepted: 09/14/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Sarcoidosis is a rare inflammatory disease with unclear natural history. Using a large, retrospective, longitudinal, population-based cohort, we sought to define its natural history in order to guide future clinical studies. METHODS We identified 722 newly diagnosed cases of sarcoidosis within Kaiser Permanente Northwest health care records between 1995 and 2015. We investigated immunosuppressive medication use in the two years following diagnosis, analyzed demographic and clinical characteristics, and quantified chest imaging and pulmonary function testing (PFTs) across the clinical course. RESULTS Over two years of follow-up, 41% of patients were treated with prednisone. Of those, 75% tapered off their first course within 100 days, although half of those patients required recurrent therapy. Five percent of the entire cohort remained on prednisone for longer than one year, with an average daily dose of 10-20 mg. Chest imaging was associated with early prednisone use, and chest CT was associated with changes in prednisone dose. PFTs or demographics were not associated with prednisone use. Cumulative prednisone doses were significantly higher in African Americans (1,845 mg additional) and those who had a chest CT (2,015 mg additional). Overall, PFTs were less frequently obtained than chest imaging and had no significant change over disease course. DISCUSSION The natural history of sarcoidosis varies greatly. For those requiring therapy, corticosteroid burden is high. Chest imaging drives medication dose changes as compared to PFTs, but neither outcome fully captures the entire history of disease. Prospective cohorts are needed with purposefully collected, repeated measures that include objective clinical assessments and symptoms.
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Affiliation(s)
- J Simmering
- University of Iowa, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, 200 Hawkins Dr., C33GH, Iowa City, IA, 52242, USA
| | - E M Stapleton
- University of Iowa, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, 200 Hawkins Dr., C33GH, Iowa City, IA, 52242, USA
| | - P M Polgreen
- University of Iowa, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, 200 Hawkins Dr., C33GH, Iowa City, IA, 52242, USA
| | - J Kuntz
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - A K Gerke
- University of Iowa, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, 200 Hawkins Dr., C33GH, Iowa City, IA, 52242, USA.
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Griffin JM, Chasler J, Wand AL, Okada DR, Smith JN, Saad E, Tandri H, Chrispin J, Sharp M, Kasper EK, Chen ES, Gilotra NA. Management of Cardiac Sarcoidosis Using Mycophenolate Mofetil as a Steroid-Sparing Agent. J Card Fail 2021; 27:1348-1358. [PMID: 34166800 DOI: 10.1016/j.cardfail.2021.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cardiac sarcoidosis (CS) is a major cause of morbidity and mortality in patients with systemic sarcoidosis. Steroid-sparing agents are increasingly used, despite a lack of randomized trials or published guidelines to direct treatment. METHODS AND RESULTS This retrospective study included 77 patients with CS treated with prednisone monotherapy (n = 32) or a combination with mycophenolate mofetil (n = 45) between 2003 and 2018. Baseline characteristics and clinical outcomes were evaluated. The mean patient age was 53 ± 11 years at CS diagnosis, 66.2% were male, and 35.1% were Black. The total exposure to maximum prednisone dose (initial prednisone dose × days at dose) was lower in the combination therapy group (1440 mg [interquartile range (IQR), 1200-2760 mg] vs 2710 mg [IQR, 1200-5080 mg]; P = .06). On 18F-fluorodeoxyglucose positron emission tomography scans, both groups demonstrated a significant decrease in the cardiac maximum standardized uptake value after treatment: a median decrease of 3.9 (IQR 2.7-9.0, P = .002) and 2.9 (IQR 0-5.0, P = .001) for prednisone monotherapy and combination therapy, respectively. Most patients experienced improvement or complete resolution in qualitative cardiac 18F-fluorodeoxyglucose uptake (92.3% and 70.4% for the prednisone and combination therapy groups, respectively). Mycophenolate mofetil was well tolerated. CONCLUSIONS Mycophenolate mofetil in combination with prednisone for the treatment of CS may minimize corticosteroid exposure and decrease cardiac inflammation without significant adverse effects.
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Affiliation(s)
- Jan M Griffin
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Jessica Chasler
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alison L Wand
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David R Okada
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Nikolhaus Smith
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elie Saad
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hari Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Sharp
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward K Kasper
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward S Chen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A Gilotra
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Corticosteroid-Sparing Drugs in Sarcoidosis: How Should We Assess Them? Lung 2021; 199:85-86. [PMID: 33825967 DOI: 10.1007/s00408-021-00439-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/19/2022]
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Drake WP, Culver DA, Baughman RP, Judson MA, Crouser ED, James WE, Ayers GD, Ding T, Abel K, Green A, Kerrigan A, Sesay A, Bernard GR. Phase II Investigation of the Efficacy of Antimycobacterial Therapy in Chronic Pulmonary Sarcoidosis. Chest 2020; 159:1902-1912. [PMID: 33387486 PMCID: PMC8129732 DOI: 10.1016/j.chest.2020.12.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022] Open
Abstract
Background A Phase I, single-center investigation found that 8 weeks of antimycobacterial therapy improved sarcoidosis FVC. Safety and efficacy assessments have not been performed in a multicenter cohort. Research Question The objective of this study was to determine the safety and efficacy of antimycobacterial therapy on the physiological and immunologic end points of sarcoidosis. Study Design and Methods In a double-blind, placebo-controlled, multicenter investigation, patients with pulmonary sarcoidosis were randomly assigned to receive 16 weeks of concomitant levofloxacin, ethambutol, azithromycin, and rifabutin (CLEAR) or matching placebo to investigate the effect on FVC. The primary outcome was a comparison of change in percentage of predicted FVC among patients randomized to receive CLEAR or placebo in addition to their baseline immunosuppressive regimen. Secondary outcomes included 6-min walk distance (6MWD), St. George’s Respiratory Questionnaire (SGRQ) score, adverse events, and decrease in mycobacterial early secreted antigenic target of 6 kDa (ESAT-6) immune responses. Results The intention-to-treat analysis revealed no significant differences in change in FVC among the 49 patients randomized to receive CLEAR (1.1% decrease) compared with the 48 randomized to receive placebo (0.02% increase) (P = .64). Physiological parameters such as the change in 6MWD were likewise similar (P = .91); change in SGRQ favored placebo (–8.0 for placebo vs –1.5 for CLEAR; P = .028). The per-protocol analysis revealed no significant change in FVC at 16 weeks between CLEAR and placebo. There was no significant change in 6MWD (36.4 m vs 6.3 m; P = .24) or SGRQ (–2.3 vs –7.0; P = .14). A decline in ESAT-6 immune responses at 16 weeks was noted among CLEAR-treated patients (P = .0003) but not patients receiving placebo (P = .24). Interpretation Despite a significant decline in ESAT-6 immune responses, a 16-week CLEAR regimen provided no physiological benefit in FVC or 6MWD among patients with sarcoidosis.
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Affiliation(s)
- Wonder P Drake
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN.
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Robert P Baughman
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - W Ennis James
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Gregory D Ayers
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Tan Ding
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Kenny Abel
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Abena Green
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Amy Kerrigan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Ahmed Sesay
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gordon R Bernard
- Division of Pulmonary and Critical Care, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Abstract
Sarcoidosis is a systemic disease of unknown etiology defined by the presence of noncaseating granulomatous inflammation that can cause organ damage and diminished quality of life. Treatment is indicated to protect organ function and decrease symptomatic burden. Current treatment options focus on interruption of granuloma formation and propagation. Clinical trials guiding evidence for treatment are lacking due to the rarity of disease, heterogeneous clinical course, and lack of prognostic biomarkers, all of which contribute to difficulty in clinical trial design and implementation. In this review, a multidisciplinary treatment approach is summarized, addressing immunuosuppressive drugs, managing complications of chronic granulomatous inflammation, and assessing treatment toxicity. Discovery of new therapies will depend on research into pathogenesis of antigen presentation and granulomatous inflammation. Future treatment approaches may also include personalized decisions based on pharmacogenomics and sarcoidosis phenotype, as well as patient-centered approaches to manage immunosuppression, symptom control, and treatment of comorbid conditions.
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Affiliation(s)
- Alicia K. Gerke
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
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Abstract
As sarcoidosis may involve any organ, sarcoidosis patients should be evaluated for occult disease. Screening for some organ involvement may not be warranted if it is unlikely to cause symptoms, organ dysfunction, or affect clinical outcome. Even organ involvement that affects clinical outcome does not necessarily require screening if early detection fails to change the patient's quality of life or prognosis. On the other hand, early detection of some forms of sarcoidosis may improve outcomes and survival. This manuscript describes the approach to screening sarcoidosis patients for previously undetected disease. Screening for sarcoidosis should commence with a meticulous medical history and physical examination. Many sarcoidosis patients present with physical signs or symptoms of sarcoidosis that have not been recognized as manifestations of the disease. Detection of sarcoidosis in these instances depends on the clinician's familiarity with the varied clinical presentations of sarcoidosis. In addition, sarcoidosis patients may present with symptoms or signs that are not related to specific organ involvement that have been described as parasarcoidosis syndromes. It is conjectured that parasarcoidosis syndromes result from systemic release of inflammatory mediators from the sarcoidosis granuloma. Certain forms of sarcoidosis may cause permanent and serious problems that can be prevented if they are detected early in the course of their disease. These include (1) ocular involvement that may lead to permanent vision impairment; (2) vitamin D dysregulation that may lead to hypercalcemia, nephrolithiasis, and permanent kidney injury; and (3) cardiac sarcoidosis that may lead to a cardiomyopathy, ventricular arrhythmias, heart block, and sudden death. Screening for these forms of organ involvement requires detailed screening approaches.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
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Abstract
A sarcoidosis patient may be refractory to corticosteroid therapy. This may be because corticosteroids are ineffective in relieving the sarcoidosis patient's symptoms/dysfunction or because the clinician has determined that the risks of corticosteroids outweigh their benefits. Interestingly, when corticosteroids truly fail to improve a sarcoidosis patient's condition, it is very rarely because of failure of the drug as an anti-granulomatous agent; rather, it is usually because the patient's symptoms were unrelated to active sarcoid granulomas. In this manuscript, we review the causes of corticosteroid refractory sarcoidosis. The clinician should consider these causes when confronted with a sarcoidosis patient who is either not responding to corticosteroids, developing corticosteroid side-effects, or is at significant risk of developing such side-effects. We believe that determining the cause of corticosteroid refractory sarcoidosis may aid the clinicians in optimizing the care of sarcoidosis patients and clinical researchers in appropriately stratifying patients for clinical trials.
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Rahaghi FF, Baughman RP, Saketkoo LA, Sweiss NJ, Barney JB, Birring SS, Costabel U, Crouser ED, Drent M, Gerke AK, Grutters JC, Hamzeh NY, Huizar I, Ennis James W, Kalra S, Kullberg S, Li H, Lower EE, Maier LA, Mirsaeidi M, Müller-Quernheim J, Carmona Porquera EM, Samavati L, Valeyre D, Scholand MB. Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis. Eur Respir Rev 2020; 29:29/155/190146. [PMID: 32198218 PMCID: PMC9488897 DOI: 10.1183/16000617.0146-2019] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/07/2020] [Indexed: 12/27/2022] Open
Abstract
Pulmonary sarcoidosis presents substantial management challenges, with limited evidence on effective therapies and phenotypes. In the absence of definitive evidence, expert consensus can supply clinically useful guidance in medicine. An international panel of 26 experts participated in a Delphi process to identify consensus on pharmacological management in sarcoidosis with the development of preliminary recommendations. The modified Delphi process used three rounds. The first round focused on qualitative data collection with open-ended questions to ensure comprehensive inclusion of expert concepts. Rounds 2 and 3 applied quantitative assessments using an 11-point Likert scale to identify consensus. Key consensus points included glucocorticoids as initial therapy for most patients, with non-biologics (immunomodulators), usually methotrexate, considered in severe or extrapulmonary disease requiring prolonged treatment, or as a steroid-sparing intervention in cases with high risk of steroid toxicity. Biologic therapies might be considered as additive therapy if non-biologics are insufficiently effective or are not tolerated with initial biologic therapy, usually with a tumour necrosis factor-α inhibitor, typically infliximab. The Delphi methodology provided a platform to gain potentially valuable insight and interim guidance while awaiting evidenced-based contributions. Expert consensus recommendations for a pulmonary sarcoidosis treatment algorithm from a modified Delphi process include corticosteroids as initial therapy, immunomodulators for steroid-sparing or severe disease, and biologics for very severe diseasehttp://bit.ly/2SmP3uG
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Vis R, van de Garde EM, Grutters JC, Korenromp IH. The effects of pharmacological interventions on quality of life and fatigue in sarcoidosis: a systematic review. Eur Respir Rev 2020; 29:29/155/190057. [DOI: 10.1183/16000617.0057-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/26/2019] [Indexed: 01/30/2023] Open
Abstract
AimsMany sarcoidosis patients experience a reduction in health-related quality of life (HRQoL) and a majority of patients report fatigue. Historically, drug trials in sarcoidosis have focused on changes in chest radiographs, lung function parameters and biomarkers, while HRQoL and fatigue have not been the main outcomes examined. We performed a systematic review of the literature to evaluate the existing evidence on the effects of pharmacological interventions on HRQoL and fatigue outcomes.MethodsThe systematic search was performed in Medline and Embase and yielded 15 records covering seven randomised controlled trials and seven single-arm open label studies, which were included in a qualitative synthesis (the results of one study were included in two publications). 12 studies evaluated immunosuppressive and/or immunomodulatory therapies and two studies evaluated stimulants.ResultsNine out of the 14 studies observed positive treatment effects from the interventions on HRQoL and/or fatigue, exceeding the minimal important difference. The risk of bias was generally high with only three studies rated as having a low risk of bias. The results suggest a potential for improvement in HRQoL and/or fatigue in patients with active disease who are either untreated or treated but not yet fully stabilised or therapy refractory.ConclusionMore randomised, double-blind and placebo-controlled trials are needed to expand the evidence base on these important outcome parameters.
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Judson MA. Developing better drugs for pulmonary sarcoidosis: determining indications for treatment and endpoints to assess therapy based on patient and clinician concerns. F1000Res 2019; 8:F1000 Faculty Rev-2149. [PMID: 31942239 PMCID: PMC6944258 DOI: 10.12688/f1000research.20696.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 12/19/2022] Open
Abstract
Pulmonary sarcoidosis involves the deposition of granulomas within the lung. These granulomas may affect lung function and lead to pulmonary symptoms, pulmonary dysfunction, functional impairment, and worsening of quality of life. Corticosteroids are generally highly effective in resolving the granulomatous inflammation of sarcoidosis. However, despite the effectiveness of corticosteroids, many corticosteroid-responsive patients continue to experience significant problems because of the development of fibrosis from previously active or active smoldering granulomatous inflammation, inflammatory effects from sarcoidosis unrelated to granuloma deposition in lung tissue (parasarcoidosis syndromes), and the development of significant corticosteroid-related side effects. For these reasons, the decision to treat pulmonary sarcoidosis and endpoints to measure meaningful outcomes may extend beyond considerations of pulmonary granulomatous inflammation alone. In this article, we propose a conceptual framework to describe the mechanisms by which pulmonary sarcoidosis significantly impacts patients. This conceptual framework suggests that indications for the treatment of pulmonary sarcoidosis and endpoints to assess treatment depend on the specific mechanisms that are causing functional or quality-of-life impairment (or both) in patients with pulmonary sarcoidosis. We believe that these concepts are important to clinicians treating pulmonary sarcoidosis and to clinical researchers designing pulmonary sarcoidosis trials.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Albany Medical College, Albany, NY, USA
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Adler BL, Wang CJ, Bui TL, Schilperoort HM, Armstrong AW. Anti-tumor necrosis factor agents in sarcoidosis: A systematic review of efficacy and safety. Semin Arthritis Rheum 2019; 48:1093-1104. [DOI: 10.1016/j.semarthrit.2018.10.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/13/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
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The Pathogenesis of Pulmonary Sarcoidosis and Implications for Treatment. Chest 2017; 153:1432-1442. [PMID: 29224832 DOI: 10.1016/j.chest.2017.11.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 12/31/2022] Open
Abstract
Thoracic sarcoidosis is the most common form of sarcoidosis, encompassing a heterogeneous group of patients with a wide range of clinical features and associated outcomes. The distinction between isolated thoracic lymphadenopathy and pulmonary involvement matters. Morbidity is often higher, and long-term outcomes are worse for the latter. Although inflammatory infiltrates in pulmonary sarcoidosis may resolve, persistent disease activity is common and can result in lung fibrosis. Given the distinct clinical features and natural history of pulmonary sarcoidosis, its pathogenesis may differ in important ways from other sarcoidosis manifestations. This review highlights recent advances in the pathogenesis of pulmonary sarcoidosis, including the nature of the sarcoidosis antigen, the role of serum amyloid A and other host factors that contribute to alterations in innate immunity, factors that shape adaptive T-cell profiles in the lung, and how these mechanisms influence the maintenance of granulomatous inflammation in sarcoidosis. We discuss questions raised by recent findings, including the role of innate immunity in the pathogenesis, the meaning of immune cell exhaustion, and mechanisms that may contribute to lung fibrosis in sarcoidosis. We conclude with a reflection on when and how immunosuppressive therapies may be helpful for pulmonary sarcoidosis, a consideration of nonpharmacologic management strategies, and a survey of potential novel therapeutic targets for this vexing disease.
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Preclinical Efficacy Failure of Human CNS-Derived Stem Cells for Use in the Pathway Study of Cervical Spinal Cord Injury. Stem Cell Reports 2017; 8:249-263. [PMID: 28199829 PMCID: PMC5312249 DOI: 10.1016/j.stemcr.2016.12.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 12/14/2016] [Accepted: 12/19/2016] [Indexed: 01/26/2023] Open
Abstract
We previously showed the efficacy of multiple research cell lines (RCLs) of human CNS neural stem cells (HuCNS-SCs) in mouse and rat models of thoracic spinal cord injury (SCI), supporting a thoracic SCI clinical trial. Experts recommend in vivo preclinical testing of the intended clinical cell lot/line (CCL) in models with validity for the planned clinical target. We therefore tested the efficacy of two HuCNS-SC lines in cervical SCI: one RCL, and one CCL intended for use in the Pathway Study of cervical SCI in man. We assessed locomotor recovery and sensory function, as well as engraftment, migration, and fate. No evidence of efficacy of the CCL was observed; some data suggested a negative impact of the CCL on outcomes. These data raise questions about the development and validation of potency/comparability assays for clinical testing of cell products, and lack of US Food and Drug Administration requirements for in vivo testing of intended clinical cell lines. Human CNS stem cells (HuCNS-SCs) have been used in multiple clinical trials Research cell lines of HuCNS-SCs are efficacious in spinal cord injury (SCI) models The clinical cell line (CCL) of HuCNS-SC was not efficacious in a cervical SCI model Despite lack of in vivo efficacy, the CCL was used in the Pathways clinical study
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Brito-Zerón P, Pérez-Alvarez R, Pallarés L, Retamozo S, Baughman RP, Ramos-Casals M. Sarcoidosis: an update on current pharmacotherapy options and future directions. Expert Opin Pharmacother 2017; 17:2431-2448. [PMID: 27817209 DOI: 10.1080/14656566.2016.1258061] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Sarcoidosis is a systemic disease of unknown etiology characterized by the development of non-caseating epitheloid granulomas. The lungs are the most commonly involved organ (>90% of cases), followed by the lymph nodes, the skin, and the eyes. Areas covered: This review summarizes current pharmacotherapy options and future directions for the development of new therapies. Glucocorticoids are the first-line therapy for sarcoidosis. For patients with the most severe forms of sarcoidosis (who will need glucocorticoids for long periods) and for those intolerant or refractory, immunosuppressive drugs are used as sparing agents. The management of extrathoracic sarcoidosis must be tailored to the specific organ or organs involved; however, there is limited data from controlled trials to guide the treatment of these patients. The emergence of biological therapies has increased the therapeutic armamentarium available to treat sarcoidosis, with monoclonal anti-TNF agents being the most promising, but their use is still limited by a lack of licensing and costs. Expert commentary: The treatment of sarcoidosis is still not totally standardized. New effective therapies are urgently needed to enable the reduction or replacement of long-term therapy with glucocorticoids in patients with sarcoidosis.
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Affiliation(s)
- Pilar Brito-Zerón
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,b Autoimmune Diseases Unit, Department of Medicine , Hospital CIMA- Sanitas , Barcelona , Spain
| | | | - Lucio Pallarés
- d Systemic Autoimmune Diseases Unit, Department of Internal Medicine , Hospital de Son Espases , Palma de Mallorca , Spain
| | - Soledad Retamozo
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,e Hospital Privado , Centro Médico de Córdoba , Córdoba , Argentina
| | - Robert P Baughman
- f Department of Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
| | - Manuel Ramos-Casals
- a Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases , ICMiD, Hospital Clínic , Barcelona , Spain.,g Department of Medicine , University of Barcelona , Barcelona , Spain
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