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Kasai H, Kawasaki H, Fukushima-Nomura A, Yasuda-Sekiguchi F, Amagai M, Ebihara T, Tanese K. Stratification of atopic dermatitis patients by patterns of response to proactive therapy with topical tacrolimus: low serum IgE levels and inadequately controlled disease activity at the start of treatment predict its failure. Ann Med 2021; 53:2205-2214. [PMID: 34797182 PMCID: PMC8805968 DOI: 10.1080/07853890.2021.2004319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/02/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Topical calcineurin inhibitors (TCIs) are an important anti-inflammatory drug for treating atopic dermatitis (AD). However, those treatment responses are variable. In this study, we stratified AD patients by patterns of response to remission maintenance therapy (proactive therapy) with topical tacrolimus, a typical TCI. Thereafter, we explored patient features that predict the success or failure of proactive therapy using TCI (TCI proactive therapy). METHODS A single-arm open-label clinical study aimed to evaluate the efficacy of TCI proactive therapy was conducted in 31 patients with AD. Patients were treated with TCS to induce remission (remission-induction period) followed by daily TCI ointment (0.1% tacrolimus) application for 4 weeks (maintenance therapy period), and twice-weekly application for 12 weeks (proactive therapy period). Based on its results, treatment outcomes were correlated with the patients' clinical and laboratory findings. RESULTS Of the 31 patients enrolled in the study, 21 successfully completed maintenance therapy (TCI responders). Among them, 13 completed (proactive-completed group) and 8 failed proactive therapy (proactive-dropout group). At the beginning of maintenance therapy, the serum IgE level was significantly higher in the TCI responders than in those who failed maintenance therapy (p = 0.049). At the beginning of proactive therapy, the mean-SCORing Atopic Dermatitis (SCORAD) score was significantly different between the proactive-completed (11.7 ± 4.6) and proactive-dropout (16.6 ± 4.2) groups (p = 0.025). In proactive-dropout group patients, worsened disease activity correlated well with the elevation of serum lactate dehydrogenase (LDH) and Thymus and activation-regulated chemokine (TARC) levels and peripheral eosinophil count. CONCLUSION AD patients were stratified into three different response patterns to TCI proactive therapy. Patients with less involvement of IgE in the pathogenesis and inadequate remission induction by TCS may not be expected to respond well to TCI proactive therapy.Key messagesAD patients can be stratified into three types according to their pattern of responsiveness to TCI proactive therapy.The efficacy of TCI proactive therapy is lower in AD patients with lower serum IgE levels.TCI proactive therapy should be done after the achievement of adequate remission induction by TCS.
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Affiliation(s)
- Hiroko Kasai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
- Department of Dermatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Hiroshi Kawasaki
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
- Medical Sciences Innovation Hub Program, RIKEN, Kanagawa, Japan
| | | | | | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Tamotsu Ebihara
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
- Department of Dermatology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Keiji Tanese
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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Cao H, Liang J, Liu J, He Y, Ke Y, Sun Y, Jiang S, Lin J. Novel Effects of Combination Therapy Through Inhibition of Caspase-1/Gasdermin D Induced-Pyroptosis in Lupus Nephritis. Front Immunol 2021; 12:720877. [PMID: 34867948 PMCID: PMC8639704 DOI: 10.3389/fimmu.2021.720877] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/04/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives Combination therapy with mycophenolate mofetil, tacrolimus and steroids are effective in achieving complete remission in lupus nephritis (LN). Combination therapy uniquely downregulated caspase-1 compared with monotherapies, which can cleave gasdermin D (GSDMD) and was recently identified as the pyroptosis executioner. We therefore investigated whether combination therapy enabled the suppression of caspase-1/GSDMD-mediated pyroptosis in LN. Methods Expression and activation of GSDMD were detected in kidney specimens of the human and mouse with LN using immunohistochemical staining and immunoblotting. Primary podocytes isolated from MRL/lpr mice were incubated with LPS+ATP, and pretreated with monotherapy or combination therapy. Inhibition of caspase-1/GSDMD-induced pyroptosis by combination therapy were assessed in MRL/lpr mice and human specimens. Pyroptosis was examined using a FAM caspase-1 kit and flow cytometry. The correlation between pyroptosis in peripheral blood and the systemic lupus erythematosus disease activity index (SLEDAI) was analyzed. Results Kidney tissue specimens from LN patients and mice exhibited greatly increased expression levels and cleavage of GSDMD. In cultured podocytes, combination treatment significantly suppressed the activation of NLRP3 and caspase-1 and reduced GSDMD N-terminal levels. Combination therapy repressed disease progression through inhibition of caspase-1/GSDMD-mediated pyroptosis in both humans and MRL/lpr mice. Caspase-1/PI positive cell numbers in peripheral blood were positively correlated with SLE-DAI. LN patients with complete remission and partial remission had remarkably reduced caspase-1/PI positive cell numbers compared to baseline. Ac-FLTD-CMK, a GSDMD-derived inhibitor, prevented the development of LN. Conclusion Combination therapy suppressed caspase-1/GSDMD-mediated pyroptosis in vitro and in vivo and reduced disease progression.
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Affiliation(s)
- Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junyu Liang
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Liu
- National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Ye He
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yini Ke
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiduo Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Song Jiang
- National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, China
- *Correspondence: Song Jiang, ; Jin Lin,
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Song Jiang, ; Jin Lin,
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Bussalino E, Panaro L, Marsano L, Bellino D, Ravera M, Paoletti E. Prevalence and clinical correlates of hyperkalemia in stable kidney transplant recipients. Intern Emerg Med 2021; 16:1787-1792. [PMID: 33544373 DOI: 10.1007/s11739-021-02649-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/19/2021] [Indexed: 12/28/2022]
Abstract
Although hyperkalemia (HK) is often associated with adverse clinical outcomes in renal patients, few studies are available in the setting of kidney transplantation. Therefore, we evaluated prevalence and clinical correlates of HK in stable kidney transplant recipients (KTRs) on standard of care immunosuppressive therapy. We studied 160 stable KTRs (post-transplant vintage 46.6 ± 16.6 months), most of whom (96.2%) on calcineurin inhibitor (CNI)-based immunosuppressive therapy. HK was defined as plasma potassium levels above 5 mEq/L, confirmed in two consecutive samples. Office blood pressure was measured, and renal graft function was expressed by estimated glomerular filtration rate (eGFR), calculated according to the CKD-EPI formula. HK prevalence was 8.8%, and plasma K above 5.5 mEq/L was found in 2.5% of all KTRs. In the univariate logistic regression analysis HK was significantly associated with serum urea concentration (OR 1.03, 95% CI 1.01-1.05 for each 1 mg/dL increase), tCO2 (OR 0.77, 95% CI 0.66-0.90 for each 1 mmol/L increase), the presence of arterial hypertension (OR 4.01, 95% CI 1.3-12.64), the use of RAAS inhibitors (OR 5.26, 95% CI 1.6-17.7), and eGFR less than 30 ml/min/1.73 m2 (OR 7.51, 95% CI 2.37-23.77). By multivariable backward stepwise regression analysis, the presence of metabolic acidosis (OR 0.83, 95% CI 0.69-0.99, P = 0.04), arterial hypertension (OR 4.65 95% CI 1.01-17.46 P = 0.03), and to be administered RAAS inhibitors (OR 6.11, 95% CI 1.03-25.96 P = 0.03) remained significantly associated with HK. We conclude that in stable KTRs the prevalence of HK is about 9%, slightly lower than previously reported. Moreover, it is not associated with eGFR, but with metabolic acidosis, arterial hypertension, and the use of RAAS inhibitors.
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Affiliation(s)
- Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Laura Panaro
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Luigina Marsano
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Diego Bellino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
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Voclosporin (Lupkynis) for lupus nephritis. Med Lett Drugs Ther 2021; 63:134-6. [PMID: 34544103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Lee SG, Jeng LB, Saliba F, Singh Soin A, Lee WC, De Simone P, Nevens F, Suh KS, Fischer L, Jin Joo D, Fung J, Joh JW, Kaido T, Grant D, Meier M, Rauer B, Sips C, Kaneko S, Levy G. Efficacy and Safety of Everolimus With Reduced Tacrolimus in Liver Transplant Recipients: 24-month Results From the Pooled Analysis of 2 Randomized Controlled Trials. Transplantation 2021; 105:1564-1575. [PMID: 33741847 PMCID: PMC8221719 DOI: 10.1097/tp.0000000000003394] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 06/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND METHODS Data from 2 randomized liver transplant trials (N = 772; H2304 [deceased donor, n = 488], H2307 [living donor, n = 284]) were pooled to further evaluate the efficacy and safety of everolimus with reduced tacrolimus (EVR + rTAC) versus standard tacrolimus (sTAC) regimen at month 24. RESULTS EVR + rTAC was comparable to sTAC for composite efficacy failure of treated biopsy-proven acute rejection, graft loss, or death (9.8% versus 10.8%; difference, -1.0%; 95% confidence interval, -5.4 to 3.4; P = 0.641) at month 24. EVR + rTAC was superior to sTAC for the mean change in estimated glomerular filtration rate (eGFR) from randomization to month 24 (-8.37 versus -13.40 mL/min/1.73 m2; P = 0.001). A subanalysis of renal function by chronic kidney disease (CKD) stage at randomization showed significantly lower decline in eGFR from randomization to month 24 for patients with CKD stage 1/2 (eGFR ≥ 60 mL/min/1.73 m2) in EVR + rTAC group versus sTAC (-12.82 versus -17.67 mL/min/1.73 m2, P = 0.009). In patients transplanted for hepatocellular carcinoma (HCC) beyond Milan criteria, HCC recurrence was numerically lower although not statistically significant with EVR + rTAC versus sTAC group (5.9% [1 of 17] versus 23.1% [6 of 26], P = 0.215), while comparable in patients within Milan criteria (2.9% [3 of 102] versus 2.1% [2 of 96], P = 1.000), irrespective of pretransplant alpha-fetoprotein levels. CONCLUSIONS EVR + rTAC versus sTAC showed comparable efficacy and safety with significantly better renal function, particularly in patients with normal/mildly decreased renal function (CKD stage 1/2) at randomization and a trend toward lower HCC recurrence in patients transplanted with HCC beyond Milan at month 24. Further long-term data would be required to confirm these results.
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Affiliation(s)
- Sung-Gyu Lee
- Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | | | - Faouzi Saliba
- AP-HPHôpital Paul Brousse, Villejuif; Université Paris-Saclay, INSERM Unit 935, and 1193, France
| | | | - Wei-Chen Lee
- Chang Gung Memorial Hospital, Tao-Yuan, Lin-Ko, Taiwan
| | | | - Frederik Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Kyung-Suk Suh
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Lutz Fischer
- University Medical Center Eppendorf, Hamburg, Germany
| | - Dong Jin Joo
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - John Fung
- Cleveland Clinic Foundation, Cleveland, OH
| | - Jae-Won Joh
- Samsung Medical Center, Seoul, Republic of Korea
| | | | | | | | | | | | | | - Gary Levy
- University of Toronto, Toronto, Canada
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Abstract
This is a comprehensive and current guide for the diagnosis, differential diagnosis, treatment, and management of eczematous dermatitis, with a focus on atopic dermatitis, irritant and allergic contact dermatitis, hand dermatitis including recurrent vesicular and hyperkeratotic types, asteatotic dermatitis, and nummular or discoid dermatitis. Diagnostic options highlighted are clinical history, physical examination, and patch testing. Therapeutic options highlighted are moisturizers, topical corticosteroids, topical calcineurin inhibitors, crisaborole, phototherapy, and systemic medications including biologics.
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MESH Headings
- Administration, Topical
- Adrenal Cortex Hormones/administration & dosage
- Adrenal Cortex Hormones/therapeutic use
- Aged
- Biological Products/therapeutic use
- Boron Compounds/administration & dosage
- Boron Compounds/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Calcineurin Inhibitors/administration & dosage
- Calcineurin Inhibitors/therapeutic use
- Child
- Child, Preschool
- Dermatitis, Allergic Contact/diagnosis
- Dermatitis, Allergic Contact/drug therapy
- Dermatitis, Allergic Contact/pathology
- Dermatitis, Atopic/diagnosis
- Dermatitis, Atopic/drug therapy
- Dermatitis, Atopic/pathology
- Diagnosis, Differential
- Eczema/diagnosis
- Eczema/drug therapy
- Eczema/pathology
- Humans
- Infant
- Middle Aged
- Patch Tests/methods
- Phototherapy/methods
- Quality of Life
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Affiliation(s)
- Cynthia X Chan
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Kathryn A Zug
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Department of Dermatology, Dartmouth-Hitchcock Medical Center, 18 Old Etna Road, Lebanon, NH 03766, USA
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Lipman ZM, Ingrasci G, Yosipovitch G. Approach to the Patient with Chronic Pruritus. Med Clin North Am 2021; 105:699-721. [PMID: 34059246 DOI: 10.1016/j.mcna.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic pruritus (itch lasting ≥6 weeks) is a bothersome chief complaint that may present in a broad variety of diseases. Most itch-causing diagnoses fit into 1 of 5 categories (inflammatory, secondary to systemic disease, neuropathic, chronic pruritus of undetermined origin, and psychogenic itch) and this broad differential can be narrowed using key findings in the history and physical. In this article, we discuss which key findings are most pertinent for narrowing this differential and guiding further workup and treatment, as well as how to treat many itchy conditions.
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Affiliation(s)
- Zoe M Lipman
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Giuseppe Ingrasci
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA.
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de Boer SE, Sanders JSF, Bemelman FJ, Betjes MGH, Burgerhof JGM, Hilbrands L, Kuypers D, van Munster BC, Nurmohamed SA, de Vries APJ, van Zuilen AD, Hesselink DA, Berger SP. Rationale and design of the OPTIMIZE trial: OPen label multicenter randomized trial comparing standard IMmunosuppression with tacrolimus and mycophenolate mofetil with a low exposure tacrolimus regimen In combination with everolimus in de novo renal transplantation in Elderly patients. BMC Nephrol 2021; 22:208. [PMID: 34078323 PMCID: PMC8172178 DOI: 10.1186/s12882-021-02409-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/18/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In 2019, more than 30 % of all newly transplanted kidney transplant recipients in The Netherlands were above 65 years of age. Elderly patients are less prone to rejection, and death censored graft loss is less frequent compared to younger recipients. Elderly recipients do have increased rates of malignancy and infection-related mortality. Poor kidney transplant function in elderly recipients may be related to both pre-existing (i.e. donor-derived) kidney damage and increased susceptibility to nephrotoxicity of calcineurin inhibitors (CNIs) in kidneys from older donors. Hence, it is pivotal to shift the focus from prevention of rejection to preservation of graft function and prevention of over-immunosuppression in the elderly. The OPTIMIZE study will test the hypothesis that reduced CNI exposure in combination with everolimus will lead to better kidney transplant function, a reduced incidence of complications and improved health-related quality of life for kidney transplant recipients aged 65 years and older, compared to standard immunosuppression. METHODS This open label, randomized, multicenter clinical trial will include 374 elderly kidney transplant recipients (≥ 65 years) and consists of two strata. Stratum A includes elderly recipients of a kidney from an elderly deceased donor and stratum B includes elderly recipients of a kidney from a living donor or from a deceased donor < 65 years. In each stratum, subjects will be randomized to a standard, tacrolimus-based immunosuppressive regimen with mycophenolate mofetil and glucocorticoids or an adapted immunosuppressive regimen with reduced CNI exposure in combination with everolimus and glucocorticoids. The primary endpoint is 'successful transplantation', defined as survival with a functioning graft and an eGFR ≥ 30 ml/min per 1.73 m2 in stratum A and ≥ 45 ml/min per 1.73 m2 in stratum B, after 2 years, respectively. CONCLUSIONS The OPTIMIZE study will help to determine the optimal immunosuppressive regimen after kidney transplantation for elderly patients and the cost-effectiveness of this regimen. It will also provide deeper insight into immunosenescence and both subjective and objective outcomes after kidney transplantation in elderly recipients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03797196 , registered January 9th, 2019. EudraCT: 2018-003194-10, registered March 19th, 2019.
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Affiliation(s)
- S E de Boer
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - J S F Sanders
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - F J Bemelman
- Department of Internal Medicine, Division of Nephrology, Amsterdam Universal Medical Center, Amsterdam, The Netherlands
| | - M G H Betjes
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L Hilbrands
- Department of Internal Medicine, Division of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - B C van Munster
- Department of Internal Medicine, Divison of Geriatrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S A Nurmohamed
- Department of Internal Medicine, Division of Nephrology, Amsterdam Universal Medical Center, Amsterdam, The Netherlands
| | - A P J de Vries
- Department of Internal Medicine, Division of Nephrology; and Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - A D van Zuilen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D A Hesselink
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S P Berger
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Gilewski W, Banach J, Rogowicz D, Wołowiec Ł, Sielski S, Grześk G. Treatment of Hypertension Because of Immunosuppressive Therapy After Solid Organ Transplantation-Pharmacological Approach. J Cardiovasc Pharmacol 2021; 77:735-744. [PMID: 34001720 DOI: 10.1097/fjc.0000000000001009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/09/2021] [Indexed: 01/18/2023]
Abstract
ABSTRACT Solid organs transplantation procedures have been performed for more than half a century. Growing knowledge of immune response and development of new immunosuppressive regimens guarantee more and more successful outcomes. However, many of the applied drugs lead to cardiovascular complications, the most frequent of which is hypertension. This article describes epidemiology, pathogenetic mechanisms, and treatment of hypertension induced by immunosuppressive medication. The main impact is focused on drugs belonging to the following groups: calcineurin inhibitors, the inhibitors of the mammalian target of rapamycin, and glucocorticosteroids. We analyze the mechanism of action of the main hypertensive drugs and their influence on the reversing hypertonic action of the immunosuppressive agents. In the absence of current guidelines addressing this problem, this article is an attempt to fill the gap, helping clinicians to choose proper medication.
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Affiliation(s)
- Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum in Bydgoszcz, Faculty of Health Sciences
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10
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Rovin BH, Teng YKO, Ginzler EM, Arriens C, Caster DJ, Romero-Diaz J, Gibson K, Kaplan J, Lisk L, Navarra S, Parikh SV, Randhawa S, Solomons N, Huizinga RB. Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet 2021; 397:2070-2080. [PMID: 33971155 DOI: 10.1016/s0140-6736(21)00578-x] [Citation(s) in RCA: 217] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Voclosporin, a novel calcineurin inhibitor approved for the treatment of adults with lupus nephritis, improved complete renal response rates in patients with lupus nephritis in a phase 2 trial. This study aimed to evaluate the efficacy and safety of voclosporin for the treatment of lupus nephritis. METHODS This multicentre, double-blind, randomised phase 3 trial was done in 142 hospitals and clinics across 27 countries. Patients with a diagnosis of systemic lupus erythematosus with lupus nephritis according to the American College of Rheumatology criteria, and a kidney biopsy within 2 years that showed class III, IV, or V (alone or in combination with class III or IV) were eligible. Patients were randomly assigned (1:1) to oral voclosporin (23·7 mg twice daily) or placebo, on a background of mycophenolate mofetil (1 g twice daily) and rapidly tapered low-dose oral steroids, by use of an interactive web response system. The primary endpoint was complete renal response at 52 weeks defined as a composite of urine protein creatinine ratio of 0·5 mg/mg or less, stable renal function (defined as estimated glomerular filtration rate [eGFR] ≥60 mL/min/1·73 m2 or no confirmed decrease from baseline in eGFR of >20%), no administration of rescue medication, and no more than 10 mg prednisone equivalent per day for 3 or more consecutive days or for 7 or more days during weeks 44 through 52, just before the primary endpoint assessment. Safety was also assessed. Efficacy analysis was by intention-to-treat and safety analysis by randomised patients receiving at least one dose of study treatment. The trial is registered with ClinicalTrials.gov, NCT03021499. FINDINGS Between April 13, 2017, and Oct 10, 2019, 179 patients were assigned to the voclosporin group and 178 to the placebo group. The primary endpoint of complete renal response at week 52 was achieved in significantly more patients in the voclosporin group than in the placebo group (73 [41%] of 179 patients vs 40 [23%] of 178 patients; odds ratio 2·65; 95% CI 1·64-4·27; p<0·0001). The adverse event profile was balanced between the two groups; serious adverse events occurred in 37 (21%) of 178 in the voclosporin group and 38 (21%) of 178 patients in the placebo group. The most frequent serious adverse event involving infection was pneumonia, occurring in 7 (4%) patients in the voclosporin group and in 8 (4%) patients in the placebo group. A total of six patients died during the study or study follow-up period (one [<1%] patient in the voclosporin group and five [3%] patients in the placebo group). None of the events leading to death were considered by the investigators to be related to the study treatments. INTERPRETATION Voclosporin in combination with MMF and low-dose steroids led to a clinically and statistically superior complete renal response rate versus MMF and low-dose steroids alone, with a comparable safety profile. This finding is an important advancement in the treatment of patients with active lupus nephritis. FUNDING Aurinia Pharmaceuticals.
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Affiliation(s)
- Brad H Rovin
- Department of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Y K Onno Teng
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Cristina Arriens
- Department of Arthritis & Clinical Immunology, Rheumatology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Dawn J Caster
- Department of Medicine, Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, KY, USA
| | - Juanita Romero-Diaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Keisha Gibson
- Department of Medicine, UNC Kidney Center, Chapel Hill, NC, United States
| | - Joshua Kaplan
- Department of Medicine, Rutgers University, Newark, NJ, USA
| | - Laura Lisk
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
| | - Sandra Navarra
- University of Santo Tomas, Manila and St Luke's Medical Center, Quezon City, Philippines
| | - Samir V Parikh
- Department of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Simrat Randhawa
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
| | - Neil Solomons
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
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11
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Seneschal J, Duplaine A, Maillard H, Passeron T, Andreu N, Lassalle R, Favary C, Droitcourt C, Taïeb A, Ezzedine K. Efficacy and Safety of Tacrolimus 0.1% for the Treatment of Facial Vitiligo: A Multicenter Randomized, Double-Blinded, Vehicle-Controlled Study. J Invest Dermatol 2021; 141:1728-1734. [PMID: 33549606 DOI: 10.1016/j.jid.2020.12.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Topical calcineurin inhibitors are used off label in the treatment of vitiligo, and there is a lack of placebo-controlled, blinded studies to support their use. OBJECTIVE This study aimed to compare the efficacy of tacrolimus 0.1% ointment with that of the vehicle for repigmentation in adult patients with facial vitiligo. DESIGN This study was a 24-week multicenter randomized parallel double-blind study with a 24-week post-treatment follow-up extension. POPULATION Participants included were adult patients with recent facial vitiligo target lesions (<2 years) without changes in pigmentation or size over the previous 3 months. INTERVENTION Patients received either tacrolimus 0.1% ointment or vehicle twice daily. MAIN OUTCOMES AND MEASURES The primary outcome was a therapeutic success, defined as a change ≥75% in the repigmentation of the target lesion between baseline and week 24, measured by ImageJ software. Secondary outcome measures were a variation of the physicians' global assessment scores and patients' satisfaction scores, safety data, and the rate of relapse at week 48. RESULTS A total of 42 patients were included. Therapeutic success was achieved in 65% of tacrolimus-treated patients versus 0% of vehicle-treated patients at week 24 (P < 0.0001). Only 40% of relapse was observed at 48 weeks. CONCLUSIONS AND RELEVANCE Twice-daily tacrolimus 0.1% ointment showed superior efficacy to that of the vehicle through the 24 weeks of intervention and 24 weeks of follow-up in adult patients with facial vitiligo. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov (identifier: NCT02466997).
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Affiliation(s)
- Julien Seneschal
- Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin disorders, Hôpital Saint-André, Bordeaux, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers (BMGIC), Université de Bordeaux, Bordeaux, France
| | - Alexandra Duplaine
- Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin disorders, Hôpital Saint-André, Bordeaux, France
| | - Hervé Maillard
- Department of Dermatology, Centre Hospitalier - Le Mans, Le Mans, France
| | - Thierry Passeron
- Department of Dermatology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Nicolas Andreu
- Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin disorders, Hôpital Saint-André, Bordeaux, France
| | - Régis Lassalle
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, Bordeaux, France
| | - Clélia Favary
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, Bordeaux, France
| | | | - Alain Taïeb
- Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin disorders, Hôpital Saint-André, Bordeaux, France
| | - Khaled Ezzedine
- Department of Dermatology, Henri Mondor University Hospital, Créteil, France; Epidemiology in Dermatology and Evaluation of Therapeutics (EpidermE), Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.
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12
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Li M, Tan W, Du J, Wang Q, Wang L, Lei M, Hao PS. Tacrolimus ointment in the treatment of hormone-dependent dermatitis: A protocol of systematic review. Medicine (Baltimore) 2020; 99:e22159. [PMID: 32925777 PMCID: PMC7489724 DOI: 10.1097/md.0000000000022159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Long-term use of corticosteroid ointment for external using or skin management products and cosmetics containing corticosteroid will produce a hormone-dependent effect on facial skin and destroy the barrier function of the skin. It is easy to cause repeated attacks of facial skin inflammation after drug withdrawal because corticosteroid hormones can cause the expression of inflammatory factors in the body, which has a serious impact on patients. The general treatment method is to stop using hormone drugs for psychotherapy and inform patients of the basic knowledge of hormone-dependent dermatitis and daily facial care, but the effect is not good. At present, non-steroidal ointment tacrolimus (a calcineurin inhibitor) is widely used in the treatment of hormone-dependent dermatitis. Tacrolimus ointment is effective for corticosteroid-dependent dermatitis, but adverse events can also occur. METHODS We plan to searched all randomized controlled trials (RCTs) fortacrolimus ointment therapy of hormone-dependent dermatitis in: MEDLINE, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Springer and Web of Science, China Biomedical Literature Database (CBM), China Science Journal Database (VIP database) and Wanfang Database, China National Knowledge Infrastructure (CNKI), without the limitation of publication status and language until September 1, 2020. The systematic review will also search will also search for identify publications, meeting minutes, and grey literature (including unpublished meeting articles). DISCUSSION The systematic review mainly to access the safety and efficacy of tacrolimus ointment for hormone-dependent dermatitis (facial corticosteroid addiction dermatitis and facial steroid dermatitis). The results of our research will facilitate evidence-based management of patients with facial corticosteroid-dependent dermatitis and provide clinical advice on their treatment options. REGISTRATION PROSPERO CRD42020171813.
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Affiliation(s)
- Mao Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Wen Tan
- Guanghan People's Hospital of Sichuan Province, Deyang, China
| | - Jingjing Du
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Qiuyue Wang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Linyue Wang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Min Lei
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Ping-Sheng Hao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
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13
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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Abstract
BACKGROUND Nemolizumab is a subcutaneously administered humanized monoclonal antibody against interleukin-31 receptor A, which is involved in pruritus and inflammation in atopic dermatitis. In phase 2 studies, nemolizumab lessened the severity of atopic dermatitis. METHODS In a 16-week, double-blind, phase 3 trial, we randomly assigned Japanese patients with atopic dermatitis and moderate-to-severe pruritus and an inadequate response to topical agents in a 2:1 ratio to receive subcutaneous nemolizumab (60 mg) or placebo every 4 weeks until week 16, with concomitant topical agents. The primary end point was the mean percent change in the visual-analogue scale (VAS) score for pruritus (range, 0 to 100, with higher scores indicating worse pruritus) from baseline to week 16. Secondary end points included the time course of change in the VAS score for pruritus up to week 4, the change in the Eczema Area and Severity Index (EASI) score (range, 0 to 72, with higher scores indicating greater severity), a score of 4 or less on the Dermatology Life Quality Index (DLQI; range, 0 to 30, with higher scores indicating a greater effect on daily life), a score of 7 or less on the Insomnia Severity Index (ISI; range, 0 to 28, with higher scores indicating greater severity), and safety. RESULTS A total of 143 patients were randomly assigned to receive nemolizumab and 72 to receive placebo. The median VAS score for pruritus at baseline was 75. At week 16, the mean percent change in the VAS score was -42.8% in the nemolizumab group and -21.4% in the placebo group (difference, -21.5 percentage points; 95% confidence interval, -30.2 to -12.7; P<0.001). The mean percent change in the EASI score was -45.9% with nemolizumab and -33.2% with placebo. The percentage of patients with a DLQI score of 4 or less was 40% in the nemolizumab group and 22% in the placebo group; the percentage of patients with an ISI score of 7 or less was 55% and 21%, respectively. The incidence of injection-related reactions was 8% with nemolizumab and 3% with placebo. CONCLUSIONS In this 16-week trial, the use of subcutaneous nemolizumab in addition to topical agents for atopic dermatitis resulted in a greater reduction in pruritus than placebo plus topical agents. The incidence of injection-site reactions was greater with nemolizumab than with placebo. Longer and larger trials are necessary to determine whether nemolizumab has a durable effect and is safe for atopic dermatitis. (Funded by Maruho; JapicCTI number, 173740.).
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MESH Headings
- Administration, Topical
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Calcineurin Inhibitors/administration & dosage
- Dermatitis, Atopic/chemically induced
- Dermatitis, Atopic/complications
- Dermatitis, Atopic/drug therapy
- Double-Blind Method
- Drug Therapy, Combination
- Female
- Glucocorticoids/administration & dosage
- Histamine Antagonists/therapeutic use
- Humans
- Injections, Subcutaneous/adverse effects
- Intention to Treat Analysis
- Male
- Middle Aged
- Pruritus/drug therapy
- Pruritus/etiology
- Visual Analog Scale
- Young Adult
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Affiliation(s)
- Kenji Kabashima
- From the Department of Dermatology, Graduate School of Medicine, Kyoto University (K.K.), and the Departments of Clinical Development (T.M.) and Data Science (H.K.), Maruho, Kyoto, and Tokyo Women's Medical University, Tokyo (M.K.) - all in Japan
| | - Takayo Matsumura
- From the Department of Dermatology, Graduate School of Medicine, Kyoto University (K.K.), and the Departments of Clinical Development (T.M.) and Data Science (H.K.), Maruho, Kyoto, and Tokyo Women's Medical University, Tokyo (M.K.) - all in Japan
| | - Hiroshi Komazaki
- From the Department of Dermatology, Graduate School of Medicine, Kyoto University (K.K.), and the Departments of Clinical Development (T.M.) and Data Science (H.K.), Maruho, Kyoto, and Tokyo Women's Medical University, Tokyo (M.K.) - all in Japan
| | - Makoto Kawashima
- From the Department of Dermatology, Graduate School of Medicine, Kyoto University (K.K.), and the Departments of Clinical Development (T.M.) and Data Science (H.K.), Maruho, Kyoto, and Tokyo Women's Medical University, Tokyo (M.K.) - all in Japan
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15
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Abstract
IMPORTANCE Approximately 125 million people worldwide have psoriasis. Patients with psoriasis experience substantial morbidity and increased rates of inflammatory arthritis, cardiometabolic diseases, and mental health disorders. OBSERVATIONS Plaque psoriasis is the most common variant of psoriasis. The most rapid advancements addressing plaque psoriasis have been in its pathogenesis, genetics, comorbidities, and biologic treatments. Plaque psoriasis is associated with a number of comorbidities including psoriatic arthritis, cardiometabolic diseases, and depression. For patients with mild psoriasis, topical agents remain the mainstay of treatment, and they include topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics. The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy in treating it and acceptable safety profiles. Specifically, inhibitors to tumor necrosis factor α (TNF-α) include etanercept, adalimumab, certolizumab, and infliximab. Other biologics inhibit cytokines such as the p40 subunit of the cytokines IL-12 and IL-13 (ustekinumab), IL-17 (secukinumab, ixekizumab, bimekizumab, and brodalumab), and the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab, and mirikizumab). Biologics that inhibit TNF-α, p40IL-12/23, and IL-17 are also approved for the treatment of psoriatic arthritis. Oral treatments include traditional agents such as methotrexate, acitretin, cyclosporine, and the advanced small molecule apremilast, which is a phosphodiesterase 4 inhibitor. The most commonly prescribed light therapy used to treat plaque psoriasis is narrowband UV-B phototherapy. CONCLUSIONS AND RELEVANCE Psoriasis is an inflammatory skin disease that is associated with multiple comorbidities and substantially diminishes patients' quality of life. Topical therapies remain the cornerstone for treating mild psoriasis. Therapeutic advancements for moderate to severe plaque psoriasis include biologics that inhibit TNF-α, p40IL-12/23, IL-17, and p19IL-23, as well as an oral phosphodiesterase 4 inhibitor.
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Affiliation(s)
- April W Armstrong
- Keck School of Medicine, Department of Dermatology, University of Southern California Los Angeles
| | - Charlotte Read
- Keck School of Medicine, Department of Dermatology, University of Southern California Los Angeles
- Department of Medicine, Imperial College London, London, United Kingdom
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16
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Frazier W, Bhardwaj N. Atopic Dermatitis: Diagnosis and Treatment. Am Fam Physician 2020; 101:590-598. [PMID: 32412211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Atopic dermatitis (atopic eczema) is a chronic relapsing and remitting inflammatory skin disease affecting one in 10 people in their lifetime. Atopic dermatitis is caused by a complex interaction of immune dysregulation, epidermal gene mutations, and environmental factors that disrupts the epidermis causing intensely pruritic skin lesions. Repeated scratching triggers a self-perpetuating itch-scratch cycle, which can have a significant impact on the patient's quality of life. The American Academy of Dermatology has created simple diagnostic criteria based on symptoms and physical examination findings. Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers. Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups. Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment. Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate. Antistaphylococcal antibiotics are effective in treating secondary skin infections. Oral antihistamines are not recommended because they do not reduce pruritus. Evidence is lacking to support the use of integrative medicine in the treatment of atopic dermatitis. Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients.
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17
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Ravanshad Y, Azarfar A, Ravanshad S, Naderi Nasab M, Ghasemi A, Golsorkhi M, Mostafavian Z, Esmaeeli M, Mehrad Majd H. A Comparison Between Tacrolimus and Cyclosporine As Immunosuppression after Renal Transplantation in Children, A Meta-Analysis and Systematic Review. Iran J Kidney Dis 2020; 14:145-152. [PMID: 32165600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/10/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION There are some randomized trials which have already evaluated different calcineurin inhibitors (CNIs), especially comparing Tacrolimus and Cyclosporine, as immunosuppressant agents in children. However, their findings have been occasionally conflicting and thus debatable. Therefore, the evidence on safety and efficacy of immunosuppressive therapy after kidney transplantation in children has been inconclusive and argued to date. This study was aimed to compare the benefits and disadvantages of tacrolimus versus cyclosporine as the primary immunosuppression after renal transplantation in children. METHODS A systematic review and meta-analysis was done. An electronic literature review was conducted to identify appropriate studies. The outcomes were presented as relative risk, with 95% confidence intervals. RESULTS Five qualified randomized controlled trials were included in this systematic review. Tacrolimus was insignificantly superior to cyclosporine considering the total effect size of graft loss (RR = 0.67, 95% CI: 0.40 - 1.11; P > .05) and acute rejection (RR = 0.79, 95% CI: 0.59 - 1.05; P > .05). On the contrary, cyclosporine seemed to be insignificantly superior to tacrolimus regarding mortality rate (RR = 1.06, 95% CI: 0.59 - 1.90; P > .05). CONCLUSION Admitting the study limitations mainly because of the nature and case study size of the included trials, it can be concluded from our systematic review results that Tacrolimus seems insignificantly superior to Cyclosporine respecting graft loss and acute rejection. However, Cyclosporine was shown to be insignificantly superior regarding mortality rate. However additional studies with a larger sample size are highly recommended.
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Affiliation(s)
| | - Anoush Azarfar
- Kidney Transplantation Complications Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Dunaway S, Tyler K, Kaffenberger J. Update on treatments for erosive vulvovaginal lichen planus. Int J Dermatol 2020; 59:297-302. [PMID: 31631346 DOI: 10.1111/ijd.14692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/02/2019] [Accepted: 09/20/2019] [Indexed: 11/29/2022]
Abstract
Vulvovaginal lichen planus (VVLP) is a debilitating disease that causes significant pain and psychological distress. Management is made difficult by the chronic course of the disease and its resistance to treatment. While topical steroids have been accepted as the first-line treatment, they fail to achieve symptomatic control in approximately 40% of patients. Second-line therapies include other topical treatments such as calcineurin inhibitors, systemic therapies including oral steroids, methotrexate, mycophenolate mofetil, biologics, and tacrolimus, and procedural options including surgery and dilation, photodynamic therapy, and ultrasound. This review provides an overview of the current treatments and explores the level of evidence supporting each of them.
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Affiliation(s)
- Spencer Dunaway
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelly Tyler
- Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jessica Kaffenberger
- Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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19
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Yildirim E, Şahin G, Kaltuş Z, Çolak E. Effect of CYP3A5 and ABCB1 Gene Polymorphisms on Tacrolimus Blood Concentration in Renal Transplant Recipients. Clin Lab 2019; 65. [PMID: 31710427 DOI: 10.7754/clin.lab.2019.190343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Tacrolimus (Tac) is a calcineurin inhibitor (CNI). Its therapeutic range is narrow and pharmacokinetic properties vary among patients. CYP3A5 and MDR1 single-nucleotide polymorphisms (SNPs) are the most effective polymorphisms that play an significant role in the pharmacokinetics of Tac. METHODS We investigated the influence of CYP3A5 (A6986G) and MDR1 (C3435T) gene polymorphisms on Tac trough concentration (C0), dose requirements (mg/kg), and dose-adjusted concentrations (ng/mL per mg/kg/d). CYP3A5 [*1/*1 (expresser), *1/*3 (expresser); *3/*3 (non-expresser)] and MDR1 (CC, CT, TT) gene polymorphisms were determined by allele-specific polymerase chain reaction in 67 adult Turkish renal transplant patients. The Tac dose (mg/kg/d) and C0 of each patient was acquired from the patient's file and dose-adjusted concentrations (ng/mL per mg/kg/d) were calculated at the 1st, 3rd, 6th, and 12th months after transplantation. The correlated serum hematocrit, platelet, urea, creatinine, and albumin were also determined. RESULTS The CYP3A5*1/*3 and CYP3A5*3/*3 allelic frequencies were 5.97% and 94.03%, respectively. There were no patients with the CYP3A5*1/*1 genotype. Tac dose was significantly lower in *3/*3 genotype than in *1/*1 genotype (3rd and 6th months: p ≤ 0.001; 12th month: p ≤ 0.05). Dose-adjusted Tac concentration was statistically higher in the *3/*3 genotype than in *1/*1 genotype at the 3rd and 6th months (p ≤ 0.05). The allelic frequencies of MDR1 CC, CT, and TT were 26.87%, 49.25%, and 23.88%, respectively. No statistically significant differences were detected between MDR1 genotypes and in all analyzed laboratory parameters. CONCLUSIONS CYP3A5 but not MDR1 genetic polymorphisms affected the Tac pharmacokinetics and dose requirements in renal transplant recipients. Pharmacogenetic methods can be used for selecting the initial dose to individualize immunosuppressive therapy.
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Abstract
The current research aimed to investigate the correlation between the effect of Wuzhi soft capsule (WZC) on FK506 concentration and CYP3A5 gene polymorphism in patients with membranous nephropathy (MN).Seventy-five patients with idiopathic MN were enrolled and divided according to the expression of CYP3A5 gene metabolic enzyme into group A (CP3A5 metabolic enzyme function expression types CYP3A5*1/*1 type and CYP3A5*1/*3 type), and group B (non-expression type CYP3A5*3/*3 type). All patients were given oral administration of tacrolimus capsule at the initial dose of 1 mg for twice a day 1 hour before breakfast and dinner. Afterwards, the oral administration of WZC was added at the dose of 0.5 g for 3 times a day within half an hour after 3 meals.The blood concentrations of FK506 in groups A and B were significantly higher than those before administration. Compared with that before administration, the FK506 blood concentration was increased by 3.051 ± 0.774 ng/ml after adding the WZC. Besides, the blood concentrations of FK506 in group A were lower than those in group B before and after administration; meanwhile, the 24 hours total urine protein and the biochemical indexes in both groups displayed no statistically significant difference. Only 1 case of diarrhea was observed, which was relieved after the reduction of tacrolimus.Wuzhi soft capsule can significantly increase the blood concentration of FK506 in MN patients. Moreover, the CYP3A5 genotyping should be considered when WZC is used to increase the blood concentration of FK506.
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Affiliation(s)
- Zhu Zhang
- Department of Nephrology, Fuwai Central China Cardiovascular Hospital
| | - Xiaobei Lu
- Department of Nephrology, People's Hospital of Zhengzhou, Zhengzhou
| | - Leipeng Dong
- Department of Nephrology, The people's Hospital of Xuchang, Xuchang
| | - Jiwei Ma
- Department of Nephrology, First affiliated Hospital of Henan university of traditional Chinese medicine, Zhengzhou, China
| | - Xiaoguang Fan
- Department of Nephrology, Fuwai Central China Cardiovascular Hospital
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Ke P, Bao X, Zhou J, Zhu Q, Zhuang J, Hu X, Liu Y, Wu D, Xue S, Zhang X, Ma X. Central Nervous System Complications after Allogeneic Hematopoietic Stem Cell Transplantation in Children. Acta Haematol 2019; 142:217-223. [PMID: 31597154 DOI: 10.1159/000499651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/16/2019] [Indexed: 12/16/2022]
Abstract
Central nervous system complications (CNSCs) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) are common and may be a significant source of morbidity and mortality. We performed a retrospective study of 153 pediatric patients who underwent allo-HSCT to determine CNSC type, incidence, and impact on survival. A total of 34 patients (22.2%) developed CNSCs. The cumulative incidence of CNSCs at 100 days and 3 years was 18.30 and 22.73%, respectively. The most common CNSC was calcineurin inhibitor (CNI)-associated neurotoxicity (50.0%). Risk factors for CNSCs were the time from diagnosis to HSCT ≥4.8 months (p = 0.032) and the development of acute graft-versus-host disease (aGVHD) grade III-IV (p = 0.002). CNSCs after allo-HSCT negatively impacted overall survival (hazard ratio [HR] 1.97, p = 0.043) and nonrelapse mortality (HR 4.84, p < 0.001). In conclusion, CNSCs after allo-HSCT are associated with poor outcomes; patients with severe aGVHD and/or late transplantation should be given more attention.
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Affiliation(s)
- Peng Ke
- Shenzhen People's Hospital, Shenzhen, China
| | - Xiebing Bao
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | - Jihao Zhou
- Shenzhen People's Hospital, Shenzhen, China
| | - Qian Zhu
- 100th Hospital of People's Liberation Army, Suzhou, China
| | - Juan Zhuang
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | - Xiaohui Hu
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | - Yuejun Liu
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | - Depei Wu
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | - Shengli Xue
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
| | | | - Xiao Ma
- First Affiliated Hospital of Soochow University, Suzhou, China
- Jiangsu Institute of Hematology, Suzhou, China
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Tedesco-Silva H, Pascual J, Viklicky O, Basic-Jukic N, Cassuto E, Kim DY, Cruzado JM, Sommerer C, Adel Bakr M, Garcia VD, Uyen HD, Russ G, Soo Kim M, Kuypers D, Buchler M, Citterio F, Hernandez Gutierrez MP, Bernhardt P, Chadban S. Safety of Everolimus With Reduced Calcineurin Inhibitor Exposure in De Novo Kidney Transplants: An Analysis From the Randomized TRANSFORM Study. Transplantation 2019; 103:1953-1963. [PMID: 30801548 DOI: 10.1097/tp.0000000000002626] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety profiles of standard therapy versus everolimus with reduced-exposure calcineurin inhibitor (CNI) therapy using contemporary protocols in de novo kidney transplant recipients have not been compared in detail. METHODS TRANSFORM was a randomized, international trial in which de novo kidney transplant patients were randomized to everolimus with reduced-exposure CNI (N = 1014) or mycophenolic acid (MPA) with standard-exposure CNI (N = 1012), both with induction and corticosteroids. RESULTS Within the safety population (everolimus 1014, MPA 1012), adverse events with a suspected relation to study drug occurred in 62.9% versus 59.2% of patients given everolimus or MPA, respectively (P = 0.085). Hyperlipidemia, interstitial lung disease, peripheral edema, proteinuria, stomatitis/mouth ulceration, thrombocytopenia, and wound healing complications were more frequent with everolimus, whereas diarrhea, nausea, vomiting, leukopenia, tremor, and insomnia were more frequent in the MPA group. The incidence of viral infections (17.2% versus 29.2%; P < 0.001), cytomegalovirus (CMV) infections (8.1% versus 20.1%; P < 0.001), CMV syndrome (13.6% versus 23.0%, P = 0.044), and BK virus (BKV) infections (4.3% versus 8.0%, P < 0.001) were less frequent with everolimus. CMV infection was less common with everolimus versus MPA after adjusting for prophylaxis therapy in the D+/R- subgroup (P < 0.001). Study drug was discontinued more frequently due to rejection or impaired healing with everolimus, and more often due to BKV infection or BKV nephropathy with MPA. CONCLUSIONS De novo everolimus with reduced-exposure CNI yielded a comparable incidence, though a distinctly different pattern, of adverse events versus current standard of care. Both regimens are safe and effective, yet their distinct profiles may enable tailoring for individual kidney transplant recipients.
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Affiliation(s)
- Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Nikolina Basic-Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elisabeth Cassuto
- Department of Nephrology and Renal Transplantation, Hôpital Pasteur, Nice, France
| | - Dean Y Kim
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Claudia Sommerer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Valter D Garcia
- Department of Renal Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Huynh-Do Uyen
- Department of Nephrology and Hypertension, Inselspital Bern, Bern, Switzerland
| | - Graeme Russ
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Myoung Soo Kim
- Department of Transplantation Surgery, Severance Hospital Yonsei University Health System, Seoul, Republic of Korea
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, Gasthuisberg University Hospital, University of Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium
| | - Matthias Buchler
- Department of Nephrology and Renal Transplantation, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Franco Citterio
- Policlinico Foundation, A Gemelli University, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Peter Bernhardt
- Research and Development, Novartis Pharma AG, Basel, Switzerland
| | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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23
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Abstract
Vitiligo is a common acquired depigmenting skin disease characterized by a progressive loss of functional melanocytes. It may appear from the first years of life to late adulthood. Childhood vitiligo (CV), defined as vitiligo that begins before the age of 12 years, is common and may differ from post-CV in terms of epidemiology, clinical presentation, comorbidities, and treatment options. Taking into consideration the potential significant psychosocial impact of the disease on both children and their parents, all available therapeutic options must be offered to patients who desire treatment. According to the most recent guidelines, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the most commonly used treatment modalities for vitiligo in children. This review presents recent data regarding the whole spectrum of CV. Differences between CV and post-CV are also discussed.
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Affiliation(s)
- Electra Nicolaidou
- First Department of Dermatology and Venereology, National and Kapodistrian University of Athens School of Medicine, "A. Sygros" Hospital for Skin and Venereal Diseases, Athens, Greece
| | - Styliani Mastraftsi
- First Department of Dermatology and Venereology, National and Kapodistrian University of Athens School of Medicine, "A. Sygros" Hospital for Skin and Venereal Diseases, Athens, Greece.
| | - Vassiliki Tzanetakou
- First Department of Dermatology and Venereology, National and Kapodistrian University of Athens School of Medicine, "A. Sygros" Hospital for Skin and Venereal Diseases, Athens, Greece
| | - Dimitrios Rigopoulos
- First Department of Dermatology and Venereology, National and Kapodistrian University of Athens School of Medicine, "A. Sygros" Hospital for Skin and Venereal Diseases, Athens, Greece
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24
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Bischof N, Hirsch HH, Wehmeier C, Amico P, Dickenmann M, Hirt-Minkowski P, Steiger J, Menter T, Helmut H, Schaub S. Reducing calcineurin inhibitor first for treating BK polyomavirus replication after kidney transplantation: long-term outcomes. Nephrol Dial Transplant 2019; 34:1240-1250. [PMID: 30476254 DOI: 10.1093/ndt/gfy346] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Reducing immunosuppression is the mainstay of treating BK polyomavirus (BKPyV) viraemia after kidney transplantation, but the best approach, efficacy and impact are undefined. We established a standard operating procedure (SOP) treating BKPyV viraemia based on first reducing calcineurin inhibitor ('CNI first'). The aim of this study was to investigate long-term outcomes in 644 consecutive transplantations using this SOP. METHODS Patients were monitored for active BKPyV infection by urinary decoy cells and, if positive, by BKPyV viraemia. In case of sustained BKPyV viraemia >1000 copies/mL, immunosuppression was reduced stepwise according to the SOP. Patients were classified as 'no decoy cells' [n = 432 (66%)], 'decoy cells/no viraemia' [n = 107 (17%)] and 'viraemia' [n = 105 (17%)]. RESULTS At 6-years post-transplant, graft survival was ∼84%, the clinical rejection rate was ∼25% and they were not different among the three groups (P = 0.14; P = 0.91). The median estimated glomerular filtration rate at the last follow-up was similar (range 49-53 mL/min, P = 0.08). Of 105 viraemic patients, 101 (96%) cleared BKPyV viraemia. In 39% of patients, viraemia clearance followed a tacrolimus reduction. A reduction of mycophenolic acid was required in 43% and discontinuation in 3%. No short-term graft loss was directly attributable to BKPyV-associated nephropathy. After a median follow-up of 5 years after clearance of BKPyV viraemia, 11/101 patients (11%) developed clinical rejection: 7 (7%) T-cell-mediated rejection and 4 (4%) antibody-mediated rejection (ABMR). CONCLUSIONS Immunosuppression reduction based on 'CNI first' leads to similar long-term outcomes in patients with/without BKPyV viraemia and is associated with a low risk for ABMR after clearance of BKPyV viraemia. Randomized trials are needed to compare the risks and benefits of immunosuppression reduction strategies in kidney transplant patients with BKPyV viraemia.
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Affiliation(s)
- Nicole Bischof
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Hans H Hirsch
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
- Division of Infection Diagnostics, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patricia Amico
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Transplantation Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Thomas Menter
- Institute for Pathology, University Hospital Basel, Basel, Switzerland
| | - Hopfer Helmut
- Institute for Pathology, University Hospital Basel, Basel, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Transplantation Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland
- HLA-Diagnostic and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
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25
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Abstract
Frontal fibrosing alopecia (FFA), first described by Kossard in the early 1990s, is a form of primary lymphocytic cicatricial alopecia characterized by selective involvement of the frontotemporal hairline and eyebrows. Since the original description, an increasing number of cases have been reported worldwide and the clinical aspects of the disease have been better characterized. However, the pathogenesis is still unknown and several hypotheses have been made about possible triggering factors, including hormones, neurogenic inflammation, smoking, UV filters, and ingredients in leave-on facial products. A genetic basis has also been hypothesized as the disease can occur in siblings and members of the same family. Besides its pathogenesis, research is also focused on treatment; FFA is a chronic condition and at present there is no validated or approved treatment for this disorder. Commonly prescribed topical treatments include corticosteroids, minoxidil, and calcineurin inhibitors. Systemic treatments include 5α-reductase inhibitors, hydroxychloroquine, and retinoids. Intralesional triamcinolone acetonide is also utilized, especially for the eyebrows. Other possible treatments include pioglitazone, naltrexone, tofacitinib, and lasers.
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Affiliation(s)
- Matilde Iorizzo
- Private Dermatology Practice, Viale Stazione 16, 6500, Bellinzona, Switzerland.
| | - Antonella Tosti
- Fredric Brandt Endowed Professor of Dermatology, Miller School of Medicine, University of Miami, Miami, FL, USA
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26
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Abstract
Cutaneous lupus erythematosus (CLE)-a common presentation of lupus erythematosus-may exist independently or as a part of the systemic manifestations of systemic lupus erythematosus. The effects of living with and treating a chronic condition such as CLE can be debilitating to a patient's health and finances. The management of patients with CLE is made particularly challenging by poor compliance, limited therapeutic options, scarcity of evidence supporting their use, and significant differences in costs of medications. Effective management of CLE should center on prevention, individualized treatment regimens, and a mutual understanding of the challenges that patients with CLE face. This article seeks to provide an overview of the efficacy, safety, and cost of therapeutic options for CLE.
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Affiliation(s)
- J D Rosen
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - S Paul
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - A Maderal
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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27
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de Kort EA, de Lil HS, Bremmers MEJ, van Groningen LFJ, Blijlevens NMA, Huls G, Brüggemann RJM, van Dorp S, van der Velden WJFM. Cyclosporine A trough concentrations are associated with acute GvHD after non-myeloablative allogeneic hematopoietic cell transplantation. PLoS One 2019; 14:e0213913. [PMID: 30897127 PMCID: PMC6428294 DOI: 10.1371/journal.pone.0213913] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/04/2019] [Indexed: 01/08/2023] Open
Abstract
Low plasma CsA concentrations (<300–350 ng/mL) early following allogeneic hematopoietic stem cell transplantation (HSCT) is associated with an increased risk of developing acute graft-versus-host disease (aGvHD). Nevertheless, the current optimal target trough concentration for CsA following HSCT is considered to be 200–400 ng/mL. Here, we performed a retrospective analysis of a homogeneous group of 129 patients who received HSCT after non-myeloablative conditioning, and we analyzed the impact of CsA trough concentration measured during the first four weeks (CsA W1-4) on the incidence aGvHD, relapse-free survival (RFS), non-relapse mortality (NRM), overall survival (OS), and toxicity. The 180-day incidence of grade II-IV aGvHD was 25% (32/129 patients). In multivariate analysis the incidence of grade II-IV aGvHD was significantly lower among patients with a CsA W1-4 concentration ≥350 ng/mL compared to patients with a concentration <350 ng/mL (18% versus 38%, respectively; P = 0.007), with a hazard ration (HR) of 0.38 (95% CI: 0.19–0.77). In contrast, we found no correlation between CsA trough concentration and RFS, NRM, or OS. Moreover, we found an increased incidence of hypomagnesemia at higher CsA concentrations, but no difference in the incidence of acute renal toxicity, hepatic toxicity, or electrolyte imbalance. Interestingly, 30% of patients experienced hyponatremia with no apparent cause other than the use of CsA, with urinalysis suggesting SIADH as the underlying cause. Our findings suggest that a CsA trough concentration of 350–500 ng/mL might be more appropriate in the first month following non-myeloablative HSCT.
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Affiliation(s)
- Elizabeth A. de Kort
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Heleen S. de Lil
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Manita E. J. Bremmers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Gerwin Huls
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Suzanne van Dorp
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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28
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Menezes MCS, Vasconcellos LDS, Nunes CB, Alberti LR. Evaluation of the use of tacrolimus ointment for the prevention of hypertrophic scars in experimental model. An Bras Dermatol 2019; 94:164-171. [PMID: 31090821 PMCID: PMC6486078 DOI: 10.1590/abd1806-4841.20197490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 03/31/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Tacrolimus, for its activity on modulation of collagen production and fibroblast activity, may have a role in the prevention of hypertrophic scars. OBJECTIVES Evaluate macroscopic, microscopic, metabolic, laboratory effects and side effects of the use of topical tacrolimus ointment, in different concentrations, in the prevention of hypertrophic scars. METHODS Twenty-two rabbits were submitted to the excision of 2 fragments of 1 cm of each ear, 4 cm apart, down to cartilage. The left ear of the animals was standardized as control and Vaseline applied twice a day. The right ear received tacrolimus ointment, at concentrations of 0.1% on the upper wound and 0.03% on the lower wound, also applied twice a day. Macroscopic, microscopic, laboratory criteria and the animals' weight were evaluated after 30 days of the experiment. RESULTS Wounds treated with tacrolimus, at concentrations of 0.1% and 0.03%, when compared to control, showed a lower average degree of thickening (p = 0.048 and p <0.001, respectively). The average of scar thickness and lymphocyte, neutrophil and eosinophil concentrations are lower in the treated wounds compared to the control (p <0.001, p=0.022, p=0.007, p=0.044, respectively). The mean concentration of lymphocytes is lower in wounds treated with a higher concentration of the drug (p=0.01). STUDY LIMITATIONS experiment lasted only 30 days. CONCLUSIONS Tacrolimus at the 2 concentrations evaluated reduced the severity of inflammatory changes and positively altered the macroscopic aspect of the scar in the short term. Its use was shown to be safe, with no evidence of systemic or local adverse effects.
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Affiliation(s)
| | - Leonardo de Souza Vasconcellos
- Department of Complementary Propaedeutic, Faculdade de
Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil
| | - Cristiana Buzelin Nunes
- Department of Anatomical Pathology, Faculdade de
Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil
- Health and Biological Science institute, Curso de
Medicina, Centro Universitário de Belo Horizonte, Belo Horizonte (MG), Brazil
- Service of Pathology, Instituto Moacyr Junqueira, Belo
Horizonte (MG), Brazil
| | - Luiz Ronaldo Alberti
- Teaching and Research Center, Santa Casa de Belo
Horizonte, Belo Horizonte (MG), Brazil
- Department of Surgery, Universidade Federal de Minas
Gerais, Belo Horizonte (MG), Brazil
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29
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Sommerer C, Suwelack B, Dragun D, Schenker P, Hauser IA, Witzke O, Hugo C, Kamar N, Merville P, Junge M, Thaiss F, Nashan B. An open-label, randomized trial indicates that everolimus with tacrolimus or cyclosporine is comparable to standard immunosuppression in de novo kidney transplant patients. Kidney Int 2019; 96:231-244. [PMID: 31027892 DOI: 10.1016/j.kint.2019.01.041] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/25/2019] [Accepted: 01/31/2019] [Indexed: 01/05/2023]
Abstract
This is a randomized trial (ATHENA study) in de novo kidney transplant patients to compare everolimus versus mycophenolic acid (MPA) with similar tacrolimus exposure in both groups, or everolimus with concomitant tacrolimus or cyclosporine (CsA), in an unselected population. In this 12-month, multicenter, open-label study, de novo kidney transplant recipients were randomized to everolimus with tacrolimus (EVR/TAC), everolimus with CsA (EVR/CsA) or MPA with tacrolimus (MPA/TAC), with similar tacrolimus exposure in both groups. Non-inferiority of the primary end point (estimated glomerular filtration rate [eGFR] at month 12), assessed in the per-protocol population of 338 patients, was not shown for EVR/TAC or EVR/CsA versus MPA/TAC. In 123 patients with TAC levels within the protocol-specified range, eGFR outcomes were comparable between groups. The mean increase in eGFR during months 1 to 12 post-transplant, analyzed post hoc, was similar with EVR/TAC or EVR/CsA versus MPA/TAC. The incidence of treatment failure (biopsy proven acute rejection, graft loss or death) was not significant for EVR/TAC but significant for EVR/CsA versus MPA/TAC. Most biopsy-proven acute rejection events in this study were graded mild (BANFF IA). There were no differences in proteinuria between groups. Cytomegalovirus and BK virus infection were significantly more frequent with MPA/TAC. Thus, everolimus with TAC or CsA showed comparable efficacy to MPA/TAC in de novo kidney transplant patients. Non-inferiority of renal function, when pre-specified, was not shown, but the mean increase in eGFR from month 1 to 12 was comparable to MPA/TAC.
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Affiliation(s)
- Claudia Sommerer
- Nephrology Unit, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Suwelack
- Department of Internal Medicine D, Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Duska Dragun
- Department of Nephrology and Intensive Care Medicine, Charité Universtätsmedizin Berlin, Berlin, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Ingeborg A Hauser
- Department of Nephrology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Duisburg-Essen, Essen, Germany; Department of Nephrology, University Duisburg-Essen, Essen, Germany
| | - Christian Hugo
- University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Pierre Merville
- Department of Nephrology-Transplantation-Dialysis-Apheresis, CHU Bordeaux, Bordeaux, France
| | | | - Friedrich Thaiss
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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30
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Emal D, Rampanelli E, Claessen N, Bemelman FJ, Leemans JC, Florquin S, Dessing MC. Calcineurin inhibitor Tacrolimus impairs host immune response against urinary tract infection. Sci Rep 2019; 9:106. [PMID: 30643171 PMCID: PMC6331640 DOI: 10.1038/s41598-018-37482-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/18/2018] [Indexed: 01/14/2023] Open
Abstract
Calcineurin inhibitor Tacrolimus, is a potent immunosuppressive drug widely used in order to prevent acute graft rejection. Urinary tract infection (UTI) is the most frequent infectious complication in renal transplant patients and long-term use of Tacrolimus might be involved in higher susceptibility to bacterial infections. It remains largely unknown how Tacrolimus affects the host innate immune response against lower and upper UTI. To address this issue, we used experimental UTI model by intravesical inoculation of uropathogenic E.coli in female wild-type mice pre-treated with Tacrolimus or solvent (CTR). We found that Tacrolimus pre-treated mice displayed higher bacterial loads (cystitis, pyelonephritis and bacteremia) than CTR mice. Granulocytes from Tacrolimus pre-treated mice phagocytized less E. coli, released less MPO and expressed decreased levels of CXCR2 receptor upon infection. Moreover, Tacrolimus reduced TLR5 expression in bladder macrophages during UTI. This immunosuppressive state can be explained by the upregulation of TLR-signaling negative regulators (A20, ATF3, IRAK-M and SOCS1) and parallel downregulation of TLR5 as observed in Tacrolimus treated granulocytes and macrophages. We conclude that Tacrolimus impairs host innate immune responses against UTI.
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Affiliation(s)
- Diba Emal
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Elena Rampanelli
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nike Claessen
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaklien C Leemans
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark C Dessing
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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31
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OTSUKA TAKAFUMI, OOI MAKOTO, TOBIMATSU KAZUTOSHI, WAKAHARA CHIKA, WATANABE DAISUKE, ADACHI SOICHIRO, YASUTOMI EIICHIRO, YAMAIRI HARUKA, KU YUNA, YOSHIDA MASARU, HOSHI NAMIKO, KODAMA YUZO. Short-Term and Long-Term Outcomes of Infliximab and Tacrolimus Treatment for Moderate to Severe Ulcerative Colitis: Retrospective Observational Study. Kobe J Med Sci 2018; 64:E140-E148. [PMID: 30728340 PMCID: PMC6347042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/20/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND/AIMS While some studies have shown that IFX and TAC exhibit similar efficacy against UC in the short-term, it is unclear which drug produces better long-term outcomes. In this study, we compared the long-term efficacy of IFX and TAC in patients with moderate to severe UC. METHODS This retrospective study was conducted from 2009 to 2017. It included patients with no history of IFX or TAC treatment. We analyzed the clinical response and remission rates at 12 and 52 weeks, and colectomy-free and relapse-free survival were evaluated until the end of the study. RESULTS At 12 weeks, 94.4% and 77.8% of the patients in the IFX group (n = 18) had demonstrated clinical responses and clinical remission, respectively, whereas 72.7% of the patients in the TAC group (n = 11) exhibited clinical responses and clinical remission. The clinical response, clinical remission, and colectomy-free rates did not differ significantly between the groups. At 52 weeks, clinical responses and clinical remission had been achieved in 76.5% and 70.6% of the patients both in the IFX group, respectively. In the TAC group, clinical responses and clinical remission were achieved in 50.0% of patients. Relapse-free and colectomy-free survival were estimated significantly better in IFX group evaluated by Kaplan-Meier curves. CONCLUSION This study indicates that IFX and TAC produce similar short-term outcomes in UC patients, but IFX produces better long-term outcomes than TAC especially with avoidance of colectomy. Our data suggest that IFX therapy may be prioritized over TAC for the treatment of moderate to severe UC.
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Affiliation(s)
- TAKAFUMI OTSUKA
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - MAKOTO OOI
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - KAZUTOSHI TOBIMATSU
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - CHIKA WAKAHARA
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - DAISUKE WATANABE
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - SOICHIRO ADACHI
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - EIICHIRO YASUTOMI
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - HARUKA YAMAIRI
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - YUNA KU
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - MASARU YOSHIDA
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Division of Metabolomics Research, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - NAMIKO HOSHI
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - YUZO KODAMA
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Mohn CH, Blix HS, Halvorsen JA, Nafstad P, Valberg M, Lagerløv P. Incidence Trends of Atopic Dermatitis in Infancy and Early Childhood in a Nationwide Prescription Registry Study in Norway. JAMA Netw Open 2018; 1:e184145. [PMID: 30646341 PMCID: PMC6324394 DOI: 10.1001/jamanetworkopen.2018.4145] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/11/2018] [Indexed: 11/20/2022] Open
Abstract
Importance With increasing prevalence of atopic dermatitis (AD) and its manifestation in most countries, together with the supporting evidence of the progression to other atopic phenotypes, AD has developed into a worldwide public health concern. The presence of the disease of has increased since the 1950s, but some recent studies suggest a stationary or decreasing trend. Objective To analyze a nationwide health register based on prescription data to determine the incidence rate (IR) of AD in an entire pediatric population. Design, Setting, and Participants All children resident in Norway younger than 6 years from January 1, 2009, through December 31, 2015, were included in this cohort study. Medical diagnoses and disease-specific medications were used as a proxy for identifying children with AD in this population-based prescription registry study. The prescription study was terminated in 2016. The total number of 295 286 disease-specific prescriptions was analyzed from August 2016 through December 2017. The hypothesis was formulated before, during, and after the data collection. Main Outcomes and Measures All children with a medical diagnosis of AD or eczema based on at least 2 prescriptions of topical corticosteroids or at least 1 prescription of topical calcineurin inhibitors. Incidence rates per person-year (PY) and IR ratios were calculated. Results A total of 295 286 disease-specific prescriptions were dispensed to 122 470 children, of whom 63 460 had AD and 56 009 (88.3%) had reimbursed prescriptions and associated AD diagnoses. The annual Norwegian study population (aged <6 years) increased from 357 451 children in 2009 to 373 954 in 2015. The overall IR increased from 0.028 per PY (95% CI, 0.028-0.029 per PY) in 2009 to 0.034 per PY (95% CI, 0.033-0.035 per PY) in 2014. For children younger than 1 year, the IR increased from 0.052 per PY (95% CI, 0.050-0.053 PY) in 2009 to 0.073 per PY (95% CI, 0.071-0.075 per PY) in 2014. In this age group, the IR was 53% higher in boys compared with girls (IR ratio, 1.53; 95% CI, 1.49-1.57; P < .001). The incidence proportion before the age of 6 years was 17.4% (95% CI, 17.2%-17.7%). The primary seasons for the onset of AD were winter and spring. Conclusions and Relevance This nationwide study suggests an increase in the IR of pediatric AD, especially among children younger than 1 year. This study's findings suggest that increase occurred with a higher IR during winter and spring seasons. Atopic dermatitis had an earlier onset in boys than in girls. During the study period, more than 1 in 6 children younger than 6 years had, at some point, been affected by AD.
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Affiliation(s)
- Cathrine H. Mohn
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Hege Salvesen Blix
- Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Jon Anders Halvorsen
- Department of Dermatology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Per Nafstad
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Valberg
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Per Lagerløv
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Bashir B, Stickle DF, Chervoneva I, Kraft WK. Drug-Drug Interaction Study of Apixaban with Cyclosporine and Tacrolimus in Healthy Volunteers. Clin Transl Sci 2018; 11:590-596. [PMID: 29972633 PMCID: PMC6226116 DOI: 10.1111/cts.12580] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/18/2018] [Indexed: 12/21/2022] Open
Abstract
Apixaban is metabolized by cytochrome P450 (CYP) 3A4 in the liver and intestine, undergoes direct intestinal excretion, and is a substrate to permeability glycoprotein (P-gp) and breast cancer resistance protein (BCRP) transporters. We examined the drug interactions between cyclosporine and tacrolimus (combined inhibitors of CYP3A4, P-gp, and BCRP) with apixaban in 12 healthy adult male volunteers. Apixaban 10 mg was administered orally alone, in combination with 100 mg cyclosporine or 5 mg tacrolimus. Co-administration with cyclosporine resulted in increase in apixaban maximum plasma concentration (Cmax ) and area under the plasma concentration-time curve from time zero to the last quantifiable concentration (AUC(0-tlast) ) with associated geometric mean ratios (GMRs) and 90% confidence intervals (CIs) of 143% (112, 183) and 120% (97, 148), respectively. Co-administration with tacrolimus resulted in reduction in apixaban Cmax and AUC(0-tlast) with associated GMRs (90% CI) of 87% (69, 112) and 78% (63, 97), respectively. The observed changes in apixaban exposure margins with cyclosporine or tacrolimus are within the range of the historical clinical development program, therefore, apixaban dose adjustments are not warranted.
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Affiliation(s)
- Babar Bashir
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
- Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Douglas F. Stickle
- Department of PathologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Inna Chervoneva
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Walter K. Kraft
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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Hao G, Huang X, Zhang D, Zheng Y, Shi H, Li Y, Jacqz‐Aigrain E, Zhao W. Population pharmacokinetics of tacrolimus in children with nephrotic syndrome. Br J Clin Pharmacol 2018; 84:1748-1756. [PMID: 29637588 PMCID: PMC6046506 DOI: 10.1111/bcp.13605] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/28/2018] [Accepted: 03/04/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS Nephrotic syndrome (NS) is the most common clinical manifestation of glomerular disease in children. Currently, tacrolimus (TAC) is widely used in children with NS. However, pharmacokinetic data in children with nephrotic syndrome is limited. This study was intended to evaluate the population pharmacokinetics (PPK) of TAC in paediatric NS and to optimize dosing regimen. METHODS Blood samples from NS children treated with TAC were collected and the blood concentrations of TAC were detected using HPLC-MS/MS. A PPK model was developed using NONMEM software. Pharmacogenetic analysis was carried out in the CYP3A5 gene. RESULTS The data from 28 children were used for PPK analysis. A one-compartment model and first-order elimination were accorded with the TAC data in paediatric NS. A covariate analysis showed that body weight and CYP3A5 genotype significantly affected TAC pharmacokinetics. Monte Carlo simulation indicated that NS children with CYP3A5*3/*3 receiving 0.10 mg kg-1 dose-1 twice daily and NS children with CYP3A5*1 receiving 0.25 mg kg-1 dose-1 twice daily TAC could achieve the target concentrations of 5-10 ng ml-1 . CONCLUSION The PPK of TAC was estimated in children with NS and a CYP3A5 genotype-based dosing regimen was set up based on simulations.
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Affiliation(s)
- Guo‐Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical SciencesShandong UniversityJinanChina
| | - Xin Huang
- Department of Pharmacy, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
| | - Dong‐Feng Zhang
- Department of Pediatric NephrologyChildren's Hospital of Hebei ProvinceShijiazhuangChina
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical SciencesShandong UniversityJinanChina
| | - Hai‐Yan Shi
- Department of Pharmacy, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
| | - Yan Li
- Department of Pharmacy, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
| | - Evelyne Jacqz‐Aigrain
- Department of Pediatric NephrologyChildren's Hospital of Hebei ProvinceShijiazhuangChina
- Department of Pediatric Pharmacology and PharmacogeneticsHôpital Robert Debré, APHPParisFrance
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical SciencesShandong UniversityJinanChina
- Department of Pharmacy, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
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Abstract
RATIONALE TAFRO syndrome is a systemic inflammatory disorder characterized by thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly. In contrast to that in multicentric Castleman disease, interleukin-6 targeting strategies seem ineffective in some TAFRO syndrome cases; however, the optimal treatment remains unclear. Here, we report 2 cases of TAFRO syndrome, where 1 with cardiomyopathy, successfully treated with tacrolimus. This is the first case report of successful treatment with tacrolimus in TAFRO syndrome. PATIENT CONCERNS Both patients (cases 1 and 2) developed fever, anasarca, thrombocytopenia, renal dysfunction, and mild hepatosplenomegaly. DIAGNOSES In both patients, lymph node pathology revealed mixed type Castleman disease-like features, and bone marrow showed reticulin myelofibrosis. TAFRO syndrome was diagnosed based on the patients' laboratory, clinical, and pathologic findings. In case 2, we observed a rare complication of cardiomyopathy with no evidence of takotsubo cardiomyopathy or viral myocarditis. INTERVENTIONS AND OUTCOMES In case 1, tocilizumab combined with glucocorticoids was ineffective and caused septic shock; additionally, cyclosporine A was discontinued because of hepatotoxicity. However, tacrolimus was effective in resolving TAFRO syndrome without any adverse events. In case 2, tacrolimus completely reversed TAFRO syndrome and was also effective in cardiomyopathy. LESSONS This report suggests that tacrolimus is potentially effective and safe as an initial treatment and a glucocorticoid-sparing agent. Our literature review shows that calcineurin inhibitors, including tacrolimus, may be effective in TAFRO syndrome. Since previous studies indicate a role of Th1 inflammation in TAFRO syndrome pathogenesis, tacrolimus may, therefore, be effective in treating TAFRO syndrome.
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Gerner T, Skov L, Thyssen JP. [Atopic dermatitis]. Ugeskr Laeger 2018; 180:V04170331. [PMID: 29393034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Atopic dermatitis is a chronic and relapsing inflammatory skin disease. The clinical features vary among different age and ethnic groups, but pruritus is a hallmark. The treatment of atopic dermatitis includes skin barrier restoration with daily application of moisturizers. Topical corticosteroids and calcineurin inhibitors are first-line treatment for acute flares. In severe cases, immunosuppressive drugs are indicated. Targeted biological drugs are being tested in clinical trials.
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Abstract
Granuloma faciale is an uncommon benign chronic dermatosis characterized by reddish-brown to violaceous asymptomatic plaques appearing predominantly on the face. The pathogenesis of granuloma faciale remains unclear, and it is frequently unresponsive to therapy. This systematic review aims to summarize all recent publications on the management of granuloma faciale. The publications are mainly individual case reports, small case series and a few retrospective studies. Treatment options included topical, intralesional and systemic corticosteroids, topical pimecrolimus and tacrolimus, topical and systemic dapsone, systemic hydroxychloroquine, clofazimine, and tumour necrosis factor-alpha inhibitors. More invasive therapies using lasers as well as cryosurgery and surgery were also reported. Topical glucocorticosteroids and tacrolimus remain treatments of first choice, possibly supplemented by topical dapsone.
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Affiliation(s)
- Claudia Lindhaus
- Department of Dermatology and Allergology, University Hospital Jena, Erfurter Strasse 35, DE-07743 Jena, Germany.
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Manzia TM, Angelico R, Toti L, Grimaldi C, Sforza D, Vella I, Tariciotti L, Lenci I, Breshanaj G, Baiocchi L, Tisone G. Ab initio Everolimus-based Versus Standard Calcineurin Inhibitor Immunosuppression Regimen in Liver Transplant Recipients. Transplant Proc 2018; 50:175-183. [PMID: 29407305 DOI: 10.1016/j.transproceed.2017.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/13/2017] [Accepted: 12/12/2017] [Indexed: 02/05/2023]
Abstract
AIM We designed a retrospective case-control study to determine the efficacy and feasibility of everolimus (EVR) combined with low-dose tacrolimus (Tac) ab initio versus standard-dose Tac after liver transplantation (LT). METHODS Seventy-one adult LT patients, receiving EVR and low-dose Tac without corticosteroids or induction therapy from postoperative day 1 (EVR group) were compared with a well-matched control group of 61 recipients treated with standard-dose Tac in association with antimetabolite. RESULTS Baseline characteristics for the two groups were comparable. The overall patient and graft survival rates were similar (P = .908). Liver function was stable during the follow-up. In the EVR group, biopsy-proven acute rejection occurred in two cases (2.8%), whereas chronic rejection occurred in one (1.4%). The EVR group experienced a better renal function already after 2 weeks (estimated glomerular filtration rate: 89.85 [36.46 to 115.3] mL/min/1.73 m2 vs. 68.77 [16.11 to 115.42] mL/min/1.73 m2; P = .013), which was also observed after a median time of 27 months (range, 0 to 82 months) from LT (estimated glomerular filtration rate: 80 [45 to 118.3] mL/min/1.73 m2 vs. 70.9 [45 to 88.4] mL/min/1.73 m2; P = .04). After a median time of 27 months, the EVR group showed lower incidence of arterial hypertension and insulin-dependent diabetes mellitus. CONCLUSION Ab initio EVR-based immunosuppression could be a valid option immediately after surgery in recipients at high-risk for post-LT renal impairment.
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Affiliation(s)
- T M Manzia
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy.
| | - R Angelico
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy; Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesu` Children's Research Hospital IRCCS, Rome, Italy
| | - L Toti
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
| | - C Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesu` Children's Research Hospital IRCCS, Rome, Italy
| | - D Sforza
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
| | - I Vella
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
| | - L Tariciotti
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
| | - I Lenci
- Department of Hepatology and Gastroenterology, Liver Unit, Tor Vergata University of Rome, Italy
| | - G Breshanaj
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
| | - L Baiocchi
- Department of Hepatology and Gastroenterology, Liver Unit, Tor Vergata University of Rome, Italy
| | - G Tisone
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Italy
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Wong LS, Otsuka A, Yamamoto Y, Nonomura Y, Nakashima C, Kitayama N, Usui K, Honda T, Kabashima K. TRPA1 channel participates in tacrolimus-induced pruritus in a chronic contact hypersensitivity murine model. J Dermatol Sci 2017; 89:207-209. [PMID: 29128286 DOI: 10.1016/j.jdermsci.2017.10.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/29/2017] [Accepted: 10/25/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Lai San Wong
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Atsushi Otsuka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Translational research department for skin and brain diseases, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawara, Sakyo-ku, Kyoto, Japan.
| | - Yasuo Yamamoto
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Central Pharmaceutical Research Institute, Japan Tobacco, Japan
| | - Yumi Nonomura
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chisa Nakashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naomi Kitayama
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Usui
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Central Pharmaceutical Research Institute, Japan Tobacco, Japan
| | - Tetsuya Honda
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Kabashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Singapore Immunology Network (SIgN) and Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), Biopolis, 139668, Singapore.
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Lemoine S, Pillot B, Augeul L, Rabeyrin M, Varennes A, Normand G, Baetz D, Ovize M, Juillard L. Dose and timing of injections for effective cyclosporine A pretreatment before renal ischemia reperfusion in mice. PLoS One 2017; 12:e0182358. [PMID: 28796779 PMCID: PMC5552114 DOI: 10.1371/journal.pone.0182358] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022] Open
Abstract
Background There is experimental evidence that lethal ischemia-reperfusion injury (IRI) is largely due to mitochondrial permeability transition pore (mPTP) opening, which can be prevented by cyclosporine A (CsA). The aim of our study is to show that a higher dose of CsA (10 mg/kg) injected just before ischemia or a lower dose of CsA (3 mg/kg) injected further in advance of ischemia (1 h) protects the kidneys and improves mitochondrial function. Methods All mice underwent a right unilateral nephrectomy followed by 30 min clamping of the left renal artery. Mice in the control group did not receive any pharmacological treatment. Mice in the three groups treated by CsA were injected at different times and with different doses, namely 3 mg/kg 1 h or 10 min before ischemia or 10 mg/kg 10 min before ischemia. After 24 h of reperfusion, the plasma creatinine level were measured, the histological score was assessed and mitochondria were isolated to calculate the calcium retention capacity (CRC) and level of oxidative phosphorylation. Results Mortality and renal function was significantly higher in the CsA 10 mg/kg-10 min and CsA 3mg/kg-1 h groups than in the CsA 3mg/kg-10 min group. Likewise, the CRC was significantly higher in the former two groups than in the latter, suggesting that the improved renal function was due to a longer delay in the opening of the mPTP. Oxidative phosphorylation levels were also higher 24 h after reperfusion in the protected groups. Conclusions Our results suggest that the protection afforded by CsA is likely limited by its availability. The dose and timing of the injections are therefore crucial to ensure that the treatment is effective, but these findings may prove challenging to apply in practice.
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Affiliation(s)
- Sandrine Lemoine
- Université Lyon1, Inserm 1060CarMeN, Lyon, France
- Renal function unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Nephrology department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- * E-mail:
| | - Bruno Pillot
- Université Lyon1, Inserm 1060CarMeN, Lyon, France
| | | | - Maud Rabeyrin
- Anatomopathology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Annie Varennes
- Biology department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Gabrielle Normand
- Université Lyon1, Inserm 1060CarMeN, Lyon, France
- Nephrology department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Michel Ovize
- Université Lyon1, Inserm 1060CarMeN, Lyon, France
- Cardiovascular Explorations, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
| | - Laurent Juillard
- Université Lyon1, Inserm 1060CarMeN, Lyon, France
- Nephrology department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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Mallat SG, Tanios BY, Itani HS, Lotfi T, McMullan C, Gabardi S, Akl EA, Azzi JR. CMV and BKPyV Infections in Renal Transplant Recipients Receiving an mTOR Inhibitor-Based Regimen Versus a CNI-Based Regimen: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Clin J Am Soc Nephrol 2017; 12:1321-1336. [PMID: 28576905 PMCID: PMC5544521 DOI: 10.2215/cjn.13221216] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The objective of this meta-analysis is to compare the incidences of cytomegalovirus and BK polyoma virus infections in renal transplant recipients receiving a mammalian target of rapamycin inhibitor (mTOR)-based regimen compared with a calcineurin inhibitor-based regimen. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a comprehensive search for randomized, controlled trials up to January of 2016 addressing our objective. Other outcomes included acute rejection, graft loss, serious adverse events, proteinuria, wound-healing complications, and eGFR. Two review authors selected eligible studies, abstracted data, and assessed risk of bias. We assessed quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS We included 28 randomized, controlled trials with 6211 participants classified into comparison 1: mTOR inhibitor versus calcineurin inhibitor and comparison 2: mTOR inhibitor plus reduced dose of calcineurin inhibitor versus regular dose of calcineurin inhibitor. Results showed decreased incidence of cytomegalovirus infection in mTOR inhibitor-based group in both comparison 1 (risk ratio, 0.54; 95% confidence interval, 0.41 to 0.72), with high quality of evidence, and comparison 2 (risk ratio, 0.43; 95% confidence interval, 0.24 to 0.80), with moderate quality of evidence. The available evidence neither confirmed nor ruled out a reduction of BK polyoma virus infection in mTOR inhibitor-based group in both comparisons. Secondary outcomes revealed more serious adverse events and acute rejections in mTOR inhibitor-based group in comparison 1 and no difference in comparison 2. There was no difference in graft loss in both comparisons. eGFR was higher in the mTOR inhibitor-based group in comparison 1 (mean difference =4.07 ml/min per 1.73 m2; 95% confidence interval, 1.34 to 6.80) and similar to the calcineurin inhibitor-based group in comparison 2. More proteinuria and wound-healing complications occurred in the mTOR inhibitor-based groups. CONCLUSIONS We found moderate- to high-quality evidence of reduced risk of cytomegalovirus infection in renal transplant recipients in the mTOR inhibitor-based compared with the calcineurin inhibitor-based regimen. Our review also suggested that a combination of a mTOR inhibitor and a reduced dose of calcineurin inhibitor may be associated with similar eGFR and rates of acute rejections and serious adverse events compared with a standard calcineurin inhibitor-based regimen at the expense of higher incidence of proteinuria and wound-healing complications.
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Affiliation(s)
| | | | - Houssam S. Itani
- Division of Nephrology, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
| | | | - Ciaran McMullan
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Steven Gabardi
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Elie A. Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jamil R. Azzi
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
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Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
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Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
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Abstract
Itch, or pruritus, is a hallmark feature of atopic dermatitis (AD). The impact of AD-related pruritus can range from mildly distressing or distracting to completely disabling. Traditionally, management of itch in AD patients has focused on restoring the altered skin barrier with topical emollients and/or reducing inflammation. A growing emphasis has been placed on directly targeting the neural transmission pathways that mediate itch signaling. Off-label use of neuromodulatory agents has helped reduce this aggravating symptom in atopic patients. This article reviews the current literature on the use of neuromodulatory agents and nonpharmacologic alternative therapies used to treat AD-related pruritus.
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Affiliation(s)
- Sarina B Elmariah
- Department of Dermatology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Pereira M, Guerra J, Neves M, Gonçalves J, Santana A, Nascimento C, da Costa AG. Predictive Factors of Acute Rejection in Low Immunologic Risk Kidney Transplant Recipients Receiving Basiliximab. Transplant Proc 2017; 48:2280-2283. [PMID: 27742279 DOI: 10.1016/j.transproceed.2016.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The optimal immunosuppressive induction therapy in kidney transplant recipients with low immunologic risk of acute rejection (AR) is still controversial. The use of basiliximab (BSX) has led to a significant decrease of AR with a low side effect profile. OBJECTIVE This study sought to evaluate predictive risk factors for AR in low immunologic risk patients subjected to immunosuppressive induction therapy with BSX. METHODS We reviewed all low immunologic risk patients (panel reactive antibody [PRA] level <50%, who had undergone a first deceased-donor transplant) subjected to immunosuppressive induction therapy with BSX, calcineurin inhibitor, mycophenolate mofetil, and prednisolone (n = 346). AR was defined as any rejection occurring until 12 months posttransplantation. Predictive risk factors for AR were evaluated by logistic regression and, to find the best cut-off of PRA related to a higher incidence of AR, receiver-operator characteristic (ROC) curve analysis was performed. RESULTS The rate of AR was 7.8%. Multivariate logistic regression analysis identified age at the time of transplantation (P = .040) and PRA level (P = .001) as independent risk factors for AR. ROC curve analysis confirmed that PRA >10% was related to an increased incidence of AR (19.2% vs 6.0%, P = .005). CONCLUSIONS A higher incidence of AR was observed in low immunologic risk kidney transplant patients with a PRA level >10%. These data support the use of more intensive immunosuppressive induction therapy in patients with low immunologic risk and a PRA level >10%.
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Affiliation(s)
- M Pereira
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.
| | - J Guerra
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - M Neves
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - J Gonçalves
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - A Santana
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - C Nascimento
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - A G da Costa
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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46
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Flores-Terry MA, Zamberk Majlis P, Franco-Muñoz M, Vera-Iglesias E, García-Arpa M, Martín-Dávila F. Dermatosis papular acantolítica de la vulva con buena respuesta a tacrólimus tópico. Dermatol Online J 2017; 23:13030/qt13x8t8fm. [PMID: 28541878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/19/2017] [Indexed: 06/07/2023] Open
Abstract
Papular acantholytic dermatosis of the vulva is a rare, chronic disorder and is an entity that remains to be fully understood. It shares clinical and histopathological overlap with Darier disease and Hailey-Hailey disease. We describe a 30-year-old woman with papular acantholytic dermatosis of the vulva. The lesions consisted of whitish papules and erosions on the labia majora. Histologically, there was hyperkeratosis and focal parakeratosis with acantholytic and dyskeratotic cells. She did not respond completely to topical steroids but clinical improvement occurred after the use of topical tacrolimus.
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Criscuolo AA, Schipani C, Cannizzaro MV, Messinese S, Chimenti S, Piccione E, Saraceno R. New therapeutic approaches in the treatment of anogenital lichen sclerosus: does photodynamic therapy represent a novel option? GIORN ITAL DERMAT V 2017; 152:117-121. [PMID: 26632959 DOI: 10.23736/s0392-0488.16.05272-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lichen sclerosus et atrophicus (LSA) is an inflammatory, mucocutaneous disorder that affects male and especially female with a debilitating impact on the quality of life. Common localization is the anogenital area. If not treated LSA can leave scars, functional impairment and can evolve in squamous cell carcinoma. The first line of treatment is represented by topical, ultra-potent corticosteroids, but often patients are unresponsive; moreover this therapy is frequently associated to relapses of the disease after discontinuation. METHODS In this prospective observational study, the efficacy of three different treatments - topical calcineurin inhibitors, avocado and soya beans extracts, and methyl aminolevulinate photodynamic therapy (MAL-PDT) - was evaluated, and an effort has been made to define a therapeutic algorithm according to the severity of the disease. RESULTS Of the 150 patients who were referred to the outpatient clinic for a dermatological and gynecological visit, 33 met the inclusion criteria. Sixteen (88%) patients showed an improvement of the lesion and a reduction of the itch; 3 (16.7%) patients with sever itch and fissurated lesions were evaluated for the MAL-PDT therapy. A total of 9 patients, after accurate examination of the lesions, were treated with MAL-PDT. The totality of the patients experienced a resolution of the lesions. CONCLUSIONS In the early stages the use of ASE can represent a valid alternative that is well tolerated by the patients reducing the itching, dryness and improving the mucosal texture. The use of MAL-PDT represents a valid treatment in the moderate-severe stages of LSA.
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Affiliation(s)
- Anna A Criscuolo
- Division of Obstetrics and Gynecology, Department of Surgery, School of Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Caterina Schipani
- Division of Dermatology, Department of Medicine, School of Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Maria V Cannizzaro
- Division of Dermatology, Department of Medicine, School of Medicine, Tor Vergata University Hospital, Rome, Italy -
| | - Serena Messinese
- Division of Dermatology, Department of Medicine, School of Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Sergio Chimenti
- Division of Dermatology, Department of Medicine, School of Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Emilio Piccione
- Division of Obstetrics and Gynecology, Department of Surgery, School of Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Rosita Saraceno
- Division of Dermatology, Department of Medicine, School of Medicine, Tor Vergata University Hospital, Rome, Italy
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48
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McGregor SP, Farhangian ME, Huang KE, Feldman SR. Treatment of Atopic Dermatitis in the United States: Analysis of Data from the National Ambulatory Medical Care Survey. J Drugs Dermatol 2017; 16:250-255. [PMID: 28301621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
UNLABELLED <p>Introduction: Atopic dermatitis (AD) affects both adult and pediatric patients, and multiple practitioners encounter and manage AD. However, differences with regard to the treatment of AD between specialties are not well characterized. OBJECTIVE The primary objective of this study was to determine if there is a difference between dermatologists and non-dermatology specialties with regard to treatment strategies for AD and to describe those differences. METHODS Data from the 1993-2010 National Ambulatory Medical Care (NAMCS) and National Hospital Ambulatory Care (NHAMCS) Surveys were used to characterize outpatient visits made for AD. Differences in demographic, geographic and seasonal characteristics were obtained and compared. Additionally, the frequency of medications prescribed at dermatologist visits were compared to other specialties. PRIMARY OUTCOME MEASURES Frequency of modalities used in the treatment of atopic dermatitis between dermatologists and non-dermatology specialties. RESULTS An estimated 3.7 million visits for AD were made to outpatient offices and hospital departments from 1993 to 2010. The rates per capita of visits for atopic dermatitis were similar when evaluated by gender and season. However, Caucasians were almost 50% less likely than African Americans or individuals of other minority races to have visits for AD. Topical corticosteroids (TCS) were mentioned at 52% of visits, and dermatologists were more likely than non-dermatologists to prescribe TCS, emollients, and topical calcineurin inhibitors. CONCLUSIONS Dermatologists were more likely to recommend TCS, emollients, and topical calciuneurin inhibitors for the treatment of AD. Dermatologists were also more likely to prescribe higher potency TCS in comparison to non-dermatology specialties, and these differences may ultimately affect patient care. As a result, there remains a disparity between dermatologists and non-dermatology specialties with regard to evidence-based approaches to the treatment of AD.</p> <p><em>J Drugs Dermatol. 2017;16(3):250-255.</em></p>.
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49
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Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin condition that requires a manifold approach to therapy. The goal of therapy is to restore the function of the epidermal barrier and to reduce skin inflammation. This can be achieved with skin moisturization and topical anti-inflammatory agents, such as topical corticosteroids and calcineurin inhibitors. Furthermore, proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare. Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation. Bacterial colonization, in particular Staphylococcus aureus, can contribute to eczematous flares and overt infection. Use of systemic antibiotics in infected lesions is warranted; however, empiric antibiotics use in uninfected lesions is controversial. Local antiseptic measures (i.e., bleach baths) and topical antimicrobial therapies can be considered in patients with high bacterial colonization. Difficult-to-treat AD is a complex clinical problem that may require re-evaluation of the initial diagnosis of AD, especially if the onset of disease occurs in adulthood. It may also necessitate evaluation for contact, food, and inhaled allergens that may exacerbate the underlying AD. There are a host of systemic therapies that have been successful in patients with difficult-to-treat AD, however, these agents are limited by their side effect profiles. Lastly, with further insight into the pathophysiology of AD, new biological agents have been investigated with promising results.
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Affiliation(s)
- Melanie Chong
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA.
| | - Luz Fonacier
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA
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50
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Lim WH, Russ GR, Wong G, Pilmore H, Kanellis J, Chadban SJ. The risk of cancer in kidney transplant recipients may be reduced in those maintained on everolimus and reduced cyclosporine. Kidney Int 2017; 91:954-963. [PMID: 28109543 DOI: 10.1016/j.kint.2016.11.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/31/2016] [Accepted: 11/10/2016] [Indexed: 01/05/2023]
Abstract
Kidney transplant recipients are at a high risk of developing cancers after transplantation. Switching from calcineurin inhibitors to sirolimus has been shown to prevent secondary nonmelanoma skin cancer but whether everolimus with reduced exposure to calcineurin inhibitors has similar anti-cancer effects remains unknown. Therefore, we compared the risk of incident cancer over seven years of follow-up among kidney transplant recipients randomized to everolimus plus reduced exposure cyclosporine versus mycophenolate sodium and standard exposure cyclosporine. Using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), we assessed the seven-year risk of incident cancer and other graft outcomes among a subgroup of recipients who had participated in the A2309 study using adjusted Cox proportional hazard models. Of 95 recipients, 66 were randomized to everolimus (1.5 mg or 3 mg) with reduced cyclosporine and 29 received mycophenolate sodium and standard exposure cyclosporine. Compared to mycophenolate sodium and standard exposure cyclosporine, everolimus treatment was associated with unadjusted hazard ratios of 0.28 (95% confidence interval 0.11-0.74), 0.39 (0.16-0.98) and 0.41 (0.23-0.71), respectively for nonmelanoma skin cancer, non-skin cancers and any cancers. Interestingly, the adjusted hazard ratios were 0.34 (0.13-0.91), 0.35 (0.09-1.25) and 0.32 (0.15-0.71), respectively. There was no association between treatment groups and rejection, graft loss or death. Compared to standard-exposure cyclosporine, everolimus with reduced exposure to cyclosporine may be associated with a reduced risk of cancer, particularly for non-melanoma skin cancer. Thus, if confirmed in larger patient cohorts, de novo use of everolimus with reduced exposure to calcineurin inhibitors may enable a reduction in cancer burden after transplantation.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; University of Western Australia, Perth, Australia
| | - Graeme R Russ
- Central and Northern Adelaide Renal and Transplantation Services, South Australia, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia
| | - Helen Pilmore
- Renal Unit, Auckland Hospital, Auckland, New Zealand; Department of Medicine, Auckland University, Auckland, New Zealand
| | - John Kanellis
- Department of Nephrology and Transplant Services, Monash Medical Centre, Melbourne, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; Kidney Node, Charles Perkins Centre, University of Sydney, Australia.
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