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Chang SH, Jung S, Chae JJ, Kim JY, Kim SU, Choi JY, Han HJ, Kim HT, Kim HJ, Kim HJ, Park WY, Sparks JA, Lee EY, Lee JS. Therapeutic single-cell landscape: methotrexate exacerbates interstitial lung disease by compromising the stemness of alveolar epithelial cells under systemic inflammation. EBioMedicine 2024; 108:105339. [PMID: 39303666 PMCID: PMC11437874 DOI: 10.1016/j.ebiom.2024.105339] [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: 03/01/2024] [Revised: 08/21/2024] [Accepted: 08/30/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) poses a serious threat in patients with rheumatoid arthritis (RA). However, the impact of cornerstone drugs, including methotrexate (MTX) and TNF inhibitor, on RA-associated ILD (RA-ILD) remains controversial. METHODS Using an SKG mouse model and single-cell transcriptomics, we investigated the effects of MTX and TNF blockade on ILD. FINDINGS Our study revealed that MTX exacerbates pulmonary inflammation by promoting immune cell infiltration, Th17 activation, and fibrosis. In contrast, TNF inhibitor ameliorates these features and inhibits ILD progression. Analysis of data from a human RA-ILD cohort revealed that patients with ILD progression had persistently higher systemic inflammation than those without progression, particularly among the subgroup undergoing MTX treatment. INTERPRETATION These findings highlight the need for personalized therapeutic approaches in RA-ILD, given the divergent outcomes of MTX and TNF inhibitor. FUNDING This work was funded by GENINUS Inc., and the National Research Foundation of Korea, and Seoul National University Hospital.
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Affiliation(s)
- Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, 31151, South Korea
| | - Seyoung Jung
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Jeong Jun Chae
- Samsung Genome Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea; Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, 06351, South Korea
| | - Jeong Yeon Kim
- Inocras, Inc., San Diego, CA, 92121, USA; Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Seon Uk Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Ji Yong Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Hye-Jeong Han
- Soonchunhyang Institute of Medi-bio Science (SIMS), Soonchunhyang University, Cheonan, 31151, Republic of Korea
| | - Hyun Taek Kim
- Soonchunhyang Institute of Medi-bio Science (SIMS), Soonchunhyang University, Cheonan, 31151, Republic of Korea
| | - Hak-Jae Kim
- Department of Clinical Pharmacology, College of Medicine, Soonchunhyang University, Cheonan, 31151, Republic of Korea
| | - Hyun Je Kim
- Department of Biomedical Science, Seoul National University, Seoul, 03080, Republic of Korea
| | - Woong Yang Park
- Samsung Genome Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea.
| | - Jeong Seok Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea; Inocras, Inc., San Diego, CA, 92121, USA.
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Petersen CL, David M, Stilgren L, Ennis ZN. Atypical fractures of the lower extremities in two patients with rheumatoid arthritis: clinical presentations of presumed methotrexate osteopathy. BMJ Case Rep 2024; 17:e256567. [PMID: 39216879 DOI: 10.1136/bcr-2023-256567] [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] [Indexed: 09/04/2024] Open
Abstract
We present two patients who developed multiple lower limb stress fractures. Potential causes, such as osteoporosis, malignancies and disturbances in calcium metabolism were investigated. This led the physicians to consider whether methotrexate (MTX) exposure posed a risk of atypical fractures.The association between MTX and lower limb fractures has been described in at least 80 cases in the literature. Stress fractures associated with MTX treatment are atypical of osteoporosis and located in the lower extremities, most often the tibia. The limited data suggest that discontinuation of MTX may improve symptoms and chances of fracture healing, while antiresorptive or osteoanabolic therapies have not proven clinically efficient. It seems evident, however, that the benefits of MTX treatment in rheumatological disease clearly outweigh the risk of MTX osteopathy and related fractures.
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Affiliation(s)
| | - Marc David
- Odense University Hospital, Svendborg, Syddanmark, Denmark
| | - Lis Stilgren
- Odense University Hospital, Svendborg, Syddanmark, Denmark
| | - Zandra Nymand Ennis
- Department of Clinical Pharmacology, Odense University Hospital, Odense C, Denmark
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Matias SLK, Pereira CADC, Soares MR, Fernandes FCV, Moreira MAC, Baptista FMDA, Prata TA, Cordeiro G, Mancuzo EV. Relative incidence of interstitial lung diseases in Brazil. J Bras Pneumol 2024; 50:e20230232. [PMID: 38536981 PMCID: PMC11095929 DOI: 10.36416/1806-3756/e20230232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/23/2023] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE To assess the relative frequency of incident cases of interstitial lung diseases (ILDs) in Brazil. METHODS This was a retrospective survey of new cases of ILD in six referral centers between January of 2013 and January of 2020. The diagnosis of ILD followed the criteria suggested by international bodies or was made through multidisciplinary discussion (MDD). The condition was characterized as unclassifiable ILD when there was no specific final diagnosis following MDD or when there was disagreement between clinical, radiological, or histological data. RESULTS The sample comprised 1,406 patients (mean age = 61 ± 14 years), and 764 (54%) were female. Of the 747 cases exposed to hypersensitivity pneumonitis (HP)-related antigens, 327 (44%) had a final diagnosis of HP. A family history of ILD was reported in 8% of cases. HRCT findings were indicative of fibrosis in 74% of cases, including honeycombing, in 21%. Relevant autoantibodies were detected in 33% of cases. Transbronchial biopsy was performed in 23% of patients, and surgical lung biopsy, in 17%. The final diagnoses were: connective tissue disease-associated ILD (in 27%), HP (in 23%), idiopathic pulmonary fibrosis (in 14%), unclassifiable ILD (in 10%), and sarcoidosis (in 6%). Diagnoses varied significantly among centers (c2 = 312.4; p < 0.001). CONCLUSIONS Our findings show that connective tissue disease-associated ILD is the most common ILD in Brazil, followed by HP. These results highlight the need for close collaboration between pulmonologists and rheumatologists, the importance of detailed questioning of patients in regard with potential exposure to antigens, and the need for public health campaigns to stress the importance of avoiding such exposure.
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Affiliation(s)
| | | | - Maria Raquel Soares
- . Hospital São Paulo, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | | | | | - Tarciane Aline Prata
- . Fundação Hospitalar do Estado de Minas Gerais, Hospital Júlia Kubistchek, Belo Horizonte (MG) Brasil
| | - Gediel Cordeiro
- . Fundação Hospitalar do Estado de Minas Gerais, Hospital Júlia Kubistchek, Belo Horizonte (MG) Brasil
| | - Eliane Viana Mancuzo
- . Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
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Harrison M, Kavanagh G, Corte TJ, Troy LK. Drug-induced interstitial lung disease: a narrative review of a clinical conundrum. Expert Rev Respir Med 2024; 18:23-39. [PMID: 38501199 DOI: 10.1080/17476348.2024.2329612] [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: 10/29/2023] [Accepted: 03/08/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Drug-induced interstitial lung disease (DI-ILD) is increasing in incidence, due to the use of many new drugs across a broad range of cancers and chronic inflammatory diseases. The presentation and onset of DI-ILD are variable even for the same drug across different individuals. Clinical suspicion is essential for identifying these conditions, with timely drug cessation an important determinant of outcomes. AREAS COVERED This review provides a comprehensive and up-to-date summary of epidemiology, risk factors, pathogenesis, diagnosis, treatment, and prognosis of DI-ILD. Relevant research articles from PubMed and Medline searches up to September 2023 were screened and summarized. Specific drugs including immune checkpoint inhibitors, CAR-T cell therapy, methotrexate, and amiodarone are discussed in detail. The potential role of pharmacogenomic profiling for lung toxicity risk is considered. EXPERT OPINION DI-ILD is likely to be an increasingly important contributor to respiratory disability in the community. These conditions can negatively impact quality of life and patient longevity, due to associated respiratory compromise as well as cessation of evidence-based therapy for the underlying disease. This clinical conundrum is relevant to all areas of medicine, necessitating increased understanding and greater vigilance for drug-related lung toxicity.
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Affiliation(s)
- Megan Harrison
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Grace Kavanagh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Tamera J Corte
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Lauren K Troy
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Damiani G, Amerio P, Bardazzi F, Carrera CG, Conti A, Cusano F, Dapavo P, DeSimone C, El Hachem M, Fabbrocini G, Gisondi P, Loconsole F, Micali G, Neri I, Parodi A, Piaserico S, Romanelli M, Stingeni L, Pigatto PDM. Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00930-2. [PMID: 37210684 DOI: 10.1007/s13555-023-00930-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/17/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND After decades of use, methotrexate displays an established safety and efficacy profile in both in-hospital and outpatient settings. Despite its widespread use, there is surprisingly little clinical evidence to guide daily practice with methotrexate in dermatology. OBJECTIVES To provide guidance for clinicians in daily practice for areas in which there is limited guidance. METHODS A Delphi consensus exercise on 23 statements was carried out on the use of methotrexate in dermatological routine settings. RESULTS Consensus was reached on statements that cover six main areas: (1) pre-screening exams and monitoring of therapy; (2) dosing and administration in patients naïve to methotrexate; (3) optimal strategy for patients in remission; (4) use of folic acid; (5) safety; and (6) predictors of toxicity and efficacy. Specific recommendations are provided for all 23 statements. CONCLUSIONS In order to optimize methotrexate efficacy, it is essential to optimize treatment using appropriate dosages, carrying out a rapid drug-based step-up on a treat-to-target strategy and preferably using the subcutaneous formulation. To manage safety aspects appropriately, it is essential to evaluate patients' risk factors and carry out proper monitoring during the course of treatment.
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Affiliation(s)
- Giovanni Damiani
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy.
- Italian Center of Precisione Medicine and Chronic Inflammation, University of Milan, Milan, Italy.
- UOC Dermatology, Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161, Milan, Italy.
| | - Paolo Amerio
- Dermatologic Clinic, Department of Medicine and Aging Science, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Federico Bardazzi
- Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo G Carrera
- Fondazione Cà Granda IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Andrea Conti
- Dermatology Unit, Ospedale Infermi di Rimini, AUSL Romagna, Rimini, Italy
| | | | - Paolo Dapavo
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Clara DeSimone
- DermatologiaDipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - May El Hachem
- Dermatology Unit and Genodermatosis Research Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Francesco Loconsole
- Department of Biomedical Sciences and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | | | - Iria Neri
- Dermatology, Sant'Orsola-Malpighi Polyclinic University Hospital-IRCCS, University of Bologna, Bologna, Italy
| | - Aurora Parodi
- Dermatology Clinic, DISSAL, Polyclinic Hospital San Martino-IRCCS, University of Genoa, Genoa, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Luca Stingeni
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Paolo D M Pigatto
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
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Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
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Acute exacerbation of interstitial lung disease associated with rheumatic disease. Nat Rev Rheumatol 2022; 18:85-96. [PMID: 34876670 DOI: 10.1038/s41584-021-00721-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
Interstitial lung disease (ILD) is a cause of morbidity and mortality in patients with rheumatic diseases, such as connective-tissue diseases, rheumatoid arthritis and systemic vasculitis. Some patients with ILD secondary to rheumatic disease (RD-ILD) experience acute exacerbations, with sudden ILD progression and high mortality during or immediately after the exacerbation, and a very low 1-year survival rate. In the ILD subtype idiopathic pulmonary fibrosis (IPF), an acute exacerbation is defined as acute worsening or development of dyspnoea associated with new bilateral ground-glass opacities and/or consolidations at high-resolution CT, superimposed on a background pattern consistent with fibrosing ILD. However, acute exacerbation in RD-ILD (AE-RD-ILD) currently has no specific definition. The aetiology and pathogenesis of AE-RD-ILD remain unclear, but distinct triggers might include infection, mechanical stress, microaspiration and DMARD treatment. At this time, no effective evidence-based therapeutic strategies for AE-RD-ILD are available. In clinical practice, AE-RD-ILD is often empirically treated with high-dose systemic steroids and antibiotics, with or without immunosuppressive drugs. In this Review, we summarize the clinical features, diagnosis, management and prognosis of AE-RD-ILD, enabling the similarities and differences with acute exacerbation in IPF to be critically assessed.
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