Rheumatoid arthritis treated with chlorambucil: a five-year follow-up

Long-term follow-up of patients treated with short-term high-dose chlorambucil for sight-threatening ocular inflammation

PURPOSE

To determine the effectiveness of short-term high-dose chlorambucil in the treatment of sight-threatening uveitis and to ascertain the incidence of severe side effects, particularly late malignancy.

DESIGN

Retrospective, noncomparative interventional case series.

PARTICIPANTS

Fifty-three patients treated at the University of Illinois at Chicago Eye and Ear Infirmary and the private office of one of the authors for severe sight-threatening uveitis.

METHODS

Treatment with short-term high-dose chlorambucil (2-9 months of therapy).

MAIN OUTCOME MEASURE

Visual acuity and degree of inflammation were assessed at every visit. The development of systemic side effects, including malignancy, was assessed using a detailed questionnaire.

RESULTS

Total cumulative dose of chlorambucil ranged from 392 to 5200 mg with an average of 1429 mg. The maximum daily dose ranged from 10 to 30 mg with an average of 20 mg. Average duration of treatment was 16 weeks with a range of 7 to 40 weeks. Seventy-seven percent of patients treated were in remission with an average follow-up of 4 years (range: 6 months to 24 years). Forty-seven percent had at least two lines of improvement in Snellen visual acuity after treatment, with an average gain of 3.5 lines. Adverse effects include secondary amenorrhea, nonophthalmic herpes zoster, testicular atrophy, and erectile dysfunction. None of the patients had developed a malignancy as of their last follow-up.

CONCLUSION

Short-term high-dose chlorambucil therapy may be a reasonable option in patients with intractable sight-threatening uveitis.

Combination therapy: the risks of infection and tumor induction

It is clear that the rate of infection is increased in most of the more serious forms of autoimmune disease and agents such as high-dose steroids and the alkylating agents increase this risk. Other agents such as MTX, CsA, LEF, AZA and the TNF antagonists do not appear to increase the risk of infection given either alone or in combination. Similarly, the risk of malignancy in certain types of autoimmune disease appears increased. However, other than the alkylating agents, none of the agents used appear to increase this risk. The more recently released agents such as CsA, LEF and the TNF antagonists need longer durations of follow-up to substantiate this, however. It is clear that, unless they are absolutely necessary, one should avoid the alkylating agents used either alone or in combination to avoid problems with infection and malignancy. In addition, the use of steroids should be kept as low as possible to avoid infections. It is possible that the use of the more benign agents alone and in combination earlier in the disease course may help to reduce both infection and the incidence of malignancy in the long run.

Chlorambucil therapy in sympathetic ophthalmia

PURPOSE

We used chlorambucil therapy in a 28-year-old man with sympathetic ophthalmia, which was incompletely controlled with systemic corticosteroids, and the patient developed serious side effects.

METHODS

The patient sustained a penetrating injury with an intraocular metal foreign body. Attempts to remove it with a magnet failed. Vitrectomy with lensectomy successfully removed the intraocular foreign body. Five weeks after the injury and one week after the vitrectomy, sympathetic ophthalmia developed, with severe visual impairment and inflammation and serous retinal detachment in the fellow eye. Sympathetic ophthalmia was poorly responsive to topical cycloplegics, topical corticosteroids, and systemic corticosteroid therapy. The patient developed side effects to the corticosteroids, which were reduced to prednisolone 60 mg daily. Chlorambucil therapy was begun at 2 mg daily, increased by 2 mg per day each week to the maximum of 8 to 12 mg per day. The total dose of chlorambucil was 793 mg; the duration of therapy was 23 weeks.

RESULTS

Successful treatment was achieved with chlorambucil therapy. There was clinical remission of inflammation and absorption of exudative retinal detachment. The neurosensory retina sealed down; the retinal pigment epithelium demonstrated severe destruction, with the characteristic sunset-glow and moth-eaten appearance. No malignancy and no serious side effect developed during one year of follow-up. After termination of therapy, the patient had sustained remission of ocular disease.

CONCLUSION

Chlorambucil immunosuppressive therapy is an alternative to corticosteroids for the treatment of corticosteroid-resistant sympathetic ophthalmia; however, because chlorambucil has potentially serious late side effects, prolonged follow-up is necessary.

Preferential reductions in lymphocyte sub-populations induced by monthly pulses of chlorambucil: studies in patients with chronic progressive multiple sclerosis

Thirty-three patients with chronic progressive multiple sclerosis (MS) were assigned to intervention groups receiving monthly pulses of chlorambucil (CB) for about one year. The monthly doses ranged from 0.4 to 1.5 mg/kg. Administration of CB resulted in preferential reduction in different lymphocyte subsets which was dose- and time-dependent. The number of B-cells (CD20) decreased more rapidly than NK-cells (CD16, CD56, CD16+CD56+) or T-cell (CD3) and T-cells subsets (CD4 and CD8). At 1.2 mg/kg, CB administration resulted in a preferential drop of T-suppressor/cytotoxic cells (CD8) compared with T-helper cells (CD4), and of the less mature "virgin" CD4 cells (CD4+CD45RA+) compared with "memory" CD4 cells (CD4+CD45RA-). The expression of activation markers (transferrin receptor, CALLa, HLA-Dr and CD38[OKT10]) within CD4, CD8 or CD20 lymphocytes was not altered by CB administration. Our data, which show that CB administration results in a preferential fall in B-cell numbers, contrast with the effects of long-term administration of the related immunosuppressive drugs, azathioprine and cyclophosphamide.

Azathioprine, cyclophosphamide and chlorambucil

Immunosuppressive agents serve a major role in the management of once-fatal conditions such as the systemic necrotizing vasculitides, but they are also being used in more common, chronic inflammatory disorders such as rheumatoid arthritis. The drugs are all capable of reducing cell division but they differ in their modes of action. This is in keeping with their differing rates of action, and different indications. Azathioprine is a valuable alternative to slow-acting antirheumatic drugs in older patients with rheumatoid arthritis. Cyclophosphamide has transformed the outlook of many forms of vasculitis. Chlorambucil is particularly useful in improving the prognosis for children with amyloidosis secondary to juvenile chronic arthritis. We have tried to highlight the role of these drugs in a number of rheumatic diseases. We have emphasized their clinical applications, with some laboratory evidence for their effects. The major side-effects are reviewed. Finally, we have discussed their possible mechanisms of action.

Chlorambucil therapy in rheumatoid arthritis: clinical experience in 28 patients and literature review

Our clinical experience in 28 patients receiving chlorambucil for rheumatoid arthritis (RA) and the reports on chlorambucil therapy are reviewed. Our study population and other reports generally represent patients with severe RA who had either failed to improve or developed significant toxicity during previous treatment with conventional slow acting anti-rheumatic drugs (SAARDs). Seventy-two percent of patients had a significant clinical improvement during chlorambucil therapy and reports of complete remission are given, although the incidence of remission is unknown. Hematologic complications are often reported, but appeared more frequently in our experience than previously reported. Hematologic toxicity required that chlorambucil be discontinued in the majority of our cases. Two deaths from suspected drug induced malignancies are reported. Although chlorambucil appears to be effective in the control of active RA, the potential for drug induced toxicity and malignancies may outweigh the benefit of continued use of this experimental therapy in RA.

Mechanisms of action and clinical applications of cytotoxic drugs in rheumatic disorders

Failure to suppress disease activity in certain rheumatic disorders such as systemic lupus, polyarteritis nodosa, or Wegener's granulomatosis may significantly heighten the probability of a fatal outcome. In other rheumatic disorders (for example, rheumatoid or psoriatic arthritis) the disease left unchecked may indeed be severely crippling but rarely is it fatal. Thus the decision on whether to add a cytotoxic drug often evolves into a benefit-to-risk analysis, a decision in which the patient must also be intimately involved. There are two few well-controlled studies of the use of cytotoxic agents to make dogmatic statements regarding their use in the treatment of rheumatic disorders. Nevertheless, a review of the literature, some of which has been cited above, does permit one to make some reasoned judgments in choosing a drug for a particular disease (Table 2).

Chlorambucil-induced chromosome damage to human lymphocytes is dose-dependent and cumulative

Sister chromatid exchanges (SCEs), a sensitive measure of chromosome damage, were counted in peripheral-blood lymphocytes from 10 patients with Behcet's syndrome receiving chlorambucil. All patients had abnormal counts. Damage was related to both daily dose and duration of therapy and was occurring at a greater rate than its repair. The patient who had been treated the longest and had received the highest total dose also had the highest SCE count. He died from acute leukaemia. SCE analysis may provide a method for detecting patients at risk from oncogenic effects of cytotoxic drugs.