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Cullivan S, Cronin E, Gaine S. Pulmonary Hypertension in Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:411-418. [PMID: 38531379 DOI: 10.1055/s-0044-1782607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Systemic sclerosis is a multisystem connective tissue disease that is associated with substantial morbidity and mortality. Visceral organ involvement is common in patients with systemic sclerosis and occurs independently of skin manifestations. Pulmonary hypertension (PH) is an important and prevalent complication of systemic sclerosis. The clinical classification of PH cohorts conditions with similar pathophysiological mechanisms into one of five groups. While patients with systemic sclerosis can manifest with a spectrum of pulmonary vascular disease, notable clinical groups include group 1 pulmonary arterial hypertension (PAH) associated with connective tissues disease, PAH with features of capillary/venous involvement, group 2 PH associated with left heart disease, and group 3 PH associated with interstitial lung disease. Considerable efforts have been made to advance screening methods for PH in systemic sclerosis including the DETECT and ASIG (Australian Scleroderma Interest Group) composite algorithms. Current guidelines recommend annual assessment of the risk of PAH as early recognition may result in attenuated hemodynamic impairment and improved survival. The treatment of PAH associated with systemic sclerosis requires a multidisciplinary team including a PH specialist and a rheumatologist to optimize immunomodulatory and PAH-specific therapies. Several potential biomarkers have been identified and there are several promising PAH therapies on the horizon such as the novel fusion protein sotatercept. This chapter provides an overview of PH in systemic sclerosis, with a specific focus on group 1 PAH.
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Affiliation(s)
- Sarah Cullivan
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eleanor Cronin
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Distler O, Allanore Y, Denton CP, Kuwana M, Matucci-Cerinic M, Pope JE, Atsumi T, Bečvář R, Czirják L, Hachulla E, Ishii T, Ishikawa O, Johnson SR, De Langhe E, Stagnaro C, Riccieri V, Schiopu E, Silver RM, Smith V, Steen V, Stevens W, Szücs G, Truchetet ME, Wosnitza M, Laapas K, Kramer F, Khanna D. Riociguat in patients with early diffuse cutaneous systemic sclerosis (RISE-SSc): open-label, long-term extension of a phase 2b, randomised, placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2023; 5:e660-e669. [PMID: 38251533 DOI: 10.1016/s2665-9913(23)00238-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The phase 2b Riociguat Safety and Efficacy in Patients with Diffuse Cutaneous Systemic Sclerosis (RISE-SSc) trial investigated riociguat versus placebo in early diffuse cutaneous systemic sclerosis. The long-term extension evaluated safety and exploratory treatment effects for an additional year. METHODS Patients were enrolled to RISE-SSc between Jan 15, 2015, and Dec 8, 2016. Those who completed the 52-week, randomised, parallel-group, placebo-controlled, double-blind phase were eligible for the long-term extension. Patients originally assigned to riociguat continued therapy (riociguat-riociguat group). Those originally assigned to placebo were switched to riociguat (placebo-riociguat group), adjusted up to 2·5 mg three times daily in a 10-week, double-blind dose-adjustment phase, followed by an open-label phase. Statistical analyses were descriptive. Safety including adverse events and serious adverse events was assessed in the long-term safety analysis set (all patients randomly assigned and treated with study medication in the double-blind phase who continued study medication in the long-term extension). The RISE-SSc trial is registered with ClinicalTrials.gov, NCT02283762. FINDINGS In total, 87 (72%) of 121 patients in the main RISE-SSc study entered the long-term extension (riociguat-riociguat, n=42; placebo-riociguat, n=45). 65 (75%) of 87 patients were women, 22 (25%) were men, and 62 (71%) were White. Overall, 82 (94%) of 87 patients in the long-term extension had an adverse event; most (66 [76%] of 87) were of mild to moderate severity, with no increase in pulmonary-related serious adverse events in patients with interstitial lung disease. INTERPRETATION No new safety signals were observed with long-term riociguat in patients with early diffuse cutaneous systemic sclerosis. Study limitations include the absence of a comparator group in this open-label extension study. FUNDING Bayer and Merck Sharp & Dohme.
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Affiliation(s)
- Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | | | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School, Tokyo, Japan
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Janet E Pope
- Schulich School of Medicine, Division of Rheumatology, University of Western Ontario, London, ON, Canada
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Radim Bečvář
- Institute of Rheumatology, Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - László Czirják
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - Eric Hachulla
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Rare Systemic Autoimmune Diseases North and North-West of France (CeRAINO), Centre Hospitalier Universitaire Lille, University of Lille, Inserm, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohuko University, Sendai, Japan
| | - Osamu Ishikawa
- Ishii Hospital, Division of Dermatology, Isezaki, Gunma, Japan
| | - Sindhu R Johnson
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University Health Network, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Ellen De Langhe
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Division of Rheumatology, University Hospitals, Leuven, Belgium
| | - Chiara Stagnaro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Riccieri
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Elena Schiopu
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Richard M Silver
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Virginia Steen
- Division of Rheumatology, Georgetown University, Washington, DC, USA
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Gabriella Szücs
- Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | | | | | | | - Frank Kramer
- Research & Development, Bayer, Wuppertal, Germany
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, Michigan Medicine University Hospital, Ann Arbor, MI, USA; University of Michigan Scleroderma Program, Ann Arbor, MI, USA.
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