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Panopoulos S, Tzilas V, Bournia VK, Tektonidou MG, Sfikakis PP. Tocilizumab plus Nintedanib for progressive interstitial lung disease in systemic sclerosis: a one-year observational study. Rheumatol Int 2024:10.1007/s00296-024-05695-1. [PMID: 39180531 DOI: 10.1007/s00296-024-05695-1] [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: 06/19/2024] [Accepted: 08/09/2024] [Indexed: 08/26/2024]
Abstract
Randomized controlled trials have recently shown that both the IL-6 inhibitor Tocilizumab and the antifibrotic Nintedanib are efficacious for Systemic Sclerosis (SSc)-associated progressive interstitial lung disease (ILD). Since real-world clinical data on Tocilizumab/Nintedanib combination are lacking, we report on their long-term safety and efficacy. Consecutive patients who received off-label Tocilizumab for SSc plus Nintedanib for progressive ILD were retrospectively studied. Adverse events, and changes in Forced Vital Capacity (FVC), Diffucing Capacity for Carbon Monoxide (DLCO) and high resolution chest tomography (HRCT) between baseline and 6 and 12 months were assessed. Tocilizumab/Nintedanib combination was well tolerated by all 20 patients [aged 52 ± 13 years (mean ± SD), 14 women, 15 diffuse SSc, disease duration of 5.7 ± 4.9 years]; 7 of 20 patients received concomitant mycophenolate mofetil safely. No serious adverse events or laboratory abnormalities were noted. Five patients developed persistent diarrhea and 2 of them reduced dosage of Nintedanib. Baseline FVC (74%±12%) and DLCO (45%±10%) remained overall stable both at 6 months (73.5%±13% and 46%±11%, respectively) and 12 months (73%±14% and 45%±11%, respectively), regardless of disease duration. The extent of fibrotic reticular pattern in available pairs of HRCTs (n = 12) remained also stable at 12 months, whereas proportion (%) of ground glass opacities decreased from 29%±16 to 21%±14% (p = 0.048); improvement in HRCTs by almost 75% was noted in 2 of these12 patients. Tocilizumab/Nintedanib combination for one year was safe and stabilized lung function in real-world SSc patients with progressive ILD. Additional studies of this combination treatment in SSc-ILD are warranted.
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Affiliation(s)
- Stylianos Panopoulos
- 1st Department of Propaedeutic and Internal Medicine, and Joint Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Vasilios Tzilas
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Vasiliki-Kalliopi Bournia
- 1st Department of Propaedeutic and Internal Medicine, and Joint Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Maria G Tektonidou
- 1st Department of Propaedeutic and Internal Medicine, and Joint Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Petros P Sfikakis
- 1st Department of Propaedeutic and Internal Medicine, and Joint Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
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Foeldvari I, Torok KS, Antón J, Blakley M, Constantin T, Cutolo M, Denton CP, Fligelstone K, Hinrichs B, Li SC, Maillard S, Marrani E, Moinzadeh P, Orteu CH, Pain CE, Pauling JD, Pilkington C, Rosser F, Smith V, Furst DF. Best clinical practice in the treatment of juvenile systemic sclerosis: expert panel guidance - the result of the International Hamburg Consensus Meeting December 2022. Expert Rev Clin Immunol 2024; 20:387-404. [PMID: 38149621 DOI: 10.1080/1744666x.2023.2298354] [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: 09/06/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1,000,000 children. Currently there is only one consensus treatment guideline concerning skin, pulmonary and vascular involvement for jSSc, the jSSc SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) initiative, which was based on data procured up to 2014. Therefore, an update of these guidelines, with a more recent literature and expert experience, and extension of the guidance to more aspects of the disease is needed. AREAS COVERED Treatment options were reviewed, and opinions were provided for most facets of jSSc including general management, some of which differs from adult systemic sclerosis, such as the use of corticosteroids, and specific organ involvement, such as skin, musculoskeletal, pulmonary, and gastroenterology. EXPERT OPINION We are suggesting the treat to target strategy to treat early to prevent cumulative disease damage in jSSc. Conclusions are derived from both expert opinion and available literature, which is mostly based on adult systemic sclerosis (aSSc), given shared pathophysiology, extrapolation of results from aSSc studies was judged reasonable.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Kathryn S Torok
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jordi Antón
- Department of Pediatric Rheumatology. Hospital Sant Joan de Déu and Universitat de Barcelona, Barcelona, Spain
| | - Michael Blakley
- Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tamás Constantin
- Unit of Pediatric Rheumatology, Tűzoltó Street Department, Pediatric Centre, Semmelweis University, Budapest, Hungary
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology-Department of Internal Medicine and Specialties, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Kim Fligelstone
- Scleroderma & Raynaud's United Kindgom (SRUK) (Research Subcommittee, Patient Research Partner), FESCA, London, UK
| | - Bernd Hinrichs
- Children's pulmonology, Asklepios Klinik Nord - Heidberg, Hamburg, Germany
| | - Suzanne C Li
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - Edoardo Marrani
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Catherine H Orteu
- UCL Institute of Immunity and Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Clare E Pain
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | - John D Pauling
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium and ERN ReCONNET
| | | | - Franziska Rosser
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Vanessa Smith
- University of California, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
| | - Daniel F Furst
- Division of Rheumatology Fellow, Geffen School of Medicine at the University of California in Los Angeles, Los Angeles, CA, USA
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Panopoulos S, Tzilas V, Bournia VK, Karamanakos A, Laskari K, Bouros D, Tektonidou M, Sfikakis PP. COVID-19 and protection of vaccination in patients with systemic sclerosis-associated interstitial lung disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:113-119. [PMID: 37284697 PMCID: PMC9755035 DOI: 10.1177/23971983221143252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/10/2022] [Indexed: 01/07/2024]
Abstract
OBJECTIVES Data on COVID-19 in patients with interstitial lung disease are scarce and whether SARS-CoV-2 may trigger interstitial lung disease progression remains unknown. We aimed to analyze outcomes of COVID-19 in patients with systemic sclerosis-associated interstitial lung disease, including possible thoracic radiographic progression. PATIENTS AND METHODS All 43 patients with systemic sclerosis-associated interstitial lung disease followed in our center (mean ± SD, 55.2 ± 11.6 years, 36 female) with confirmed SARS-CoV2 infection up to 1 September 2022 were analyzed. Individual interstitial lung disease extent on high resolution CT (HRCT) performed before (up to 3 months) and after COVID-19 (2-5 months) was compared. RESULTS At SARS-CoV-2 infection, 9/43 patients were unvaccinated, whereas 5, 26, and 3 had received 2, 3, or 4 doses of an mRNA vaccine, respectively. Thirty-one patients were either on monotherapy with immunosuppressives (mycophenolate, n = 7; cyclophosphamide, n = 2; methotrexate, n = 10; tocilizumab, n = 7; rituximab, n = 1; etanercept, n = 1), or their combinations (n = 3). Eight patients (20%), of whom four unvaccinated, required hospitalization for pneumonia and three (7%) died of acute respiratory failure (n = 2, both unvaccinated) or cardiac arrest. Lack of vaccination was the only independent predictor for hospitalization (OR = 7.98, 95% CI: 1.25-51.09) and marginally for death (OR = 32.7, 95% CI: 0.97-1110.98), regardless of the presence of diffuse systemic sclerosis, interstitial lung disease extent greater than 20% or immunosuppressive treatment. In 22 patients with available HRCT pairs (vaccinated = 20), the interstitial lung disease extent before COVID-19 (20.4%± 17.8%) remained unchanged (22.4% ± 18.5%) in all but one patient. CONCLUSION SARS-CoV-2 vaccination is of outmost importance for every systemic sclerosis patient with interstitial lung disease. COVID-19 does not seem to promote progression of systemic sclerosis-associated interstitial lung disease in vaccinated patients, but further studies are warranted.
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Affiliation(s)
- Stylianos Panopoulos
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Vasilios Tzilas
- 5th Respiratory Medicine Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - Vasiliki-Kalliopi Bournia
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Anastasios Karamanakos
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Katerina Laskari
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Demosthenes Bouros
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
- Medical Center, Athens, Greece
| | - Maria Tektonidou
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Petros P. Sfikakis
- 1st Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
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Xie M. Long-Term Efficacy and Low Adverse Events of Methylprednisolone Pulses Combined to Low-Dose Glucocorticoids for Systemic Sclerosis: A Retrospective Clinical Study of 10 Years' Follow-Up [Letter]. J Inflamm Res 2022; 15:5041-5042. [PMID: 36081761 PMCID: PMC9448348 DOI: 10.2147/jir.s387159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mingrui Xie
- Medway NHS Foundation Trust, Gillingham, Kent, UK
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Cardoneanu A, Burlui AM, Macovei LA, Bratoiu I, Richter P, Rezus E. Targeting Systemic Sclerosis from Pathogenic Mechanisms to Clinical Manifestations: Why IL-6? Biomedicines 2022; 10:biomedicines10020318. [PMID: 35203527 PMCID: PMC8869570 DOI: 10.3390/biomedicines10020318] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Systemic sclerosis (SS) is a chronic autoimmune disorder, which has both cutaneous and systemic clinical manifestations. The disease pathogenesis includes a triad of manifestations, such as vasculopathy, autoimmunity, and fibrosis. Interleukin-6 (IL-6) has a special role in SS development, both in vascular damage and in the development of fibrosis. In the early stages, IL-6 participates in vascular endothelial activation and apoptosis, leading to the release of damage-associated molecular patterns (DAMPs), which maintain inflammation and autoimmunity. Moreover, IL-6 plays an important role in the development of fibrotic changes by mediating the transformation of fibroblasts into myofibroblasts. All of these are associated with disabling clinical manifestations, such as skin thickening, pulmonary fibrosis, pulmonary arterial hypertension (PAH), heart failure, and dysphagia. Tocilizumab is a humanized monoclonal antibody that inhibits IL-6 by binding to the specific receptor, thus preventing its proinflammatory and fibrotic actions. Anti-IL-6 therapy with Tocilizumab is a new hope for SS patients, with data from clinical trials supporting the favorable effect, especially on skin and lung damage.
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Affiliation(s)
- Anca Cardoneanu
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence:
| | - Alexandra Maria Burlui
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
| | - Luana Andreea Macovei
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.M.B.); (L.A.M.); (I.B.); (P.R.); (E.R.)
- Rehabilitation Hospital, 700661 Iasi, Romania
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