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Liu R, Guo Z, Xu H, He J, Wang B, Jin Y, Zhao Z, Tang X, Zhou X. Traditional Chinese medicine for sjögren's syndrome: a national survey of attitudes and perceptions among Chinese patients and rheumatologists. BMC Complement Med Ther 2024; 24:291. [PMID: 39080629 PMCID: PMC11290160 DOI: 10.1186/s12906-024-04591-2] [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: 03/06/2023] [Accepted: 07/16/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND This study explored similarities and differences among Chinese patients and rheumatologists in their attitudes towards and perceptions of traditional Chinese medicine (TCM) for Sjögren's syndrome (SS), including analyzing factors that influenced their decision making. METHODS An anonymous questionnaire was used to conduct a multicenter survey among patients with SS at three tertiary care medical centers in Beijing and among rheumatology clinicians at several hospitals across China. Results were analyzed using descriptive statistics. RESULTS There were 942 valid questionnaires from patients from 31 provinces and cities in China, with a male-to-female ratio of approximately 1:14, a mean age of 48.81 years, and a median disease duration of 7 (4, 10) years. There were 320 valid questionnaires from rheumatologists, covering 30 provinces and cities in China, with a male-to-female ratio of approximately 0.87:1, a mean age of 48 years, and a median work duration of 10.5 (6, 15) years. The rheumatologists treated a median of 15 (11, 50) SS cases per month, and the median proportion of SS to all rheumatic diseases was 6.66% (6-10%). Many patients believed TCM could cure the root of the disease, and the most expected TCM therapies were TCM patent prescriptions and medicinal teas. Conversely, rheumatologists placed high value on the efficacy of TCM, and most commonly prescribed Chinese herbal decoctions. Most doctor-patient groups were positive about TCM treatment, citing the low side effects as the major advantage. Regression analysis showed that for patients over 40 years old with a course of disease > 4 years, the probability of using TCM has increased by 1-6 times; the probability of recommending TCM in clinical work of doctors who have worked for more than 15 years, TCM and integrated traditional Chinese and western medicine has increased 1-2 times. CONCLUSIONS TCM has become widely accepted and earned attention from doctor-patient groups, especially among older patients and experienced rheumatologists. However, negative prejudices and absence of accurate information about TCM treatments and SS itself require improvement. The contradiction between TCM dosage form and efficacy is a major problem, and patient demand for convenient and efficient TCM patent preparations suggests future work should focus on developing TCM patent preparations with clear compositions and mechanisms.
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Affiliation(s)
- Ruihua Liu
- Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine, Beijing, China
| | - Zilin Guo
- Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine, Beijing, China
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Haodong Xu
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Jiangsu, China
| | - Jing He
- Peking University People's Hospital, Beijing, China
| | - Bei Wang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yuebo Jin
- Peking University People's Hospital, Beijing, China
| | - Ziying Zhao
- Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine, Beijing, China
| | - Xiaopo Tang
- Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine, Beijing, China.
| | - Xinyao Zhou
- Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine, Beijing, China.
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Nguyen Y, Nocturne G, Henry J, Ng WF, Belkhir R, Desmoulins F, Bergé E, Morel J, Perdriger A, Dernis E, Devauchelle-Pensec V, Sène D, Dieudé P, Couderc M, Fauchais AL, Larroche C, Vittecoq O, Salliot C, Hachulla E, Le Guern V, Gottenberg JE, Mariette X, Seror R. Identification of distinct subgroups of Sjögren's disease by cluster analysis based on clinical and biological manifestations: data from the cross-sectional Paris-Saclay and the prospective ASSESS cohorts. THE LANCET. RHEUMATOLOGY 2024; 6:e216-e225. [PMID: 38437852 PMCID: PMC10949202 DOI: 10.1016/s2665-9913(23)00340-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND Sjögren's disease is a heterogenous autoimmune disease with a wide range of symptoms-including dryness, fatigue, and pain-in addition to systemic manifestations and an increased risk of lymphoma. We aimed to identify distinct subgroups of the disease, using cluster analysis based on subjective symptoms and clinical and biological manifestations, and to compare the prognoses of patients in these subgroups. METHODS This study included patients with Sjögren's disease from two independent cohorts in France: the cross-sectional Paris-Saclay cohort and the prospective Assessment of Systemic Signs and Evolution of Sjögren's Syndrome (ASSESS) cohort. We first used an unsupervised multiple correspondence analysis to identify clusters within the Paris-Saclay cohort using 26 variables comprising patient-reported symptoms and clinical and biological manifestations. Next, we validated these clusters using patients from the ASSESS cohort. Changes in disease activity (measured by the European Alliance of Associations for Rheumatology [EULAR] Sjögren's Syndrome Disease Activity Index [ESSDAI]), patient-acceptable symptom state (measured by the EULAR Sjögren's Syndrome Patient Reported Index [ESSPRI]), and lymphoma incidence during follow-up were compared between clusters. Finally, we compared our clusters with the symptom-based subgroups previously described by Tarn and colleagues. FINDINGS 534 patients from the Paris-Saclay cohort (502 [94%] women, 32 [6%] men, median age 54 years [IQR 43-64]), recruited between 1999 and 2022, and 395 patients from the ASSESS cohort (370 [94%] women, 25 [6%] men, median age 53 years [43-63]), recruited between 2006 and 2009, were included in this study. In both cohorts, hierarchical cluster analysis revealed three distinct subgroups of patients: those with B-cell active disease and low symptom burden (BALS), those with high systemic disease activity (HSA), and those with low systemic disease activity and high symptom burden (LSAHS). During follow-up in the ASSESS cohort, disease activity and symptom states worsened for patients in the BALS cluster (67 [36%] of 186 patients with ESSPRI score <5 at month 60 vs 92 [49%] of 186 at inclusion; p<0·0001). Lymphomas occurred in patients in the BALS cluster (five [3%] of 186 patients; diagnosed a median of 70 months [IQR 42-104] after inclusion) and the HSA cluster (six [4%] of 158 patients; diagnosed 23 months [13-83] after inclusion). All patients from the Paris-Saclay cohort with a history of lymphoma were in the BALS and HSA clusters. This unsupervised clustering classification based on symptoms and clinical and biological manifestations did not correlate with a previous classification based on symptoms only. INTERPRETATION On the basis of symptoms and clinical and biological manifestations, we identified three distinct subgroups of patients with Sjögren's disease with different prognoses. Our results suggest that these subgroups represent different heterogeneous pathophysiological disease mechanisms, stages of disease, or both. These findings could be of interest when stratifying patients in future therapeutic trials. FUNDING Fondation pour la Recherche Médicale, French Ministry of Health, French Society of Rheumatology, Innovative Medicines Initiative 2 Joint Undertaking, Medical Research Council UK, and Foundation for Research in Rheumatology.
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Affiliation(s)
- Yann Nguyen
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France; Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Paris, France
| | - Gaëtane Nocturne
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France; Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Paris, France
| | - Julien Henry
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Wan-Fai Ng
- Faculty of Medical Sciences, Clinical and Translational Research Institute, Newcastle University, NIHR Newcastle Biomedical Research Centre and NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Rakiba Belkhir
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Frédéric Desmoulins
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Elisabeth Bergé
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Jacques Morel
- Rheumatology Department, CHU de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Aleth Perdriger
- Rheumatology Department, CHU Rennes, Université Rennes, Rennes, France
| | - Emmanuelle Dernis
- Department of Rheumatology and Clinical Immunology, General Hospital, Le Mans, France
| | - Valérie Devauchelle-Pensec
- Department of Rheumatology, CHU de Brest, INSERM 1227, LBAI, Université de Bretagne Occidentale, Centre de Référence des Maladies Auto-Immunes Rares de l'Adulte, Brest, France
| | - Damien Sène
- Department of Internal Medicine, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Philippe Dieudé
- Department of Rheumatology, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, INSERM UMR1152, Paris-Cité University, Paris, France
| | - Marion Couderc
- Department of Rheumatology, CHU de Clermont-Ferrand, INSERM UMR 1240, Clermont Auvergne University, Clermont-Ferrand, France
| | - Anne-Laure Fauchais
- Department of Internal Medicine, University Hospital of Limoges, Limoges, France
| | - Claire Larroche
- Department of Internal Medicine, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Bobigny, France
| | - Olivier Vittecoq
- Department of Rheumatology, Rouen University Hospital, Rouen, France
| | - Carine Salliot
- Department of Rheumatology, Centre Hospitalier Universitaire d'Orléans, Orléans, France
| | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Hôpital Claude Huriez, University of Lille, Lille, France
| | - Véronique Le Guern
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Jacques-Eric Gottenberg
- Rheumatology Department, EA 3432, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Xavier Mariette
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France; Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Paris, France
| | - Raphaèle Seror
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Paris, France; Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Paris, France.
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Arends S, Vissink A, Bootsma H. Subgroups of Sjögren's disease: are they of any help? THE LANCET. RHEUMATOLOGY 2024; 6:e191-e193. [PMID: 38437853 DOI: 10.1016/s2665-9913(24)00029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen and University Medical Center Groningen, Groningen, Netherlands.
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
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Berry J, Tarn J, Lendrem D, Casement J, Ng WF. What can patients tell us in Sjögren's syndrome? RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:34-41. [PMID: 38571930 PMCID: PMC10985711 DOI: 10.1515/rir-2024-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 10/04/2023] [Indexed: 04/05/2024]
Abstract
In Sjögren's Syndrome (SS), clinical heterogeneity and discordance between disease activity measures and patient experience are key obstacles to effective therapeutic development. Patient reported outcome measures (PROMs) are useful tools for understanding the unmet needs from the patients' perspective and therefore they are key for the development of patient centric healthcare systems. Initial concern about the subjectivity of PROMs has given way to methodological rigour and clear guidance for the development of PROMs. To date, several studies of patient stratification using PROMs have identified similar symptom-based subgroups. There is evidence to suggest that these subgroups may represent different disease endotypes with differing responses to therapeutic interventions. Stratified medicine approaches, alongside sensitive outcome measures, have the potential to improve our understanding of SS pathobiology and therapeutic development. The inclusion of PROMs is important for the success of such approaches. In this review we discuss the opportunities of using PROMs in understanding the pathogenesis of and therapeutic development for SS.
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Affiliation(s)
- Joe Berry
- Translational and Clinical Research Institute, Newcastle University, Newcastle uponTyne, UK
| | - Jessica Tarn
- Translational and Clinical Research Institute, Newcastle University, Newcastle uponTyne, UK
| | - Dennis Lendrem
- Translational and Clinical Research Institute, Newcastle University, Newcastle uponTyne, UK
| | - John Casement
- Translational and Clinical Research Institute, Newcastle University, Newcastle uponTyne, UK
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University, Newcastle uponTyne, UK
- National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre& NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle uponTyne, UK
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Berry JS, Tarn J, Casement J, Duret PM, Scott L, Wood K, Johnsen SJ, Nordmark G, Devauchelle-Pensec V, Seror R, Fisher B, Barone F, Bowman SJ, Bombardieri M, Lendrem D, Felten R, Gottenberg JE, Ng WF. Examining the biological pathways underlying clinical heterogeneity in Sjogren's syndrome: proteomic and network analysis. Ann Rheum Dis 2024; 83:88-95. [PMID: 37657927 DOI: 10.1136/ard-2023-224503] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/20/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Stratification approaches are vital to address clinical heterogeneity in Sjogren's syndrome (SS). We previously described that the Newcastle Sjogren's Stratification Tool (NSST) identified four distinct clinical subtypes of SS. We performed proteomic and network analysis to analyse the underlying pathobiology and highlight potential therapeutic targets for different SS subtypes. METHOD We profiled serum proteins using O-link technology of 180 SS subjects. We used 5 O-link proteomics panels which included a total of 454 unique proteins. Network reconstruction was performed using the ARACNE algorithm, with differential expression estimates overlaid on these networks to reveal the key subnetworks of differential expression. Furthermore, data from a phase III trial of tocilizumab in SS were reanalysed by stratifying patients at baseline using NSST. RESULTS Our analysis highlights differential expression of chemokines, cytokines and the major autoantigen TRIM21 between the SS subtypes. Furthermore, we observe differential expression of several transcription factors associated with energy metabolism and redox balance namely APE1/Ref-1, FOXO1, TIGAR and BACH1. The differentially expressed proteins were inter-related in our network analysis, supporting the concept that distinct molecular networks underlie the clinical subtypes of SS. Stratification of patients at baseline using NSST revealed improvement of fatigue score only in the subtype expressing the highest levels of serum IL-6. CONCLUSIONS Our data provide clues to the pathways contributing to the glandular and non-glandular manifestations of SS and to potential therapeutic targets for different SS subtypes. In addition, our analysis highlights the need for further exploration of altered metabolism and mitochondrial dysfunction in the context of SS subtypes.
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Affiliation(s)
- Joe Scott Berry
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Jessica Tarn
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - John Casement
- Bioinformatics Support Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Lauren Scott
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Karl Wood
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Svein-Joar Johnsen
- Department of Rheumatology, Stavanger University Hospital, Stavanger, Norway
| | | | - Valérie Devauchelle-Pensec
- Lymphocytes B et auto-immunité, Inserm U1227, Brest university and La Cavale Blanche Hospital, Brest, France
| | - Raphaele Seror
- Centre for Immunology of Viral Infections and Autoimmune Diseases, Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
| | - Benjamin Fisher
- Institute of Inflammation and Ageing, University Hospitals Birmingham, Birmingham, UK
- Department of Rheumatology, National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Fransesca Barone
- Institute of Inflammation and Ageing, University Hospitals Birmingham, Birmingham, UK
| | - Simon J Bowman
- Institute of Inflammation and Ageing, University Hospitals Birmingham, Birmingham, UK
| | - Michele Bombardieri
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
| | - Dennis Lendrem
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Renaud Felten
- Centre National de Référence des maladies auto-immunes et systémiques rares Est/Sud-Ouest (RESO), Hôpitaux universitaires de Strasbourg, Strasbourg, France
- Laboratoire d'Immunologie, Immunopathologie et Chimie Thérapeutique, Institut de Biologie Moléculaire et Cellulaire (IBMC), Strasbourg, France
| | - Jacques-Eric Gottenberg
- Centre National de Référence des maladies auto-immunes et systémiques rares Est/Sud-Ouest (RESO), Hôpitaux universitaires de Strasbourg, Strasbourg, France
- Laboratoire d'Immunologie, Immunopathologie et Chimie Thérapeutique, Institut de Biologie Moléculaire et Cellulaire (IBMC), Strasbourg, France
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- National Institute for Health and Care Research (NIHR), Newcastle Biomedical Research Centre & NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Wang S, Arizmendi CJ, Blalock DV, Chen D, Lin L, Thissen D, Huang IC, DeWalt DA, Reeve BB. Health-related quality of life profiles in adolescents and young adults with chronic conditions. Qual Life Res 2023; 32:3171-3183. [PMID: 37340132 PMCID: PMC11264194 DOI: 10.1007/s11136-023-03463-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with chronic conditions. METHODS AYAs (N = 872) aged 14-20 years completed NIH's Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, pain interference, fatigue, social health, depression, anxiety, and anger. Latent profile analysis (LPA) was used to group AYAs into HRQOL profiles using PROMIS T-scores. The optimal number of profiles was determined by model fit statistics, likelihood ratio test, and entropy. Multinomial logistic regression models were used to examine how LPA's HRQOL profile membership was associated with patient demographic and chronic conditions. The model prediction accuracy on profile membership was evaluated using Huberty's I index with a threshold of 0.35 for good effect. RESULTS A 4-profile LPA model was selected. A total of 161 (18.5%), 256 (29.4%), 364 (41.7%), and 91 (10.4%) AYAs were classified into Minimal, Mild, Moderate, and Severe HRQOL Impact profiles. AYAs in each profile had distinctive mean scores with over a half standard deviation (5-points in PROMIS T-scores) of difference between profiles across most HRQOL domains. AYAs who were female or had conditions such as mental health condition, hypertension, and self-reported chronic pain were more likely to be in the Severe HRQOL Impact profile. The Huberty's I index was 0.36. CONCLUSIONS Approximately half of AYAs with a chronic condition experience moderate to severe HRQOL impact. The availability of risk prediction models for HRQOL impact will help to identify AYAs who are in greatest need of closer clinical care follow-up.
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Affiliation(s)
- Suwei Wang
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street; Suite 230, DUMC 104023, Durham, NC, 27701, USA
| | - Cara J Arizmendi
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street; Suite 230, DUMC 104023, Durham, NC, 27701, USA
| | - Dan V Blalock
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Dandan Chen
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street; Suite 230, DUMC 104023, Durham, NC, 27701, USA
| | - Li Lin
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street; Suite 230, DUMC 104023, Durham, NC, 27701, USA
| | - David Thissen
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Darren A DeWalt
- Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street; Suite 230, DUMC 104023, Durham, NC, 27701, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
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Lee AYS, Wang JJ, Gordon TP, Reed JH. Phases and Natural History of Sjögren's Disease: A New Model for an Old Disease? Arthritis Care Res (Hoboken) 2023; 75:1580-1587. [PMID: 36063396 PMCID: PMC10953327 DOI: 10.1002/acr.25011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/07/2023]
Abstract
Sjögren's disease (SjD) is an archetypal and heterogenous autoimmune disorder that is characterized by exocrine glandular dysfunction. A proportion of patients develop severe extraglandular manifestations, such as cryoglobulinemia, and have an increased risk of lymphoma, both of which can adversely affect quality of life and occasionally mortality. As with most autoimmune disorders, the pathogenesis is poorly understood and difficult to predict, and, frustratingly, there is a lack of targeted therapies to cure this disease. We review the disease manifestations of SjD and propose a staged model for understanding the evolution of pathology. In longitudinal studies, most patients remain relatively stable in terms of their laboratory and clinical parameters. However, in the setting of various risk factors, a proportion of patients develop severe symptoms and/or lymphoma. We discuss potential underlying mechanisms for disease progression and the strengths and limitations of using a staged model to correlate the pathogenesis and spectrum of manifestations in SjD. Ultimately, understanding how and why some patients remain relatively stable, whereas others progress and develop florid systemic disease and a fraction develop lymphoma, is key to developing preventative and therapeutic treatments.
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Affiliation(s)
- Adrian Y. S. Lee
- The Westmead Institute for Medical ResearchUniversity of Sydney, Westmead Hospital, NSW Health PathologyWestmeadNew South WalesAustralia
| | - Jing Jing Wang
- SA Pathology and Flinders UniversityBedford ParkSouth AustraliaAustralia
| | - Tom P. Gordon
- SA Pathology and Flinders UniversityBedford ParkSouth AustraliaAustralia
| | - Joanne H. Reed
- The Westmead Institute for Medical ResearchUniversity of SydneyWestmeadNew South WalesAustralia
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Arends S, Verstappen GM, de Wolff L, Pringle S, Kroese FGM, Vissink A, Bootsma H. Why do drug treatments fail in Sjögren's disease? Considerations for treatment, trial design and interpretation of clinical efficacy. Expert Rev Clin Immunol 2023; 19:1187-1194. [PMID: 37551702 DOI: 10.1080/1744666x.2023.2234641] [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: 05/01/2023] [Accepted: 07/05/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Despite ongoing efforts to develop effective therapeutics, no disease-modifying drugs have been officially licensed for the indication of Sjögren's disease (SjD). This is partly due to heterogeneity in disease manifestations, which complicates drug target selection, trial design and interpretation of clinical efficacy in SjD. AREAS COVERED Here, we summarize developments and comment on challenges in 1) identifying the right target for treatment, 2) selection of the primary study endpoint for trials and definition of clinically relevant response to treatment, 3) inclusion criteria and patient stratification, 4) distinguishing between disease activity and damage and 5) establishing the effect of treatment considering measurement error, natural variation, and placebo or nocebo responses. EXPERT OPINION Targets that are involved in both the immune cell response and dysregulation of glandular epithelial cells (e.g. B-lymphocytes, type-I interferon) are of particular interest to treat both glandular and extra-glandular manifestations of SjD. The recent development of composite study endpoints (CRESS and STAR) may be a crucial step forward in the search for clinically effective systemic treatment of patients with SjD. Important additional areas for future research are symptom-based and/or molecular pathway-based patient stratification, prevention of irreversible damage, and establishing the effect of treatment.
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Affiliation(s)
- Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gwenny M Verstappen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Liseth de Wolff
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sarah Pringle
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frans G M Kroese
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Mohammadi T, Yavari T, Ghorbani S, Mohammadi B. Associations of diagnostic findings with disease activity in primary Sjӧgren's syndrome: a cluster analysis. Rev Clin Esp 2023; 223:209-215. [PMID: 36841475 DOI: 10.1016/j.rceng.2023.02.004] [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: 02/27/2023]
Abstract
OBJECTIVE The diagnosis of primary Sjӧgren's syndrome still relies upon a constellation of clinical, laboratory, imaging, and pathological findings. We aimed to evaluate the relation of the disease activity with the results of diagnostic tests for primary Sjӧgren's syndrome. METHODS A principal component with cluster analysis was performed to classify 69 patients with primary Sjӧgren's syndrome based on the results of diagnostic evaluations. RESULTS Anti-SSA autoantibody was the most represented feature on the principal components. The anti-SSA and ultrasound score were positively correlated (p=0.001). We identified two distinct clusters of low or high disease activity (p<0.001). Except for disease duration and serum beta2-microglobulin, the clusters were significantly different in salivary flow (p= 0.004), ultrasound findings (p<0.001), IgG (p= 0.001), and salivary beta2-microglobulin (p= 0.048). Also, positive findings were significantly different between the clusters in rheumatoid factor, antinuclear antibody, anti-SSA, and anti-SSB (all p≤0.013). CONCLUSION Patients with higher syndrome activity were best recognized with serological and ultrasound assessments. However, patients with lower syndrome activity had a longer disease duration, higher stimulated salivary flow rate, and a positive biopsy of minor salivary glands (56%).
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Affiliation(s)
- T Mohammadi
- University of Tehran, College of Science, School of Mathematics, Statistics, and Computer Science, Tehran, Iran
| | - T Yavari
- Tehran University of Medical Sciences, Faculty of Medicine, Shariati Hospital, Tehran, Iran
| | - S Ghorbani
- Kerman University of Medical Sciences, Shafa Hospital, Department of Otorhinolaryngology, Kerman, Iran
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Ridgewell D, Thalayasingam N, Ng WF. Sjögren's syndrome: shedding light on emerging and key drug targets. Expert Opin Ther Targets 2022; 26:869-882. [PMID: 36576336 DOI: 10.1080/14728222.2022.2157259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Sjögren's syndrome (SS) is an immune-mediated inflammatory condition characterized by sicca syndrome, musculoskeletal pain, and fatigue. Extra-glandular manifestations are common and there is a markedly increased risk of lymphoma development. SS is associated with high health-economic burden driven largely by the symptom burden on patients. Currently, there is no approved disease-modifying treatment and management is based on empirical evidence. Progress in the understanding of SS pathogenesis has led to an expanding portfolio of more targeted therapies under development. AREAS COVERED This review summarizes the key development in targeted biological therapies in SS including emerging targets. It also highlights the challenges in therapeutic development in SS such as disease heterogeneity and defining appropriate disease assessment tools to evaluate therapeutic efficacy. EXPERT OPINION Early trials in SS failed to meet their primary outcomes which may in part due to the use of inappropriate or insensitive study endpoints. Recent trials targeting B-cells, B-T cell co-stimulation and IFN signaling have shown promising results. Development of composite endpoints including patient reported outcomes and objective disease measure may provide a more holistic approach to disease assessment. The impact of these new tools on therapeutic development that benefit patients remains to be fully evaluated.
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Affiliation(s)
- Dominic Ridgewell
- Musculoskeletal Theme, NIHR Newcastle Biomedical Research Centre and NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nishanthi Thalayasingam
- Musculoskeletal Theme, NIHR Newcastle Biomedical Research Centre and NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Wan-Fai Ng
- Musculoskeletal Theme, NIHR Newcastle Biomedical Research Centre and NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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McCoy SS, Woodham M, Bartels CM, Saldanha IJ, Bunya VY, Maerz N, Akpek EK, Makara MA, Baer AN. Symptom-Based Cluster Analysis Categorizes Sjögren's Disease Subtypes: An International Cohort Study Highlighting Disease Severity and Treatment Discordance. Arthritis Rheumatol 2022; 74:1569-1579. [PMID: 35594474 PMCID: PMC9427679 DOI: 10.1002/art.42238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Although symptom relief is a critical aspect for successful drug development in Sjögren's disease, patient experiences with Sjögren's-related symptoms are understudied. Our objective was to determine how pain, dryness, and fatigue, the cardinal symptoms of Sjögren's disease, drive cluster phenotypes. METHODS We used data from the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry and a Sjögren's Foundation survey. We performed hierarchical clustering of symptoms by levels of dryness, fatigue, and pain. Using international and US cohorts, we performed multiple logistic regression analysis to compare the clusters, which included comparisons of differences in symptoms, quality of life (QoL), medication use, and systemic manifestations. RESULTS Four similar clusters were identified among 1,454 SICCA registrants and 2,920 Sjögren's Foundation survey participants: 1) low symptom burden in all categories (LSB); 2) dry with low pain and low fatigue (DLP); 3) dry with high pain and low to moderate fatigue (DHP); and 4) high symptom burden in all categories (HSB). Distribution of SICCA registrants matching the symptom profile for each cluster was 10% in the LSB cluster, 30% in the DLP cluster, 23% in the DHP cluster, and 37% in the HSB cluster. Distribution of survey participants matching the symptom profile for each cluster was 23% in the LSB cluster, 14% in the DLP cluster, 21% in the DHP cluster, and 42% in the HSB cluster. Individuals in the HSB cluster had more total symptoms and lower QoL but lower disease severity than those in the other clusters. Despite having milder disease as measured by laboratory tests and organ involvement, individuals in the HSB cluster received immunomodulatory treatment most often. CONCLUSION We identified 4 symptom-based Sjögren's clusters and showed that symptom burden and immunomodulatory medication use do not correlate with Sjögren's end-organ or laboratory abnormalities. Findings highlight a discordance between objective measures and treatments and offer updates to proposed symptom-based clustering approaches.
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