Novel pain management therapies for patients with pemphigus

Pemphigus is a class of rare autoimmune diseases that causes incredibly painful blistering of the skin and significantly impacts patients' day-to-day lives and well-being. Many strides have been made in treating pemphigus; however, no comprehensive literature exists on how to treat the pain that accompanies the disease. It is important to remember that treating pemphigus involves a two-fold treatment plan assessing both the underlying autoimmune disease and the pain involved with the lesions. This literature review explores novel therapies that have been shown to be effective in treating pain in pemphigus.

Caspase Inhibition as a Possible Therapeutic Strategy for Pemphigus Vulgaris: A Systematic Review of Current Evidence

Simple Summary

Pemphigus vulgaris is a potentially fatal disease characterised by blister formation affecting the skin and mouth. The mechanisms of blister formation may involve a biological process called apoptosis—a type of cell death—and some death-associated molecules known as caspases. Our review of the existing literature shows that caspase inhibitors exhibit an inhibitory effect on PV-induced apoptosis formation in vitro. In particular, activity of caspase 1 and caspase 3 is essential for the development of PV in vitro and in vivo. However, a majority of in vivo studies assessing caspase inhibition in PV models have a high risk of bias.

Abstract

Background: Pemphigus vulgaris (PV) is an IgG-mediated autoimmune disease characterised by epithelial cell–cell detachment (acantholysis) resulting in mucocutaneous blistering. The exact pathogenesis of blister formation is unknown and this has hampered the development of non-steroidal, mechanism-based treatments for this autoimmune disease. This systematic review aims to investigate the role of caspases in the pathogenesis of PV to inform the choice of more targeted therapeutic agents. Methods: A systematic search of MEDLINE/PubMed and Scopus databases was conducted to identify eligible studies. Multiple phases of inclusion and exclusion of the primary articles were conducted in pairs, and studies were recorded and analysed according to the latest version of the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Risk of bias assessment was conducted for extracted in vivo animal intervention studies using SYRCLE’s risk of bias tool. Results: Eight articles from a total of 2338 in vitro, in vivo, and human studies met the inclusion criteria, with a high degree of inter-rater reliability. By and large, the results show that caspase activation was pathogenic in experimental PV because pan-caspase inhibitors could block or reduce PV acantholysis and blistering in vitro and in vivo, respectively. The pathogenic pathways identified involved caspase-1 and caspase-3. One study failed to show any improvement in the PV model with a caspase inhibitor. The majority of animal studies had high or unclear risk of bias. Conclusion: There are consistent data pointing towards a pathogenic role of caspase activation in PV acantholysis. However, high-quality evidence to confirm that caspase inhibition can prevent PV-induced blistering in vivo is limited. Therefore, further research is required to test the preclinical efficacy of caspase inhibitors in PV.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Current methods of treatment of true acantholytic pemphigus

Major stages of the pathogenesis of true acantholytic pemphigus are interpreted in terms of autoimmune pathology; therefore, treatment of this group of diseases remains pathogenetic and is aimed at suppressing the synthesis of autoantibodies against keratinocyte proteins. Treatment with the use of systemic glucocorticosteroids is currently the main method of treatment for true acantholytic pemphigus. To reduce the course dose of glucocorticosteroids, decrease the risk of adverse effect development and achieve long-term remission, further studies of disease pathogenesis and development of new treatment methods for reducing the doses of glucocorticosteroids are of great importance.

Miscellaneous indications for extracorporeal photochemotherapy (ECP)

Extracorporeal photochemotherapy (ECP) has been applied to many T-cell mediated diseases where immunosuppressive drugs are insufficient or not tolerated. As ECP is mainly used in rare indications after failure of other therapies, controlled studies are hardly possible. In addition, the importance of the extracorporeal circuit imposes ethical doubts in organising sham ECP procedure, which explains the rarity of controlled double-blind studies. However, encouraging and even successful results have been reported in newly developed diabetes mellitus, erosive lichen planus, Crohn's disease, systemic sclerosis, nephrogenic fibrosing dermopathy, atopic dermatitis, rheumatoid arthritis, systemic lupus erythematodes, psoriasis arthritis, cutaneous mucinosis, scleromyxoedema, pemphigus vulgaris, multiple sclerosis, eosinophilic fasciitis and in the prevention of percutaneous transluminal coronary angioplasty (PTCA) restenosis. This article discusses the various levels of evidence in the above cited indications.

B-cell targeted therapeutics in clinical development

B lymphocytes are the source of humoral immunity and are thus a critical component of the adaptive immune system. However, B cells can also be pathogenic and the origin of disease. Deregulated B-cell function has been implicated in several autoimmune diseases, including systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis. B cells contribute to pathological immune responses through the secretion of cytokines, costimulation of T cells, antigen presentation, and the production of autoantibodies. DNA-and RNA-containing immune complexes can also induce the production of type I interferons, which further promotes the inflammatory response. B-cell depletion with the CD20 antibody rituximab has provided clinical proof of concept that targeting B cells and the humoral response can result in significant benefit to patients. Consequently, the interest in B-cell targeted therapies has greatly increased in recent years and a number of new biologics exploiting various mechanisms are now in clinical development. This review provides an overview on current developments in the area of B-cell targeted therapies by describing molecules and subpopulations that currently offer themselves as therapeutic targets, the different strategies to target B cells currently under investigation as well as an update on the status of novel therapeutics in clinical development. Emerging data from clinical trials are providing critical insight regarding the role of B cells and autoantibodies in various autoimmune conditions and will guide the development of more efficacious therapeutics and better patient selection.

Pemphigus vulgaris treated with adalimumab: case study

The study describes the case of a patient with a clinical and histopathological diagnosis of pemphigus vulgaris accompanied by severe side-effects of combined immunosuppressive therapy, who achieved a remission of the disease with adalimumab. Pemphigus vulgaris is a chronic blistering disease of the skin and mucous membranes. Before corticosteroids were introduced, mortality was high. Corticosteroids are currently used as first-line therapy. To reduce the dose of corticosteroids, therapeutic combinations with corticosteroid-sparing immunosuppressive agents are used. The therapy brings a number of complications due to its side effects. To achieve a remission of the disease by treating our patient with combined immunosuppressives, we administered adalimumab and achieved a very good clinical response.

Diagnosis and treatment of pemphigus

Pemphigus is an autoimmune bullous disease, in which autoantibodies react with the cell–cell adhesion structures, desmosomes, causing blisters and erosions on the oral mucosa and skin. Pemphigus is divided into two major subtypes: pemphigus vulgaris and pemphigus foliaceus. Oral corticosteroids are the primary treatment modality for pemphigus, while other therapeutic options, such as steroid pulse therapy, immunosuppressants, intravenous immunoglobulins, plasmapheresis and anti-CD20 monoclonal antibody therapy, are occasionally employed. Immunosuppressants used to treat pemphigus include azathioprine, cyclophosphamide, cyclosporine, mycophenolate mofetil and mizoribine. In this review, we summarize the current concepts of immunotherapy for the treatment of pemphigus in the Japanese population.

The C5a receptor on mast cells is critical for the autoimmune skin-blistering disease bullous pemphigoid

Bullous pemphigoid (BP) is an autoimmune skin-blistering disease characterized by the presence of autoantibodies against the hemidesmosomal proteins BP230 and BP180. In the IgG passive transfer mouse model of BP, subepidermal blistering is triggered by anti-BP180 antibodies and depends on the complement system, mast cell (MC) degranulation, and neutrophil infiltration. In this study, we have identified the signaling events that connect the activation of the complement system and MC degranulation. We found that mice deficient in MCs or the C5a receptor (C5aR) injected with pathogenic anti-BP180 IgG failed to develop subepidermal blisters and exhibited a drastic reduction in p38 MAPK phosphorylation compared with WT mice. Local reconstitution with MCs from WT but not C5aR-deficient mice restored high levels of p38 MAPK phosphorylation and subepidermal blistering in MC-deficient mice. Local injection of recombinant C5a induced phosphorylation of p38 MAPK in WT but not MC-deficient mice. Cultured mouse MCs treated with recombinant C5a exhibited a significant increase in p38 MAPK phosphorylation and MC degranulation. Taken together, these data demonstrate that C5a interacts with C5aR on MCs and that this C5a-C5aR interaction triggers activation of the p38 MAPK pathway, subsequent MC degranulation, and ultimately BP blistering.