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Moriano Morales C, Graña Gil J, Brito García N, Martín Varillas JL, Calvo Del Río V, Moya Alvarado P, Narváez García FJ, Espinosa G, Díaz Del Campo Fontecha P, Guerra Rodríguez M, Mateo Arranz J, López Gómez M, Francisco Hernández FM, Trujillo MM, Dos Santos Sobrín R, Martín Sánchez JI, Maese Manzano J, Suárez Cuba J. SER recommendations on treatment of refractory Behçet's syndrome. REUMATOLOGIA CLINICA 2024; 20:204-217. [PMID: 38614885 DOI: 10.1016/j.reumae.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 04/15/2024]
Abstract
OBJECTIVE To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (BS) (difficult to treat, severe resistant, severe relapse) to conventional treatment. METHODS A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format (patient, intervention, comparison and outcome). Systematic reviews of the evidence were conducted, the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations Assessment, Development, and Evaluation (GRADE). After that, the multidisciplinary panel formulated the specific recommendations. RESULTS 4 PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with BS with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus. CONCLUSIONS The treatment of most severe clinical manifestations of BS lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official Recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.
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Affiliation(s)
| | - Jenaro Graña Gil
- Servicio de Reumatología, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | - José Luis Martín Varillas
- Servicio de Reumatología, Hospital de Laredo, Laredo, Cantabria, Spain; Grupo de Inmunopatología, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Cantabria, Spain
| | - Vanesa Calvo Del Río
- Grupo de Inmunopatología, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Cantabria, Spain
| | | | | | - Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Hospital Clínic, Barcelona, Spain
| | | | | | - José Mateo Arranz
- Unidad de Hemostasia y Trombosis, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - M Mar Trujillo
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Santa Cruz de Tenerife, Spain
| | - Raquel Dos Santos Sobrín
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Juan Ignacio Martín Sánchez
- Instituto Aragonés de Ciencias de la Salud, Centro de Investigación Biomédica de Aragón (CIBA), Zaragoza, Spain
| | | | - Julio Suárez Cuba
- Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Emmi G, Bettiol A, Hatemi G, Prisco D. Behçet's syndrome. Lancet 2024; 403:1093-1108. [PMID: 38402885 DOI: 10.1016/s0140-6736(23)02629-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 02/27/2024]
Abstract
Behçet's syndrome is a rare, chronic multisystemic inflammatory disorder also known as the Silk Route disease due to its geographical distribution. Behçet's syndrome is a multifactorial disease and infectious, genetic, epigenetic, and immunological factors contribute to its pathogenesis. Its heterogeneous spectrum of clinical features include mucocutaneous, articular, ocular, vascular, neurological, and gastrointestinal manifestations that can present with a relapsing and remitting course. Differential diagnosis is often hampered by the non-specific clinical presentation and the absence of laboratory biomarkers or pathognomonic histological features. The therapeutic approach is tailored on the basis of patient-specific manifestations and relies on glucocorticoids, colchicine, and traditional and biological immunosuppressants. Despite progress in the knowledge and management of the disease, unmet needs in diagnostics, monitoring, prediction, and treatment personalisation challenge clinical practice, making Behçet's syndrome a complex disorder associated with an increased risk of morbidity.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, VIC, Australia.
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gülen Hatemi
- Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Türkiye
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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3
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Sota J, Capuano A, Emmi G, Iannone F, Cantarini L, Hatemi G, Lopalco G. Therapeutic approach to central nervous system involvement of Behçet's disease. Semin Arthritis Rheum 2023; 61:152206. [PMID: 37172497 DOI: 10.1016/j.semarthrit.2023.152206] [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: 02/19/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Neurologic involvement in Behçet's disease (BD) represents a major cause of disease morbidity and mortality. Early recognition and timely treatment represent crucial aspects that aim at preventing long-term disability. The absence of robust and evidence-based studies further complicates the management of neuro-BD (NBD). In this review we aim at collecting the best available evidence and suggest a treatment algorithm for an optimal and personalized management of NBD. EVIDENCE ACQUISITION PubMed (NLM) database for papers written in English language was used to retrieve relevant articles for this review. RESULTS AND CONCLUSIONS Neurologic involvement in BD is one of the most serious and challenging aspects to manage, particularly in its chronic progressive form. It is important to distinguish between acute and chronic progressive NBD, as treatment may vary considerably. Currently, no standardized treatment guidelines support physicians in the decision-making process that therefore relies on low-level evidence. High dose corticosteroids remain the cornerstone for managing acute phase both in the parenchymal and non-parenchymal involvement. Prevention of relapses and control of disease progression represent crucial goals for acute and chronic progressive NBD respectively. In this regard, mycophenolate mofetil and azathioprine are valuable options in the acute NBD. On the other hand, low weekly dose methotrexate has been suggested for chronic progressive NBD. Refractory cases or intolerant patients to conventional therapies may benefit from biologic agents, particularly infliximab. First-line infliximab may be preferred in severe patients with high risk of damage. Other agents including tocilizumab, interleukin-1 inhibitors, B-cell depletion therapy and to a lesser extent, interferon-α and intravenous immunoglobulins are potential options in severe and multidrug resistant cases. Due to multiple organ involvement in BD, long-term treatment should be determined by a multidisciplinary approach. Therefore, multicenter collaborations in the context of international registry-based projects could promote data sharing, standardization of more clinical outcomes and knowledge diffusion that hopefully may optimize therapy and personalize the management of patients with such a complex syndrome.
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Affiliation(s)
- Jurgen Sota
- Department of Medical Sciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Adriana Capuano
- Department of Precision and Rigenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, Piazza G. Cesare 11, Bari 70124, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Centre for Inflammatory Diseases, Monash Medical Centre, Monash University Department of Medicine, Clayton, Victoria, Australia
| | - Florenzo Iannone
- Department of Precision and Rigenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, Piazza G. Cesare 11, Bari 70124, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Gulen Hatemi
- Behçet's Disease Research Center, Istanbul University-Cerrahpasa, Turkey; Department of Internal Medicine, Division of Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Giuseppe Lopalco
- Department of Precision and Rigenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, Piazza G. Cesare 11, Bari 70124, Italy.
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Correia JA, Crespo J, Alves G, Salvador F, Matos-Costa J, Alves JD, Fortuna J, Almeida I, Campar A, Brandão M, Faria R, Marado D, Oliveira S, Santos L, Silva F, Vasconcelos C, Fernandes M, Marinho A. Biologic therapy in large and small vessels vasculitis, and Behçet's disease: Evidence- and practice-based guidance. Autoimmun Rev 2023:103362. [PMID: 37230310 DOI: 10.1016/j.autrev.2023.103362] [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: 05/02/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Vasculitis are a very heterogenous group of systemic autoimmune diseases, affecting large vessels (LVV), small vessels or presenting as a multisystemic variable vessel vasculitis. We aimed to define evidence and practice-based recommendations for the use of biologics in large and small vessels vasculitis, and Behçet's disease (BD). METHODS Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice on autoimmune diseases management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2022. Preliminary recommendations were drafted by working groups for each disease and voted in two rounds, in June and September 2021. Recommendations with at least 75% agreement were approved. RESULTS A total of 32 final recommendations (10 for LVV treatment, 7 for small vessels vasculitis and 15 for BD) were approved by the experts and several biologic drugs were considered with different supporting evidence. Among LVV treatment options, tocilizumab presents the higher level of supporting evidence. Rituximab is recommended for treatment of severe/refractory cryoglobulinemic vasculitis. Infliximab and adalimumab are most recommended in treatment of severe/refractory BD manifestations. Other biologic drugs can be considered is specific presentations. CONCLUSION These evidence and practice-based recommendations are a contribute to treatment decision and may, ultimately, improve the outcome of patients living with these conditions.
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Affiliation(s)
- João Araújo Correia
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira, Centro Hospitalar Alto Ave, Rua dos Cutileiros 4810-055, Guimarães, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, 5000-508 Vila Real, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Avenida Bernardo Santareno, 2005-177 Santarém,Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal; 4Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School; R. Câmara Pestana 6, 1150-082 Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal; CIMAGO, Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Milene Fernandes
- RWE & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, R. Tierno Galvan, 1250-096 Lisboa, Portugal
| | - António Marinho
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal.
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Karakaş Ö, Dogan İ, Güven SC, Erel Ş, Erten S. Evaluation of Tuberculosis Risk under Interleukin-1 Inhibitor Agents
in Patients with Autoinflammatory Diseases: Experience from a Region with
Moderate Tuberculosis Prevalence. AKTUEL RHEUMATOL 2023. [DOI: 10.1055/a-2015-2683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Abstract
Background We aimed to investigate the rate of TBC reactivation in
patients with autoinflammatory conditions who had been followed up under
treatment with IL-1 antagonists in our clinic. We further aimed to evaluate
whether latent TBC screening and isoniazid prophylaxis before IL-1 inhibitor
treatment is beneficial in the prevention of reactivation.
Patients and Methods This study was designed as a cross-sectional and
observational study. It received the approval of the local ethics committee and
was therefore performed in accordance with the ethical standards laid down in
the 1964 Declaration of Helsinki and its later amendments. Adult patients who
had been followed up in our clinic under treatment with IL-1 antagonists were
evaluated with regard to whether they had a TBC infection before and after these
treatments and whether they had been screened for latent TBC infection before
IL-1 antagonist treatment and received prophylaxis. Clinical and laboratory data
were obtained from hospital records and via telephone interviews after the
patients had given their verbal consent to participate.
Results Fifty-nine patients under IL-1 antagonists were consecutively
enrolled. 58 were under follow-up with the diagnosis of familial Mediterranean
fever and one patient with a diagnosis of adult-onset Still’s disease.
35 patients (59.3%) were treated with anakinra and 24 (40.7%)
were treated with canakinumab. 12 (50%) of the canakinumab users had
previously received anakinra treatment and were switched to canakinumab due to
side-effects or ineffectiveness. The number of patients who underwent latent
tuberculosisc infection (LTBI) screening before treatment was 37
(62.7%); the number of patients who received prophylaxis was 13
(22%). None of the patients receiving IL-1 antagonists developed active
tuberculosis.
Conclusion Blocking the IL-1 pathway may be safe regarding the activation
of LTBI or development of a new tuberculosis infection even in locations with a
high geographical risk.
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Affiliation(s)
| | - İsmail Dogan
- Rheumatology, Ankara Yildirim Beyazit University Faculty of Medicine,
Ankara, Turkey
| | | | - Şule Erel
- İnternal medicine, Ankara City Hospital, ankara,
Turkey
| | - Sukran Erten
- Rheumatology, Yildirim Beyazit University Faculty of Medicine, Ankara,
Turkey
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Fragoulis GE, Bertsias G, Bodaghi B, Gul A, van Laar J, Mumcu G, Saadoun D, Tugal-Tutkun I, Hatemi G, Sfikakis PP. Treat to target in Behcet's disease: Should we follow the paradigm of other systemic rheumatic diseases? Clin Immunol 2023; 246:109186. [PMID: 36410686 DOI: 10.1016/j.clim.2022.109186] [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: 10/17/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
During the last decades the efficacy of biologic agents, mainly of anti-TNFs, in controlling the activity of serious manifestations of Behcet's Disease (BD) has been established. On the other hand, the clinical heterogeneity of BD has precluded the validation of a widely-accepted composite index for disease assessment and for target disease-state definitions, such as low disease activity and remission, and the testing of their implementation in clinical practice. Therefore, in contrast to other systemic rheumatic diseases, a treat-to-target strategy has not yet been developed in BD. There are several challenges towards this approach, including standardization of outcome measures for assessing the disease activity in each-affected organ and construction of a composite disease activity index. The challenges for the development of a treat-to-target strategy and possible solutions are discussed in this position paper, which stemmed from a round table discussion that took place in the 19th International Conference on BD.
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Affiliation(s)
- George E Fragoulis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete Medical School, Heraklion, Greece
| | - Bahram Bodaghi
- Dept of Ophthalmology, IHU FOReSIGHT, Sorbonne University, APHP, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Jan van Laar
- Departments of Internal Medicine and Immunology, Division Clinical Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gonca Mumcu
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - David Saadoun
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, National reference center for autoinflammatory diseases and for rare systemic autoimmune diseases, F-75013 Paris, France
| | - Ilknur Tugal-Tutkun
- Istanbul University, Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul, Turkey; Eye Protection Foundation Bayrampasa Eye Hospital, Istanbul, Turkey
| | - Gulen Hatemi
- Department of Internal Medicine, Division of Rheumatology, Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey; Behçet's Disease Research Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Petros P Sfikakis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece.
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7
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Giani T, Luppino AF, Ferrara G. Treatment Options in Pediatric Behçet's Disease. Paediatr Drugs 2023; 25:165-191. [PMID: 36626047 PMCID: PMC9838500 DOI: 10.1007/s40272-022-00548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 01/11/2023]
Abstract
Behçet's disease is a rare and poorly understood vasculitis affecting blood vessels of all types and sizes. Uveitis and oral and genital ulcers represent the typical clinical triad. Populations along the ancient trading route connecting the Mediterranean basin with the Middle and Far East are most affected. Up to a quarter of the cases has a pediatric onset, typically around puberty. The aim of the treatment is early intervention to control inflammation, with symptom relief and prevention of relapses, damage, and complications. The heterogeneous clinical presentation often requires a multidisciplinary and tailored approach. Ocular, neurological, gastrointestinal, and vascular involvement is associated with a worse prognosis and needs more aggressive treatments. In young patients with expected prolonged disease, treatment should also focus on preventive measures and lifestyle advice. In recent years, the pharmacological armamentarium has grown progressively, although only a limited number of drugs are currently authorized for pediatric use. Most evidence for these drugs still derives from adult studies and experience; these are prescribed as off-label medications and are only available as adult formulations. Corticosteroids frequently represent the mainstay for the management of the initial acute phases, but their potential serious adverse effects limit their use to short periods. Different conventional disease-modifying anti-rheumatic drugs have long been used. Many other biologic drugs targeting different cytokines such as interleukin-1, interleukin-6, and interleukin-17 and treatments with small molecules including the phosphodiesterase 4 and Janus kinase inhibitors are emerging as novel promising therapeutic agents. In recent years, a growing interest has developed around anti-tumor necrosis factor agents that have often proven to be effective in severe cases, especially in those with a gastrointestinal and ocular involvement.
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8
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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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9
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Arnold DD, Yalamanoglu A, Boyman O. Systematic Review of Safety and Efficacy of IL-1-Targeted Biologics in Treating Immune-Mediated Disorders. Front Immunol 2022; 13:888392. [PMID: 35874710 PMCID: PMC9296857 DOI: 10.3389/fimmu.2022.888392] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background The cytokine interleukin (IL)-1 plays a pivotal role in immune-mediated disorders, particularly in autoinflammatory diseases. Targeting this cytokine proved to be efficacious in treating numerous IL-1-mediated pathologies. Currently, three IL-1 blockers are approved, namely anakinra, canakinumab and rilonacept, and two additional ones are expected to receive approval, namely gevokizumab and bermekimab. However, there is no systematic review on the safety and efficacy of these biologics in treating immune-mediated diseases. Objective To evaluate safety and efficacy of anakinra, canakinumab, rilonacept, gevokizumab, and bermekimab for the treatment of immune-mediated disorders compared to placebo, standard-of-care treatment or other biologics. Methods The PRISMA checklist guided the reporting of the data. We searched the PubMed database between 1 January 1984 and 31 December 2020 focusing on immune-mediated disorders. Our PubMed literature search identified 7363 articles. After screening titles and abstracts for the inclusion and exclusion criteria and assessing full texts, 75 articles were included in a narrative synthesis. Results Anakinra was both efficacious and safe in treating cryopyrin-associated periodic syndromes (CAPS), familial Mediterranean fever (FMF), gout, macrophage activation syndrome, recurrent pericarditis, rheumatoid arthritis (RA), and systemic juvenile idiopathic arthritis (sJIA). Conversely, anakinra failed to show efficacy in graft-versus-host disease, Sjögren’s syndrome, and type 1 diabetes mellitus (T1DM). Canakinumab showed efficacy in treating CAPS, FMF, gout, hyper-IgD syndrome, RA, Schnitzler’s syndrome, sJIA, and TNF receptor-associated periodic syndrome. However, use of canakinumab in the treatment of adult-onset Still’s disease and T1DM revealed negative results. Rilonacept was efficacious and safe for the treatment of CAPS, FMF, recurrent pericarditis, and sJIA. Contrarily, Rilonacept did not reach superiority compared to placebo in the treatment of T1DM. Gevokizumab showed mixed results in treating Behçet’s disease-associated uveitis and no benefit when assessed in T1DM. Bermekimab achieved promising results in the treatment of hidradenitis suppurativa. Conclusions This systematic review of IL-1-targeting biologics summarizes the current state of research, safety, and clinical efficacy of anakinra, bermekimab, canakinumab, gevokizumab, and rilonacept in treating immune-mediated disorders. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021228547.
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Affiliation(s)
- Dennis D. Arnold
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Ayla Yalamanoglu
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Onur Boyman
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- *Correspondence: Onur Boyman,
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10
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Hatemi G, Mahr A, Takeno M, Kim D, Melikoğlu M, Cheng S, McCue S, Paris M, Chen M, Yazici Y. Impact of apremilast on quality of life in Behçet's syndrome: analysis of the phase 3 RELIEF study. RMD Open 2022; 8:rmdopen-2022-002235. [PMID: 35798511 PMCID: PMC9263903 DOI: 10.1136/rmdopen-2022-002235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess apremilast's impact on patient quality of life (QoL) in active Behçet's syndrome and correlations between improvement in patients' QoL and efficacy measures in the phase 3 RELIEF study. METHODS QoL measures included Behçet's Disease QoL (BDQoL), 36-Item Short-Form Health Survey V.2 (SF-36v2) Physical/Mental Component Summary (PCS/MCS) and eight subscale scores, focusing on Physical Functioning (PF). Pearson's correlation coefficients assessed relationships between efficacy endpoints (oral ulcer count, oral ulcer pain, Behçet's Syndrome Activity Scale (BSAS), Behçet's Disease Current Activity Form (BDCAF)) and QoL endpoints for apremilast at Week 12. RESULTS Apremilast (n=104) demonstrated significantly greater improvements versus placebo (n=103) in SF-36v2 PCS (3.1 vs 0.9), MCS (4.6 vs ─0.7) and PF (2.9 vs 0.14), respectively (all p<0.05). Mild correlations were observed in improvements of SF-36v2 measures (PCS, MCS, PF) with oral ulcer count (r=-0.11, PCS), and change in oral ulcer pain from baseline (r=-0.28, PCS; r=-0.10, PF) and BSAS (r=-0.38, PCS; r=-0.20, PF; r=-0.16, MCS). Correlations among BDCAF and SF-36v2 components and BDQoL were variable. BDQoL showed mild/moderate correlations with SF-36v2 components (r=-0.18, PCS; r=-0.13, PF; r=-0.45, MCS). CONCLUSIONS Apremilast was associated with significant improvements in QoL measures of SF-36v2 PCS, MCS and PF and BDQoL in patients with Behçet's syndrome. Correlations of improvement among QoL endpoints support the beneficial clinical effects of apremilast in Behçet's syndrome. TRIAL REGISTRATION NUMBER NCT02307513.
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Affiliation(s)
- Gülen Hatemi
- Cerrahpaşa School of Medicine and Behçet's Disease Research Center, Istanbul University, Istanbul, Turkey
| | - Alfred Mahr
- Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Doyoung Kim
- Yonsei University College of Medicine and Severance Hospital, Seoul, South Korea
| | - Melike Melikoğlu
- Cerrahpaşa School of Medicine and Behçet's Disease Research Center, Istanbul University, Istanbul, Turkey
| | - Sue Cheng
- Amgen Inc, Thousand Oaks, California, USA
| | | | | | - Mindy Chen
- Amgen Inc, Thousand Oaks, California, USA
| | - Yusuf Yazici
- New York University School of Medicine, New York, New York, USA
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11
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Liu D, Zhang T, Zhou H, Meng Y, Wu C, Sun Y, Xu Y, Deng X, Wang H, Jiang L. Role of biologics in refractory recurrent aphthous stomatitis. J Oral Pathol Med 2022; 51:694-701. [PMID: 35637621 DOI: 10.1111/jop.13320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 02/05/2023]
Abstract
Refractory recurrent aphthous stomatitis (RRAS) manifests as severe ulcerative lesions of the oral mucosa with poor healing and a poor response to conventional therapy, with or without systemic diseases. Its treatment remains a clinical challenge owing to the lack of effective therapies. Recently, biologics have emerged as promising targeted therapies for RRAS. The biologics targeting specific inflammatory pathways involved in the pathogenesis of RRAS, including tumor necrosis factor-alpha inhibitors and interleukin inhibitors, offer a more precise and promising therapeutic approach for RRAS. These targeted therapies have been shown to promote healing and decrease recurrence frequency in, and improve the quality of life of patients with RRAS. Herein, the types and mechanisms of biologics currently used to treat RRAS have been reviewed; furthermore, the dose, duration, therapeutic efficacy, and adverse effects of RRAS with or without certain associated systemic diseases, and the current problems and future directions have been discussed.
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Affiliation(s)
- Dan Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Tianyu Zhang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Hangfan Zhou
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yang Meng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Chuanji Wu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yutong Sun
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Yiming Xu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoting Deng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Hui Wang
- Department of Oral Medicine, School of Stomatology, Capital Medical University, Beijing, China
| | - Lu Jiang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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12
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Robert M, Miossec P, Hot A. The Th17 Pathway in Vascular Inflammation: Culprit or Consort? Front Immunol 2022; 13:888763. [PMID: 35479069 PMCID: PMC9035791 DOI: 10.3389/fimmu.2022.888763] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
The involvement of IL-17A in autoimmune and inflammatory diseases has prompted the development of therapeutic strategies to block the Th17 pathway. Promising results came from their use in psoriasis and in ankylosing spondylitis. IL-17A acts on various cell types and has both local and systemic effects. Considering the premature mortality observed during chronic inflammatory diseases, IL-17A action on vascular cells was studied. Both in vitro and in vivo results suggest that this cytokine favors inflammation, coagulation and thrombosis and promotes the occurrence of cardiovascular events. These observations led to study the role of IL-17A in diseases characterized by vascular inflammation, namely allograft rejection and vasculitis. Increased circulating levels of IL-17A and histological staining reveal that the Th17 pathway is involved in the pathogenesis of these diseases. Vasculitis treatment faces challenges while the use of steroids has many side effects. Regarding results obtained in giant cell arteritis with IL-6 inhibitors, a cytokine involved in Th17 differentiation, the use of anti-IL-17 is a promising strategy. However, lessons from rheumatoid arthritis and multiple sclerosis must be learnt before targeting IL-17 in vasculitis, which may be culprit, consort or both of them.
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Affiliation(s)
- Marie Robert
- Department of Clinical Immunology and Rheumatology, and Immunogenomics and Inflammation Research Unit, University of Lyon, Hôpital Edouard Herriot, Lyon, France
- Department of Internal Medicine, University of Lyon, Hôpital Edouard Herriot, Lyon, France
- *Correspondence: Marie Robert,
| | - Pierre Miossec
- Department of Clinical Immunology and Rheumatology, and Immunogenomics and Inflammation Research Unit, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Hot
- Department of Internal Medicine, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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13
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Kul Cinar O, Romano M, Guzel F, Brogan PA, Demirkaya E. Paediatric Behçet’s Disease: A Comprehensive Review with an Emphasis on Monogenic Mimics. J Clin Med 2022; 11:jcm11051278. [PMID: 35268369 PMCID: PMC8911352 DOI: 10.3390/jcm11051278] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023] Open
Abstract
Behçet’s disease (BD) is a polygenic condition with a complex immunopathogenetic background and challenging diagnostic and therapeutic concepts. Advances in genomic medicine have provided intriguing insights into disease pathogenesis over the last decade, especially into monogenic mimics of BD. Although a rare condition, paediatric BD should be considered an important differential diagnosis, especially in cases with similar phenotypes. Emerging reports of monogenic mimics have indicated the importance of genetic testing, particularly for those with early-onset, atypical features and familial aggregation. Treatment options ought to be evaluated in a multidisciplinary setting, given the complexity and diverse organ involvement. Owing to the rarity of the condition, there is a paucity of paediatric trials; thus, international collaboration is warranted to provide consensus recommendations for the management of children and young people. Herein, we summarise the current knowledge of the clinical presentation, immunopathogenetic associations and disease mechanisms in patients with paediatric BD and BD-related phenotypes, with particular emphasis on recently identified monogenic mimics.
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Affiliation(s)
- Ovgu Kul Cinar
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK; (O.K.C.); (P.A.B.)
- Division of Medicine, National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Micol Romano
- Department of Pediatrics, Division of Pediatric Rheumatology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON N6A 5W9, Canada;
- Canadian Behcet and Autoinflammatory Disease Center (CAN-BE-AID), University of Western Ontario, London, ON N6A 4V2, Canada
| | - Ferhat Guzel
- Molecular Genetics Laboratories, Department of Research and Development, Ant Biotechnology, Istanbul 34775, Turkey;
| | - Paul A. Brogan
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK; (O.K.C.); (P.A.B.)
- Great Ormond Street Institute of Child Health, University College London, 30 Guildford Street, London WC1N 1EH, UK
| | - Erkan Demirkaya
- Department of Pediatrics, Division of Pediatric Rheumatology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON N6A 5W9, Canada;
- Canadian Behcet and Autoinflammatory Disease Center (CAN-BE-AID), University of Western Ontario, London, ON N6A 4V2, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON N6A 5W9, Canada
- Correspondence: ; Tel.: +1-519-685-8500; Fax: +1-519-685-8156
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14
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Hall BS, Hsieh LTH, Sacre S, Simmonds RE. The One That Got Away: How Macrophage-Derived IL-1β Escapes the Mycolactone-Dependent Sec61 Blockade in Buruli Ulcer. Front Immunol 2022; 12:788146. [PMID: 35154073 PMCID: PMC8826060 DOI: 10.3389/fimmu.2021.788146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
Buruli ulcer (BU), caused by Mycobacterium ulcerans, is a devastating necrotizing skin disease. Key to its pathogenesis is mycolactone, the exotoxin virulence factor that is both immunosuppressive and cytotoxic. The discovery that the essential Sec61 translocon is the major cellular target of mycolactone explains much of the disease pathology, including the immune blockade. Sec61 inhibition leads to a loss in production of nearly all cytokines from monocytes, macrophages, dendritic cells and T cells, as well as antigen presentation pathway proteins and costimulatory molecules. However, there has long been evidence that the immune system is not completely incapable of responding to M. ulcerans infection. In particular, IL-1β was recently shown to be present in BU lesions, and to be induced from M. ulcerans-exposed macrophages in a mycolactone-dependent manner. This has important implications for our understanding of BU, showing that mycolactone can act as the "second signal" for IL-1β production without inhibiting the pathways of unconventional secretion it uses for cellular release. In this Perspective article, we validate and discuss this recent advance, which is entirely in-line with our understanding of mycolactone's inhibition of the Sec61 translocon. However, we also show that the IL-1 receptor, which uses the conventional secretory pathway, is sensitive to mycolactone blockade at Sec61. Hence, a more complete understanding of the mechanisms regulating IL-1β function in skin tissue, including the transient intra-macrophage stage of M. ulcerans infection, is urgently needed to uncover the double-edged sword of IL-1β in BU pathogenesis, treatment and wound healing.
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Affiliation(s)
- Belinda S Hall
- Department of Microbial Sciences, School of Bioscience and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Louise Tzung-Harn Hsieh
- Department of Microbial Sciences, School of Bioscience and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Sandra Sacre
- Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Rachel E Simmonds
- Department of Microbial Sciences, School of Bioscience and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
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15
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Calabrese L, Fiocco Z, Satoh TK, Peris K, French LE. Therapeutic potential of targeting IL-1 family cytokines in chronic inflammatory skin diseases. Br J Dermatol 2022; 186:925-941. [PMID: 34990008 DOI: 10.1111/bjd.20975] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 11/27/2022]
Abstract
The interleukin-1 (IL-1) family of cytokines is a central regulator of a myriad of immunological responses. It comprises several cytokines, including those belonging to the IL-1, IL-36 and IL-18 subfamilies, as well as IL-33. The IL-1 family primarily plays a role in orchestrating innate immune responses but also in adaptive immunity. Increased interest in the IL-1 family occurred following the discovery that dysregulation of IL-1 signalling underlies the pathogenesis of several monogenic auto-inflammatory diseases, characterized by sterile inflammation involving the skin and other organs. This also provided increased understanding of the role of innate immunity and the IL-1 family in polygenic auto-inflammatory skin conditions, such as neutrophilic dermatoses, as well as in some of the most common chronic inflammatory skin diseases, such as psoriasis or hidradenitis suppurativa. Several therapeutic agents have been developed to inhibit the IL-1 family members and their signalling pathways. These have shown therapeutic efficacy in several chronic inflammatory skin disorders. The aim of this review is to thoroughly describe the consequences of pathological dysregulation of IL-1, IL-33, IL-36, IL-18 pathways in dermatological conditions and to provide a forward-looking update on therapeutic strategies targeting signalling by IL-1 family cytokines.
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Affiliation(s)
- Laura Calabrese
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Zeno Fiocco
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Ketty Peris
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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16
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Alpsoy E, Bozca BC, Bilgic A. Behçet Disease: An Update for Dermatologists. Am J Clin Dermatol 2021; 22:477-502. [PMID: 34061323 DOI: 10.1007/s40257-021-00609-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
Behçet disease (BD) is a chronic, relapsing, systemic vasculitis of unknown etiology with the clinical features of oral and genital ulcers, cutaneous vasculitic lesions, ocular, articular, vascular, gastrointestinal, neurologic, urogenital and cardiac involvement. BD usually appears around the third or fourth decade of life. Gender distribution is roughly equal. The disease is much more frequent in populations along the ancient 'Silk Road', extending from Eastern Asia to countries in the Middle East and the Mediterranean, compared with Western countries, but has universal distribution. Mucocutaneous manifestations are the clinical hallmarks of BD. The diagnostic criteria widely used in the disease's diagnosis are based on mucocutaneous manifestations because of their high sensitivity and/or specificity. Genetic factors are the key driver of BD pathogenesis, and HLA-B51 antigen is the strongest genetic susceptibility factor. Streptococcus sanguinis (S. sanguinis) or microbiome change can trigger innate immune system-mediated inflammation sustained by adaptive immune responses. Epistatic interaction between HLA-B51 and endoplasmic reticulum aminopeptidase 1 (ERAP1) in antigen-presenting cells disrupt T-cell homeostasis leading to downregulation of Tregs and expansion of Th1 and Th17. Thus, neutrophil activation and intense neutrophil infiltration of the affected organs develop in the early stage of inflammation. BD has a variable clinical course with unpredictable exacerbations and remissions. The disease is associated with a high mortality rate, especially in young male patients, and large-vessel, neurological, gastrointestinal system and cardiac involvement are the most important causes of death. The principal aim of treatment should be to prevent irreversible organ damage, especially during the disease's early, active phase. A better understanding of the disease's pathogenesis has provided important information on its management. New drugs, especially apremilast and anti-TNF-α agents are effective in the management of BD and have the potential to improve patients' quality of life, prognosis and survival.
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Affiliation(s)
- Erkan Alpsoy
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey.
| | - Burcin Cansu Bozca
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey
| | - Asli Bilgic
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey
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17
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Abstract
Purpose of Review To assess current management of Behcet’s disease (BD). Controversies on therapeutic approaches to different manifestations, whether conventional immunosuppressives (IS) or biologic agents, should be chosen, and options for refractory disease are discussed. Recent Findings Glucocorticoids are still the main agents for remission-induction and azathioprine the first-line conventional IS in maintenance phase to prevent relapses of major organ involvement. Apremilast is shown to be a safe and effective option approved by the FDA for oral ulcers. Large case series confirmed the efficacy and safety of TNFα inhibitors and Interferon-α. Promising results are observed with IL-1 inhibitors, ustekinumab, secukinumab, and tocilizumab for refractory BD. Summary Although both conventional IS and biologic agents are effectively used to suppress inflammation in BD, there is still an unmet need for clear therapeutic strategies in the management for different manifestations. Further controlled studies with new biologic agents, anticoagulants and the benefit of concomitant IS usage with biologics are needed to optimize the management of BD.
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Stefania S, Colia R, Cinzia R, Corrado A, Cantatore FP. Off-label use of anti-IL-1 drugs in rheumatic diseases. Int J Immunopathol Pharmacol 2021; 35:20587384211006584. [PMID: 33855881 PMCID: PMC8056561 DOI: 10.1177/20587384211006584] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Interleukin-1 (IL-1) plays a key role in the pathogenesis of different rheumatic diseases. There are now several agents available on the market capable of blocking IL-1. The proven effectiveness and excellent safety of these drugs makes them a possible therapeutic option in the treatment of IL-1 driven diseases, when previous therapies are contraindicated or ineffective. This article discusses the European wide off-label use of these drugs for the treatment of rheumatic diseases.
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Affiliation(s)
- Silvia Stefania
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ripalta Colia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Rotondo Cinzia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Francesco Paolo Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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19
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Karadag O, Bolek EC. Management of Behcet's syndrome. Rheumatology (Oxford) 2021; 59:iii108-iii117. [PMID: 32348509 DOI: 10.1093/rheumatology/keaa086] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/28/2020] [Indexed: 12/13/2022] Open
Abstract
Behcet's syndrome (BS) is a variable vessel vasculitis with heterogeneous clinical features. Skin, mucosa and joint involvement can cause impairment of quality of life but do not cause permanent damage whereas untreated eye, vascular, nervous system and gastrointestinal system involvement can cause serious damage and even death. Management of BS as a multidisciplinary team enables a faster and more accurate diagnosis and well-integrated treatment strategies. Corticosteroids are the mainstay of therapy. Colchicine, AZA, ciclosporin-A, cyclophosphamide, IFN alpha, and tumour necrosis factor alpha inhibitors are other agents used as induction and/or maintenance therapy. Although biologic agents have been increasingly used, there are still unmet needs. Head-to-head comparison studies of some therapeutic options (e.g. TNF inhibitors vs IFN alpha in uveitis) are required. Novel therapeutic agents in the pipeline could change the standard of care for BS in the future.
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Affiliation(s)
- Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey.,Hacettepe University Vasculitis Centre (HUVAC), Ankara, Turkey
| | - Ertugrul Cagri Bolek
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey.,Hacettepe University Vasculitis Centre (HUVAC), Ankara, Turkey
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20
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Malcova H, Milota T, Strizova Z, Cebecauerova D, Striz I, Sediva A, Horvath R. Interleukin-1 Blockade in Polygenic Autoinflammatory Disorders: Where Are We now? Front Pharmacol 2021; 11:619273. [PMID: 33708123 PMCID: PMC7941751 DOI: 10.3389/fphar.2020.619273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Polygenic autoinflammatory diseases (AIDs), such as systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease, Kawasaki disease, idiopathic recurrent pericarditis (IRP), Behçet’s Syndrome, Crystal-induced arthropatihes such as gout or Calcium pyrophosphate deposition disease are characterized by the overexpression of inflammasome-associated genes, leading to a dysregulation of the innate immune response. The IL-1 cytokine family (IL-1α, IL-1β, IL-1Ra, IL-18, IL-36Ra, IL-36α, IL-37, IL-36β, IL-36g, IL-38, IL-33) was defined to be principally responsible for the inflammatory nature of polygenic AIDs. Several clinical trials were initiated, and IL-1 blockade has been proven to cause a rapid reduction of clinical symptoms and normalization of laboratory parameters in the majority of cases. Randomized, placebo-controlled, clinical trials, together with registry-based clinical trials and open-label, retrospective and prospective observational studies, supported the efficacy and safety of IL-1 inhibitors in the treatment of polygenic AIDs. Most of the current data are focused on the therapeutic use of anakinra, an IL-1 receptor antagonist, canakinumab, an anti-IL-1β monoclonal antibody, and rilonacept, a soluble decoy receptor. However, other promising agents, such as gevokizumab, IL-1β blocking monoclonal antibody, tadekinig alfa, a human recombinant IL-18-binding protein, and tranilast, an analog of a tryptophan metabolite, are currently being tested. Anakinra, canakinumab and rilonacept caused impressive improvements in both systemic and musculoskeletal symptoms. Furthermore, the anti-IL-1 therapy allowed corticosteroid tapering and, in some cases, even withdrawal. This article reviews the current IL-1 inhibitors and the results of all clinical trials in which they have been tested for the management of broad spectrum of polygenic AIDs.
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Affiliation(s)
- Hana Malcova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Tomas Milota
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia.,Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Zuzana Strizova
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Dita Cebecauerova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Ilja Striz
- Department of Clinical Immunology and Allergology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Rudolf Horvath
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
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Perazzio SF, Andrade LEC, de Souza AWS. Understanding Behçet's Disease in the Context of Innate Immunity Activation. Front Immunol 2020; 11:586558. [PMID: 33193413 PMCID: PMC7606308 DOI: 10.3389/fimmu.2020.586558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/28/2020] [Indexed: 12/24/2022] Open
Abstract
Behçet´s disease (BD) is a heterogeneous condition consisting of idiopathic systemic vasculitis affecting large and small blood vessels of different types (i.e., arteries, veins, or capillaries). The disease frequently occurs in young adults without gender predilection, differently from several other autoimmune conditions. This challenging illness has recently been proposed by some authors as an example of complex autoinflammatory syndrome. Although much remains unanswered about BD pathogenesis, recent understanding of some aspects of innate immunity have clarified a few issues (and raised others). HLA-B*51 represents the strongest genetic risk factor for BD to date, albeit several other HLA-independent loci have also been associated with the disease. The consistent hyper-reactivity against Streptococcus sanguinis antigens and alterations in oral and gut microbioma suggests that infectious agents may play an important role. Moreover, functional abnormalities of pattern recognition receptors, especially Toll-like receptors in monocytes, have been demonstrated in patients with BD and can be associated with the development of the disease. Neutrophil hyperactivity is one of the most consistent findings in BD pathogenesis, as demonstrated by exacerbated constitutive oxidative burst, chemotaxis and NET formation. However, some studies suggest that the phagocyte-activated status in BD is not primary to the disease itself, but rather restricted to a fraction of patients with severe disease activity, and probably secondary to activating soluble factors carried by serum/plasma from BD patients. Herein we review the state of the art on BD etiopathogenesis with special emphasis on the participation of the innate immune system
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Affiliation(s)
- Sandro F Perazzio
- Division of Rheumatology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis E C Andrade
- Division of Rheumatology, Universidade Federal de São Paulo, São Paulo, Brazil
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Lopalco G, Rigante D, Lopalco A, Emmi G, Venerito V, Vitale A, Capozio G, Denora N, Cantarini L, Iannone F. Safety of systemic treatments for Behçet's syndrome. Expert Opin Drug Saf 2020; 19:1269-1301. [PMID: 32883123 DOI: 10.1080/14740338.2020.1817379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Treatment of Behçet's syndrome (BS) is aimed at controlling all symptoms of such a complex disorder, ensuring a good quality of life and preventing life-threatening complications. A better understanding of the pathogenic role of different chemokines has improved our knowledge of BS and elicited a more specific use of therapies currently available, minimizing the burden of potential side-effects related to treatment. AREAS COVERED This work aims to provide a detailed overview of the safety profile for current therapies available in the treatment of BS, focusing on the main side-effects, toxicity and contraindications. EXPERT OPINION The greatest experience in the management of BS has been achieved with the employment of monoclonal anti-tumor necrosis factor antibodies which have been advocated for BS refractory manifestations. Moreover, interleukin-1 inhibitors have proven to be effective as well as safe, despite escalation of their dosage, especially to manage the most severe and difficult-to-treat ocular manifestations. However, general treatment of BS patients remains awkward as protean clinical features may respond differently to the same treatment or even worsen. Therefore, patients' safety for therapies used in BS promotes the implementation of precision medicine, which could help targeting accurately the pathogenetic mechanisms concealed behind specific clinical phenotypes.
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Affiliation(s)
- Giuseppe Lopalco
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy.,Università Cattolica Sacro Cuore , Rome, Italy
| | - Antonio Lopalco
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence , Florence, Italy
| | - Vincenzo Venerito
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Antonio Vitale
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Giovanna Capozio
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy
| | - Nunzio Denora
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Luca Cantarini
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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Tegtmeyer K, Atassi G, Zhao J, Maloney NJ, Lio PA. Off-Label studies on anakinra in dermatology: a review. J DERMATOL TREAT 2020; 33:73-86. [PMID: 32279586 DOI: 10.1080/09546634.2020.1755417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose: Anakinra (Kineret®) is an interleukin-1 receptor antagonist (IL-1Ra) FDA approved for use in rheumatoid arthritis and in neonatal-onset multisystem inflammatory disease (NOMID). It has been used off-label for a variety of dermatologic conditions. A review of the available studies and cases of these off-label uses would be valuable to the dermatologist considering alternative treatments for these oftentimes poorly studied conditions.Materials and methods: The PubMed/MEDLINE, EMBASE, Scopus, and ClinicalTrials.gov databases were searched with the term 'anakinra.' Results were manually screened to identify published data on off-label uses of anakinra in dermatologic conditions and systemic conditions with prominent dermatologic manifestations.Results: Anakinra appears to show efficacy for numerous dermatologic conditions, with the strongest evidence for hidradenitis suppurativa, Bechet's disease, Muckle-Wells syndrome, and SAPHO syndrome. Case reports and case series data are available for numerous other dermatologic conditions.Conclusion: Anakinra is a potential option for patients with certain difficult-to-treat dermatologic diseases, given its relatively benign adverse effect profile and its effectiveness in a wide array of conditions. Overall, anakinra appears to be a promising option in the treatment of numerous dermatologic inflammatory conditions refractory to first line therapies, but further and higher-quality data is needed to clarify its therapeutic role.
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Affiliation(s)
- Kyle Tegtmeyer
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Giancarlo Atassi
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey Zhao
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nolan J Maloney
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peter A Lio
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Medical Dermatology Associates of Chicago, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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An Overview of Conventional and Recent Treatment Options for Behcet’s Disease. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pain CE. Juvenile-onset Behçet's syndrome and mimics. Clin Immunol 2020; 214:108381. [PMID: 32165216 DOI: 10.1016/j.clim.2020.108381] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
Behçet's syndrome (BS) presents in childhood in up to 20% of reported cases. Diagnosis is clinical and multiple classification criteria have been developed. Presentation is heterogenous with recurrent oral ulceration often being the presenting feature. Mucocutaneous disease including genital ulceration and skin involvement is a common phenotype. Vascular and neurological manifestations are rarer, particularly in childhood. Musculoskeletal and gastro-intestinal involvement which do not form part of commonly used classification criteria, appear more frequent in children. Treatment approaches are extrapolated from studies of adult onset disease. The pathogenesis of BS is not well defined although dysregulation in both innate and adaptive immune systems, together with abnormal antigen presentation have been described. The recent discovery of monogenic mimics of BS requires further genetic studies to understand the burden of monogenic autoinflammatory conditions affecting those with a BS phenotype.
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Affiliation(s)
- Clare E Pain
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Bettiol A, Hatemi G, Vannozzi L, Barilaro A, Prisco D, Emmi G. Treating the Different Phenotypes of Behçet's Syndrome. Front Immunol 2019; 10:2830. [PMID: 31921115 PMCID: PMC6915087 DOI: 10.3389/fimmu.2019.02830] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
Behçet's syndrome (BS) is a multisystemic vasculitis, characterized by different clinical involvements, including mucocutaneous, ocular, vascular, neurological, and gastrointestinal manifestations. Based on this heterogeneity, BS can be hardly considered as a single clinical entity. Growing evidence supports that, within BS, different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, three major BS phenotypes have been reported: (a) the mucocutaneous and articular phenotype, (b) the extra-parenchymal neurological and peripheral vascular phenotype, and (c) the parenchymal neurological and ocular phenotype. To date, guidelines for the management of BS have been focused on the pharmacological treatment of each specific BS manifestation. However, tailoring the treatments on patient's specific phenotype, rather than on single disease manifestation, could represent a valid strategy for a personalized therapeutic approach to BS. In the present literature review, we summarize current evidence on the pharmacological treatments for the first-, second-, and third-line treatment of the major BS phenotypes.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Lorenzo Vannozzi
- Eye Clinic, Careggi Teaching Hospital, University of Florence, Florence, Italy
| | - Alessandro Barilaro
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre, Careggi University Hospital, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Zheng Z, Zeng X, Nie X, Cheng Y, Liu J, Lin X, Yao H, Ji C, Chen X, Jun F, Wu S. Interleukin-1 blockade treatment decreasing cardiovascular risk. Clin Cardiol 2019; 42:942-951. [PMID: 31415103 PMCID: PMC6788469 DOI: 10.1002/clc.23246] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/22/2019] [Accepted: 07/30/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Interleukin-1 (IL-1) played a role in the occurrence and development of atherosclerosis and cardiovascular events. However, the association between IL-1 blockage treatment and reducing of cardiovascular risk remains poorly defined. HYPOTHESIS IL-1 blockage treatment reduce the risk and incidence rate of overall major adverse cardiovascular events (MACE), all-cause death, acute myocardial infarction(MI), unstable angina and heart failure. METHODS We performed a search of published reports by using MEDLINE database (January 1, 2005 to April 1, 2018). The randomized controlled trials (RCTs) that reported sample size and occurrence numbers in test group and placebo group for the associations of interest were included. RESULTS Eight RCT studies involving 15 647 participants were identified. Compared with those who took no IL-1 blockage, patients taking IL-1 blockage experienced a decreased risk of overall MACE (RR 0.88, 95% CI 0.82-0.94), unstable angina (RR 0.80, 95% CI 0.66-0.98), and breakthrough or recurrence of heart failure (RR 0.44, 95% CI 0.22-0.87). No association was found between IL-1 blockage treatment and death from all cause (RR 0.91, 95% CI 0.83-1.00) as well as acute MI (RR 0.85, 95% CI 0.71-1.01). The RRs associated with overall MACE, death from all cause, acute MI, and unstable angina for anakinra were 1.05, 1.16, 2.97, and 0.56, respectively, and for canakinumab were 1.05, 0.91, 0.80, and 0.80, respectively. CONCLUSIONS Administration of IL-1 blockage was associated with decrease risks of overall MACE, unstable angina, and breakthrough or recurrence of heart failure, but not with death from all cause as well as acute MI.
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Affiliation(s)
- Zi‐Heng Zheng
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Xun Zeng
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
- Outpatient DepartmentThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
| | - Xiao‐Ying Nie
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
- Outpatient DepartmentThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
| | - Yun‐Jiu Cheng
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Jun Liu
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Xiao‐Xiong Lin
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Hao Yao
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Cheng‐Cheng Ji
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Xu‐Miao Chen
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Fan Jun
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
| | - Su‐Hua Wu
- Department of CardiologyThe First Affiliated Hospital, Sun Yat‐Sen University and Key Laboratory on Assisted Circulation, NHCGuangzhouChina
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Speeckaert R, Lambert J, van Geel N. Learning From Success and Failure: Biologics for Non-approved Skin Diseases. Front Immunol 2019; 10:1918. [PMID: 31440261 PMCID: PMC6694799 DOI: 10.3389/fimmu.2019.01918] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 12/14/2022] Open
Abstract
The impressive potential of biologics has been demonstrated in psoriasis, hidradenitis suppurativa, and urticaria. Numerous biologicals are entering the field for a restricted number of skin disorders. Off-label use of biologics in other recalcitrant skin diseases has increased. Mounting data point to the potential of already existing biologics acting on the IL-17/IL-23 pathway in skin disorders with epidermal hyperkeratosis (e.g., pityriasis rubra pilaris), acneiform inflammation (e.g., hidradenitis suppurativa), and loss of mucosal integrity (e.g., aphthosis). TNF-α blockers are also effective in the latter conditions but seem of particular value in granulomatous (e.g., granuloma annulare) and neutrophilic disorders (e.g., pyoderma gangrenosum). Failure of IL-17 blockade in skin diseases resulting from immune-mediated cell destruction (e.g., alopecia areata and vitiligo) illustrates its limited involvement in Th1-dependent skin immunology. Overall, disappointing results of TNF-α blockers in alopecia areata and vitiligo point to the same conclusion although promising results in toxic epidermal necrolysis suggest TNF-α exerts at least some in vivo Th1-related activities. Acting on both the Th1 and Th17 pathway, ustekinumab has a rather broad potential with interesting results in lupus and alopecia areata. The efficacy of omalizumab in bullous pemphigoid has revealed an IgE-mediated recruitment of eosinophils leading to bullae formation. Reconsidering reimbursement criteria for less common but severe diseases seems appropriate if substantial evidence is available (e.g., pityriasis rubra pilaris). For other disorders, investigator- and industry-initiated randomized clinical trials should be stimulated. They are likely to improve patient outcome and advance our understanding of challenging skin disorders.
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Affiliation(s)
| | - Jo Lambert
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Nanja van Geel
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
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Abstract
Behçet syndrome (BS) is a multi-systemic complex disorder with unknown etiology and a unique geographic distribution. It could not be possible to include it into specific classification schemes and it is certainly not a uniform disease. Several cluster and association studies revealed that it has been composed of multiple phenotypes ascribing the principal problem such as skin-mucosa, joint, eye, vascular, neurological and gastrointestinal involvement. Each phenotype has its own characteristic demographic and clinical features as such their management strategies and prognosis differ substantially. Actually, the concept of phenotyping has been well known for some time and is considered one of the basic elements of the still continuing debate whether to call this entity 'disease' or 'syndrome'. Further supporting evidence comes from the observation of the geographical differences of disease expression. In this setting, BS resembles rather a construction made of several dynamic and interactive LEGO pieces of different shapes and colors. These pieces presenting phenotypes with their own disease mechanism have presumably different genetic determinants. The analysis of phenotyping could help us to identify this disorder and hence could contribute to find better ways of treatment.
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Affiliation(s)
- Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, 81310, Istanbul, Turkey.
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Abstract
The autoinflammatory diseases comprise a broad spectrum of disorders characterized by unchecked activation of the innate immune system. Whereas aberrations in adaptive immunity have long been identified in 'autoimmune' disorders, the concept of 'autoinflammation' emerged relatively recently, first describing a group of clinical disorders characterized by spontaneous episodes of systemic inflammation without manifestations typical of autoimmune disorders. Improved knowledge of innate immune mechanisms, coupled with remarkable progress in genomics and an expanding number of clinical cases, has since led to an increasing number of disorders classified as autoinflammatory or containing an autoinflammatory component. Biologic therapies targeting specific components of the innate immune system have provided immense clinical benefit, and have further elucidated the role of innate immunity in autoinflammatory disorders. This article reviews the basic mechanisms of autoinflammation, followed by an update on the pathophysiology and treatment of the monogenic and multifactorial autoinflammatory diseases, and the common dermatologic conditions in which autoinflammation plays a major role.
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Abstract
Behçet's syndrome (BS) is a complex disease that shows important heterogeneity in clinical findings and physiopathology. Its treatment can be problematic as BS manifestations in different organs may respond differently to the same drug. The cornerstone of therapy for inducing remission is corticosteroids whereas immunomodulatory and immunosuppressive agents such as colchicine, azathioprine, cyclosporine-A, interferon-alpha, and cyclophosphamide are used as steroid-sparing agents and to prevent further relapses. However, a considerable number of patients continue to have mucocutaneous lesions despite therapy, and some patients require more aggressive treatment for refractory major organ involvement. Tumor necrosis factor alpha inhibitors, especially infliximab and adalimumab, are increasingly used for various refractory BS manifestations despite the lack of controlled studies. In this review, we aim to focus on both the traditional and new treatment modalities for BS, with more emphasis on recent data on newer agents.
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Affiliation(s)
- Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey.
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Haploinsufficiency of A20 and other paediatric inflammatory disorders with mucosal involvement. Curr Opin Rheumatol 2019; 30:506-513. [PMID: 29916847 DOI: 10.1097/bor.0000000000000532] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims at summarizing the current knowledge of A20 haploinsufficiency and other paediatric inflammatory disorders with mucosal involvement. RECENT FINDINGS A20 haploinsufficiency is a newly described autoinflammatory disease caused by loss-of-function mutations in TNFAIP3 that result in the activation of the nuclear factor (NF)-kB pathway. Patients may present with dominantly inherited, early-onset systemic inflammation and a Behçet-like disease, or a variety of autoinflammatory and autoimmune features. In Behçet disease, recent literature provides insights into genetic susceptibility and emerging treatment options; in addition, the first paediatric classification criteria were published. Recent advances in periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA) suggest that the disease has a complex underlying genetic mechanism and in some cases is inherited in an autosomal dominant pattern with reduced penetrance phenotype in many family members. Activation of the pyrin inflammasome through the RoA signalling pathway uncovers an interesting molecular connection between hyperimmunoglobulinemia D syndrome and familial Mediterranean fever. The description of new monogenic types of inflammatory bowel disease (IBD) may provide novel insights into disease pathogenesis. Finally, recent studies highlighted the role of gut microorganisms and dysbiosis in IBD. SUMMARY Monogenic diseases such as A20 haploinsufficiency may help to advance our understanding of disease pathogenesis and to develop targeted therapies for more common, multifactorial disorders with mucosal inflammation.
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Lisitsyna TA, Alekberova ZS, Goloeva RG. New guidelines for the management of patients with Behcet's disease/syndrome (EULAR, 2018). RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-133-141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The article is devoted to the new guidelines of EULAR on the management of patients with Behcet's disease/syndrome (BD), which include 5 principles and 10 specific recommendations for the treatment of various organ lesions. The methodology of their creation, as well as unresolved issues of management of patients with BD, which are planned to be investigated in the future, are considered.
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Patra MC, Shah M, Choi S. Toll-like receptor-induced cytokines as immunotherapeutic targets in cancers and autoimmune diseases. Semin Cancer Biol 2019; 64:61-82. [PMID: 31054927 DOI: 10.1016/j.semcancer.2019.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/27/2019] [Accepted: 05/01/2019] [Indexed: 12/14/2022]
Abstract
Immune cells of the myeloid and lymphoid lineages express Toll-like receptors (TLRs) to recognize pathogenic components or cellular debris and activate the immune system through the secretion of cytokines. Cytokines are signaling molecules that are structurally and functionally distinct from one another, although their secretion profiles and signaling cascades often overlap. This situation gives rise to pleiotropic cell-to-cell communication pathways essential for protection from infections as well as cancers. Nonetheless, deregulated signaling can have detrimental effects on the host, in the form of inflammatory or autoimmune diseases. Because cytokines are associated with numerous autoimmune and cancerous conditions, therapeutic strategies to modulate these molecules or their biological responses have been immensely beneficial over the years. There are still challenges in the regulation of cytokine function in patients, even in those who take approved biological therapeutics. In this review, our purpose is to discuss the differential expression patterns of TLR-regulated cytokines and their cell type specificity that is associated with cancers and immune-system-related diseases. In addition, we highlight key structural features and molecular recognition of cytokines by receptors; these data have facilitated the development and approval of several biologics for the treatment of autoimmune diseases and cancers.
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Affiliation(s)
- Mahesh Chandra Patra
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea
| | - Masaud Shah
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea
| | - Sangdun Choi
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea.
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Demir S, Sönmez HE, Özen S. Vasculitis: Decade in Review. Curr Rheumatol Rev 2019; 15:14-22. [PMID: 30047330 DOI: 10.2174/1573397114666180726093731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/26/2018] [Accepted: 07/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the last decade, we have come to better understand and manage the vasculitides. The classification of vasculitides has been revised. Genome- wide association studies and linkage analyses have been undertaken in hope of better understanding the pathogenesis of vasculitides. Comprehensive genetic studies have highlighted new pathways that may guide us in more targeted therapies. Description of the monogenic forms of vasculitis, such as deficiency of adenosine deaminase type 2 (DADA2), Haploinsufficiency of A20 (HA20), have introduced a new perspective to vasculopathies, and introduced alternative treatments for these diseases. CONCLUSION In this review, the important discoveries in pathogenesis and consensus treatment recommendations from the past decade will be summarized.
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Affiliation(s)
- Selcan Demir
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Özen
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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The right place of interleukin-1 inhibitors in the treatment of Behçet's syndrome: a systematic review. Rheumatol Int 2019; 39:971-990. [PMID: 30799530 DOI: 10.1007/s00296-019-04259-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/16/2019] [Indexed: 12/14/2022]
Abstract
Behçet's syndrome (BS) is a chronic (auto)-inflammatory disorder characterized by different clusters of symptoms, including mucocutaneous and ocular involvements. Interleukin-1 inhibitors anakinra (ANA), canakinumab (CAN), and gevokizumab (GEV) represent a promising therapeutic alternative in BS. To date, evidence on the use of ANA, CAN, and GEV is mainly based on small isolated studies or case series, and the real place of anti-IL1 agents in the treatment of BS is still unclear. We performed a systematic review of current evidence on the efficacy and safety of anti-IL1 agents in BS. The PubMed search yielded a total of 398 references, from which we retrieved 24 studies for inclusion (4 clinical trials, 6 observational studies, 14 case reports, case series or letters to the editor). Four studies evaluated the overall efficacy of IL-1 inhibitors, 15 studies focused on the specific efficacy of ANA, whereas efficacy of CAN and GEV was evaluated in 8 and 3 studies, respectively. Both ANA and CAN were associated with good control of mucocutaneous and ocular manifestations. ANA resulted effective also for osteoarticular manifestations. GEV was studied only for ocular manifestations, but gave contrasting results. Discordant evidence supports the use of ANA and CAN in pediatric setting and for first-line treatment of general BS manifestations. Most frequent side effects were local or diffuse cutaneous reactions and injection site reactions, particularly for ANA treatment. Blocking the IL-1 pathway could be an effective therapeutic strategy in particular BS involvements.
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Cavalli G, Dinarello CA. Anakinra Therapy for Non-cancer Inflammatory Diseases. Front Pharmacol 2018; 9:1157. [PMID: 30459597 PMCID: PMC6232613 DOI: 10.3389/fphar.2018.01157] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/24/2018] [Indexed: 12/14/2022] Open
Abstract
Interleukin-1 (IL-1) is the prototypical inflammatory cytokine: two distinct ligands (IL-1α and IL-1β) bind the IL-1 type 1 receptor (IL-1R1) and induce a myriad of secondary inflammatory mediators, including prostaglandins, cytokines, and chemokines. IL-1α is constitutively present in endothelial and epithelial cells, whereas IL-1β is inducible in myeloid cells and released following cleavage by caspase-1. Over the past 30 years, IL-1-mediated inflammation has been established in a broad spectrum of diseases, ranging from rare autoinflammatory diseases to common conditions such as gout and rheumatoid arthritis (RA), type 2 diabetes, atherosclerosis, and acute myocardial infarction. Blocking IL-1 entered the clinical arena with anakinra, the recombinant form of the naturally occurring IL-1 receptor antagonist (IL-1Ra); IL-1Ra prevents the binding of IL-1α as well as IL-1β to IL-1R1. Quenching IL-1-mediated inflammation prevents the detrimental consequences of tissue damage and organ dysfunction. Although anakinra is presently approved for the treatment of RA and cryopyrin-associated periodic syndromes, off-label use of anakinra far exceeds its approved indications. Dosing of 100 mg of anakinra subcutaneously provides clinically evident benefits within days and for some diseases, anakinra has been used daily for over 12 years. Compared to other biologics, anakinra has an unparalleled record of safety: opportunistic infections, particularly Mycobacterium tuberculosis, are rare even in populations at risk for reactivation of latent infections. Because of this excellent safety profile and relative short duration of action, anakinra can also be used as a diagnostic tool for undefined diseases mediated by IL-1. Although anakinra is presently in clinical trials to treat cancer, this review focuses on anakinra treatment of acute as well as chronic inflammatory diseases.
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Affiliation(s)
- Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Charles A. Dinarello
- Department of Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine, University of Colorado Denver, Denver, CO, United States
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Leccese P, Ozguler Y, Christensen R, Esatoglu SN, Bang D, Bodaghi B, Celik AF, Fortune F, Gaudric J, Gül A, Kötter I, Mahr A, Moots RJ, Richter J, Saadoun D, Salvarani C, Scuderi F, Sfikakis PP, Siva A, Stanford M, Tugal-Tutkun I, West R, Yurdakul S, Olivieri I, Yazici H, Hatemi G. Management of skin, mucosa and joint involvement of Behçet's syndrome: A systematic review for update of the EULAR recommendations for the management of Behçet's syndrome. Semin Arthritis Rheum 2018; 48:752-762. [PMID: 29954598 DOI: 10.1016/j.semarthrit.2018.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this systematic review was to inform the update of European League Against Rheumatism (EULAR) Recommendations for the management of Behçet's syndrome (BS), on the evidence for the treatment of skin, mucosa and joint involvement of BS. METHODS A systematic literature search, data extraction, statistical analyses and assessment of the quality of evidence were performed according to a pre-specified protocol using the PRISMA guidelines. Studies that assessed the efficacy of an intervention in comparison to an active comparator or placebo for oral ulcers, genital ulcers, papulopustular lesions, nodular lesions or arthritis were included. Where possible, risk ratios were calculated for binary outcomes and mean difference for continuous outcomes. RESULTS Among the 3927 references that were screened, 37 were included in the analyses. Twenty-seven of these assessed mucocutaneous and 17 assessed joint involvement. Twenty-one of these studies were randomised controlled trials (RCTs). RCTs with colchicine, azathioprine, interferon-alpha, thalidomide, etanercept and apremilast showed beneficial results with some differences according to lesion type and gender. These agents were generally well tolerated with few adverse events causing withdrawal from the study. CONCLUSIONS RCTs comprised more than a half (21/37, 57%) of the sources included in the evidence synthesis related to skin, mucosa and joint involvement applicable for the EULAR Recommendations for the management of BS. Differences in the outcome measures that were used across the included studies often made it difficult to combine and compare the results.
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Affiliation(s)
- Pietro Leccese
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
| | - Yesim Ozguler
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul 34098, Turkey
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital & Department of Rheumatology, Odense University Hospital, Copenhagen, Denmark
| | - Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul 34098, Turkey
| | - Dongsik Bang
- Department of Dermatology, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Aykut Ferhat Celik
- Division of Gastroenterology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Farida Fortune
- Centre for Clinical and Diagnostic Oral Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, and the London Behçet's Centre, Barts Health London, London, United Kingdom
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ahmet Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ina Kötter
- Asklepios Clinic Altona, Department of Rheumatology, Immunology and Nephrology, Hamburg, Germany
| | - Alfred Mahr
- Department of Internal Medicine, Hospital Saint-Louis, Paris, France
| | - Robert J Moots
- National Behcet's Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
| | - Jutta Richter
- Institute for Haematopathology Hamburg, Hamburg, Germany
| | - David Saadoun
- Department of Inflammation-Immunopathology-Biotherapy, Sorbonne Universités, UPMC Univ Paris 06, Paris, France; INSERM, Paris, France; CNRS, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires, Paris, France
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena and Reggio Emilia, Italy
| | | | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine & Rheumatology Unit, National Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Miles Stanford
- Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Richard West
- patient research partner, member of the UK Behcet's Syndrome Society and Director of Behcets International, London, United Kingdom
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul 34098, Turkey
| | - Ignazio Olivieri
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, and the Basilicata Ricerca Biomedica (BRB) Foundation, Potenza and Matera, Italy
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul 34098, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul 34098, Turkey.
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Hatemi G, Christensen R, Bang D, Bodaghi B, Celik AF, Fortune F, Gaudric J, Gul A, Kötter I, Leccese P, Mahr A, Moots R, Ozguler Y, Richter J, Saadoun D, Salvarani C, Scuderi F, Sfikakis PP, Siva A, Stanford M, Tugal-Tutkun I, West R, Yurdakul S, Olivieri I, Yazici H. 2018 update of the EULAR recommendations for the management of Behçet's syndrome. Ann Rheum Dis 2018; 77:808-818. [PMID: 29625968 DOI: 10.1136/annrheumdis-2018-213225] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022]
Abstract
Several new treatment modalities with different mechanisms of action have been studied in patients with Behçet's syndrome (BS). The aim of the current effort was to update the recommendations in the light of these new data under the auspices of the European League Against Rheumatism (EULAR) Standing Committee for Clinical Affairs. A task force was formed that included BS experts from different specialties including internal medicine, rheumatology, ophthalmology, dermatology, neurology, gastroenterology, oral health medicine and vascular surgery, along with a methodologist, a health professional, two patients and two fellows in charge of the systematic literature search. Research questions were determined using a Delphi approach. EULAR standardised operating procedures was used as the framework. Results of the systematic literature review were presented to the task force during a meeting. The former recommendations were modified or new recommendations were formed after thorough discussions followed by voting. The recommendations on the medical management of mucocutaneous, joint, eye, vascular, neurological and gastrointestinal involvement of BS were modified; five overarching principles and a new recommendation about the surgical management of vascular involvement were added. These updated, evidence-based recommendations are intended to help physicians caring for patients with BS. They also attempt to highlight the shortcomings of the available clinical research with the aim of proposing an agenda for further research priorities.
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Affiliation(s)
- Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital & Department of Rheumatology, Odense University Hospital, Copenhagen, Denmark
| | - Dongsik Bang
- Department of Dermatology, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Aykut Ferhat Celik
- Division of Gastroenterology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Farida Fortune
- Centre for Clinical and Diagnostic Oral Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, and the London Behçet's Centre, Barts Health London, London, UK
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ina Kötter
- Department of Rheumatology, Immunology and Nephrology, Asklepios Clinic Altona, Hamburg, Germany
| | - Pietro Leccese
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
| | - Alfred Mahr
- Department of Internal Medicine, Hospital Saint-Louis, Paris, France
| | - Robert Moots
- National Behcet's Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
| | - Yesim Ozguler
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Jutta Richter
- Institute for Haematopathology Hamburg, Hamburg, Germany
| | - David Saadoun
- Department of Inflammation-Immunopathology-Biotherapy, Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM, Paris, France.,CNRS, Paris, France.,Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena and Reggio Emilia, Italy
| | | | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine & Rheumatology Unit, National Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Miles Stanford
- Department of Ophthalmology, St. Thomas' Hospital, London, UK
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Richard West
- Patient Research Partner, Member of the UK Behcet's Syndrome Society and Director of Behcets International, London, UK
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ignazio Olivieri
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, and the Basilicata Ricerca Biomedica (BRB) Foundation, Potenza and Matera, Italy
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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Winthrop KL, Mariette X, Silva JT, Benamu E, Calabrese LH, Dumusc A, Smolen JS, Aguado JM, Fernández-Ruiz M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors). Clin Microbiol Infect 2018; 24 Suppl 2:S21-S40. [PMID: 29447987 DOI: 10.1016/j.cmi.2018.02.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection. IMPLICATIONS Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.
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Affiliation(s)
- K L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - X Mariette
- Department of Rheumatology, Hôpitaux Universitaire Paris-Sud, Université Paris-Sud, INSERM U1184, Paris, France
| | - J T Silva
- Department of Infectious Diseases, University Hospital of Badajoz, Fundación para La Formación e Investigación de Los Profesionales de La Salud (FundeSalud), Badajoz, Spain
| | - E Benamu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L H Calabrese
- Department of Rheumatic and Immunological Diseases, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH, USA
| | - A Dumusc
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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Mirouse A, Cacoub P, Desbois AC, Comarmond C, Pagnoux C, Saadoun D. Investigational drugs in systemic vasculitis. Expert Opin Investig Drugs 2017; 26:1049-1061. [PMID: 28758504 DOI: 10.1080/13543784.2017.1361928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Treatment of systemic vasculitis is based on glucocorticoids (GC) in association with immunosuppressive therapy. There are still unmet needs, including earlier onset of response, more targeted therapies, reduction of relapse-risk and decrease of long-term GC and classic immunosuppressants toxicities. Areas covered: In this review, we discuss investigational drugs in early phase clinical trials for induction of remission in vasculitis. We focus on ANCA-associated vasculitis, Behçet's disease, giant cell arteritis, Takayasu arteritis, and cryoglobulinemic vasculitis. We performed a comprehensive review of articles published on pubmed and a review of clinical trials registered online ( https://clinicaltrials.gov ) for each vasculitis. Expert opinion: Recent progress in the pathogenesis identifies new therapeutic targets. Some of these therapies are promising in GC sparing effects, in reducing relapse rate, and for their safety profile. These results need to be confirmed in large-scale phase III studies.
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Affiliation(s)
- Adrien Mirouse
- a Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biothérapie (DHU i2B) , Sorbonne Universités , UPMC Université Paris 06, UMR 7211 , Paris , France.,b INSERM, UMR_S 959 , Paris , France.,c CNRS, FRE3632 , Paris , France.,d AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique , National Center for Autoimmune and Systemic Diseases and for Autoinflammatory Diseases , Paris , France
| | - Patrice Cacoub
- a Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biothérapie (DHU i2B) , Sorbonne Universités , UPMC Université Paris 06, UMR 7211 , Paris , France.,b INSERM, UMR_S 959 , Paris , France.,c CNRS, FRE3632 , Paris , France.,d AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique , National Center for Autoimmune and Systemic Diseases and for Autoinflammatory Diseases , Paris , France
| | - Anne Claire Desbois
- a Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biothérapie (DHU i2B) , Sorbonne Universités , UPMC Université Paris 06, UMR 7211 , Paris , France.,b INSERM, UMR_S 959 , Paris , France.,c CNRS, FRE3632 , Paris , France.,d AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique , National Center for Autoimmune and Systemic Diseases and for Autoinflammatory Diseases , Paris , France
| | - Cloé Comarmond
- a Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biothérapie (DHU i2B) , Sorbonne Universités , UPMC Université Paris 06, UMR 7211 , Paris , France.,b INSERM, UMR_S 959 , Paris , France.,c CNRS, FRE3632 , Paris , France.,d AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique , National Center for Autoimmune and Systemic Diseases and for Autoinflammatory Diseases , Paris , France
| | - Christian Pagnoux
- e Vasculitis Clinic, Mount Sinai Hospital , University of Toronto , Toronto , Canada
| | - David Saadoun
- a Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biothérapie (DHU i2B) , Sorbonne Universités , UPMC Université Paris 06, UMR 7211 , Paris , France.,b INSERM, UMR_S 959 , Paris , France.,c CNRS, FRE3632 , Paris , France.,d AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique , National Center for Autoimmune and Systemic Diseases and for Autoinflammatory Diseases , Paris , France
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