Novel therapy in the treatment of scleroderma

A case of advanced systemic sclerosis with severe GERD successfully treated with acotiamide

The majority of systemic sclerosis (SSc) patients have gastrointestinal tract involvement, but therapies of prokinetic agents are usually unsatisfactory. Patients are often compromised by the use of steroid; therefore, a surgical indication including fundoplication has been controversial. There is no report that advanced SSc with severe gastroesophageal reflux disease (GERD) is successfully treated with acotiamide, which is the acetylcholinesterase (AChE) inhibitor designed for functional dyspepsia (FD). We report a 44-year-old woman of SSc with severe GERD successfully treated with acotiamide. She had received medical treatment in our hospital since 2003. She had been aware of the significant gastroesophageal reflux symptoms (e.g., heartburn, chest pain, and dysphagia) due to the development of esophageal hardening associated with SSc since 2014. As a result of upper gastrointestinal series, upper gastrointestinal endoscopy, and 24-h pH monitoring and frequency scale for the symptoms of the GERD (FSSG) scoring, she has been diagnosed with GERD associated with SSc. First of all, she started to take prokinetic agents Rikkunshito and mosapride and proton pump inhibitor; there was no change in reflux symptoms. So, we started to prescribe her the acotiamide.

After oral administration started, reflux symptoms have been improved. Five months after oral administration, FSSG score, a questionnaire for evaluation of the symptoms of GERD, was improved. Since its introduction of acotiamide, the patient has kept free from symptoms for 6 months.

The role of acetaldehyde in ethanol reinforcement assessed by Pavlovian conditioning in newborn rats

RATIONALE

Animal studies indicate that central acetaldehyde, dependent on catalase metabolism of ethanol (EtOH), modulates ethanol reinforcement. Brain catalase activity and acetaldehyde (ACD) production are significantly higher in rat pups compare d with adults. Interestingly, infant rats show high EtOH affinity for alcohol consumption and are particularly sensitive to the drug's reinforcing effects.

OBJECTIVES

We tested whether central ACD is necessary and sufficient to induce appetitive conditioning in newborn rats through the artificial nipple technique.

METHODS

Vehicle, EtOH (100 mg%), and acetaldehyde (0.35 μmol) were administered into the cisterna magna (1 μl). Half of the animals also received a central administration of 75 μg (experiment 1) or 40 μg of D-penicillamine (experiment 2). Afterwards, pups were exposed to an olfactory cue (conditioned stimulus). One hour later, neonates were tested with an artificial nipple in the presence of the conditioned cue. Nipple attachment duration, mean grasp duration, and number of nipple disengagements served as dependent variables.

RESULTS

Positive responses to the scented nipple occurred in neonates conditioned with EtOH or ACD (experiments 1 and 2). In experiment 1, there were indications that D-penicillamine weakened the reinforcing effects of EtOH and ACD. In experiment 2, D-penicillamine (40 μg) significantly inhibited appetitive conditioned responses dependent upon EtOH or ACD.

CONCLUSIONS

Appetitive conditioning was observed when employing either central EtOH or ACD as unconditioned stimuli. Central abduction of ACD inhibited conditioned appetitive responsiveness to the surrogate nipple. Central ACD is involved in the determination or modulation of EtOH's motivational properties during early stages in development.

Prevention of Ethanol-Induced Behavioral Stimulation by d-Penicillamine: A Sequestration Agent for Acetaldehyde

BACKGROUND

D-Penicillamine, a sulfhydryl amino acid derived from penicillin, is a highly selective agent for sequestering in vivo acetaldehyde, the first metabolic product of ethanol. A substantial amount of research supports the idea that brain acetaldehyde, produced by central ethanol metabolism, plays a key role in determining some of the behavioral effects of ethanol administration. This study addressed two questions. First, we tested if D-penicillamine was able to modify the depressant effects of acetaldehyde on behavior. Second, we studied the effect of D-penicillamine on ethanol-induced behavioral stimulation.

METHODS

Mice were pretreated with 75.00 mg/kg of D-penicillamine, and 30 min later, they received acetaldehyde at 0, 100, 200, or 300 mg/kg intraperitoneally. Different groups of animals were treated with 0.0, 37.5, 75, 150, or 300 mg/kg of D-penicillamine simultaneously 30, 90, 150, or 210 min before the intraperitoneal administration of saline or 1.2, 1.8, 2.4, 3.0, or 3.6 g/kg of ethanol, respectively. The specificity of D-penicillamine effects was addressed using two drugs: cocaine (4 mg/kg) and caffeine (15 mg/kg).

RESULTS

Our results revealed that behavioral depression caused by acetaldehyde (200 and 300 mg/kg) could be attenuated by D-penicillamine treatment. In addition, D-penicillamine was also effective in lowering behavioral locomotion induced by ethanol (1.8 and 2.4 g/kg), without altering spontaneous locomotor activity. This sulfhydryl amino acid specifically modified the effect of ethanol on locomotion because cocaine- or caffeine-induced locomotion was unaffected. In addition, blood ethanol levels were not different between D-penicillamine- and saline-pretreated mice.

CONCLUSIONS

Behavioral effects produced by acetaldehyde and ethanol are blocked when animals are treated with D-penicillamine, an effective sequestration agent for acetaldehyde. These results suggest that some of the psychopharmacological effects, classically attributed to ethanol, could be mediated by its first metabolite, acetaldehyde.

Voluntary ethanol consumption decreases after the inactivation of central acetaldehyde by d-penicillamine

Acetaldehyde, the first metabolite of ethanol, may mediate some ethanol-induced effects. Previous research in our laboratory has shown that D-penicillamine, an inactivation agent for acetaldehyde, is effective in decreasing locomotor stimulation and conditioned place preference induced by ethanol in mice. In the present study, the effects of D-penicillamine on the voluntary consumption of ethanol were assessed. Male rats were offered ethanol under restricted access, without food or water deprivation. Daily availability of ethanol was limited to a 15-min period in the home cages. When the response for 10% ethanol was stable, rats received an intraperitoneal (IP) injection of D-penicillamine (0, 25, 50 or 75 mg/kg) over a 5-day period, given 30 min before exposure to ethanol. In a second study we determined the specificity of D-penicillamine effects (50 mg/kg) on voluntary sucrose consumption (3%). Another study was conducted to evaluate whether IP D-penicillamine (50 mg/kg) alters taste reactivity responses. In the final experiment, rats were treated with intracerobroventricular (ICV) infusions of D-penicillamine (75 microg) for 5 days before drinking ethanol or sucrose. D-Penicillamine was found to reduce ethanol intake in a dose-dependent manner. Sucrose consumption was also affected by this thiol amino acid. We also demonstrated that D-penicillamine produced changes in the ingestive and flavor properties of sucrose and ethanol, measured by means of a taste reactivity test. When D-penicillamine was administered ICV, only voluntary ethanol consumption was modified. These findings indicate that the central inactivation of acetaldehyde blocks ethanol intake in rats, and suggest that acetaldehyde plays a key role in the motivational properties of ethanol.

Ethanol-induced conditioned place preference, but not aversion, is blocked by treatment with D -penicillamine, an inactivation agent for acetaldehyde

RATIONALE

There is evidence to suggest that acetaldehyde is involved in the control of ethanol-seeking behavior and reward. D -penicillamine, a thiol amino acid, is a highly selective agent for the inactivation of acetaldehyde. Previous studies from our laboratory have demonstrated that D -penicillamine prevents both behavioral stimulation induced by ethanol and acetaldehyde-produced locomotor depression in mice.

OBJECTIVES

The contribution of ethanol-derived acetaldehyde to the affective effects of ethanol (preference and aversion) was assessed using an unbiased place conditioning design.

METHODS

Male mice received four pairings of a distinctive floor stimulus (CS+: GRID+ or HOLE+) with injections of saline and ethanol (2 g/kg) given before (preference) or after (aversion) the 5-min exposure to the place conditioning apparatus. A different floor stimulus (CS-: GRID- or HOLE-), associated with saline-saline injections on alternate days, was presented. For a different group of animals, the pairings with the CS+ were associated with saline and ethanol injections, but on alternate days, they received D -penicillamine (50 or 75 mg/kg) and ethanol injections paired with the CS-floor stimulus. A 60-min preference test was carried out 24 h after the last conditioning trial. A similar procedure was followed to test the effect of D -penicillamine on morphine (16 mg/kg) and cocaine-induced (20 mg/kg) conditioned place preference (CPP).

RESULTS

CPP and conditioned place aversion (CPA) were observed for ethanol, but D -penicillamine only blocked CPP. D -penicillamine, by itself, did not produce either rewarding or aversive effects. CPP observed for morphine and cocaine was unaffected by D -penicillamine pretreatment.

CONCLUSIONS

The results of the present study suggest that the selective inactivation of acetaldehyde blocked the rewarding, but not aversive, effects of ethanol and support the role of this ethanol metabolite in the affective properties of ethanol.

Paclitaxel modulates TGFbeta signaling in scleroderma skin grafts in immunodeficient mice

BACKGROUND

Systemic sclerosis (SSc) is characterized by excessive fibrosis and obliterative vascular lesions. Abnormal TGFbeta activation is implicated in the pathogenesis of SSc. Aberrant TGFbeta/Smad signaling can be controlled by stabilization of microtubules with paclitaxel.

METHODS AND FINDINGS

SSc and healthy human skin biopsies were incubated in the presence or absence of paclitaxel followed by transplantation into severe combined immunodeficient mice. TGFbeta signaling, fibrosis, and neovessel formation were evaluated by quantitative RT-PCR and immunohistochemical staining. Paclitaxel markedly suppressed Smad2 and Smad3 phosphorylation and collagen deposition in SSc grafts. As a result, the autonomous maintenance/reconstitution of the SSc phenotype was prevented. Remarkably, SSc grafts showed a 2-fold increase in neovessel formation relative to normal grafts, regardless of paclitaxel treatment. Angiogenesis in SSc grafts was associated with a substantial increase in mouse PECAM-1 expression, indicating the mouse origin of the neovascular cells.

CONCLUSION

Low-dose paclitaxel can significantly suppress TGFbeta/Smad activity and lessen fibrosis in SCID mice. Transplantation of SSc skin into SCID mice elicits a strong angiogenesis-an effect not affected by paclitaxel. Although prolonged chemotherapy with paclitaxel at higher doses is associated with pro-fibrotic and anti-angiogenic changes, the findings described here indicate that low-dose paclitaxel may have therapeutic benefits for SSc via modulating TGFbeta signaling.

[Treatment of therapy-resistant acral ulcers with iloprost]

Patients with systemic sclerosis (SSc) develop often acral ulcers which are resistant to therapy and may result in gangrene and amputation. We investigated the effects of iloprost infusion on the acral ulcers and necrosis in patients with five patients with SSc and one with mixed connective tissue disease who had been previously treated with various modalities without improvement. All patients had Raynaud phenomenon, acral ulcers and necrosis. Iloprost 25 microg per day was administered intravenously daily over six hours for ten consecutive days. Eight weeks later all patients were treated with a second iloprost therapy cycle for five days. Two patients with severe ulceration received a third cycle until remission occurred. In all cases acral ulcers healed completely and no patient relapsed during an observation period of 6 months.

A modified model of graft-versus-host-induced systemic sclerosis (scleroderma) exhibits all major aspects of the human disease

OBJECTIVE

Diffuse systemic sclerosis (SSc; scleroderma) is a debilitating disease characterized by excessive dermal fibrosis with later progression to internal organs. In addition to the fibrotic component, major aspects of the disease include vascular or circulatory involvement and immune dysregulation evidenced by inflammatory cells in affected tissues and production of autoantibodies. Many animal models resembling this disease have been studied, including genetic models in mice and chickens, challenge with chemicals such as bleomycin or vinyl chloride to induce fibrosis, and models of graft-versus-host (GVH)-induced disease using certain strains of mice with differences in minor histocompatibility loci. The present studies were undertaken to determine if alteration of the induction of GVH-induced scleroderma could result in a model that more fully represented the human condition.

METHODS

Disease was induced by injection of spleen cells from B10.D2 mice into BALB/c mice deficient in mature T and B cells (recombination-activating gene 2 targeted). Dermal thickening, collagen deposition, vasoconstriction, and parameters of immunity were analyzed.

RESULTS

Similar to the human disease, this modified GVH model of SSc demonstrated evidence of dermal thickening, particularly in the extremities, progressive fibrosis of internal organs, vasoconstriction and altered expression of vascularity markers in skin and internal organs, early immune activation, inflammation in skin and internal organs, and autoantibody generation.

CONCLUSION

This modified model of GVH-induced SSc exhibits all major components of human disease and is likely to contribute to better understanding of the disease mechanisms and, ultimately, improved treatments for patients.

[Colchicine in dermatology]

<zakljucak> Kolhicin je stari lek cija je primena, kao monoterapija ili u kombinaciji sa drugim lekovima, aktuelna i u savremenoj medicini. Najznacajnija mu je primena za lecenje i profilaksu perzistentne palmoplantarne pustuloze i oralnih aftoznih ulceracija, lecenje Svitovog sindroma, Beh?etove bolesti, sklerodermije i fibromatoze penisa.

Update on disease-modifying antirheumatic drugs in the treatment of systemic sclerosis

Treatment of systemic sclerosis has been somewhat haphazard and treatment has often been "borrowed" from the experience gained from treating other connective tissue diseases. There was a period of time that was focused mainly on organ-specific manifestations of systemic sclerosis and some advance in preventing vital organ damage (such as renal crisis) was achieved. The vast improvement in mortality from the use of ACE inhibitors raises one's hopes for other effective therapeutic interventions. At this juncture, the evidence is strong that the ACE inhibitors that are used in scleroderma renal crisis are disease-modifying, even without proving it by a randomized controlled trial. The evidence is strong that the use of epoprostenol for primary pulmonary hypertension is life-saving; however, whether epoprostenol is life-saving in the pulmonary hypertension in scleroderma remains to be proven. There are suggestions that bosentan (for the pulmonary hypertension of scleroderma), cyclophosphamide (for SSc alveolitis), stem cell transplant, interferon-gamma (for interstitial pulmonary fibrosis), and methotrexate (for the skin thickening of diffuse scleroderma) may improve organ function or functional activities, but whether they are truly disease-modifying remains to be proven. As we increase our understanding of the pathophysiology of systemic sclerosis and we learn how better to design trials for systemic sclerosis, we may be more successful in developing optimal disease-modifying therapy. Although the treatment of systemic sclerosis remains difficult, there are an increasing number of potentially effective regimens that are undergoing clinical investigations. A rational approach to therapy seems possible, based on a hypothesis of the pathogenesis of systemic sclerosis. Thus, there is accumulating evidence that supports the use of prostacyclin derivatives to treat systemic sclerosis, some evidence that antifibrotic regimens may be effective, and moderate evidence that immunosuppression also may be effective in certain stages of this disease.

Treatment of scleroderma: an update

The goal of this article is to update the reader and focus on novel therapies and clinical trials published since our last review [6]. Evidence suggests that drug intervention should target one or all of three biological processes: vascular disease, autoimmunity and tissue fibrosis. Efforts should be made to classify the subtype of scleroderma, to determine the activity of the disease process and the degree of specific organ involvement before specific treatment decisions are made. Cyclophosphamide in fibrosing alveolitis, intravenous prostaglandins and other vasodilators for the vascular disease, endothelin-1 inhibition in pulmonary hypertension and immunosuppressive therapy for early inflammatory disease, all appear to have benefit. Several agents used in vitro and in animal models of fibrosis also show promise including anti-transforming growth factor-beta, the statins and anti-integrins. More experience in well-designed clinical trials is needed to define the role of these agents in treating scleroderma.