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Koczanowski S, Morrisroe K, Fairley J, Nikpour M, Oon S, Brown Z. Role of intravenous immunoglobulins in systemic sclerosis (SSc): A systematic literature review. Semin Arthritis Rheum 2024; 68:152471. [PMID: 38954999 DOI: 10.1016/j.semarthrit.2024.152471] [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: 02/19/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Systemic sclerosis (SSc) is a heterogenous, multi-system autoimmune disease that causes progressive fibrosis of the skin and internal organs, resulting in high morbidity and mortality. Intravenous Immunoglobulin (IVIG) is a therapeutic option for SSc; however, reports of its efficacy have been variable, and its use across multiple organ manifestations of SSc has not been comprehensively reviewed. AIM The aim of this study was to systematically assess the existing literature on the role of IVIG use across a range of SSc manifestations. METHODS Medline, Embase, Cochrane, Web of Science and Scopus were searched from 01/01/2003-15/04/2024 using terms related to SSc and IVIG. Included studies were English-language full texts, where ≥5 adults with SSc received IVIG, and where a reportable outcome was documented. RESULTS Of 418 potentially relevant records, 12 were included in this review, comprising 266 patients across one randomised control trial, two pilot studies, one open label study, seven retrospective studies and one case control study. Eighteen outcomes were documented across five different organ systems: cutaneous, respiratory, musculoskeletal, gastrointestinal, and other (clinical improvement and corticosteroid sparing benefit). Results showed a favourable effect of IVIG in reducing the extent of skin thickening, muscle and joint pain, gastrointestinal symptoms, steroid dosing and improving patient/physician reported quality of life. Whilst IVIG may appear to be less beneficial for respiratory disease, the stabilisation in pulmonary function tests and radiological features may be considered a positive outcome in itself. Limitations included a lack of high-quality studies, and the use of concomitant therapies in many studies, rendering the efficacy of IVIG alone difficult to ascertain. CONCLUSION IVIG showed benefit in treating some manifestations of SSc, however there was a lack of convincing evidence for the efficacy in others. The lack of high-quality data highlights the need for further well-designed clinical trials to confirm these findings and inform guidelines for IVIG use.
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Affiliation(s)
| | - Kathleen Morrisroe
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Jessica Fairley
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Shereen Oon
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Zoe Brown
- Department of Medicine, The University of Melbourne, Australia; Department of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
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2
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Tandaipan J, Guillén-Del-Castillo A, Simeón-Aznar CP, Carreira PE, De la Puente C, Narváez J, Lluch J, Rubio-Rivas M, Alegre-Sancho JJ, Bonilla G, Moriano C, Casafont-Sole I, García-Vicuña R, Ortiz-Santamaría V, Riera E, Atienza-Mateo B, Blanco R, Galisteo C, Gonzalez-Martin JJ, Pego-Reigosa JM, Pros A, Heredia S, Castellví I. Immunoglobulins in systemic sclerosis management. A large multicenter experience. Autoimmun Rev 2023; 22:103441. [PMID: 37708984 DOI: 10.1016/j.autrev.2023.103441] [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: 08/08/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To analyze the effectiveness and safety of intravenous immunoglobulin (IVIG) given in routine care to patients with systemic sclerosis (SSc). METHODS A retrospective multicenter observational study was conducted in SSc patients treated with IVIG. We collected data on epidemiological parameters and clinical outcomes. Firstly, we assessed changes in organ manifestations during IVIG treatment. Secondly, we analyzed the frequency of adverse effects. The following parameters were collected from baseline to the last follow-up: the patient's weight, modified Rodnan Skin Score (mRSS), modified manual muscle strength scale (MRC), laboratory test(creatine kinase(CK), hemoglobin and protein levels), The University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA GIT 2.0) questionnaire, pulmonary function tests, and echocardiography. RESULTS Data were collected on 78 patients (82% females; 59% with diffuse SSc). Inflammatory idiopathic myopathy was the most frequent concomitant overlap disease (41%). The time since Raynaud's phenomenon and SSc onset were 8.8 ± 18 and 6.2 ± 6.7 years respectively. The most frequent IVIG indication was myositis (38/78), followed by gastrointestinal (27/78) and cutaneous (17/78) involvement. The median number of cycles given were 5. 54, 53 and 9 patients have been treated previously with glucocorticoids, synthetic disease-modifying antirheumatic drugs and biologic therapies respectively. After IVIG use we found significant improvements in muscular involvement (MRC ≥ 3/5 92% IVIG, p = 0.001 and CK levels from 1149 ± 2026 UI to 217 ± 224 UI, p = 0.02), mRSS (15 ± 12.4 to 13 ± 12.5, p = 0.015) and improvement in total score of UCLA GIT 2.0 (p = 0.05). None Anti-RNA polymerase III patients showed an adequate response in gastrointestinal involvement (0/7) in comparison with other antibodies (0 vs. 25, p = 0,039). Cardiorespiratory involvement remained stable. A total of 12 adverse events were reported with only one withdrawn due to serious adverse effect. CONCLUSIONS this study suggest that IVIG may improve myositis, gastrointestinal and skin involvement in SSc patients treated in routine care and seems to have a good safety profile.
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Affiliation(s)
- J Tandaipan
- Department of Rheumatology and Systemic Autoinmune Diseases, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A Guillén-Del-Castillo
- Unit of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - C P Simeón-Aznar
- Unit of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - P E Carreira
- Department of Rheumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - C De la Puente
- Department of Rheumatology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - J Narváez
- Department of Rheumatology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - J Lluch
- Department of Rheumatology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - M Rubio-Rivas
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - J J Alegre-Sancho
- Department of Rheumatology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - G Bonilla
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
| | - C Moriano
- Department of Rheumatology, Complejo Asistencial Universitario de León, León, Spain
| | - I Casafont-Sole
- Department of Rheumatology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - R García-Vicuña
- Department of Rheumatology, Hospital Universitario de La Princesa, Madrid, Spain
| | - V Ortiz-Santamaría
- Department of Rheumatology, Hospital General de Granollers, Granollers, Spain
| | - E Riera
- Department of Rheumatology, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - B Atienza-Mateo
- Department of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - R Blanco
- Department of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - C Galisteo
- Department of Rheumatology, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J J Gonzalez-Martin
- Department of Rheumatology, Hospital Universitario HM San Chinarro, Madrid, Spain
| | - J M Pego-Reigosa
- Department of Rheumatology, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute (IISGS), Vigo, Spain
| | - A Pros
- Department of Rheumatology, Hospital del Mar, Barcelona, Spain
| | - S Heredia
- Department of Rheumatology, Hospital Sant Joan Despí Moisès Broggi, Sant Joan Despí, Spain
| | - I Castellví
- Department of Rheumatology and Systemic Autoinmune Diseases, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Medicine, Universitat Autonoma de Barcelona, Spain.
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Speca S, Farhat MM, Jendoubi M, Guerrier T, Sanges S, Staumont-Sallé D, Hachulla E, Dubucquoi S, Sobanski V, Collet A, Launay D. Intravenous immunoglobulins improve skin fibrosis in experimental models of systemic sclerosis. Sci Rep 2023; 13:15102. [PMID: 37700078 PMCID: PMC10497569 DOI: 10.1038/s41598-023-42464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/11/2023] [Indexed: 09/14/2023] Open
Abstract
Systemic sclerosis (SSc) is the most severe systemic autoimmune disease with currently no cure. Intravenous immunoglobulins (IVIg) are an attractive candidate in this disease to counteract inflammation and fibrosis but data are scarce and conflicting. This study, assessed the effects of IVIg in a murine HOCl-induced model of SSc. We showed that IVIg prevented skin inflammation and fibrosis, by mitigating the immune cell infiltration (p = 0.04), proinflammatory cytokines gene overexpression (IL1β, p = 0.04; TNFα, p = 0.04; IL6, p = 0.05), skin and dermal thickening (p = 0.003 at d21 and p = 0.0003 at d42), the expression markers of fibrosis, such as αSMA (p = 0.031 for mRNA and p = 0.05 for protein), collagen (p = 0.05 for mRNA and p = 0.04 for protein, p = 0.05 for the hydroxyproline content) and fibronectin (p = 0.033 for mRNA). Moreover, IVIg prevented HOCl-induced alterations in splenic cell homeostasis. When administered in curative mode, despite their ability to reduce skin and dermal thickness (p < 0.0001 and p = 0.0002), IVIg showed partial or more mixed effects on skin inflammation and established fibrosis. These data favor further clinical trials in SSc patients on the potential efficiency of early and/or repeated IVIg administration.
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Affiliation(s)
- Silvia Speca
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Meryem-Maud Farhat
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Manel Jendoubi
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Thomas Guerrier
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Sébastien Sanges
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Delphine Staumont-Sallé
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Service de Dermatologie, CHU Lille, Lille, France
| | - Eric Hachulla
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Sylvain Dubucquoi
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Institut d'Immunologie, Centre de Biologie Pathologie, CHU Lille, Lille, France
| | - Vincent Sobanski
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Aurore Collet
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Institut d'Immunologie, Centre de Biologie Pathologie, CHU Lille, Lille, France
| | - David Launay
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France.
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France.
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Matsuda KM, Yoshizaki A, Kuzumi A, Toyama S, Awaji K, Miyake T, Sato S. Rapid improvement of systemic sclerosis-associated intestinal pseudo-obstruction with intravenous immunoglobulin administration. Rheumatology (Oxford) 2023; 62:3139-3145. [PMID: 36825818 PMCID: PMC10473276 DOI: 10.1093/rheumatology/kead093] [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: 01/04/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES SSc is an autoimmune disease characterized by excessive fibrosis in multiple organs, including the gastrointestinal (GI) tract. GI symptoms of SSc such as intestinal pseudo-obstruction (IPO) are often refractory to conventional intervention and can result in longer in-hospital stay or even increased mortality. We aimed to summarize the insights to date regarding the efficacy of IVIG against GI symptoms of SSc to unveil what we should focus on in future studies. METHODS Herein we report the response of GI symptoms in three cases with SSc-myositis overlap who received IVIG administration. We also conducted a systematic literature review to summarize previous reports regarding the efficacy of IVIG upon the GI manifestations of SSc, according to the PRISMA 2020 guideline. RESULTS The case series demonstrated remarkable and rapid improvement of GI symptoms, including IPO, after IVIG administration. The literature review revealed that previous reports also support the efficacy and safety of IVIG against GI manifestations of SSc. However, they were all retrospective studies and lacking description of the short-term outcome after IVIG administration with objective and quantitative metrics. CONCLUSION IVIG seems to be a promising therapeutic option for the management of GI symptoms in SSc, including IPO. Investigators should focus more on short-term outcomes to properly assess the therapeutic benefit of IVIG, ideally using reliable quantitative measures in a multicentre randomized placebo-controlled setting.
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Affiliation(s)
- Kazuki M Matsuda
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ai Kuzumi
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Toyama
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kentaro Awaji
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tomomi Miyake
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Cacciapaglia F, Stano S, Fornaro M, Iannone F. Subcutaneous immunoglobulin therapy for refractory skin thickening in rapidly progressive systemic sclerosis: A case report and literature review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:101-106. [PMID: 37287951 PMCID: PMC10242697 DOI: 10.1177/23971983221124180] [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: 07/11/2022] [Accepted: 08/17/2022] [Indexed: 06/04/2024]
Abstract
The use of immunoglobulin is a therapeutic option with increasing evidence of efficacy for different rheumatologic autoimmune systemic diseases. Some studies concerning immunoglobulin use in systemic sclerosis have been published with encouraging results. We present the case of a young woman diagnosed with rapidly progressive diffuse cutaneous systemic sclerosis, refractory to therapy with methotrexate and rituximab, which presented a relevant skin improvement after one year of subcutaneous immunoglobulin (2 g/kg cumulative monthly dose, refracted in weekly administrations). Furthermore, a narrative literature review of the evidence for alternative treatments with a focus on immunoglobulin use for systemic sclerosis skin involvement was carried out.
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Affiliation(s)
- Fabio Cacciapaglia
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Stefano Stano
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Marco Fornaro
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Transplantation of Organs (DETO), University of Bari Aldo Moro, Bari, Italy
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Velikova T, Sekulovski M, Bogdanova S, Vasilev G, Peshevska-Sekulovska M, Miteva D, Georgiev T. Intravenous Immunoglobulins as Immunomodulators in Autoimmune Diseases and Reproductive Medicine. Antibodies (Basel) 2023; 12:antib12010020. [PMID: 36975367 PMCID: PMC10045256 DOI: 10.3390/antib12010020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Intravenous administration of immunoglobulins has been routinely used for more than 60 years in clinical practice, developed initially as replacement therapy in immunodeficiency disorders. Today, the use of intravenous immunoglobulins (IVIGs) is embedded in the modern algorithms for the management of a few diseases, while in most cases, their application is off-label and thus different from their registered therapeutic indications according to the summary of product characteristics. In this review, we present the state-of-the-art use of IVIGs in various autoimmune conditions and immune-mediated disorders associated with reproductive failure, as approved therapy, based on indications or off-label. IVIGs are often an alternative to other treatments, and the administration of IVIGs continues to expand as data accumulate. Additionally, new insights into the pathophysiology of immune-mediated disorders have been gained. Therefore, the need for immunomodulation has increased, where IVIG therapy represents an option for stimulating, inhibiting and regulating various immune processes.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Correspondence:
| | - Metodija Sekulovski
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Anesthesiology and Intensive Care, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Simona Bogdanova
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
| | - Georgi Vasilev
- Clinic of Neurology, UMHAT “Sv. Georgi”, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
| | - Monika Peshevska-Sekulovska
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Gastroenterology, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Dimitrina Miteva
- Department of Genetics, Faculty of Biology, Sofia University St. Kliment Ohridski, 8 Dragan Tzankov Str., 1164 Sofia, Bulgaria
| | - Tsvetoslav Georgiev
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
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DeMaio A, Hashemi KB, Avery A, Metcalf JS, Winterfield LS. A case of nivolumab-induced scleroderma-like syndrome successfully treated with intravenous immunoglobulin. JAAD Case Rep 2022; 31:76-79. [PMID: 36545488 PMCID: PMC9761324 DOI: 10.1016/j.jdcr.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alexa DeMaio
- Medical University of South Carolina, School of Medicine, Charleston, South Carolina
| | - Kimberly B. Hashemi
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
| | - Alexandria Avery
- Department of Pathology, Medical University of South Carolina, Charleston, South Carolina
| | - John S. Metcalf
- Department of Pathology, Medical University of South Carolina, Charleston, South Carolina
| | - Laura S. Winterfield
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina,Correspondence to: Laura S. Winterfield, MD, MPH, Department of Dermatology, Medical University of South Carolina, 135 Rutledge Avenue, Floor 11 Charleston, SC 29425.
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Agostini E, De Luca G, Bruni C, Bartoli F, Tofani L, Campochiaro C, Pacini G, Moggi-Pignone A, Guiducci S, Bellando-Randone S, Shoenfeld Y, Dagna L, Matucci-Cerinic M. Intravenous immunoglobulins reduce skin thickness in systemic sclerosis: evidence from Systematic Literature Review and from real life experience. Autoimmun Rev 2021; 20:102981. [PMID: 34718166 DOI: 10.1016/j.autrev.2021.102981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intravenous immunoglobulins (IVIG) are a new therapeutic approach in systemic sclerosis SSc. An immunomodulatory and antifibrotic activity has been postulated. IVIG are generally well tolerated and have only rare side effects. Our retrospective study focused its attention on SSc, an autoimmune connective tissue disease, characterized by several complications which has a significant impact on patient's quality of life. The pathophysiology comprises fibrotic, vascular and immunological aspects. AIM The aim of this study was to verify the effectiveness of IVIG on SSc skin involvement. Moreover, a systematic review of the literature (SLR) of the results obtained to date on the use of Intravenous immunoglobulin (IVIG) in SSc has been also performed. PATIENTS AND METHODS The data of 24 patients (21 women, 3 male) with refractory diffuse SSc skin involvement were evaluated (mean age was 52.13 years). IVIG infusion at a dosage of 2 g/Kg body weight for 4 consecutive days/month, was started between 2002 and 2019. Skin involvement was evaluated with the modified Rodnan Skin Score (mRSS) before therapy and then again after 6 and 12 months. To perform the SLR, the PubMed, Medline, Embase, and Web of Science database were searched from 1990 to 2020 (keywords: IVIG, systemic sclerosis). Three assessors (E.A., C.B. & M.M.C) identified the criteria to scan all papers. RESULTS From the total SLR (106 results), 17 papers were identified after the separation of the clinical cases from the studies (total number of treated patients 183). The studies were classified according to the organ involvement considered in each study, as well as the prescribed dose (high or low doses), and the therapeutic regimens. In the selected papers, the organs mainly involved were the skin, the gastrointestinal, the joint and the cardiovascular systems. Only in one case, plasmapheresis was associated to IVIG. All papers reported significant reduction of the skin involvement, although generally the strength of the works was limited the lack of control cases or by the low number of patients involved. From the real life experience, a statistically significant reduction of mRSS was obtained at 6 months follow-up (average value of -6.61 ± 5.2, p < 0.001), and it was further maintained with a significant stabilization after 12-months (-11.45 ± 9.63, p < 0.002). DISCUSSION This SLR and the data of the retrospective study suggest that IVIG may improve skin involvement reducing mRSS in particular in those patients that were refractory to other standard of care therapies and represents a therapeutic option in patients with concomitant myositis. The literature review revealed encouraging perspectives on the use of this therapy, given the effectiveness found in the selected works.
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Affiliation(s)
- Elana Agostini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Cosimo Bruni
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Bartoli
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Lorenzo Tofani
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Pacini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Alberto Moggi-Pignone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Internal Medicine, AOUC, Florence, Italy
| | - Serena Guiducci
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Silvia Bellando-Randone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Yehuda Shoenfeld
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Saint Petersburg State University, Saint-Petersburg, Russia
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Marco Matucci-Cerinic
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Division of Rheumatology, AOUC, Florence, Italy.
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Torok KS. Updates in Systemic Sclerosis Treatment and Applicability to Pediatric Scleroderma. Rheum Dis Clin North Am 2021; 47:757-780. [PMID: 34635303 DOI: 10.1016/j.rdc.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Juvenile-onset systemic sclerosis (jSSc) is a complex multisystem inflammatory-driven disease of fibrosis, requiring multifaceted treatment including pharmacologic therapy, supportive care, and lifestyle modification. Most regimens are adapted from adult SSc treatment given the rarity of the disease. Landmark trials over the past decade in adult SSc have led to 2 Food and Drug Administration-approved therapies for SSc-associated interstitial lung disease, and several ongoing trials of other biological agents are underway. Resetting the immune system with autologous stem cell transplant to halt this disease earlier in its course, especially in pediatric onset where disease burden can accumulate, is on the horizon.
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Affiliation(s)
- Kathryn S Torok
- Division of Pediatric Rheumatology, UPMC & University of Pittsburgh Scleroderma Center; Pediatric Scleroderma Clinic, University of Pittsburgh |UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA.
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10
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Abstract
Systemic sclerosis (SSc) is a connective tissue disease characterized by progressive fibrosis of the skin and internal organs and has significant clinical sequelae. Management of SSc cutaneous disease remains challenging and often is driven by extracutaneous manifestations. Methotrexate is the typical first-line therapy for patients with early progressive cutaneous disease. However, in patients with diffuse progressive skin disease and inflammatory arthritis, methotrexate or rituximab monotherapy should be considered. First-line therapy for patients with concomitant myositis includes methotrexate or intravenous immunoglobulin (IVIG). For patients with both cutaneous findings and interstitial lung disease, studies have suggested the efficacy of mycophenolate mofetil or rituximab. Second-line therapies, including UVA-1 phototherapy, IVIG, or rituximab, can be considered in patients with disease refractory to first-line treatments. Clinical trials investigating the utility of emerging therapies such as abatacept and tocilizumab in the treatment of SSc are under way, and preliminary results are promising. Nonetheless, all patients with SSc benefit from a gentle skin-care regimen to alleviate pruritis, which is a commonly reported symptom. Additional cutaneous manifestations of SSc include telangiectasias, calcinosis cutis, microstomia, and Raynaud’s phenomenon. Telangiectasia may be managed with camouflage techniques, pulse dye laser, and intense pulse light. Calcinosis cutis therapy is guided by the size of the calcium deposits, although treatment options are limited. Mouth augmentation and oral stretching exercises are recommended for patients with reduced oral aperture. Raynaud’s phenomenon is treated with a combination of lifestyle modification and calcium channel blockers, such as amlodipine. Overall, SSc is a clinically heterogenous disease that affects multiple organ systems. Providers should assess extracutaneous involvement and use evidence-based recommendations to select the most appropriate therapy for patients with SSc.
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Affiliation(s)
- Jane L Zhu
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX, USA
| | - Samantha M Black
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX, USA
| | - Henry W Chen
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX, USA
| | - Heidi T Jacobe
- Department of Dermatology, University of Texas at Southwestern Medical Center, Dallas, TX, USA
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11
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Connolly MK. Systemic sclerosis (scleroderma): remaining challenges. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:438. [PMID: 33842659 PMCID: PMC8033370 DOI: 10.21037/atm-20-5449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite progress in treating internal organ involvement in systemic sclerosis (scleroderma) (SSc), such as pulmonary disease, effective treatments for the hallmark of the disease, cutaneous fibrosis, remain elusive. None of the disease-modifying antirheumatic drugs (DMARDS) have shown proven efficacy for SSc skin fibrosis, and there remain no FDA-approved medications, all of which are off-label, for cutaneous fibrosis in SSc. This review article will briefly summarize conventional therapies, biologics and hematopoietic stem cell transplants and select ongoing clinical trials in SSc. The gold standard for measuring skin fibrosis in SSc is the modified Rodnan skin score (MRSSS). This is a validated test that measures skin thickness (0 to 3) at 17 locations for a total score of 51. Improvements in skin score over time are used in clinical trials to quantitate skin fibrosis. Although recording the Rodnan skin score is technically straightforward, requiring no special equipment, and noninvasive, the fluctuating natural history of the disease includes improvement over time without interventions, rendering meaningful trials difficult to assess. Understanding of the basic molecular mechanisms driving pathologic fibrosis in SSc remains lacking, and underpins the often empiric nature and likely the lack of efficacy of many therapeutics that have been tried. Although repeated skin biopsies might be a more precise way to follow disease progression and regression, this is necessarily invasive and requires special tools. Here, this review will look at conventional therapies, biologics, autologous hematopoietic stem cell transplantation, and catalog some of the ongoing clinical trials in SSc with a focus on cutaneous fibrosis.
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Affiliation(s)
- Mary Karin Connolly
- Department of Dermatology, University of California, San Francisco, San Francisco, CA 94115, USA
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12
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Alhendi FJ, Werth VP, Sollecito TP, Stoopler ET. Systemic sclerosis: Update for oral health care providers. SPECIAL CARE IN DENTISTRY 2021; 40:418-430. [PMID: 33448431 DOI: 10.1111/scd.12492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022]
Abstract
Systemic sclerosis (SSc), also known as scleroderma, is an autoimmune disease of unknown origin characterized by an uncontrolled inflammatory process resulting in fibrosis of the skin, internal organs and vasculopathy. Manifestations of SSc are heterogenous and can include pulmonary, cardiac, neural, renal, muscular, cutaneous and orofacial complications. Recent scientific advances have led to a better understanding of disease etiopathogenesis and the development of a new classification system. Therapeutic management is often multidisciplinary and targeted toward the affected organs. Oral health care providers (OHCPs) should be familiar with SSc, particularly as it relates to its impact on the orofacial region and modifications to delivery of oral health care for patients with this condition.
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Affiliation(s)
- Fatmah J Alhendi
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Dermatology, Philadelphia V.A. Hospital, Hospital of the University of Pennsylvania and the Veteran's Administration Medical Center, Philadelphia, Pennsylvania
| | - Thomas P Sollecito
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
| | - Eric T Stoopler
- Department of Oral Medicine, Penn Dental Medicine, Philadelphia, Pennsylvania
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13
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Fallet B, Walker UA. Current immunosuppressive and antifibrotic therapies of systemic sclerosis and emerging therapeutic strategies. Expert Rev Clin Pharmacol 2020; 13:1203-1218. [PMID: 33008265 DOI: 10.1080/17512433.2020.1832466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare, difficult to treat disease with profound effects on quality of life and high mortality. Complex and incompletely understood pathophysiologic processes and greatly heterogeneous clinical presentations and outcomes have hampered drug development. AREAS COVERED This review summarizes the currently available immunosuppressive and antifibrotic therapies and discusses novel approaches for the treatment of SSc. We reviewed the literature using the MEDLINE and ClinicalTrial.gov databases between May and September 2020. EXPERT OPINION Available immunosuppressive and antifibrotic drugs only modestly impact the course of the disease. Most drugs are currently only investigated in the subset of patients with early diffuse cutaneous SSc. In this patient population, hematopoietic stem-cell transplantation is currently the only treatment that has demonstrated reversal of lung involvement, enhanced quality of life and reduced long-term mortality, but carries the risk of short-term treatment-related mortality. A great need to provide better therapeutic options to patients exists also for those patients who have limited cutaneous skin involvement. A better understanding of SSc pathophysiology has enabled the identification of numerous new therapeutic targets. The progress made in the design of clinical trials and outcome parameters will likely result in the improvement of effective management options.
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Affiliation(s)
- Bénédict Fallet
- Department of Rheumatology, University Hospital Basel , Basel, Switzerland
| | - Ulrich A Walker
- Department of Rheumatology, University Hospital Basel , Basel, Switzerland
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14
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Ghouri YA, Tahan V, Shen B. Secondary causes of inflammatory bowel diseases. World J Gastroenterol 2020; 26:3998-4017. [PMID: 32821067 PMCID: PMC7403802 DOI: 10.3748/wjg.v26.i28.3998] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/15/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), conventionally consist of Crohn’s disease (CD) and ulcerative colitis. They occur in individuals with high risk genotype for the disease in the setting of appropriate environmental factors. The pathogenesis of IBD involves a dysregulated autoimmune response to gut dysbiosis, which in turn is triggered due to exposure to various inciting environmental factors. But there is no clearly defined etiology of IBD and this type of disease is termed as “idiopathic IBD”, “classic IBD”, or “primary IBD”. We reviewed the current medical literature and found that certain etiological factors may be responsible for the development of IBD or IBD-like conditions, and we consider this form of de novo IBD as “secondary IBD”. Currently known factors that are potentially responsible for giving rise to secondary IBD are medications; bowel altering surgeries and transplantation of organs, stem cells or fecal microbiome. Medications associated with the development of secondary IBD include; immunomodulators, anti-tumor necrosis factor alpha agents, anti-interleukin agents, interferons, immune stimulating agents and checkpoint inhibitors. Colectomy can in some cases give rise to de novo CD, pouchitis of the ileal pouch, or postcolectomy enteritis syndrome. After solid organ transplantation or hematopoietic stem cell transplantation, the recipient may develop de novo IBD or IBD flare. Fecal microbiota transplantation has been widely used to treat patients suffering from recurrent Clostridium difficile infection but can also causes IBD flares.
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Affiliation(s)
- Yezaz A Ghouri
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Missouri- School of Medicine, Columbia, MO 65201, United States
| | - Veysel Tahan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Missouri- School of Medicine, Columbia, MO 65201, United States
| | - Bo Shen
- Department of Medicine and Surgery, Interventional IBD Center, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY 10032, United States
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15
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Perković D, Petrić M, Božić I, Borić K, Marasović Krstulović D, Radić M, Martinović Kaliterna D. Low dose intravenous immunoglobulin in addition to cyclophosphamide in systemic sclerosis : Single centre experience. Wien Klin Wochenschr 2020; 133:1070-1075. [PMID: 32451820 DOI: 10.1007/s00508-020-01669-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/29/2020] [Indexed: 11/26/2022]
Abstract
AIM Systemic sclerosis (SSc) is a rare chronic disease characterized by pathologic collagen deposits in the skin and internal organs. Although it is considered to be an autoimmune disease, immunosuppressants have a limited effect on severe SSc. Intravenous immunoglobulins (IVIG) have shown favorable effects in patients with SSc by suppressing the action of profibrotic cytokines, so they could have additional effect on standard treatment such as cyclophosphamide (CYC). This article presents the immunomodulatory effect of low-dose IVIG in addition to CYC in the treatment of severe SSc in this center during the last 9 years. METHODS This retrospective observational study analyzed the medical documentation of nine patients with SSc treated with low-dose IVIG (0.4 g/kg and month) together with intravenous CYC (600 mg/m2 and month). The therapeutic effect on lung and skin manifestations was assessed. RESULTS Of the patients one had interstitial lung diseases (ILD), two had progressive skin diseases, and six had a combination of skin and lung involvement. The best results were achieved in skin changes, where complete healing of digital ulcers (DU) was recorded in every reported case. A decrease in the modified Rodnan skin score (mRSS) was noted in three patients and increased diffusion capacity of the lungs for carbon monoxide in another three patients. CONCLUSION The results of the study suggest that IVIG may be an additional treatment option together with CYC for patients for whom other therapies have failed, but further studies on the exact role of IVIG in the treatment of severe SSc are required.
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Affiliation(s)
- Dijana Perković
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Marin Petrić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia.
| | - Ivona Božić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Katarina Borić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Daniela Marasović Krstulović
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Mislav Radić
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
| | - Dušanka Martinović Kaliterna
- Department of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital of Split, Šoltanska 1, 21000, Split, Croatia
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16
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Abstract
PURPOSE OF REVIEW This review provides a risk-stratified and evidence-based management for subsets of systemic sclerosis (SSc) patients in the first five years from disease onset. RECENT FINDINGS Cardiopulmonary disease remains the primary cause of mortality in SSc patients. Morbidity and mortality in SSc-associated pulmonary arterial hypertension have improved with combination treatment, in either an upfront or sequential treatment pattern. Traditional therapies for interstitial lung disease (SSc-ILD) have targeted those with clinically significant and progressive ILD with immunosuppression. New data suggest a possible paradigm shift, introducing immunosuppressive therapy to patients before they develop clinically significant or progressive ILD. The year 2019 saw the approval of the first FDA-approved therapy for SSc-associated interstitial lung disease, using an antifibrotic agent previously approved for idiopathic pulmonary fibrosis. To date, only autologous hematopoietic stem cell transplant has demonstrated a mortality benefit for SSc-ILD, albeit in a narrow spectrum of SSc-ILD patients. SUMMARY SSc is a highly heterogeneous autoimmune disease typified by varying clinical trajectories. Its management may be stratified within the first five years by subclassifying patients based on factors that have important prognostic significance: skin distribution and autoantibody status.
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Affiliation(s)
- David Roofeh
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
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17
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Corticosteroid-sparing benefit of intravenous immunoglobulin in systemic sclerosis-associated myopathy: A comparative study in 52 patients. Autoimmun Rev 2020; 19:102431. [DOI: 10.1016/j.autrev.2019.102431] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 11/22/2022]
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18
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Gomes JP, Santos L, Shoenfeld Y. Intravenous immunoglobulin (IVIG) in the vanguard therapy of Systemic Sclerosis. Clin Immunol 2018; 199:25-28. [PMID: 30543921 DOI: 10.1016/j.clim.2018.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Systemic Sclerosis (SSc) is a rare autoimmune disease that is characterized by a progressive skin fibrosis, an obliteration of the microvasculature and an exaggerated extracellular matrix deposition, which lead to a multisystemic dysfunction. Various pathogenetic mechanisms were described. The lack of a successful therapy make SSc a disease with a poor prognosis. The intravenous immunoglobulin (IVIG) has been used for a long time in different autoimmune diseases, and firstly used in SSc patients in 2000. IVIG has multiple non-specific mechanisms of action and, beyond an impressive improvement in muscle symptoms, a French nationwide cohort demonstrated that IVIG ameliorates the skin disease and systemic inflammation, and helps the daily dose corticosteroid's tapering at the end of the treatment. The benefits on gastrointestinal symptoms of IVIG was reported by a recent English article, in which the patients consistently reported a decrease in the gastro-esophageal reflux disease symptoms and their frequencies. The impact on the lung involvement still remains unclear. One of the advantages of IVIG is its safe profile. Few adverse effects were reported and most of them are mild, and can be managed and usually they do not relapse. Harmful effects were described, but they can be avoid with cautious and judicious use of this therapy.
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Affiliation(s)
- João Pedro Gomes
- Zabludowicz Center for Autoimmune Disease, Sheba Medical Center, Tel Hashomer, Israel; Department A of Internal Medicine, Hospital and University Centre of Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal.
| | - Lèlita Santos
- Department A of Internal Medicine, Hospital and University Centre of Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal.
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Zabludowicz Center for Autoimmune Disease, Sheba Medical Center, Tel Hashomer, Israel.
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19
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Raine C, Canning B, Marks J, Donnelly S, Ong V, Tahir H. Severe gangrene in a patient with anti-RNP positive limited cutaneous systemic sclerosis/rheumatoid arthritis overlap syndrome caused by vasculopathy and vasculitis. Eur J Rheumatol 2018; 5:269-271. [PMID: 30071937 PMCID: PMC6267747 DOI: 10.5152/eurjrheum.2018.17177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/08/2018] [Indexed: 11/28/2022] Open
Abstract
In this paper, we describe a case of a male patient with anti-U1RNP positive limited cutaneous systemic sclerosis/rheumatoid arthritis overlap syndrome, who presented acutely with rapidly progressive digital ischemia, which lead to extensive gangrene. Management with conventional vasodilator therapy was unsuccessful. There were constitutional symptoms and a marked inflammatory response in the absence of evidence of infection, implying a component of vasculitis underlying the presentation. Treatment with immunosuppression and intravenous immunoglobulin led to resolution of the inflammatory process with no further progression of tissue necrosis. Here we discuss pertinent issues raised by the case, including the management of digital ischemia and gangrene in this context and the relevance of the anti-U1RNP in systemic sclerosis overlap syndromes.
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Affiliation(s)
- Charles Raine
- Department of Rheumatology, Royal Free Hospital, London, UK
| | - Benjamin Canning
- Department of Rheumatology, Whipps Cross University Hospital, London, UK
| | - Jonathan Marks
- Department of Rheumatology, Royal Free Hospital, London, UK
| | - Simon Donnelly
- Department of Rheumatology, Whipps Cross University Hospital, London, UK
| | - Voon Ong
- Department of Rheumatology, Royal Free Hospital, London, UK
| | - Hasan Tahir
- Department of Rheumatology, Whipps Cross University Hospital, London, UK
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20
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Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
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Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
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21
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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22
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Harris ES, Meiselman HJ, Moriarty PM, Metzger A, Malkovsky M. Therapeutic plasma exchange for the treatment of systemic sclerosis: A comprehensive review and analysis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:132-152. [PMID: 35382237 PMCID: PMC8892860 DOI: 10.1177/2397198318758606] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/03/2018] [Indexed: 01/30/2023]
Abstract
Background Therapeutic plasma exchange has been tried as a treatment approach for systemic sclerosis since 1978 based on the rationale that some circulating factor is involved in disease pathogenesis, for example, autoantibodies or immune complexes, and that removing the potential pathogenic factors could lead to symptom improvement. Based on our impression that clinicians and researchers are largely unaware that a large volume of research has been published about the use of therapeutic plasma exchange as a treatment for systemic sclerosis, we conducted a comprehensive review and analysis of all published research on this topic. Results We identified 46 relevant articles that met our search criteria, involving a total of 572 patients. Of these, 19 were case studies; the rest ranged from small observational studies to prospective randomized clinical trials. In all but two studies, most patients receiving therapeutic plasma exchange showed improvements in both clinical symptoms and laboratory markers, including significant improvement in Raynaud's symptoms and healing of digital ulceration after three to four weekly treatments. The beneficial effects from even a short course of therapeutic plasma exchange treatments were long-lasting, typically 6 months or longer. Therapeutic plasma exchange was very well tolerated. Adverse events were rare and, in almost all cases, mild and transitory. Conclusion These results suggest that long-term therapeutic plasma exchange may offer a low-risk way to control and in some cases reverse systemic sclerosis symptoms. The mechanism for the clinical improvements seen from therapeutic plasma exchange in systemic sclerosis patients is unclear. Therefore, additional studies of therapeutic plasma exchange effects in systemic sclerosis appear to be highly desirable.
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Affiliation(s)
- Edward S Harris
- Department of Medicine, University of
Wisconsin, Madison, WI, USA
| | - Herbert J Meiselman
- Department of Physiology &
Biophysics, Keck School of Medicine, University of Southern California, Los Angeles,
CA, USA
| | - Patrick M Moriarty
- Division of Clinical Pharmacology,
University of Kansas Medical Center, Lawrence, KS, USA
| | | | - Miroslav Malkovsky
- Department of Medical Microbiology and
Immunology, University of Wisconsin, Madison, WI, USA
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23
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Forbat E, Ali FR, Al-Niaimi F. Intravenous immunoglobulins in dermatology. Part 2: clinical indications and outcomes. Clin Exp Dermatol 2018; 43:659-666. [PMID: 29774587 DOI: 10.1111/ced.13552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/29/2022]
Abstract
Intravenous immunoglobulin (IVIg) is a solution of human IgG, salt, sugars and solvents used to treat a multitude of diseases. Although IVIg has been known to treat many diseases safely and successfully, there are relatively few supporting randomized controlled trials. In part two of this review, we assess the clinical indications of IVIg in dermatological disorders and the outcomes of its use.
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Affiliation(s)
- E Forbat
- Chelsea and Westminster Hospital, London, UK
| | - F R Ali
- Dermatological Surgery and Laser Unit, St John's Institute of Dermatology, Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | - F Al-Niaimi
- Dermatological Surgery and Laser Unit, St John's Institute of Dermatology, Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
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24
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Furue M, Mitoma C, Mitoma H, Tsuji G, Chiba T, Nakahara T, Uchi H, Kadono T. Pathogenesis of systemic sclerosis-current concept and emerging treatments. Immunol Res 2018; 65:790-797. [PMID: 28488090 DOI: 10.1007/s12026-017-8926-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Systemic sclerosis (SSc) is an intractable multifaceted disease with high mortality. Although its pathogenesis is not fully understood, recent studies have advanced our knowledge on SSc. The cardinal pathological features of SSc are autoimmunity, vasculopathy, and fibrosis. The B cells in SSc are constitutively activated and lead to the production of a plethora of autoantibodies, such as anti-topoisomerase I and anti-centromere antibodies. In addition to these autoantibodies, which are valuable for diagnostic criteria or biomarkers, many other autoantibodies targeting endothelial cells, including endothelin type A receptor and angiotensin II type I receptor, are known to be functional and induce activation or apoptosis of endothelial cells. The autoantibody-mediated endothelial cell perturbation facilitates inflammatory cell infiltration, cytokine production, and myofibroblastic transformation of fibroblasts and endothelial cells. Profibrotic cytokines, such as transforming growth factor β, connective tissue growth factor, interleukin 4/interleukin 13, and interleukin 6, play a pivotal role in collagen production from myofibroblasts. Specific treatments targeting these causative molecules may improve the clinical outcomes of patients with SSc. In this review, we summarize recent topics on the pathogenesis (autoantibodies, vasculopathy, and fibrosis), animal models, and emerging treatments for SSc.
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Affiliation(s)
- Masutaka Furue
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan. .,Research and Clinical Center for Yusho and Dioxin, Kyushu University, Fukuoka, Japan. .,Division of Skin Surface Sensing, Department of Dermatology, Kyushu University, Fukuoka, Japan.
| | - Chikage Mitoma
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan.,Research and Clinical Center for Yusho and Dioxin, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Clinical Immunology and Rheumatology/Infectious Disease, Kyushu University, Fukuoka, Japan
| | - Gaku Tsuji
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan.,Research and Clinical Center for Yusho and Dioxin, Kyushu University, Fukuoka, Japan
| | - Takahito Chiba
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan
| | - Takeshi Nakahara
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan.,Division of Skin Surface Sensing, Department of Dermatology, Kyushu University, Fukuoka, Japan
| | - Hiroshi Uchi
- Department of Dermatology, Kyushu University, Maidashi 3-1-1, Higashiku, Fukuoka, 812-8582, Japan
| | - Takafumi Kadono
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
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Pearson DR, Werth VP, Pappas-Taffer L. Systemic sclerosis: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:459-474. [PMID: 30047430 DOI: 10.1016/j.clindermatol.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.
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Affiliation(s)
- David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Miller JB, Paik JJ. Overlap Syndromes in Inflammatory Myopathies. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0074-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
BACKGROUND Intravenously administered immunoglobulins have multiple modes of action that are anti-inflammatory. They can therefore be beneficial in a number of autoimmune disorders. OBJECTIVE The aim of this article is to analyze and summarize studies on the administration of intravenous immunoglobulins in rheumatological diseases. METHODS A selective search and analysis of the literature was carried out related to the mode of action and efficacy of intravenous immunoglobulins in rheumatological diseases. RESULTS AND CONCLUSION Intravenous immunoglobulins have a broad mode of action and can therefore be beneficial in almost all autoimmune diseases. Conditions in which they are of special benefit include immunothrombopenia (ITP), Kawasaki disease and idiopathic inflammatory myopathies. In rare situations, they may also be indicated in systemic lupus erythematosus (SLE), Sjögren's syndrome and neuropathies, catastrophic antiphospholipid syndrome (APS), scleroderma, antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, pyoderma gangrenosum and scleromyxedema. Severe adverse events are rare. In view of the high costs of the therapy, intravenous immunoglobulins are mostly applied in emergency situations, as salvage therapy when other standard therapies have failed or when severe infections are a contraindication to the administration of immunosuppressants.
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Affiliation(s)
- T Witte
- Klinik für Immunologie und Rheumatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Kumar S, Singh J, Rattan S, DiMarino AJ, Cohen S, Jimenez SA. Review article: pathogenesis and clinical manifestations of gastrointestinal involvement in systemic sclerosis. Aliment Pharmacol Ther 2017; 45:883-898. [PMID: 28185291 PMCID: PMC5576448 DOI: 10.1111/apt.13963] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/18/2016] [Accepted: 01/11/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastrointestinal tract (GIT) involvement is a common cause of debilitating symptoms in patients with systemic sclerosis (SSc). There are no disease modifying therapies for this condition and the treatment remains symptomatic, largely owing to the lack of a clear understanding of its pathogenesis. AIMS To investigate novel aspects of the pathogenesis of gastrointestinal involvement in SSc. To summarise existing knowledge regarding the cardinal clinical gastrointestinal manifestations of SSc and its pathogenesis, emphasising recent investigations that may be valuable in identifying potentially novel therapeutic targets. METHODS Electronic (PubMed/Medline) and manual Google search. RESULTS The GIT is the most common internal organ involved in SSc. Any part of the GIT from the mouth to the anus can be affected. There is substantial variability in clinical manifestations and disease course and symptoms are nonspecific and overlapping for a particular anatomical site. Gastrointestinal involvement can occur in the absence of cutaneous disease. Up to 8% of SSc patients develop severe GIT symptoms. This subset of patients display increased mortality with only 15% survival at 9 years. Dysmotiity of the GIT causes the majority of symptoms. Recent investigations have identified a novel mechanism in the pathogenesis of GIT dysmotility mediated by functional anti-muscarinic receptor autoantibodies. CONCLUSIONS Despite extensive investigation, the pathogenesis of gastrointestinal involvement in systemic sclerosis remains elusive. Although treatment currently remains symptomatic, an improved understanding of novel pathogenic mechanisms may allow the development of potentially highly effective approaches including intravenous immunoglobulin and microRNA based therapeutic interventions.
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Affiliation(s)
- Sumit Kumar
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Jagmohan Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Anthony J DiMarino
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sidney Cohen
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sergio A. Jimenez
- Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
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Quillinan N, Clark KEN, Youl B, Vernes J, McIntosh D, Haq S, Denton CP. Multiplex serum protein analysis reveals potential mechanisms and markers of response to hyperimmune caprine serum in systemic sclerosis. Arthritis Res Ther 2017; 19:45. [PMID: 28270187 PMCID: PMC5341430 DOI: 10.1186/s13075-017-1252-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/01/2017] [Indexed: 11/30/2022] Open
Abstract
Background Hyperimmune caprine serum (HICS) is a novel biological therapy with potential benefit for skin in established diffuse cutaneous systemic sclerosis. Here we report multiplex protein analysis of blood samples from a placebo-controlled phase II clinical trial and explore mechanisms of action and markers of response. Methods Patients were treated with HICS (n = 10) or placebo (n = 10) over 26 weeks, with follow-up open-label treatment to 52 weeks in 14 patients. Serum or plasma samples at baseline, 26 and 52 weeks were analysed using multiplex or individual immunoassays for 41 proteins. Patterns of change were analysed by clustering using Netwalker 1.0, Pearson coefficient and significance analysis of microarrays (SAM) correction. Results Cluster analysis, SAM multiplex testing and paired comparison of individual analytes identified proteins that were upregulated or downregulated during treatment with HICS. There was upregulation of the hypothalamo-pituitary-adrenal axis after HICS treatment evidenced by increases in α-MSH and ACTH in cases treated with HICS. Interestingly, significant increase in PIIINP was associated with HICS treatment and improved MRSS suggesting that this may be a marker of extracellular matrix turnover. Other relevant factors reduced in HICS-treated patients compared with controls, although not reaching statistical significance included COMP, CCL2, IL6, TIMP2, Fractalkine and TGFβ1 levels. Conclusions Our results suggest mechanisms of action for HICS, including upregulation of α-MSH, that has been shown to be anti-fibrotic in preclinical models, and possible markers to be included in future trials targeting skin in diffuse cutaneous systemic sclerosis. Trial registration Eudract, No. 2007-003122-24. ClinTrials.gov, No. NCT00769028. Registered 7 October 2008. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1252-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Niamh Quillinan
- Centre for Rheumatology, UCL Division of Medicine, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Kristina E N Clark
- Centre for Rheumatology, UCL Division of Medicine, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Bryan Youl
- Department of Neurophysiology, Royal Free London NHS Foundation Trust, London, UK
| | | | | | | | - Christopher P Denton
- Centre for Rheumatology, UCL Division of Medicine, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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Sanges S, Rivière S, Mekinian A, Martin T, Le Quellec A, Chatelus E, Lescoat A, Jego P, Cazalets C, Quéméneur T, Le Gouellec N, Senet P, Francès C, Deroux A, Imbert B, Fain O, Boukari L, Sené T, Deligny C, Mathian A, Agard C, Pugnet G, Speca S, Dubucquoi S, Hatron PY, Hachulla É, Launay D. Intravenous immunoglobulins in systemic sclerosis: Data from a French nationwide cohort of 46 patients and review of the literature. Autoimmun Rev 2017; 16:377-384. [PMID: 28232167 DOI: 10.1016/j.autrev.2017.02.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/26/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND As intravenous immunoglobulins (IVIG) exhibit immunomodulatory and antifibrotic properties, they may be a relevant treatment for systemic sclerosis (SSc). The objectives of this work were thus to report on the efficacy and safety of IVIG in a population of SSc patients and to review the available literature. METHODS 46 patients from 19 French centers were retrospectively recruited. They were included if they had a diagnosis of SSc and received at least 1 IVIG infusion at a dosage >1g/kg/cycle. Relevant data collected at IVIG discontinuation were compared to those collected at IVIG initiation. A comprehensive literature review was performed. RESULTS We observed a significant improvement of muscle pain (74% vs. 20%, p<0.0001), muscle weakness (45% vs. 21%, p=0.01), joint pain (44% vs. 19%, p=0.02), CK levels (1069±1552UI vs. 288±449UI, p<0.0001) and CRP levels (13.1±17.6mg/L vs. 9.2±16.6mg/L, p=0.001). We also noted a trend for an improvement of gastro-esophageal reflux disease (68% vs. 53%, p=0.06) and bowel symptoms (42% vs. 27%, p=0.06). Skin and cardiorespiratory involvements remained stable. Finally, corticosteroid daily dose was significantly lower by the end of treatment (13.0±11.6mg/day vs. 8.9±10.4mg/day, p=0.01). Only two severe adverse events were reported (one case of deep vein thrombosis and one case of diffuse edematous syndrome). CONCLUSION Our work suggests that IVIG are a safe therapeutic option that may be effective in improving musculoskeletal involvement, systemic inflammation, digestive tract symptoms and could be corticosteroid sparing.
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Affiliation(s)
- Sébastien Sanges
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - Sébastien Rivière
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Arsène Mekinian
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Thierry Martin
- Service d'Immunologie Clinique, Hôpitaux universitaires de Strasbourg, UPR CNRS 3572, Strasbourg, France
| | - Alain Le Quellec
- Service de Médecine Interne et Maladies Multi-Organiques de l'Adulte, Hôpital Saint-Éloi, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Emmanuel Chatelus
- Hôpitaux Universitaires de Strasbourg, CHU Hautepierre, Service de Rhumatologie, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg, INSERM UMR 1109, Strasbourg, France
| | - Alain Lescoat
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Patrick Jego
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Claire Cazalets
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Thomas Quéméneur
- Service de Médecine Interne, Néphrologie et Médecine Vasculaire, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Noémie Le Gouellec
- Service de Médecine Interne, Néphrologie et Médecine Vasculaire, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Patricia Senet
- Service de Dermatologie, Hôpital Tenon, AP-HP, UPMC, Paris, France
| | - Camille Francès
- Service de Dermatologie, Hôpital Tenon, AP-HP, UPMC, Paris, France
| | - Alban Deroux
- Service de Médecine Interne, Université Grenoble Alpes, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Bernard Imbert
- Service de Médecine Interne, Université Grenoble Alpes, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Olivier Fain
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne, Paris, France; UPMC Université Paris 06, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Latifatou Boukari
- Service de Médecine Interne, Hôpital Jean-Verdier, AP-HP, Université Paris-13, Bondy, France
| | - Thomas Sené
- Service de Médecine Interne et Rhumatologie, GH Diaconesses Croix Saint Simon, Paris, France
| | - Christophe Deligny
- Service de Médecine Interne et Rhumatologie 3C/5D, Centre Hospitalier Universitaire Pierre Zobda-Quitman, Fort-de-France, Martinique
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National pour le Lupus et le Syndrome des Antiphospholipides, institut E3M, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Sorbonne universités, UPMC université Paris 06, 75013 Paris, France
| | - Christian Agard
- Service de Médecine interne, Hôtel-Dieu, CHU de Nantes, Université de Nantes, Nantes, France
| | - Grégory Pugnet
- CHU, Université de Toulouse, Faculté de Médecine, Service de Médecine Interne, Toulouse, France; INSERM, UMR 1027, Toulouse, France
| | - Silvia Speca
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France
| | - Sylvain Dubucquoi
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France
| | - Pierre-Yves Hatron
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - Éric Hachulla
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET)
| | - David Launay
- Univ. Lille, INSERM U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France; INSERM, U995, F-59000 Lille, France; CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France; Centre National de Référence Maladies Systémiques et Auto-immunes Rares (Sclérodermie Systémique), F-59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET).
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Shoenfeld Y, Zandman-Goddard G, Levy Y. Comment on published article in Lupus: Autoimmune myelofibrosis with pancytopenia as a presenting manifestation of systemic lupus erythematosus responsive to mycophenolate mofetil; IVIG in myelofibrosis in SLE. Lupus 2017; 26:224. [DOI: 10.1177/0961203316662725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Y Shoenfeld
- Chaim Sheba Medical Center, Zabludowicz Center for Autoimmune Diseases, Tel-Hashomer, Israel
| | | | - Y Levy
- Meir Medical Center – Internal Medicine W, Kfar-Saba, Israel
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Yanaba K. Strategy for treatment of fibrosis in systemic sclerosis: Present and future. J Dermatol 2017; 43:46-55. [PMID: 26782006 DOI: 10.1111/1346-8138.13026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/06/2015] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis (SSc) is a generalized connective tissue disorder characterized by microvascular damage, autoimmunity, and excessive fibrosis of the skin and various internal organs. Regardless of the recent progress in medicine, no radical therapy for SSc has been developed, and the risk of mortality remains high. Therefore, diagnosis in the early disease stage, risk stratification for the development of serious organ involvement and therapeutic intervention with disease-modifying drugs can reduce the maximum degree of fibrosis, leading to improved long-term survival. Recently, new criteria for very early diagnosis of SSc have been proposed, which are expected to be useful for regularly following up patients with very early SSc, regardless of the absence of skin sclerosis, and for detecting the development of internal organ involvement as early as possible. At present, several immunosuppressants, including methotrexate, corticosteroids and cyclophosphamide, are being used for the treatment of fibrosis. Furthermore, mycophenolate mofetil, i.v. immunoglobulins, B-cell depletion, anti-interleukin-6 receptor antibody, autologous hematopoietic stem cell transplantation, rapamycin, pirfenidone and imatinib mesylate are potential candidates for the treatment of SSc, although their efficacy has not been validated. Moreover, targeting transforming growth factor-1 and its signaling pathway or modulating the imbalance between T-helper 1 and 2 immune responses are also attractive therapeutic options. This review describes recent advances in the strategy for treatment of fibrosis in SSc and future perspectives.
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Affiliation(s)
- Koichi Yanaba
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016. [DOI: 10.5301/jsrd.5000228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy. Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs. The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.
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Bruni C, Praino E, Allanore Y, Distler O, Gabrielli A, Iannone F, Matucci-Cerinic M. Use of biologics and other novel therapies for the treatment of systemic sclerosis. Expert Rev Clin Immunol 2016; 13:469-482. [PMID: 27899043 DOI: 10.1080/1744666x.2017.1263153] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by vasculopathy, inflammation and fibrosis. These three main disease-determining pathways are the target of the currently available treatments used to possibly modify the progression of disease-related manifestations, although this synergy has not been fully applied on SSc joint, skin or lung involvement yet. Areas covered: we describe the current status of SSc treatment/therapy performing a literature search in MEDLINE/Pubmed and Thomson Reuter's Web of Science for articles published until March 2016. Moreover, ongoing registered clinical trials (RCTs) on SSc were searched through clinicaltrials.gov website. Expert commentary: presently, promising drugs are under evaluation to target the different pathogenic pathways of systemic sclerosis: Tocilizumab and Abatacept for skin and lung fibrosis; Riociguat and Selexipag are approved for pulmonary arterial hypertension but promising anti-fibrotic effects are now being studied. Finally, several anti-fibrotic molecules are currently involved in RCTs, such as Nintedanib, IVA-337, Terguride.
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Affiliation(s)
- Cosimo Bruni
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
| | - Emanuela Praino
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy.,b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Yannick Allanore
- c Department of Rheumatology A and INSERM U1016 , Paris Descartes University, Cochin Hospital , Paris , France
| | - Oliver Distler
- d Department of Rheumatology , University Hospital Zurich , Zurich , Switzerland
| | - Armando Gabrielli
- e Department Of Clinical and Molecular Sciences, Clinica Medica , University 'Politecnica delle Marche' , Ancona , Italy
| | - Florenzo Iannone
- b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Marco Matucci-Cerinic
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
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Abstract
Treatment of skin manifestations in systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and dermatomyositis (DM) is based on the results of only few randomized controlled trials. The first-line treatment for disfiguring and widespread cutaneous involvement in SLE is antimalarials, but some patients are therapy resistant. Recently, the monoclonal antibody belimumab was approved for SLE as an adjunct therapy for patients with autoantibody-positive disease who despite standard therapy show high disease activity, intolerance of other treatments, or an unacceptably high need for corticosteroids. However, a validated skin score has not been used to confirm the efficacy of belimumab on mucocutaneous manifestations. In SSc, another multi-systemic progressive disease, involvement of the lung, kidney, and the heart is frequently treated with corticosteroids and immunosuppressives, but therapeutic modalities for cutaneous lesions, such as skin sclerosis and digital ulcers, are limited. In the past years, treatment with the endothelin-receptor antagonist bosentan has been proven to reduce the occurrence of new digital ulcers in SSc patients but has no or limited effect on healing of digital ulcers. DM is an idiopathic autoimmune disease characterized by inflammation of the muscles and skin, which is treated with immunosuppressives. Corticosteroids are the first-line treatment for muscle involvement in DM, but skin lesions often flare by reduction or discontinuation. In summary, there is a high unmet need for new therapeutic strategies focusing on skin involvement in systemic autoimmune diseases. Therefore, innovative designs of randomized controlled trials with validated skin scores are warranted to develop new therapeutic strategies for patients with cutaneous manifestations.
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Kumar S, Singh J, Kedika R, Mendoza F, Jimenez SA, Blomain ES, DiMarino AJ, Cohen S, Rattan S. Role of muscarinic-3 receptor antibody in systemic sclerosis: correlation with disease duration and effects of IVIG. Am J Physiol Gastrointest Liver Physiol 2016; 310:G1052-60. [PMID: 27173508 PMCID: PMC4935481 DOI: 10.1152/ajpgi.00034.2016] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/31/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal dysmotility in systemic sclerosis (SSc) is associated with autoantibodies against muscarinic-3 receptor (M3-R). We investigated the temporal course of the site of action of these autoantibodies at the myenteric neurons (MN) vs. the smooth muscle (SM) M3-R in relation to disease duration, and determined the role of intravenous immunoglobulin (IVIG) in reversing these changes. Immunoglobulins purified from SSc patients (SScIgG) were used to assess their differential binding to MN and SM (from rat colon) employing immunohistochemistry (IHC). Effect of SScIgG on neural and direct muscle contraction was determined by cholinergic nerve stimulation and bethanechol-induced SM contraction. Effects of IVIG and its antigen-binding fragment F(ab')2 on SScIgG binding were studied by enzyme-linked immunosorbent assay (ELISA) of rat colonic longitudinal SM myenteric plexus (LSMMP) lysate and to second extracellular loop peptide of M3-R (M3-RL2). SScIgG from all patients demonstrated significantly higher binding to MN than to SM. With progression of SSc duration, binding at MN and SM increased in a linear fashion with a correlation coefficient of 0.696 and 0.726, respectively (P < 0.05). SScIgG-mediated attenuation of neural and direct SM contraction also increased with disease duration. ELISA analysis revealed that IVIG and F(ab')2 significantly reduced SScIgG binding to LSMMP lysate and M3-RL2. Dysmotility in SSc occurs sequentially, beginning with SScIgG-induced blockage of cholinergic neurotransmission (neuropathy), which progresses to inhibition of acetylcholine action at the SM cell (myopathy). IVIG reverses this cholinergic dysfunction at the neural and myogenic receptors by anti-idiotypic neutralization of SScIgG.
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Affiliation(s)
- Sumit Kumar
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Jagmohan Singh
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Ramalinga Kedika
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Fabian Mendoza
- 2Division of Rheumatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Sergio A. Jimenez
- 3Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Erik S. Blomain
- 4Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Anthony J. DiMarino
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Sidney Cohen
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania;
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Fuschiotti P. Current perspectives on the immunopathogenesis of systemic sclerosis. Immunotargets Ther 2016; 5:21-35. [PMID: 27529059 PMCID: PMC4970639 DOI: 10.2147/itt.s82037] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Systemic sclerosis (SSc or scleroderma) is a progressive and highly debilitating autoimmune disorder characterized by inflammation, vasculopathy, and extensive fibrosis. SSc is highly heterogeneous in its clinical presentation, extent and severity of skin and internal organ involvement, and clinical course and has the highest fatality rate among connective tissue diseases. While clinical outcomes have improved in recent years, no current therapy is able to reverse or slow the natural progression of SSc, a reflection of its complex pathogenesis. Although activation of the immune system has long been recognized, the mechanisms responsible for the initiation of autoimmunity and the role of immune effector pathways in the pathogenesis of SSc remain incompletely understood. This review summarizes recent progress in disease pathogenesis with particular focus on the immunopathogenetic mechanisms of SSc.
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Affiliation(s)
- Patrizia Fuschiotti
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Desbois AC, Cacoub P. Systemic sclerosis: An update in 2016. Autoimmun Rev 2016; 15:417-26. [PMID: 26802722 DOI: 10.1016/j.autrev.2016.01.007] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/11/2016] [Indexed: 01/27/2023]
Abstract
Systemic sclerosis (SSc) is a chronic immune disorder of unknown origin, dominated by excessive fibrosis responsible for cutaneous and pulmonary fibrosis, and by vascular endothelial dysfunction at the origin of skin ischemia, renal and pulmonary artery lesions. Renal and pulmonary complications are mainly responsible for the severity of the disease. Recent advances led to a better understanding of pathological mechanisms and a more accurate classification of patients according to clinical and biological (auto-antibodies) phenotype. Recent trials provided interesting data on different therapeutic strategies, depending on organ involvement. These data are of particular importance in such disease, still characterized by increased mortality and morbidity rates. In this review, we aim to synthetize recent advances in diagnosis and prognosis leading to better classification of SSc patients, and in therapeutic management.
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Affiliation(s)
- Anne Claire Desbois
- Sorbonne Universités, UPMC Université Paris 06, UMR 7211, Paris, France; Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France; CNRS, FRE3632, F-75005 Paris, France
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Université Paris 06, UMR 7211, Paris, France; Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005 Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, 83 boulevard de l'hôpital, F-75013 Paris, France.
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Yasuoka H. Recent Treatments of Interstitial Lung Disease with Systemic Sclerosis. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2016; 9:97-110. [PMID: 26819563 PMCID: PMC4720185 DOI: 10.4137/ccrpm.s23315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 02/06/2023]
Abstract
Systemic sclerosis (SSc) is a disorder characterized by immune dysfunction, microvascular injury, and fibrosis. Organ involvement in patients with SSc is variable; however, pulmonary involvement occurs in up to 90% of patients with SSc. Interstitial lung disease (ILD) is a major cause of mortality and, thus, a major determinant in the prognosis of patients with SSc. This review summarizes current findings about the characteristics of ILD in patients with SSc, selection of patients with SSc-ILD who are candidates for the treatment, and current treatment options.
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Affiliation(s)
- Hidekata Yasuoka
- Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW To review pharmacologic and nonpharmacologic therapies in the treatment of systemic sclerosis (SSc) from 2011 to 2014 through a systematic review. RECENT FINDINGS Our systematic review identifies randomized controlled trials, meta-analyses, systematic reviews, case series, and observational studies which support organ-based therapy with known immunosuppressive agents, novel agents, and hematopoietic stem cell transplantation, and also includes nonpharmacologic therapies improving visceral and physical function. SUMMARY SSc is an orphan autoimmune disorder with significant morbidity and mortality. Although there has been significant progress over the years in therapeutic options for SSc, the mainstays of treatment are organ-based and primarily symptom management. Our systematic review of the last 4 years of treatment emphasizes known treatment strategies already in practice, but also identifies new therapeutic approaches with additional biologic agents and hematopoietic stem cell transplantation.
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Mendoza FA, Mansoor M, Jimenez SA. Treatment of Rapidly Progressive Systemic Sclerosis: Current and Futures Perspectives. Expert Opin Orphan Drugs 2015; 4:31-47. [PMID: 27812432 PMCID: PMC5087809 DOI: 10.1517/21678707.2016.1114454] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Systemic Sclerosis (SSc) is a systemic autoimmune disease characterized by severe and often progressive cutaneous, pulmonary, cardiac and gastrointestinal tract fibrosis, cellular and humoral immunologic alterations, and pronounced fibroproliferative vasculopathy. There is no effective SSc disease modifying therapy. Patients with rapidly progressive SSc have poor prognosis with frequent disability and very high mortality. AREAS COVERED This paper reviews currently available therapeutic approaches for rapidly progressive SSc and discuss novel drugs under study for SSc disease modification. EXPERT OPINION The extent, severity, and rate of progression of SSc skin and internal organ involvement determines the optimal therapeutic interventions for SSc. Cyclophosphamide for progressive SSc-associated interstitial lung disease and mycophenolate for rapidly progressive cutaneous involvement have shown effectiveness. Methotrexate has been used for less severe skin progression and for patients unable to tolerate mycophenolate. Rituximab was shown to induce improvement in SSc-cutaneous and lung involvement. Autologous bone marrow transplantation is reserved for selected cases in whom poor survival risk outweighs the high mortality rate of the procedure. Novel agents capable of modulating fibrotic and inflammatory pathways involved in SSc pathogenesis, including tocilizumab, pirfenidone, tyrosine kinase inhibitors, lipid lysophosphatidic acid 1, and NOX4 inhibitors are currently under development for the treatment of rapidly progressive SSc.
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Affiliation(s)
- Fabian A. Mendoza
- Department of Medicine, Division of Rheumatology, Thomas Jefferson University Philadelphia, PA 19107, USA
- Jefferson Institute of Molecular Medicine, and Scleroderma Center, Thomas Jefferson University Philadelphia, PA 19107, USA
| | - Maryah Mansoor
- Department of Medicine, Division of Rheumatology, Thomas Jefferson University Philadelphia, PA 19107, USA
| | - Sergio A. Jimenez
- Jefferson Institute of Molecular Medicine, and Scleroderma Center, Thomas Jefferson University Philadelphia, PA 19107, USA
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Raja J, Nihtyanova SI, Murray CD, Denton CP, Ong VH. Sustained benefit from intravenous immunoglobulin therapy for gastrointestinal involvement in systemic sclerosis. Rheumatology (Oxford) 2015; 55:115-9. [DOI: 10.1093/rheumatology/kev318] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Indexed: 11/14/2022] Open
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Raja J, Denton CP. Cytokines in the immunopathology of systemic sclerosis. Semin Immunopathol 2015; 37:543-57. [PMID: 26152640 DOI: 10.1007/s00281-015-0511-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023]
Abstract
Cytokines and growth factors are key regulators of immune activation, vascular alteration and excessive production of extracellular matrix which are hallmark events in the pathogenesis of systemic sclerosis (SSc). They modulate cell-cell and cell-matrix interactions. In particular, cytokines play a central role in the immunopathogenesis of SSc on the basis of molecular pathways which are complex and not completely understood. The majority of cytokines that may be involved in SSc pathogenesis have effect upon or are derived from cells of the immune system, including both the innate and adaptive compartments. Novel therapies that block key mediators that drive the fibrotic response are being developed and appear as potential therapeutic tools in the treatment of SSc, highlighting the importance for an effective therapy targeted towards the molecular and cellular pathways. This article reviews cytokine biology in that context, with particular emphasis on immunopathology of the disease, therapeutic targeting and the way that current or emerging treatments for SSc might impact on cytokine biology.
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Affiliation(s)
- Jasmin Raja
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School, Royal Free Campus, London, NW3 2QG, UK
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