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Hof S, Lingens L, Michels M, Marcus C, Kuebart A, Herminghaus A, Bauer I, Picker O, Truse R, Vollmer C. Local carbachol application induces oral microvascular recruitment and improves gastric tissue oxygenation during hemorrhagic shock in dogs. Front Immunol 2024; 15:1369617. [PMID: 38566995 PMCID: PMC10985194 DOI: 10.3389/fimmu.2024.1369617] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Hemorrhagic shock is characterized by derangements of the gastrointestinal microcirculation. Topical therapy with nitroglycerine or iloprost improves gastric tissue oxygenation but not regional perfusion, probably due to precapillary adrenergic innervation. Therefore, this study was designed to investigate the local effect of the parasympathomimetic carbachol alone and in combination with either nitroglycerine or iloprost on gastric and oral microcirculation during hemorrhagic shock. Methods In a cross-over design five female foxhounds were repeatedly randomized into six experimental groups. Carbachol, or carbachol in combination with either nitroglycerine or iloprost were applied topically to the oral and gastric mucosa. Saline, nitroglycerine, or iloprost application alone served as control groups. Then, a fixed-volume hemorrhage was induced by arterial blood withdrawal followed by blood retransfusion after 1h of shock. Gastric and oral microcirculation was determined using reflectance spectrophotometry and laser Doppler flowmetry. Oral microcirculation was visualized with videomicroscopy. Statistics: 2-way-ANOVA for repeated measurements and Bonferroni post-hoc analysis (mean ± SEM; p < 0.05). Results The induction of hemorrhage led to a decrease of gastric and oral tissue oxygenation, that was ameliorated by local carbachol and nitroglycerine application at the gastric mucosa. The sole use of local iloprost did not improve gastric tissue oxygenation but could be supplemented by local carbachol treatment. Adding carbachol to nitroglycerine did not further increase gastric tissue oxygenation. Gastric microvascular blood flow remained unchanged in all experimental groups. Oral microvascular blood flow, microvascular flow index and total vessel density decreased during shock. Local carbachol supply improved oral vessel density during shock and oral microvascular flow index in the late course of hemorrhage. Conclusion The specific effect of shifting the autonomous balance by local carbachol treatment on microcirculatory variables varies between parts of the gastrointestinal tract. Contrary to our expectations, the improvement of gastric tissue oxygenation by local carbachol or nitroglycerine application was not related to increased microvascular perfusion. When carbachol is used in combination with local vasodilators, the additional effect on gastric tissue oxygenation depends on the specific drug combination. Therefore, modulation of tissue oxygen consumption, mitochondrial function or alterations in regional blood flow distribution should be investigated.
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Affiliation(s)
- Stefan Hof
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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2
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Harris E. FDA Approves Iloprost as First Drug to Treat Severe Frostbite. JAMA 2024; 331:907. [PMID: 38416474 DOI: 10.1001/jama.2024.1116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
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Hsiao CY, Lu WH. Effective control of refractory pulmonary hypertension with iloprost inhalation in an infant with congenital absence of the right pulmonary artery: a case report. Cardiol Young 2024; 34:690-693. [PMID: 38224236 DOI: 10.1017/s104795112300450x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Unilateral absence of the pulmonary artery is a rare congenital cardiovascular anomaly that can lead to pulmonary hypertension and poor outcomes. We report the case of a 1-month-old infant with isolated unilateral absence of the pulmonary artery and severe pulmonary hypertension on the right and left sides, respectively. The patient was unresponsive to multiple medications for pulmonary hypertension, and surgical revascularisation was unfeasible. However, iloprost inhalation was effective.
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Affiliation(s)
- Chu-Yuan Hsiao
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Hsien Lu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Fooyin University, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
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Johansson PI, Fenger Eriksen C, Bovbjerg PE, Gaarder C, Pall M, Henriksen HH, Pedersen KH, Vigstedt M, Lange T, Næss PA, Strømgaard Andersen M, Kirkegaard H, Stensballe J. Prostacyclin in trauma patients with hemorrhagic shock: A randomized clinical trial. J Trauma Acute Care Surg 2024; 96:476-481. [PMID: 37962189 DOI: 10.1097/ta.0000000000004150] [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: 11/15/2023]
Abstract
BACKGROUND A main cause of trauma morbidity and mortality is multiple-organ failure, and endotheliopathy has been implicated. Pilot studies indicate that low-dose prostacyclin improves endothelial functionality in critically ill patients, suggesting that this intervention may improve trauma patient outcome. METHODS We conducted a multicenter, randomized, blinded, clinical investigator-initiated trial in 229 trauma patients with hemorrhagic shock who were randomized 1:1 to 72 hours infusion of the prostacyclin analog iloprost (1 ng/kg/min) or placebo. The primary outcome was the number of intensive care unit (ICU)-free days alive within 28 days of admission. Secondary outcomes included 28-day all-cause mortality and hospital length of stay. RESULTS The mean number of ICU-free days alive within 28 days was 15.64 days in the iloprost group versus 13.99 days in the placebo group (adjusted mean difference, -1.63 days [95% confidence interval (CI), -4.64 to 1.38 days]; p = 0.28). The 28-day mortality was 18.8% in the iloprost group versus 19.6% in the placebo group (odds ratio, 1.01 [95% CI, 0.51-2.0]; p = 0.97). The mean hospital length of stay was 19.96 days in the iloprost group versus 27.32 days in the placebo group (adjusted mean difference, 7.84 days [95% CI, 1.66-14.02 days], p = 0.01). CONCLUSION Iloprost did not result in a statistically significant increase in the number of ICU-free days alive within 28 days of admission, whereas it was safe and a statistically significant reduction in hospital length of stay was observed. Further research on prostacyclin in shocked trauma patients is warranted. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
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Affiliation(s)
- Pär I Johansson
- From the CAG Center for Endotheliomics (P.I.J.), Copenhagen University Hospital-Rigshospitalet; Department of Clinical Medicine (P.I.J.), University of Copenhagen, Copenhagen; Department of Anesthesiology (C.F.E., M.S.A.), Aarhus University Hospital, Aarhus; Department of Orthopedic Surgery (P.E.B.), Odense University Hospital, Odense, Denmark; Department of Traumatology (C.G., P.A.N.), Oslo University Hospital; Institute of Clinical Medicine (C.G., P.A.N.), University of Oslo, Oslo, Norway; Department of Anesthesiology (M.P.) and Intensive Care V (M.P.), Odense University Hospital, Odense; CAG Center for Endotheliomics (H.H.H., K.H.P., M.V.), Copenhagen University Hospital-Rigshospitalet; Section of Biostatistics (T.L.), University of Copenhagen, Copenhagen; Research Center for Emergency Medicine (H.K.), Aarhus University Hospital; Aarhus University (H.K.), Aarhus; and CAG Center for Endotheliomics (J.S.), and Department of Anesthesiology (J.S.), Department of Anesthesiology, Centre of Head and Orthopedics (J.S.), Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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Beytout Q, Dutheil A, Cristofari S, Barbaud A, Chasset F, Senet P. Intra-arterial facial injection of hyaluronic acid complicated by Nicolau's dermatitis: Treatment with iloprost. J Eur Acad Dermatol Venereol 2023; 37:e1314-e1315. [PMID: 37415383 DOI: 10.1111/jdv.19304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Affiliation(s)
- Quentin Beytout
- Department of Dermatology and Allergology, Tenon Hopital, AP-HP Sorbonne Universite, Paris, France
| | - Amelie Dutheil
- Department of Dermatology and Allergology, Tenon Hopital, AP-HP Sorbonne Universite, Paris, France
| | - Sarra Cristofari
- Service de Chirurgie Plastique, Hôpital Tenon AP-HP, Paris, France
| | - Annick Barbaud
- Department of Dermatology and Allergology, Tenon Hopital, AP-HP Sorbonne Universite, Paris, France
- Department of Dermatology and Allergology, INSERM, Institut Pierre Louis d'Epidemiologie et de Sante Publique, AP-HP Sorbonne Universite, Tenon Hopital, Sorbonne Université, Paris, France
| | - Francois Chasset
- Service de Dermatologie et Allergologie, Hôpital Tenon, INSERM U-1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Faculté de Médecine, AP-HP, Sorbonne Université, Paris, France
| | - Patricia Senet
- Department of Dermatology and Allergology, Tenon Hopital, AP-HP Sorbonne Universite, Paris, France
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Magnani L, Ariani A, Lo Monaco A, Girelli F, Spinella A, Lumetti F, Reta M, Arrigoni E, Ursini F, Bezzi A, Cataleta P, Montaguti L, Trevisani M, Colina M, Bernardi S, De Pinto M, Galoppini G, Testoni S, Becciolini A, Pignataro F, Ciaffi J, Bravi E, Focherini M, Moscatelli S, Sambo P, Fusconi M, Corvaglia S, Bajocchi G, Conti D, Salvarani C, Giuggioli D. Real life use of prostacyclin analog (iloprost), a multi-centric survey data from the Scleroderma study group Emilia Romagna (Sclero-RER) and review of the literature. Acta Biomed 2023; 94:e2023148. [PMID: 37539603 PMCID: PMC10440762 DOI: 10.23750/abm.v94i4.14317] [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: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND AIM Iloprost is recommend worldwide for the treatment of RP and the healing of DUs. The aim of this study is to report the regimens of Iloprost administered in different rheumatological centers within the same regional Health System Methods: A questionnaire exploring different items related to the use of Iloprost was developed and reviewed by three expert rheumatologists. The questionnaire was distributed as an online survey to all local SSc referral centers in Emilia-Romagna (Italy). Data are reported as percentage or median with interquartile range (IQR), as appropriate. An updated review of world literature on this topic was also carried out. RESULTS All the invited centers completed the survey. There were both local (8) and university hospitals (4). The majority (58%) had a rheumatologist as head physician. All centers used Iloprost: a single monthly administration was the most common treatment (75%). The cycle lasted 1 [IQR 1-2] days with a 0.5-2.0 ng/Kg/min dose according to the drug tolerance of the patients. There were overall 68 spots (beds, reclining armchair, or simple armchair); 2.0 [1.5-4.0] patients were able to receive Iloprost at the same time. University Hospitals had more physicians at their disposal than local hospitals but less paramedic personnel (respectively: 1.8 vs 1.2 physicians, 1.5 vs 2.1 nurses). CONCLUSIONS These observations were in line with the majority of previous studies reporting different regimens, comparing similar (but not identical) dose and schedule administration, however, despite differences being at times substantial, no standard infusion method is yet available.
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Affiliation(s)
- Luca Magnani
- a:1:{s:5:"en_US";s:40:"Arcispedale S. Maria Nuova Reggio Emilia";}.
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Sarı Küçük R, Uluç K, Merve Çolakoğlu Ş, Kılınç Berktaş C, Mutlu S, Turgut N. The effect of using iloprost on prognosis in COVID-19 patients with ARDS: a retrospective clinical study. Eur Rev Med Pharmacol Sci 2023; 27:4269-4279. [PMID: 37203853 DOI: 10.26355/eurrev_202305_32337] [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] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Epithelial damage together with endothelitis and microvascular thrombi are responsible for COVID-19 associated acute respiratory distress syndrome (ARDS). Iloprost, improves endothelial damage and reduces thrombotic complications with its vasodilator, anti-platelet, anti-inflammatory, and anti-fibrotic effects. In our study, we aimed to determine the effect of iloprost on oxygenation, hemodynamics, weaning, and mortality in severe COVID-19 ARDS. PATIENTS AND METHODS This was a retrospective study conducted in a pandemic hospital in the city of Istanbul, Turkey. Patients, with severe COVID-19 ARDS, who were receiving iloprost for seven days were included in the study. The demographic data, APACHE II, and SOFA (Sequential Organ Failure Assessment score) scores (at admission and discharge), pH, PaO2, PCO2, SatO2, lactate, PaO2/FiO2 (inspiratory fractionated oxygen), respiratory rate-oxygenation (ROX) index (peripheral oxygen saturation/fraction of inhaled oxygen), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressures (MAP), heart rate (HR) values were recorded before starting iloprost (T0), and on days of iloprost administration (2.0 nanograms/kg/minute/6 hours/day) (T1, T2, T3, T4, T5, T6, T7), and the day after last day of iloprost administration (Tfinal). Also, mortality was recorded in a retrospective manner. Two groups were formed according to mortality (Group M) and discharge (Group D). RESULTS A total of 22 patients (16 men, 6 women) were evaluated. Age, APACHE II, SOFA scores were higher in Group M. The lactate value at T1-3-4-5-7 was lower than T0 in both groups. PaO2 value between T2-Tfinal was higher than T0. A statistically significant increase was found in PaO2/FiO2 levels in both groups. The PaO2/FiO2value between T5-Tfinal was significantly lower in Group M compared to Group D. ROX index was significantly higher between T4-Tfinal when compared with T0. CONCLUSIONS Iloprost improves oxygenation but has no effect on mortality in COVID-19 ARDS.
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Affiliation(s)
- R Sarı Küçük
- Department of Intensive Care, Prof. Dr. Cemil Taşcıoğlu City Hospital, Turkey, Istanbul.
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8
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Paraskevopoulos K, Keskinis A, Vasios IS, Makiev KG, Tilkeridis K, Drosos GI, Ververidis AN. Comparison of various treatment modalities for the management of bone marrow edema syndrome/transient osteoporosis in men and non-pregnant women: a systematic review. Osteoporos Int 2023; 34:269-290. [PMID: 36370218 DOI: 10.1007/s00198-022-06584-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 11/13/2022]
Abstract
UNLABELLED Transient osteoporosis (TO) or bone marrow edema syndrome (BMES) is a self-limited clinical condition, which affects middle-aged men and women. It can be treated with miscellaneous conservative and surgical measures, which are analyzed in this systematic review. INTRODUCTION BMES/TO is a transient clinical entity, which can be treated with various therapeutic modalities. The aim of our study was to assess the efficacy of different therapeutic options for the alleviation of pain and reduction of bone marrow edema (BME) in patients with BMES/TO, as well as to propose a therapeutic algorithm. METHODS PubMed, Scopus, Cochrane, and Google Scholar were searched. Eligibility and extraction of studies were conducted by two authors. Methodological quality assessment was carried out with the modified Delphi technique, Methodological Index for Non-Randomized Studies (MINORS) criteria, and Cochrane Collaboration's risk of bias tool. Outcomes that were compared were time of pain resolution, VAS pain scores, and BME regression on magnetic resonance imaging (MRI). RESULTS A total of 36 articles (880 patients) were included. Bisphosphonates had higher efficiency in less than 1-month outcomes on pain resolution compared with core decompression (CD), while iloprost was more efficient at 1-3 months compared with bisphosphonates and CD. At 3-6 months, all three of the aforementioned showed equal results on pain resolution, and at a period of 6-12 months, CD and extracorporeal shockwave therapy (ESWT) showed excellent results followed by bisphosphonates and the conservative group (CG) consisting of non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics and/or restricted weight bearing. On MRI at 1-3 months, bisphosphonates, iloprost, and CD had relatively the same outcomes on BME resolution, with the least promising being the CG. At 3-6 months, CD seemed to have achieved the best results on the resolution of BME, followed by ESWT, CG, and bisphosphonates group. At 6-12 months, ESWT had the best outcomes compared with the conservative, bisphosphonates, and iloprost groups. CONCLUSION BMES/TO has been treated with many non-standardized measures due to the low number of highly reliable studies. Current literature shows promising results with regard to the reduction of the clinical course of BMES/TO, but further large multicenter randomized controlled trials, as well as standardized radiological and clinical scores, are warranted to acquire evidence-based recommendations on the therapeutic algorithm.
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Affiliation(s)
- Konstantinos Paraskevopoulos
- Medical Centre of Kato Nevrokopi, Department of Orthopaedic Surgery, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece.
| | - Anthimos Keskinis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Ioannis S Vasios
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos G Makiev
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos Tilkeridis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Georgios I Drosos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Athanasios N Ververidis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
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Dwyer-Nield L, Keith RL, Tennis MA. Protocol for intranasal chemoprevention delivery in a urethane mouse lung cancer model. STAR Protoc 2022; 3:101750. [PMID: 36201319 PMCID: PMC9535317 DOI: 10.1016/j.xpro.2022.101750] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 01/26/2023] Open
Abstract
Mouse iloprost lung cancer chemoprevention studies typically use oral delivery. Here, we present a protocol for intranasal iloprost delivery within a urethane lung adenocarcinoma mouse model. We detail steps for intraperitoneal urethane injection in mice, followed by nine-week monitoring, intranasal iloprost treatment, and lungs harvesting for analysis. This iloprost delivery approach parallels an ongoing phase II clinical trial of inhaled iloprost for lung cancer chemoprevention. This protocol diversifies options for chemoprevention studies and offers a relevant and translatable model. For complete details on the use and execution of this protocol, please refer to Sompel et al. (2022).
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Affiliation(s)
- Lori Dwyer-Nield
- University of Colorado School of Pharmacy, Aurora, CO 80045, USA
| | - Robert L Keith
- Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA; University of Colorado School of Medicine, Aurora, CO 80045, USA
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Evola FR, Compagnoni R, Pieroni A, Tassi A, Menon A, Randelli P. The Efficacy of Conservative Treatment of Bone Marrow Edema Syndrome: A Scoping Review of the Last Ten Years of Literature. J Clin Densitom 2022; 25:506-517. [PMID: 35987803 DOI: 10.1016/j.jocd.2022.06.003] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 05/24/2022] [Accepted: 06/23/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The purpose of this review was to conduct a literature search assessing the efficacy of various conservative treatments of BMES. METHODS According to the PRISMA guidelines, a literature search was conducted in April 2021 in MEDLINE database via PubMed and Embase to identify original articles describing the results of conservative treatments for BMES of hip and knee published in the last ten years. For each study, information regarding study characteristics, description of the treatment, patient's demographic and clinical data, length of follow-up, clinical outcome measure, disability, adverse events, classification, and extent and of edema on MRI, were extracted. RESULTS A total of 12 studies were identified. Two studies described treatment with iloprost, three with hyperbaric oxygen (HBO), two with bisphosphonates, five with extracorporeal shockwave therapy (ESWT). The total number of patients was 351: 34 treated with iloprost, 64 with hyperbaric oxygen, 37 with bisphosphonates, 216 with ESWT. In ESWT studies, treatment with a higher flux density and a higher number of therapy sessions lead to better clinical and radiological scores. In iloprost studies, a more remarkable improvement in the VAS scale was observed in the study on hip patients. CONCLUSIONS The treatment of idiopathic bone marrow edema is currently not standardized, making it difficult to find data that can be compared in a highly reliable way. The studies available in the literature show promising results as for the possibility to cure bone marrow edema efficiently. Standardized radiological scores for evaluating bone marrow edema area are needed in future studies.
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Affiliation(s)
- Francesco Roberto Evola
- Azienda Ospedaliera per L'Emergenza "Cannizzaro", U.O.C Ortopedia e Traumatologia, Catania. Via Messina 829, 95126 Catania
| | - Riccardo Compagnoni
- Department of Biomedical, Surgical and Dental sciences. Università degli Studi di Milano. Via della Commenda 10, 20122, Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Arianna Pieroni
- 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy.
| | - Alberto Tassi
- U.O.C. WEEK SURGERY di Ortopedia e Traumatologia, Azienda Socio-Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Alessandra Menon
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Pietro Randelli
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
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Colasanti T, Stefanantoni K, Fantini C, Corinaldesi C, Vasile M, Marampon F, Di Luigi L, Antinozzi C, Sgrò P, Lenzi A, Riccieri V, Crescioli C. The Prostacyclin Analogue Iloprost Modulates CXCL10 in Systemic Sclerosis. Int J Mol Sci 2022; 23:ijms231710150. [PMID: 36077548 PMCID: PMC9456348 DOI: 10.3390/ijms231710150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
The prostacyclin analogue iloprost is used to treat vascular alterations and digital ulcers, the early derangements manifesting in systemic sclerosis (SSc), an autoimmune disease leading to skin and organ fibrosis. Bioindicator(s) of SSc onset and progress are still lacking and the therapeutic approach remains a challenge. The T helper 1 (Th1) chemokine interferon (IFN)γ-induced protein 10 (IP-10/CXCL10) associates with disease progression and worse prognosis. Endothelial cells and fibroblasts, under Th1-dominance, release CXCL10, further enhancing SSc’s detrimental status. We analyzed the effect of iloprost on CXCL10 in endothelial cells, dermal fibroblasts, and in the serum of SSc patients. Human endothelial cells and dermal fibroblasts activated with IFNγ/Tumor Necrosis Factor (TNF)α, with/without iloprost, were investigated for CXCL10 secretion/expression and for intracellular signaling cascade underlying chemokine release (Signal Transducer and Activator of Transcription 1, STAT1; Nuclear Factor kappa-light-chain-enhancer of activated B cells, NF-kB; c-Jun NH2-terminal kinase, JNK: Phosphatidyl-Inositol 3-kinase (PI3K)/protein kinase B, AKT; Extracellular signal-Regulated Kinase 1/2, ERK1/2). CXCL10 was quantified in sera from 25 patients taking iloprost, satisfying the American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) 2013 classification criteria for SSc, and in sera from 20 SSc sex/age-matched subjects without therapy, previously collected. In human endothelial cells and fibroblasts, iloprost targeted CXCL10, almost preventing IFNγ/TNFα-dependent cascade activation in endothelial cells. In SSc subjects taking iloprost, serum CXCL10 was lower. These in vitro and in vivo data suggest a potential role of iloprost to limit CXCL10 at local vascular/dermal and systemic levels in SSc and warrant further translational research aimed to ameliorate SSc understanding/management.
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Affiliation(s)
- Tania Colasanti
- Rheumatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
| | - Katia Stefanantoni
- Rheumatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
| | - Cristina Fantini
- Unit of Biology and Genetics of Movement, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
| | - Clarissa Corinaldesi
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
- Institute for Cancer Genetics, Columbia University, New York, NY 10027, USA
| | - Massimiliano Vasile
- Rheumatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
| | - Francesco Marampon
- Department of Radiotherapy, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
| | - Luigi Di Luigi
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
| | - Cristina Antinozzi
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
| | - Paolo Sgrò
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
| | - Valeria Riccieri
- Rheumatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155-00161 Rome, Italy
- Correspondence: (V.R.); (C.C.); Tel.: +39-06-49974641 (V.R.); +39-06-36733395 (C.C.)
| | - Clara Crescioli
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis, 006-00135 Rome, Italy
- Correspondence: (V.R.); (C.C.); Tel.: +39-06-49974641 (V.R.); +39-06-36733395 (C.C.)
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Saiki C, Kashiwado Y, Yokoyama T, Ayano M, Imabayashi K, Kawano S, Higashioka K, Kimoto Y, Fukata M, Mitoma H, Ono N, Arinobu Y, Akashi K, Horiuchi T, Niiro H. Successful transition from intravenous epoprostenol to oral selexipag and inhaled iloprost in a case of severe pulmonary arterial hypertension associated with systemic lupus erythematosus. Mod Rheumatol Case Rep 2022; 6:183-188. [PMID: 35134204 DOI: 10.1093/mrcr/rxac009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/01/2021] [Revised: 01/06/2022] [Accepted: 01/26/2022] [Indexed: 06/14/2023]
Abstract
A 25-year-old woman was admitted to our hospital with severe pulmonary arterial hypertension associated with systemic lupus erythematosus (SLE-PAH). Her mean pulmonary arterial pressure was 56 mmHg, and her SLE Disease Activity Index-2 K score was 14 on admission. In addition to a strong immunosuppressive regimen, which included steroid pulse therapy followed by high-dose oral prednisolone (1 mg/kg) and intravenous cyclophosphamide, an upfront combination of vasodilator therapy, including oral tadalafil, macitentan, and intravenous epoprostenol, was administered in the early phase. Two months later, her mean pulmonary arterial pressure was 29 mmHg, and her other haemodynamic markers showed significant improvement. She refused to start life-long intravenous epoprostenol therapy and so was switched to oral selexipag and inhaled iloprost. The transition was successful, and she has experienced no exacerbations of SLE-PAH during the 10 months since the onset of pulmonary arterial hypertension. To the best of our knowledge, this is the first report of intravenous epoprostenol being switched to alternative oral and inhaled therapy in a patient with SLE-PAH. In combination with adequate immunosuppressive therapy, it is probably easier to make this transition in patients with SLE-PAH than in those with pulmonary arterial hypertension of a different aetiology. Continuous infusion of epoprostenol can have potentially life-threatening complications and a detrimental effect on the quality of life. Our alternative treatment strategy was successful, and we hope that it will prove beneficial in other cases.
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Affiliation(s)
- Chihiro Saiki
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yusuke Kashiwado
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Taku Yokoyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Keisuke Imabayashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Kazuhiko Higashioka
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Oita, Japan
| | - Mitsuhiro Fukata
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Oita, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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13
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Abstract
OBJECTIVE Despite its low incidence, pulmonary hypertension in children places a substantial burden on families and society because survival can be shorter than 10 months and treatment options are limited and ineffective. Drugs to treat pulmonary hypertension include endothelin antagonists, phosphodiesterase type 5 inhibitors and prostacyclin, which is the most widely used to treat pediatric pulmonary hypertension. The main aim of this study was to provide a comprehensive overview of the advantages and disadvantages of prostacyclin and its analogs for treating pulmonary hypertension in children. MATERIALS AND METHODS To retrieve a thorough collection of studies, we performed a search in PubMed using the following combination of keywords: (Prostacyclins) or (Epoprostenol) or (Iloprost) or (Treprostinil) or (Beraprost), (children) and (pulmonary arterial hypertension). The time limits used for the search were December 1983 to May 2021. RESULTS The search retrieved a total of 238 articles. Titles and abstracts of articles were screened for relevance, and all relevant articles published in English were included. CONCLUSIONS Epoprostenol can be effective against severe pulmonary hypertension. Iloprost can treat severe persistent pulmonary hypertension in newborns and inhaled iloprost can be used in pulmonary vasoreactivity testing. Treprostinil is a long-acting prostacyclin analog, and it shows the highest antiproliferative activity among prostacyclins. Beraprost may be effective in premature infants, but available evidence comes from only one patient, so more clinical testing is needed.
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Affiliation(s)
- Y Wu
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China.
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14
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Küçükoğlu MS, Hanta İ, Akdeniz B, Güllülü S, Atahan E, Sayın T, Okumuş G, Önen ZP, Yokuşoğlu M, Baygül A. Clinical efficacy, safety, tolerability, and survival outcome of long-term inhaled iloprost treatment in the management of pulmonary arterial hypertension: Data from prospective multicenter observational OPTION study. Anatol J Cardiol 2021; 25:721-732. [PMID: 34622787 PMCID: PMC8504660 DOI: 10.5152/anatoljcardiol.2021.03009] [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] [Accepted: 04/26/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate clinical efficacy, safety and tolerability of long-term inhaled iloprost treatment in the daily practice for the management of pulmonary arterial hypertension (PAH). METHODS A total of 115 patients with PAH on inhaled iloprost treatment were included. New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and 6-minute walk distance (6MWD) were recorded at baseline and at 3rd to 24th month visits. Safety and tolerability of iloprost treatment were also evaluated during follow-up, as were the survival, clinical worsening, and the related risk factors. RESULTS The treatment was associated with an increase in the percentage NYHA functional class II (from 0.0% at enrolment to 36.2% at 24th month visit) patients but no significant difference was noted in 6MWD values. Clinical worsening was observed in 63.5% patients, while survival rate was 69.6%. NT-proBNP levels were significantly higher in non-survivors than in survivors (p=0.042). Cox regression analysis revealed the association of female sex [odds ratio (OR)=0.318; 95% confidence interval (CI), 0.128-0.792; p=0.014] and scleroderma-related PAH (OR=0.347; 95% CI, 0.140-0.860; p=0.022) with significantly lower risk (3.14 fold and 2.88 fold, respectively) of mortality. CONCLUSION Our findings indicate favorable efficacy, safety, and tolerability of long-term iloprost treatment in the management of PAH, whereas improved NYHA functional class was not accompanied with a significant change in 6MWD values. Patient age was a risk factor for clinical worsening, while female sex, scleroderma subtype, and lower NT-proBNP levels were associated with significantly lower mortality risk.
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Affiliation(s)
| | - İsmail Hanta
- Department of Chest Diseases, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Bahri Akdeniz
- Department of Cardiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Sümeyye Güllülü
- Department of Cardiology, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Ersan Atahan
- Department of Chest Diseases, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Tamer Sayın
- Department of Cardiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gülfer Okumuş
- Department of Chest Diseases, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Zeynep Pınar Önen
- Department of Chest Diseases, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Yokuşoğlu
- Department of Cardiology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Arzu Baygül
- Department of Biostatistics, Koc University School of Medicine, Istanbul, Turkey
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15
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Gu SX, Tyagi T, Jain K, Gu VW, Lee SH, Hwa JM, Kwan JM, Krause DS, Lee AI, Halene S, Martin KA, Chun HJ, Hwa J. Thrombocytopathy and endotheliopathy: crucial contributors to COVID-19 thromboinflammation. Nat Rev Cardiol 2021; 18:194-209. [PMID: 33214651 PMCID: PMC7675396 DOI: 10.1038/s41569-020-00469-1] [Citation(s) in RCA: 246] [Impact Index Per Article: 82.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 02/06/2023]
Abstract
The core pathology of coronavirus disease 2019 (COVID-19) is infection of airway cells by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that results in excessive inflammation and respiratory disease, with cytokine storm and acute respiratory distress syndrome implicated in the most severe cases. Thrombotic complications are a major cause of morbidity and mortality in patients with COVID-19. Patients with pre-existing cardiovascular disease and/or traditional cardiovascular risk factors, including obesity, diabetes mellitus, hypertension and advanced age, are at the highest risk of death from COVID-19. In this Review, we summarize new lines of evidence that point to both platelet and endothelial dysfunction as essential components of COVID-19 pathology and describe the mechanisms that might account for the contribution of cardiovascular risk factors to the most severe outcomes in COVID-19. We highlight the distinct contributions of coagulopathy, thrombocytopathy and endotheliopathy to the pathogenesis of COVID-19 and discuss potential therapeutic strategies in the management of patients with COVD-19. Harnessing the expertise of the biomedical and clinical communities is imperative to expand the available therapeutics beyond anticoagulants and to target both thrombocytopathy and endotheliopathy. Only with such collaborative efforts can we better prepare for further waves and for future coronavirus-related pandemics.
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Affiliation(s)
- Sean X Gu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tarun Tyagi
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kanika Jain
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Vivian W Gu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Seung Hee Lee
- Division of Cardiovascular Diseases, Center for Biomedical Sciences, National Institute of Health, Cheongju, Chungbuk, Korea
| | - Jonathan M Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kwan
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Diane S Krause
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine and Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine and Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Kathleen A Martin
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Hyung J Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
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Tsou PS, Palisoc PJ, Flavahan NA, Khanna D. Dissecting the Cellular Mechanism of Prostacyclin Analog Iloprost in Reversing Vascular Dysfunction in Scleroderma. Arthritis Rheumatol 2021; 73:520-529. [PMID: 33001586 PMCID: PMC7914149 DOI: 10.1002/art.41536] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Intravenous iloprost improves Raynaud's phenomenon (RP) and promotes healing of digital ulcers in systemic sclerosis (SSc; scleroderma). Despite a short half-life, its clinical efficacy lasts weeks. Endothelial adherens junctions, which are formed by VE-cadherin clustering between endothelial cells (ECs), regulate endothelial properties including barrier function, endothelial-to-mesenchymal transition (EndoMT), and angiogenesis. We undertook this study to investigate the hypothesis that junctional disruption contributes to vascular dysfunction in SSc, and that the protective effect of iloprost is mediated by strengthening of those junctions. METHODS Dermal ECs from SSc patients and healthy controls were isolated. The effect of iloprost on ECs was examined using immunofluorescence, permeability assays, Matrigel tube formation, and quantitative polymerase chain reaction. RESULTS Adherens junctions in SSc were disrupted compared to normal ECs, as indicated by reduced levels of VE-cadherin and increased permeability in SSc ECs (P < 0.05). Iloprost increased VE-cadherin clustering at junctions and restored junctional levels of VE-cadherin in SSc ECs (mean ± SD 37.3 ± 4.3 fluorescence units) compared to normal ECs (mean ± SD 29.7 ± 3.4 fluorescence units; P < 0.05), after 2 hours of iloprost incubation. In addition, iloprost reduced permeability of monolayers, increased tubulogenesis, and blocked EndoMT in both normal and SSc ECs (n ≥ 3; P < 0.05). The effects in normal ECs were inhibited by a function-blocking antibody that prevents junctional clustering of VE-cadherin. CONCLUSION Our data suggest that the long-lasting effects of iloprost reflect its ability to stabilize adherens junctions, resulting in increased tubulogenesis and barrier function and reduced EndoMT. These findings provide a mechanistic basis for the use of iloprost in treating SSc patients with RP and digital ulcers.
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Affiliation(s)
- Pei-Suen Tsou
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Pamela J. Palisoc
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Nicholas A. Flavahan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- University of Michigan Scleroderma Program, Ann Arbor, MI
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17
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Abignano G, Mennillo GA, Lettieri G. Foot ulcers in systemic sclerosis escape surgical amputation. Lancet 2020; 396:e29. [PMID: 32919519 DOI: 10.1016/s0140-6736(20)31896-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/28/2020] [Accepted: 07/30/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Giuseppina Abignano
- Rheumatology Institute of Lucania and Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
| | - Gianna A Mennillo
- Rheumatology Institute of Lucania and Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy
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Martins-Rocha T, Matias JP, Vicente Ferreira M, Mota B, Brito I. Post-infectious Digital Ischemia Successfully Treated with Iloprost in a Child. Reumatol Clin (Engl Ed) 2020; 16:364-365. [PMID: 30030105 DOI: 10.1016/j.reuma.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - José Pedro Matias
- Department of Pediatrics, Centro Hospitalar de São João, Porto, Portugal
| | | | - Bárbara Mota
- Department of Pediatrics, Centro Hospitalar de São João, Porto, Portugal
| | - Iva Brito
- Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal; Rheumatology Department, Faculty de Medicine University of Porto (FMUP), Portugal
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Johansson PI, Bestle M, Søe-Jensen P, Kristiansen KT, Stensballe J, Clausen NE, Perner A. The effect of prostacyclin (Iloprost) infusion at a dose of 1 ng/kg/min for 72 hours compared to placebo in mechanically ventilated patients with COVID-19: A structured summary of a study protocol for a randomized controlled trial. Trials 2020; 21:746. [PMID: 32847626 PMCID: PMC7447606 DOI: 10.1186/s13063-020-04696-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To investigate the effect of continuous infusion of the potential endothelial cytoprotective agent prostacyclin (Iloprost) 1 ng/kg/min vs. placebo for 72 hours on pulmonary endotheliopathy in mechanically ventilated COVID-19 patients. TRIAL DESIGN A multicenter, randomized (1:1, active: placebo), blinded, parallel group exploratory trial PARTICIPANTS: Inclusion criteria are: Adult patients (>18 years); Confirmed COVID-19 infection; Need for mechanical interventions; Endothelial biomarker soluble thrombomodulin >4ng/ml. EXCLUSION CRITERIA Withdrawal from active therapy; Pregnancy (non-pregnancy confirmed by patient being postmenopausal (age 60 or above) or having a negative urine- or plasma-hCG); Known hypersensitivity to iloprost or to any of the other ingredients; Previously included in this trial or a prostacyclin trial within 30 days; Consent cannot be obtained; Life-threatening bleeding defined by the treating physician; Known severe heart failure (NYHA class IV); Suspected acute coronary syndrome The study is conducted at five intensive care units in the Capital Region of Denmark at Rigshospitalet, Herlev Hospital, Hvidovre Hospital, Bispebjerg Hospital, Nordsjællands Hospital. INTERVENTION AND COMPARATOR The patients are randomized to 72-hours continuous infusion of either prostacyclin (Iloprost/Ilomedin) at a dose of 1 ng/kg/min or Placebo (normal saline). MAIN OUTCOMES Primary endpoint: Days alive without mechanical ventilation in the intensive care units within 28 days RANDOMISATION: The randomisation sequence is performed in permuted blocks of variable sizes stratified for trial site using centralised, concealed allocation. The randomisation sequence is generated 1:1 (active/placebo) using the online randomisation software 'Sealed Envelope' ( https://www.sealedenvelope.com/ ). Once generated the randomisation sequence is formatted and uploaded into Research Electronic Data Capture system (REDCap) to facilitate centralised, web-based allocation according to local written instruction. BLINDING (MASKING) The following are blinded: all clinicians, patients, investigators, and those assessing the outcomes including the statisticians. NUMBERS TO BE RANDOMISED (SAMPLE SIZE) Forty patients are planned to be randomized to each group, with a total sample size of 80 patients. TRIAL STATUS Protocol version 1.4 dated May 25, 2020. Recruitment is ongoing. The recruitment was started June 15, 2020 and the anticipated finish of recruitment is February 28, 2021 with 90 days follow up hereafter. TRIAL REGISTRATION Trial registration at clinicaltrialregisters.eu; EudraCT no. 2020-001296-33 on 3 April 2020 and at ClinicalTrials.gov Identifier: NCT04420741 on 9 June 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1).In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
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Affiliation(s)
| | - Morten Bestle
- Department of Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Jakob Stensballe
- Department of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Anders Perner
- Department of Intensive Care 4131, Rigshospitalet, Copenhagen, Denmark
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20
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Abstract
BACKGROUND Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic, segmental inflammatory pathology that most commonly affects the small and medium sized arteries, veins, and nerves in the upper and lower extremities. The aetiology is unknown, but involves hereditary susceptibility, tobacco exposure, immune and coagulation responses. In many cases, there is no possibility of revascularisation to improve the condition. Pharmacological treatment is an option for patients with severe complications, such as ischaemic ulcers or rest pain.This is an update of the review first published in 2016. OBJECTIVES To assess the effectiveness of any pharmacological agent (intravenous or oral) compared with placebo or any other pharmacological agent in patients with Buerger's disease. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 15 October 2019. The review authors searched LILACS, ISRCTN, Australian New Zealand Clinical Trials Registry, EU Clinical Trials Register, clincialtrials.gov and the OpenGrey Database to 5 January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving pharmacological agents used in the treatment of Buerger's disease. DATA COLLECTION AND ANALYSIS Two review authors, independently assessed the studies, extracted data and performed data analysis. MAIN RESULTS No new studies were identified for this update. Five randomised controlled trials (total 602 participants) compared prostacyclin analogue with placebo, aspirin, or a prostaglandin analogue, and folic acid with placebo. No studies assessed other pharmacological agents such as cilostazol, clopidogrel and pentoxifylline or compared oral versus intravenous prostanoid. Compared with aspirin, intravenous prostacyclin analogue iloprost improved ulcer healing (risk ratio (RR) 2.65; 95% confidence interval (CI) 1.15 to 6.11; 98 participants; 1 study; moderate-certainty evidence), and helped to eradicate rest pain after 28 days (RR 2.28; 95% CI 1.48 to 3.52; 133 participants; 1 study; moderate-certainty evidence), although amputation rates were similar six months after treatment (RR 0.32; 95% CI 0.09 to 1.15; 95 participants; 1 study; moderate-certainty evidence). When comparing prostacyclin (iloprost and clinprost) with prostaglandin (alprostadil) analogues, ulcer healing was similar (RR 1.13; 95% CI 0.76 to 1.69; 89 participants; 2 studies; I² = 0%; very low-certainty evidence), as was the eradication of rest pain after 28 days (RR 1.57; 95% CI 0.72 to 3.44; 38 participants; 1 study; low-certainty evidence), while amputation rates were not measured. Compared with placebo, the effects of oral prostacyclin analogue iloprost were similar for: healing ischaemic ulcers (iloprost 200 mcg: RR 1.11; 95% CI 0.54 to 2.29; 133 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 0.90; 95% CI 0.42 to 1.93; 135 participants; 1 study; moderate-certainty evidence), eradication of rest pain after eight weeks (iloprost 200 mcg: RR 1.14; 95% CI 0.79 to 1.63; 207 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 1.11; 95% CI 0.77 to 1.59; 201 participants; 1 study; moderate-certainty evidence), and amputation rates after six months (iloprost 200 mcg: RR 0.54; 95% CI 0.19 to 1.56; 209 participants; 1 study, and iloprost 400 mcg: RR 0.42; 95% CI 0.13 to 1.31; 213 participants; 1 study). When comparing folic acid with placebo in patients with Buerger's disease and hyperhomocysteinaemia, pain scores were similar, there were no new cases of amputation in either group, and ulcer healing was not assessed (very low-certainty evidence). Treatment side effects such as headaches, flushing or nausea were not associated with treatment interruptions or more serious consequences. Outcomes such as amputation-free survival, walking distance or pain-free walking distance, and ankle brachial index were not assessed by any study. Overall, the certainty of the evidence was very low to moderate, with few studies, small numbers of participants, variation in severity of disease of participants between studies and missing information (for example regarding baseline tobacco exposure). AUTHORS' CONCLUSIONS Moderate-certainty evidence suggests that intravenous iloprost (prostacyclin analogue) is more effective than aspirin for eradicating rest pain and healing ischaemic ulcers in Buerger's disease, but oral iloprost is not more effective than placebo. Very low and low-certainty evidence suggests there is no clear difference between prostacyclin (iloprost and clinprost) and the prostaglandin analogue alprostadil for healing ulcers and relieving pain respectively in severe Buerger's disease. Very low-certainty evidence suggests there is no clear difference in pain scores and amputation rates between folic acid and placebo, in people with Buerger's disease and hyperhomocysteinaemia. Further well designed RCTs assessing the effectiveness of pharmacological agents (intravenous or oral) in people with Buerger's disease are needed.
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Affiliation(s)
- Daniel G Cacione
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
| | - Cristiane R Macedo
- Brazilian Cochrane Centre, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | | | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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Wong TH, Gau RJ, Chen YF, Shen HH, Lin CTY, Chen SL, Suen JL. Dendritic cells treated with a prostaglandin I 2 analog, iloprost, promote antigen-specific regulatory T cell differentiation in mice. Int Immunopharmacol 2019; 79:106106. [PMID: 31874369 DOI: 10.1016/j.intimp.2019.106106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/17/2019] [Accepted: 11/29/2019] [Indexed: 11/19/2022]
Abstract
Iloprost, a stable prostaglandin I2 (PGI2) analog, can inhibit allergic inflammation in an ovalbumin (OVA)-induced asthma model via inhibition of airway dendritic cell (DC) function. However, the underlying mechanism of PGI2 signaling-mediated immunosuppression remains unclear. This study explored whether iloprost-treated DCs can suppress inflammation by promoting antigen-specific regulatory T cell (Treg) differentiation through PGI2-G-protein-coupled receptor (IP). We established an allergic lung inflammation model using a hydrogel biomaterial delivery system and observed that iloprost significantly suppressed OVA-induced Th2 lung inflammation and increased the frequency of OVA-specific Tregs in vivo. We further observed that iloprost-treated DCs displayed tolerogenic characteristics, including low inflammatory cytokine (IL-12, TNF-α, IL-6, IL-23) expression levels, high anti-inflammatory cytokine (IL-10) production, and a semimature phenotype. In addition, iloprost-treated DCs increased OVA-specific CD4+Foxp3+ T cell differentiation from naïve T cells in an IP-dependent pathway in vitro and in vivo. Blocking experiments showed that iloprost-treated DCs promoted Treg differentiation, at least in part, through programmed death ligand 1 (PD-L1), whereas iloprost-induced PD-L1 expression in DCs was through the IP receptor. Furthermore, iloprost treatment suppressed DC-mediated airway inflammation and increased the frequency of OVA-specific Tregs through PD-L1 in vivo. Taken together, these results show that PGI2-IP signaling mediated by iloprost in DCs may lead to immune tolerance, suggesting that the PGI2 analog has the potential to be applied therapeutically for tolerogenic DC immunotherapy in autoimmune diseases or allergic asthma.
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Affiliation(s)
- Tzu-Hsuan Wong
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Rung-Jiun Gau
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu, Taiwan, ROC
| | - Yu-Fang Chen
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Hsin-Hsin Shen
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu, Taiwan, ROC
| | - Carl Tsai-Yu Lin
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu, Taiwan, ROC
| | - Sen-Lu Chen
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu, Taiwan, ROC
| | - Jau-Ling Suen
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC.
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Affiliation(s)
- Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
| | - Franz Hafner
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Affiliation(s)
- Xin Jiang
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, and Chinese Academy Medical Sciences & Peking Union Medical College
| | - Xi-Qi Xu
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, and Chinese Academy Medical Sciences & Peking Union Medical College
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Blagojevic J, Bellando-Randone S, Abignano G, Avouac J, Cometi L, Czirják L, Denton CP, Distler O, Frerix M, Guiducci S, Huscher D, Jaeger VK, Lóránd V, Maurer B, Nihtyanova S, Riemekasten G, Siegert E, Tarner IH, Vettori S, Walker UA, Allanore Y, Müller-Ladner U, Del Galdo F, Matucci-Cerinic M. Classification, categorization and essential items for digital ulcer evaluation in systemic sclerosis: a DeSScipher/European Scleroderma Trials and Research group (EUSTAR) survey. Arthritis Res Ther 2019; 21:35. [PMID: 30678703 PMCID: PMC6346551 DOI: 10.1186/s13075-019-1822-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 09/06/2018] [Accepted: 01/11/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A consensus on digital ulcer (DU) definition in systemic sclerosis (SSc) has been recently reached (Suliman et al., J Scleroderma Relat Disord 2:115-20, 2017), while for their evaluation, classification and categorisation, it is still missing. The aims of this study were to identify a set of essential items for digital ulcer (DU) evaluation, to assess if the existing DU classification was useful and feasible in clinical practice and to investigate if the new categorisation was preferred to the simple distinction of DU in recurrent and not recurrent, in patients with systemic sclerosis (SSc). METHODS DeSScipher is the largest European multicentre study on SSc. It consists of five observational trials (OTs), and one of them, OT1, is focused on DU management. The DeSScipher OT1 items on DU that reached ≥ 60% of completion rate were administered to EUSTAR (European Scleroderma Trials and Research group) centres via online survey. Questions about feasibility and usefulness of the existing DU classification (DU due to digital pitting scars, to loss of tissue, derived from calcinosis and gangrene) and newly proposed categorisation (episodic, recurrent and chronic) were also asked. RESULTS A total of 84/148 (56.8%) EUSTAR centres completed the questionnaire. DeSScipher items scored by ≥ 70% of the participants as essential and feasible for DU evaluation were the number of DU defined as a loss of tissue (level of agreement 92%), recurrent DU (84%) and number of new DU (74%). For 65% of the centres, the proposed classification of DU was considered useful and feasible in clinical practice. Moreover, 80% of the centres preferred the categorisation of DU in episodic, recurrent and chronic to simple distinction in recurrent/not recurrent DU. CONCLUSIONS For clinical practice, EUSTAR centres identified only three essential items for DU evaluation and considered the proposed classification and categorisation as useful and feasible. The set of items needs to be validated while further implementation of DU classification and categorisation is warranted. TRIAL REGISTRATION Observational trial on DU (OT1) is one of the five trials of the DeSScipher project (ClinicalTrials.gov; OT1 Identifier: NCT01836263 , posted on April 19, 2013).
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Affiliation(s)
- J. Blagojevic
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - S. Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - G. Abignano
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Rheumatology Institute of Lucania (IReL), Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
| | - J. Avouac
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | - L. Cometi
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - L. Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - C. P. Denton
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - O. Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - M. Frerix
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - S. Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - D. Huscher
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - V. K. Jaeger
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - V. Lóránd
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - B. Maurer
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - S. Nihtyanova
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - G. Riemekasten
- Clinic of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - E. Siegert
- Department of Rheumatology and Clinical Immunology, Charité – Universitaetsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - I. H. Tarner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - S. Vettori
- Rheumatology Section, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - U. A. Walker
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Y. Allanore
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | - U. Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - F. Del Galdo
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - M. Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - EUSTAR co-workers
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Rheumatology Institute of Lucania (IReL), Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
- Department of Rheumatology, University of Paris Descartes, Paris, France
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Rheumatology, University of Basel, Basel, Switzerland
- Clinic of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
- Department of Rheumatology and Clinical Immunology, Charité – Universitaetsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Rheumatology Section, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
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New ML, White CM, McGonigle P, McArthur DG, Dwyer-Nield LD, Merrick DT, Keith RL, Tennis MA. Prostacyclin and EMT Pathway Markers for Monitoring Response to Lung Cancer Chemoprevention. Cancer Prev Res (Phila) 2018; 11:643-654. [PMID: 30045935 PMCID: PMC6170683 DOI: 10.1158/1940-6207.capr-18-0052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/02/2018] [Accepted: 07/16/2018] [Indexed: 12/17/2022]
Abstract
Lung cancer is the leading cause of cancer death worldwide and global burden could be reduced through targeted application of chemoprevention. The development of squamous lung carcinoma has been linked with persistent, high-grade bronchial dysplasia. Bronchial histology improved in former smokers in a chemoprevention trial with the prostacyclin analogue iloprost. Prostacyclin acts through peroxisome proliferator-activated receptor gamma (PPARγ) to reverse epithelial to mesenchymal transition and promote anticancer signaling. We hypothesized that the prostacyclin signaling pathway and EMT could provide response markers for prostacyclin chemoprevention of lung cancer. Human bronchial epithelial cells were treated with cigarette smoke condensate (CSC) or iloprost for 2 weeks, CSC for 16 weeks, or CSC for 4 weeks followed by 4 weeks of CSC and/or iloprost, and RNA was extracted. Wild-type or prostacyclin synthase transgenic mice were exposed to 1 week of cigarette smoke or one injection of urethane, and RNA was extracted from the lungs. We measured potential markers of prostacyclin and iloprost efficacy in these models. We identified a panel of markers altered by tobacco carcinogens and inversely affected by prostacyclin, including PPARγ, 15PGDH, CES1, COX-2, ECADHERIN, SNAIL, VIMENTIN, CRB3, MIR34c, and MIR221 These data introduce a panel of potential markers for monitoring interception of bronchial dysplasia progression during chemoprevention with prostacyclin. Chemoprevention is a promising approach to reduce lung cancer mortality in a high-risk population. Identifying markers for targeted use is critical for success in future clinical trials of prostacyclin for lung cancer chemoprevention. Cancer Prev Res; 11(10); 643-54. ©2018 AACR.
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Affiliation(s)
- Melissa L New
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Collin M White
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Polly McGonigle
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | | | - Lori D Dwyer-Nield
- Department of Pharmaceutical Sciences, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Daniel T Merrick
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Robert L Keith
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Eastern Colorado Veterans Affairs Medical Center, Aurora, Colorado
| | - Meredith A Tennis
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado.
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Zippelius T, Perka C, Preininger B, Matziolis G, Strube P, Röhner E. Long-term effects of intravenous iloprost therapy in patients with bone marrow oedema of the hip. Acta Orthop Belg 2018; 84:172-178. [PMID: 30462600] [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: 06/09/2023]
Abstract
Bone marrow oedema (BMO) is a multifactorial condition. Various conservative treatment options include analgesic therapy, immobilisation of the affected joint and/or systemic intravenous iloprost or bisphosphonate therapy. Many studies confirm the positive effect of iloprost therapy in larger joints, e.g. the hip and knee joint, after short-term follow up. The objective of this study was to investigate that treatment with iloprost leads to positive long-term functional and radiological outcomes for BMO of the hip joint. Nineteen patients with BMO of the hip joint, ARCO stage 1-2, were included in this study. The Harris Hip Score, the SF-36, the WOMAC score and a visual analogue pain scale (VAS) were evaluated before and 29 ± 11 months after Ilomedin therapy. All patients underwent MRI for radiological follow-up monitoring three months after treatment. Significant improvements were found in the WOMAC Index and the VAS. In 79% of patients, follow-up MRI after three months showed complete regression of the oedema. Based on the positive results of our study, we support treatment with iloprost for BMO of the hip joint at ARCO stage 1-2.
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Sen I, Agarwal S, Tharyan P, Forster R. Lumbar sympathectomy versus prostanoids for critical limb ischaemia due to non-reconstructable peripheral arterial disease. Cochrane Database Syst Rev 2018; 4:CD009366. [PMID: 29658630 PMCID: PMC6494604 DOI: 10.1002/14651858.cd009366.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is a common circulatory problem that can lead to reduced blood flow to the limbs, which may result in critical limb ischaemia (CLI), a painful manifestation that occurs when a person is at rest. The mainstay of treatment for CLI is surgical or endovascular repair. However, when these means of treatment are not suitable, due to anatomical reasons or comorbidities, treatment for pain is limited. Lumbar sympathectomy and prostanoids have both been shown to reduce pain from CLI in people who suffer from non-reconstructable PAD, but there is currently insufficient evidence to determine if one treatment is superior. Due to the severity of the rest pain caused by CLI, and its impact on quality of life, it is important that people are receiving the best pain relief treatment available, therefore interest in this area of research is high. OBJECTIVES To compare the efficacy of lumbar sympathectomy with prostanoid infusion in improving symptoms and function and avoiding amputation in people with critical limb ischaemia (CLI) due to non-reconstructable peripheral arterial disease (PAD). SEARCH METHODS The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched 29 March 2017) and CENTRAL (2017, Issue 2). The CIS also searched clinical trials databases for ongoing or unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs), with parallel treatment groups, that compared lumbar sympathectomy (surgical or chemical) with prostanoids (any type and dosage) in people with CLI due to non-reconstructable PAD. DATA COLLECTION AND ANALYSIS Three review authors independently selected trials, extracted data and assessed risk of bias. Any disagreements were resolved by discussion. We performed fixed-effect model meta-analyses, when there was no overt sign of heterogeneity, with risk ratios (RRs) and 95% confidence intervals (CIs). We graded the quality of evidence according to GRADE. MAIN RESULTS We included a single study in this review comparing lumbar sympathectomy with prostanoids for the treatment of CLI in people with non-reconstructable PAD. The single study included 200 participants with Buerger's disease, a form of PAD, 100 in each treatment group, but only 162 were actually included in the analyses. The study compared an open surgical technique for lumbar sympathectomy with the prostanoid, iloprost, and followed participants for 24 weeks.Risk of bias was low for most evaluated domains. Due to the nature of the treatment, blinding of the participants and those providing the treatment would be impossible as a surgical procedure was compared with intravenous injections. It was not mentioned if blinded assessors evaluated the study outcomes, therefore, we judged subjective outcomes (i.e. pain reduction) to be at unclear risk of detection bias and objective outcomes (i.e. ulcer healing, amputation and mortality) at low risk of detection bias. We also rated the risk of attrition bias as unclear; 38 out of 200 (19%) participants were not included in the analysis without clear explanation (16 of 100 in the iloprost arm and 22 of 100 in the sympathectomy arm). The quality of evidence was low due to serious imprecision because the study numbers were low and there was only one study included.The single included study reported on the outcome of complete healing without pain or major amputation, which fell under three separate outcomes for our review: relief of rest pain, complete ulcer healing and avoidance of major amputation. We chose to keep the outcome as a singularly reported outcome in order to not introduce bias into the outcomes, which may have been the case if reported separately. The limited evidence suggests participants who received prostaglandins had improved complete ulcer healing without rest pain or major amputation when compared with those who received lumbar sympathectomy (RR 1.63, 95% CI 1.30 to 2.05), but as it was the only included study, we rated the data as low-quality and could not draw any overall conclusions. The study authors stated that more participants who received prostaglandins reported adverse effects, such as headache, flushing, nausea and abdominal discomfort, but only one participant experienced severe enough adverse effects to drop out. Five participants who underwent lumbar sympathectomy reported minor wound infection (low-quality evidence). There was no reported mortality in either of the treatment groups (low-quality evidence).The included study did not report on claudication distances, quality of life or functional status, ankle brachial pressure index (ABPI), tissue oxygenation or toe pressures, or progression to minor amputation, complications or provide any cost-effectiveness data. AUTHORS' CONCLUSIONS Low-quality evidence from a single study in a select group of participants (people with Buerger's disease) suggests that prostaglandins are superior to open surgical lumbar sympathectomy for complete ulcer healing without rest pain or major amputation, but possibly incur more adverse effects. Further studies are needed to better understand if prostaglandins truly are more efficacious than open surgical lumbar sympathectomy and if there are any concerns with adverse effects. It would be of great importance for future studies to include other forms of PAD (as Buerger's disease is a select type of PAD), other methods of sympathectomy as well as data on quality of life, complications and cost-effectiveness.
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Affiliation(s)
- Indrani Sen
- Christian Medical CollegeVascular SurgeryVelloreTamil NaduIndia632004
| | - Sunil Agarwal
- Christian Medical CollegeSurgery Unit IIVelloreIndia632004
| | - Prathap Tharyan
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Center for Evidence‐Informed Health Care and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
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Arapoglou S, Kambaroudis A, Grivas I, Delis GA, Karkos C, Ballas K, Zacharioudakis G, Petras P, Aftzoglou M, Gouziotis I, Koliakos G, Karakwta M, Hahalis G. The Effect of Iloprost in the Healing of Colonic Anastomosis in Rats under Chemotherapy with Irinotecan. Chirurgia (Bucur) 2018; 112:705-713. [PMID: 29288613 DOI: 10.21614/chirurgia.112.6.705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2017] [Indexed: 01/27/2023]
Abstract
PURPOSE We have investigated the possible positive effect of iloprost in the healing of colonic anastomosis, in rats under intraperitoneal chemotherapy with irinotecan. METHOD Forty male Wistar rats have been divided into four groups. They underwent a partial colectomy and a termino-terminal anastomosis. They were administered, intraperitoneally, saline (group 1), irinotecan (group 2), iloprost (group 3), or irinotecan and iloprost (Group 4). After the sacrifice of the animals what followed was an autopsy, a macroscopic examination and the measurement of the anastomotic rupture pressure. A portion of the anastomosis was sent over for histological examination and determination of hydroxyproline levels. Results: The frequency of the leakage from the anastomosis was considered as significantly increased in group 2 compared with the other groups. In group 2, a significantly greater degree of adhesions, compared to all the remaining groups, was observed. The bursting pressure of the anastomosis was significantly lower in group 2, as compared with all the remaining groups, and significantly increased in the group 4 compared with group 2. Leukocytosis, fibroblasts, the neocollagen and the levels of hydroxyproline in group 4 showed significantly increased values, compared with group 2. The angiogenesis was significantly increased in groups 3 and 4 compared with group 2. Conclusions: Intraperitoneal administration of iloprost after colectomy, termino-terminal anastomosis and intraperitoneal administration of irinotecan promotes the healing process of the colon anastomoses as it competes the inhibitory effect of irinotecan.
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Ingegnoli F, Schioppo T, Allanore Y, Caporali R, Colaci M, Distler O, Furst DE, Hunzelmann N, Iannone F, Khanna D, Matucci-Cerinic M. Practical suggestions on intravenous iloprost in Raynaud's phenomenon and digital ulcer secondary to systemic sclerosis: Systematic literature review and expert consensus. Semin Arthritis Rheum 2018; 48:686-693. [PMID: 29706243 DOI: 10.1016/j.semarthrit.2018.03.019] [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: 01/13/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Systemic sclerosis (SSc) is an autoimmune chronic disease characterized by vascular impairment, immune dysfunction and collagen deposition. Raynaud's phenomenon (RP) and digital ulcers (DU) are prominent features of SSc. Intravenous (IV) iloprost (ILO), according to the recently updated EULAR recommendations, is indicated for RP after failure of oral therapy. Moreover, IV ILO could be useful in DU healing. IV ILO is currently available mainly on the European market approved for RP secondary to SSc with 3-5 days infusion cycle. Unfortunately, data published varies regarding regimen (dosage, duration and frequency). Up to now, ILO has been studied in small cohorts of patients and in few randomized controlled trials. METHODS A systematic review of studies on IV ILO in patients with SSc complicated by DU and RP was performed. Insufficient data were available to perform a meta-analysis according to the GRADE system. We performed a three-stage internet-based Delphi consensus exercise. RESULTS Three major indications were identified for IV ILO usage in SSc: RP non-responsive to oral therapy, DU healing, and DU prevention. IV ILO should be administered between 0.5 and 2.0ng/kg/min according to patient tolerability with a frequency depending on the indication. CONCLUSIONS Although these suggestions are supported by this expert group to be used in clinical setting, it will be necessary to formally validate the present suggestions in future clinical trials.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Clinical Rheumatology, ASST Pini-CTO, Milano, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy.
| | | | - Yannick Allanore
- Paris Descartes University, Cochin Hospital, Rheumatology A department, INSERM U1016, Paris, France
| | - Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS S. Matteo Foundation, Pavia, Italy
| | - Michele Colaci
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Switzerland
| | - Daniel E Furst
- Los Angeles, USA UCLA (emeritus); University of Washington, Seattle Wash; University of Florence, Florence, Italy
| | | | | | - Dinesh Khanna
- Ann Arbor, University of Michigan, Ann Arbor, Michigan
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence & Department of Geriatric Medicine, Division of Rheumatology AOUC, Florence, Italy
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Abstract
Case report of a patient with age-related macular degeneration whose digital ischemia can most plausibly be attributed to ranibizumab. PURPOSE To report ranibizumab as the probable cause of digital ischemia in a patient treated for age-related macular degeneration. METHODS Single-patient case report. RESULTS An 83-year-old woman with an unremarkable medical history suffered acute ischemia in her left hand with necrosis of the distal phalange of the fifth finger after six intravitreal injections of ranibizumab. Her etiological work-up was negative. Her condition improved after endovascular revascularization and remained good at six months' follow-up after three months of dual antithrombotic therapy (low molecular weight heparin then rivaroxaban, both with aspirin) followed by rivaroxaban alone and four courses of intravenous iloprost. CONCLUSION The increased incidence of peripheral arterial thromboembolic events in patients under ranibizumab treatment is slight but significant, with 0.8-5% of patients affected, most of which suffer strokes. These events seem to occur at a random time after ranibizumab treatment is initiated and no reliable marker has yet been identified. The most probable cause of digital ischemia in our patient was ranibizumab.
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Affiliation(s)
- R Attal
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France.
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France
| | - G Angelopoulos
- Service de radiologie interventionnelle, hôpital privé de Parly-II, 78150 Le-Chesnay, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France
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Abstract
BACKGROUND Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010. OBJECTIVES To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials. SELECTION CRITERIA Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author. MAIN RESULTS For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
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Affiliation(s)
- Valeria Vietto
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Victoria Saenz
- Unidad Asistencial Dr. César MilsteinInternal MedicineLa Rioja 951Ciudad Autónoma de Buenos AiresBuenos AiresArgentinaC1221ACI
| | - Denise Cytryn
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
| | - Jose Chas
- Hospital Italiano de Buenos AiresCardiovascular Surgery DepartmentBuenos AiresArgentinaPerón 4190
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
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GERACI MARKW. TARGETING THE PROSTACYCLIN/PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR GAMMA AXIS IN LUNG CANCER CHEMOPREVENTION. Trans Am Clin Climatol Assoc 2018; 129:48-55. [PMID: 30166698 PMCID: PMC6116597] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Lung cancer remains an important target of cancer research, and accounts for most deaths of any cancer type in the United States. Chemoprevention refers to the use of agents to prevent the development of cancer in high-risk populations, often in patients with predisposing lesions. In the following, we describe our ongoing work examining the role of the eicosanoid prostacyclin in lung cancer chemoprevention. Our findings include the fact that most adenocarcinomas lose the expression of prostacyclin synthase through methylation silencing. In addition, transgenic mice with overexpression of prostacyclin synthase are protected from tumorigenesis in multiple preclinical lung cancer models. Our phase IIb clinical trial using iloprost, a prostacyclin analogue, showed the reversal of airway dysplasia in high-risk individuals. This trial represents the first to show regression of airway dysplasia from the administration of a chemoprevention agent and forms the basis for future trials in lung cancer chemoprevention.
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Affiliation(s)
- MARK W. GERACI
- Correspondence and reprint requests: Mark W. Garaci, MD, Department of Medicine, Indiana University,
545 Barnhill Dr., Emerson Hall 305, Indianapolis, Indiana 46202317-274-8438317-274-1437
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Smaoui F, Koubaa M, Rekik K, Mejdoub Y, Mezghani S, Maaloul I, Hammami A, Marrakchi C, Ben Jemaa M. [Symmetrical peripheral gangrene: 4 cases]. Ann Dermatol Venereol 2017; 145:95-99. [PMID: 29169658 DOI: 10.1016/j.annder.2017.09.592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 03/12/2017] [Revised: 06/28/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases. PATIENTS AND METHODS We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction. RESULTS Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes. CONCLUSION SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.
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Affiliation(s)
- F Smaoui
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Koubaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie.
| | - K Rekik
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - Y Mejdoub
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - S Mezghani
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - I Maaloul
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - A Hammami
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - C Marrakchi
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Ben Jemaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
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Colaci M, Lumetti F, Giuggioli D, Guiducci S, Bellando-Randone S, Fiori G, Matucci-Cerinic M, Ferri C. Long-term treatment of scleroderma-related digital ulcers with iloprost: a cohort study. Clin Exp Rheumatol 2017; 35 Suppl 106:179-183. [PMID: 28980901] [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: 04/04/2017] [Accepted: 07/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Raynaud's phenomenon and chronic/recurrent digital ulcers (DU) are main features of systemic sclerosis (SSc). Their treatment includes both systemic (i.e., iloprost) and local therapies. We report the therapeutic effects of iloprost in a cohort of SSc patients during a long-lasting follow-up period. METHODS Fifty consecutive SSc patients (M/F 7/43, age at SSc diagnosis 43.5±12.7SD years) received iloprost infusions for 10±4.2SD years. Iloprost schedule consisted in monthly infusion at 0.8-1 ng/kg body weight/min (average cumulative dose 25 μg), according to patients' tolerance. For recalcitrant cases, continuous infusion of iloprost (3 days, average 0.2 mg) was administered. RESULTS 31/50 (62%) patients showed DU at the beginning of iloprost therapy: among them, 22 (71%) resolved during the follow-up, while the other 9 presented recurrent or chronic DU, despite the treatment. With regards the 19/50 patients without DU at baseline, only one developed skin lesions at the end of 10-year follow-up, when severe pulmonary hypertension developed, which lead to exitus. Considering the 31 patients with DU at baseline, a diffuse skin subset was present in 3/22 patients with healed DU, and in 5/9 who did not (13.6% vs. 55.5%; p=0.027). CONCLUSIONS Iloprost is a long-term effective treatment to achieve healing and prevention in SSc-related DU. Besides the possible problems concerning patients' tolerability or clinical management, iloprost therapy may be considered of great help in the therapeutic strategy of SSc-related ischaemic manifestations.
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Affiliation(s)
- Michele Colaci
- Rheumatology Unit, Scleroderma Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Federica Lumetti
- Rheumatology Unit, Scleroderma Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Dilia Giuggioli
- Rheumatology Unit, Scleroderma Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Florence, Italy
| | - Ginevra Fiori
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Florence, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, Scleroderma Unit, University of Modena and Reggio Emilia, Modena, Italy
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Unal S, Aktas S, Aksu M, Hirfanoglu IM, Atalay Y, Turkyilmaz C. Iloprost Instillation in Two Neonates with Pulmonary Hypertension. J Coll Physicians Surg Pak 2017; 27:257-259. [PMID: 28492159] [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: 03/07/2016] [Accepted: 01/16/2017] [Indexed: 06/07/2023]
Abstract
Pulmonary hypertension may coexist with certain diseases in neonates. Iloprost inhalation is one of the treatments which cause selective pulmonary vasodilatation. Inhalation is not an easy way of drug administration in mechanically ventilated infants; as some exhibit desaturations during inhalation. Moreover, inhalation of drug requires cessation of mechanical ventilation, if patient is on high frequency oscillatory ventilation. We presented two patients with pulmonary hypertension; term baby with congenital diaphragmatic hernia and preterm baby with respiratory distress syndrome; who had iloprost instillation during mechanical ventilation treatment. Iloprost instillation was well tolerated with no side effects in the term patient with diaphragmatic hernia; whereas severe blood pressure fluctuations were observed in the preterm infant. This report may courage administration of iloprost in term neonates with resistant pulmonary hypertension.
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MESH Headings
- Administration, Inhalation
- Female
- Humans
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/etiology
- Iloprost/administration & dosage
- Iloprost/therapeutic use
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/etiology
- Infant, Very Low Birth Weight
- Male
- Respiratory Distress Syndrome, Newborn/complications
- Respiratory Distress Syndrome, Newborn/therapy
- Treatment Outcome
- Vasodilator Agents/administration & dosage
- Vasodilator Agents/therapeutic use
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Affiliation(s)
- Sezin Unal
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
- Department of Neonatology, Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Selma Aktas
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
| | - Meltem Aksu
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
| | - Ibrahim M Hirfanoglu
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
| | - Yildiz Atalay
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
| | - Canan Turkyilmaz
- Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey
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Parker LK, Ponte C, Howell KJ, Ong VH, Denton CP, Schreiber BE. Clinical features and management of erythromelalgia: long term follow-up of 46 cases. Clin Exp Rheumatol 2017; 35:80-84. [PMID: 27494156] [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: 03/03/2016] [Accepted: 07/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To review our clinical experience of this rare condition and describe the clinical features and response to therapy in a cohort of patients with erythromelalgia (EM), a rare condition, characterised by paroxysmal hyperthermia of the extremities with erythema, pain and intense burning. METHODS A review was made of the electronic and paper medical records of patients with the diagnosis of EM, with a telephone interview to verify and complete clinical information relating treatment and outcome. RESULTS 46 patients (41 females) were included in this study. Mean age was 57 years and mean duration of symptoms was 16 years. Raynaud's phenomenon was present in 36 patients (80%) and 4 patients (9%) had systemic sclerosis. Smoking (current or previous) was identified as a possible risk factor in 26 cases and exposure to chronic vibration in 3 cases. Overall, the effect on quality of life was mild in 15% of cases, moderate in 30% and severe in 48%. The most common symptoms were burning (96%), heat (93%), pain (87%), and redness (83%). Symptoms affected the lower limbs in 98% of cases, upper limbs in 76%, face in 20% and trunk in 11%. Triggers included heat (85%), exercise (78%) and time of day (76%). Various medications were tried, showing poor effect in most cases. Intravenous iloprost was given to 27 patients, with benefit in 17 patients (63%). CONCLUSIONS Erythromelalgia is a rare chronic debilitating condition. Exercise, heat and night time are common triggers. Current medical therapies are seldom effective and further research is sorely needed.
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Affiliation(s)
- Louise K Parker
- Centre for Rheumatology, Royal Free London NHS Foundation Trust, London, UK
| | - Cristina Ponte
- Department of Rheumatology, Hospital de Santa Maria, Lisbon; and Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Kevin J Howell
- Microvascular Diagnostics, Institute of Immunity and Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Voon H Ong
- Centre for Rheumatology, Royal Free London NHS Foundation Trust, London, UK
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Affiliation(s)
- Alexander Poole
- Whitehorse General Hospital (Poole, Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; College of Pharmacy and Nutrition (Gauthier), University of Saskatchewan, Saskatoon, Sask.
| | - Josianne Gauthier
- Whitehorse General Hospital (Poole, Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; College of Pharmacy and Nutrition (Gauthier), University of Saskatchewan, Saskatoon, Sask
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Melillo E, Lucaccini E, Berchiolli R, Adami D, Nuti M, Dell'Omo G, Farina A, Panigada G, Roberts AT, Meini S. Long-term survival of patients with critical limb ischemia treated with iloprost: response rate and predictive criteria. A retrospective analysis of 102 patients. Eur Rev Med Pharmacol Sci 2016; 20:5233-5241. [PMID: 28051243] [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] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Critical limb ischemia (CLI) patients have poor long-term prognosis. We showed that iloprost improves outcomes (major amputation and survival) up a 5-year follow-up, but it is not known if in this length of time the survival curves, of clinical responders and non-responders, differ. PATIENTS AND METHODS A retrospective study enrolling 102 consecutive patients between 2004-2008, with clinical and instrumental (ultrasound, angiography, transcutaneous tensiometry of oxygen TcpO2 and carbon dioxide TcpCO2 in the affected and contralateral limbs) diagnosis of critical ischemia. All patients received the best medical therapy. Iloprost was administered (0.5-2 ng/kg/min 6 hours/day for 2-4 weeks) in all patients initially considered unsuitable for revascularization, repeating it regularly in time every six-twelve months in the case of positive response. The minimum expected follow-up was 4 years. RESULTS 71.5% of patients were treated with iloprost and the responder rate was 71.2%. Most of the patients were regularly retreated with repeated cycles. Initial median supine TcpCO2 in symptomatic limb was higher in untreated patients than those treated (58 vs. 49 mmHg; p < 0.05) and in non-responders compared to responders (60 vs. 49 mmHg; p < 0.05). TcpCO2 directly and significantly correlated with the highest risk of mortality and seems to represent a new accurate prognostic criterion of unfavourable short and long-term response to prostanoid. In iloprost group, major amputations were significantly reduced. Revascularization was significantly higher in non-responders (57.1% vs. 11.5%; p < 0.05). There was a significantly higher prevalence of subsequent myocardial infarction in the non-iloprost group (27.6% vs. 9.6%; p < 0.05). The survival rate of non-responders was higher than untreated up until the second year (76.2% vs. 62%; p < 0.05). At 4 years we found higher survival in patients treated with iloprost (64.3% vs. 41% in untreated; p < 0.05) and in responders (75% vs. 38.1% in non-responders; p < 0.05). CONCLUSIONS Our results confirm the favourable role of iloprost on the long-term outcome in patients with CLI. In particular, the maximum benefit is obtained in responder patients treated with multiple cycles of infusion.
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Affiliation(s)
- E Melillo
- Cardiothoracic and Vascular Department, Angiology Unit, University of Pisa, Pisa, Italy.
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Abstract
In intermittent claudication, pharmacologic drugs and invasive measures are indicated in patients who do not benefit from exercise training. To evaluate the therapeutic role of prostaglandins (PGs), especially of prostaglandin E1 (PGE1), for this indication, the author performed a meta-analysis of all published prospective, randomized, controlled clinical studies in which descriptive sample statistics of the pain-free walking distance (PFWD) and the maximum walking distance (MWD) were available. In total, 9 studies with PGE1 and 4 studies with other PGs (beraprost, iloprost, AS-013) that met these selection criteria could be analyzed. In patients treated with PGE1 (n=344), PFWD increased significantly (p<0.001) more (+107%) than in patients treated with other PGs (n=402; +42%) or placebo (n=470; +24%). Similar results were also found for the MWD. Side effects were significantly (p<0.001) fewer with PGE1 therapy than with other PGs (14.0% vs 30.8% of patients). In conclusion, PGE1 proved to be the most effective and best tolerated of the PGs evaluated.
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Affiliation(s)
- Klaus Amendt
- Diakonie-Krankenhaus Mannheim, Mannheim, Germany.
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Polignano R, Baggiore C, Falciani F, Restelli U, Troisi N, Michelagnoli S, Panigada G, Tatini S, Farina A, Landini G. Efficacy, safety and feasibility of intravenous iloprost in the domiciliary treatment of patients with ischemic disease of the lower limbs. Eur Rev Med Pharmacol Sci 2016; 20:3720-3726. [PMID: 27649677] [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] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Intravenous iloprost is an important option in the treatment of ischemic disease of the lower limbs; however, the administration of therapy is frequently compromised because of the need for long cycles of infusion in a hospital setting. The aim of the study is to evaluate the efficacy, safety, feasibility, and the economic impact of infusion therapy in the outpatient setting. PATIENTS AND METHODS Twenty-four consecutive patients were treated with iloprost at their homes where they were administered a slow rate of infusion for 24 hours a day, during 9.9 ± 2.3 days, with a portable syringe pump (Infonde®). RESULTS The clinical condition of patients evaluated with the modified SVS/ISCVS scale significantly improved after treatment (+1.29 ± 1.04 points vs. baseline, p<0.001). The drug was well tolerated; neither significant adverse events associated with medication nor problems related to venous access were recorded at home. Ninety-six percent of patients successfully completed the entire treatment cycle, and the evaluation questionnaire showed a high acceptance of the therapy. From the perspective of the hospital authority, lower direct medical costs were estimated for the domiciliary infusion process compared with the inpatient infusion setting. CONCLUSIONS Treatment with iloprost in the outpatient setting is effective, safe, feasible, and more acceptable to patients than infusion at the hospital. In addition, it has a favorable economic and organizational impact on the medical ward.
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Affiliation(s)
- R Polignano
- Medical Department, USL Centro Toscana, Florence, Italy.
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Melillo E, Ferrari M, Balbarini A, Pedrinelli R. Transcutaneous Oxygen and Carbon Dioxide Levels with Iloprost Administration in Diabetic Critical Limb Ischemia. Vasc Endovascular Surg 2016; 40:303-11. [PMID: 16959724 DOI: 10.1177/1538574406291824] [Citation(s) in RCA: 5] [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: 11/15/2022]
Abstract
Iloprost, a prostacyclin analogue, is a treatment option for surgically unsuitable diabetic chronic critical limb ischemia (CLI), although its outcome is difficult to be anticipated clinically. Whether transcutaneous (tc) oxygen tension (PO2) predicts the response to iloprost in diabetic CLI is unclear at this point and, in that same context, the prognostic role of tc carbon dioxide tension (PCO2), another ischemia-sensitive parameter, is unknown. Supine and dependent tcPO2 and tcPCO2 were measured at baseline and after 4 weeks of iloprost treatment in 31 limbs of 26 type-2 diabetic arteriopaths with CLI not amenable to surgery. Success was defined as pain relief and significant reduction of analgesics. Clinical outcome was stratified by baseline tcPO2 and tcPCO2 tertiles, and likelihood ratios (LR) quantified the increase from pretest chances given a certain result. Iloprost succeeded in 16 (52%) and failed in 15 limbs (48%) and post-treatment tcPO2 followed a parallel course. Failures increased by ascending baseline tcPCO2 and descending tcPO2 tertiles; successes behaved specularly. Predictions of failure based on elevated tcPCO2 (>53 mm Hg) were more efficient than relying on depressed tcPO2 (LR 10.7 vs 3.6); success was almost certain when tcPO2 was >23 mm Hg (LR = 17.8). Dependent determinations were less useful than supine measurements for prognostic use. Elevated tcPCO2 predicted failure efficiently and high tcPO2 was a useful prognostic tool for success of iloprost, suggesting that their combined use may allow better prognostic stratification and improve the therapeutic approach to diabetic CLI.
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Affiliation(s)
- Elio Melillo
- Dipartimento Cadio Toracico, Università di Pisa, Pisa, Italy
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Affiliation(s)
- Fredrick M Wigley
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
| | - Nicholas A Flavahan
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
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Poredos P, Poredos P. Raynaud's Syndrome: a neglected disease. INT ANGIOL 2016; 35:117-121. [PMID: 25673314] [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: 06/04/2023]
Abstract
Raynaud's Syndrome is a frequent manifestation of digital ischemia which occurs or is aggravated upon exposure to cold temperatures or emotional distress. Primary Raynaud is a benign disease which predominantly affects younger women and is transient without serious sequelae. In contrast, secondary Raynaud is usually one of the manifestations of systemic disease and is, in addition to symptoms of the basic disease, associated with ischemic lesions. The diagnosis of primary Raynaud is mostly based on the clinical presentation. In secondary Raynaud, additional investigating techniques including imaging investigations and laboratory tests for the detection of underline disease are needed. Treatment is based on lifestyle modification, which includes smoking cessation, avoiding low outside temperatures, avoiding the use of vibrating tools and limiting repeated hand actions. Drug treatment consists of calcium-channel blockers, nitroglycerine ointments, prostacyclins and various new drugs such as endothelin receptor antagonists, phosphodiesterase inhibitors and serotonin receptor antagonists. Most of these drugs are effective in less than 50% of treated patients and do not completely abolish vasospastic attacks, but reduce the severity and frequency of attacks. The prostacyclin derivate iloprost is the most promising drug in the management of secondary Raynaud's disease. Other therapeutic procedures including chemical or surgical sympathectomy are obsolete and without any long-term positive effects.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia -
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Abstract
BACKGROUND Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic, segmental inflammatory pathology that most commonly affects the small and medium sized arteries, veins, and nerves in the upper and lower extremities. The etiology is unknown, but involves hereditary susceptibility, tobacco exposure, immune and coagulation responses. In many cases, there is no possibility of revascularization to improve the condition. Pharmacological treatment is an option for patients with severe complications, such as ischaemic ulcers or rest pain. OBJECTIVES To assess the effectiveness of any pharmacological agent (intravenous or oral) compared with placebo or any other pharmacological agent in patients with Buerger's disease. SEARCH METHODS The Cochrane Vascular Trials Search Co-ordinator searched their Specialised Register (last searched in April 2015) and the Cochrane Register of Studies (Issue 3, 2015). The review authors searched trial registers and the European grey literature; screened reference lists of relevant studies, and contacted study authors and major pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) involving pharmacological agents used in the treatment of Buerger's disease. DATA COLLECTION AND ANALYSIS Two review authors, independently assessed the studies, extracted data and performed data analysis. MAIN RESULTS Five randomised controlled trials (total 602 participants) compared prostacyclin analogue with placebo, aspirin, or a prostaglandin analogue, and folic acid with placebo. No studies assessed other pharmacological agents such as cilostazol, clopidogrel and pentoxifylline or compared oral versus intravenous prostanoid.Compared with aspirin, intravenous prostacyclin analogue iloprost improved ulcer healing (risk ratio (RR) 2.65; 95% confidence interval (CI) 1.15 to 6.11; 98 participants; one study; moderate quality evidence), and helped to eradicate rest pain after 28 days (RR 2.28; 95% CI 1.48 to 3.52; 133 participants; one study; moderate quality evidence), although amputation rates were similar six months after treatment (RR 0.32; 95% CI 0.09 to 1.15; 95 participants; one study; moderate quality evidence). When comparing prostacyclin (iloprost and clinprost) with prostaglandin (alprostadil) analogues, ulcer healing was similar (RR 1.13; 95% CI 0.76 to 1.69; 89 participants; two studies; I² = 0%; very low quality evidence), as was the eradication of rest pain after 28 days (RR 1.57; 95% CI 0.72 to 3.44; 38 participants; one study; low quality evidence), while amputation rates were not measured. Compared with placebo, the effects of oral prostacyclin analogue iloprost were similar for: healing ischaemic ulcers (iloprost 200 mcg: RR 1.11; 95% CI 0.54 to 2.29; 133 participants; one study; moderate quality evidence, and iloprost 400 mcg: RR 0.90; 95% CI 0.42 to 1.93; 135 participants; one study; moderate quality evidence), eradication of rest pain after eight weeks (iloprost 200 mcg: RR 1.14; 95% CI 0.79 to 1.63; 207 participants; one study; moderate quality evidence, and iloprost 400 mcg: RR 1.11; 95% CI 0.77 to 1.59; 201 participants; one study; moderate quality evidence), and amputation rates after six months (iloprost 200 mcg: RR 0.54; 95% CI 0.19 to 1.56; 209 participants; one study, and iloprost 400 mcg: RR 0.42; 95% CI 0.13 to 1.31; 213 participants; one study). When comparing folic acid with placebo in patients with Buerger's disease and hyperhomocysteinaemia, pain scores were similar, there were no new cases of amputation in either group, and ulcer healing was not assessed (very low quality evidence).Treatment side effects such as headaches, flushing or nausea were not associated with treatment interruptions or more serious consequences. Outcomes such as amputation-free survival, walking distance or pain-free walking distance, and ankle brachial index were not assessed by any study.Overall, the quality of the evidence was very low to moderate, with few studies, small numbers of participants, variation in severity of disease of participants between studies and missing information regarding for example baseline tobacco exposure. AUTHORS' CONCLUSIONS Moderate quality evidence suggests that intravenous iloprost (prostacyclin analogue) is more effective than aspirin for eradicating rest pain and healing ischaemic ulcers in Buerger's disease, but oral iloprost is not more effective than placebo. Verylow and low quality evidence suggests there is no difference between prostacyclin (iloprost and clinprost) and the prostaglandin analogue alprostadil for healing ulcers and relieving pain respectively in severe Buerger's disease. Very-low quality evidence suggests there is no difference in pain scores and amputation rates between folic acid and placebo, in people with Buerger's disease and hyperhomocysteinaemia. High quality trials assessing the effectiveness of pharmacological agents (intravenous or oral) in people with Buerger's disease are needed.
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Affiliation(s)
- Daniel G Cacione
- UNIFESP – Escola Paulista de MedicinaDepartment of SurgeryRua Borges Lagoa, 564 cj 124Vila ClementinoSão PauloBrazil04038000
| | - Cristiane R Macedo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeBrazilian Cochrane CentreRua Borges Lagoa, 564 cj 63São PauloSPBrazil04038‐000
| | - Jose CC Baptista‐Silva
- Universidade Federal de São PauloEvidence Based Medicine, Cochrane BrazilRua Borges Lagoa, 564, cj 124São PauloSão PauloBrazil04038‐000
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Abstract
BACKGROUND Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic, segmental inflammatory pathology that most commonly affects the small and medium sized arteries, veins, and nerves in the upper and lower extremities. The etiology is unknown, but involves hereditary susceptibility, tobacco exposure, immune and coagulation responses. In many cases, there is no possibility of revascularization to improve the condition. Pharmacological treatment is an option for patients with severe complications, such as ischaemic ulcers or rest pain. OBJECTIVES To assess the effectiveness of any pharmacological agent (intravenous or oral) compared with placebo or any other pharmacological agent in patients with Buerger's disease. SEARCH METHODS The Cochrane Vascular Trials Search Co-ordinator searched their Specialised Register (last searched in April 2015) and the Cochrane Register of Studies (Issue 3, 2015). The review authors searched trial registers and the European grey literature; screened reference lists of relevant studies, and contacted study authors and major pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) involving pharmacological agents used in the treatment of Buerger's disease. DATA COLLECTION AND ANALYSIS Two review authors, independently assessed the studies, extracted data and performed data analysis. MAIN RESULTS Five randomised controlled trials (total 602 participants) compared prostacyclin analogue with placebo, aspirin, or a prostaglandin analogue, and folic acid with placebo. No studies assessed other pharmacological agents such as cilostazol, clopidogrel and pentoxifylline or compared oral versus intravenous prostanoid.Compared with aspirin, intravenous prostacyclin analogue iloprost improved ulcer healing (risk ratio (RR) 2.65; 95% confidence interval (CI) 1.15 to 6.11; 98 participants; one study; moderate quality evidence), and helped to eradicate rest pain after 28 days (RR 2.28; 95% CI 1.48 to 3.52; 133 participants; one study; moderate quality evidence), although amputation rates were similar six months after treatment (RR 0.32; 95% CI 0.09 to 1.15; 95 participants; one study; moderate quality evidence). When comparing prostacyclin (iloprost and clinprost) with prostaglandin (alprostadil) analogues, ulcer healing was similar (RR 1.13; 95% CI 0.76 to 1.69; 89 participants; two studies; I² = 0%; very low quality evidence), as was the eradication of rest pain after 28 days (RR 1.57; 95% CI 0.72 to 3.44; 38 participants; one study; low quality evidence), while amputation rates were not measured. Compared with placebo, the effects of oral prostacyclin analogue iloprost were similar for: healing ischaemic ulcers (iloprost 200 mcg: RR 1.11; 95% CI 0.54 to 2.29; 133 participants; one study; moderate quality evidence, and iloprost 400 mcg: RR 0.90; 95% CI 0.42 to 1.93; 135 participants; one study; moderate quality evidence), eradication of rest pain after eight weeks (iloprost 200 mcg: RR 1.14; 95% CI 0.79 to 1.63; 207 participants; one study; moderate quality evidence, and iloprost 400 mcg: RR 1.11; 95% CI 0.77 to 1.59; 201 participants; one study; moderate quality evidence), and amputation rates after six months (iloprost 200 mcg: RR 0.54; 95% CI 0.19 to 1.56; 209 participants; one study, and iloprost 400 mcg: RR 0.42; 95% CI 0.13 to 1.31; 213 participants; one study). When comparing folic acid with placebo in patients with Buerger's disease and hyperhomocysteinaemia, pain scores were similar, there were no new cases of amputation in either group, and ulcer healing was not assessed (very low quality evidence).Treatment side effects such as headaches, flushing or nausea were not associated with treatment interruptions or more serious consequences. Outcomes such as amputation-free survival, walking distance or pain-free walking distance, and ankle brachial index were not assessed by any study.Overall, the quality of the evidence was very low to moderate, with few studies, small numbers of participants, variation in severity of disease of participants between studies and missing information regarding for example baseline tobacco exposure. AUTHORS' CONCLUSIONS Moderate quality evidence suggests that intravenous iloprost (prostacyclin analogue) is more effective than aspirin for eradicating rest pain and healing ischaemic ulcers in Buerger's disease, but oral iloprost is not more effective than placebo. Verylow and low quality evidence suggests there is no difference between prostacyclin (iloprost and clinprost) and the prostaglandin analogue alprostadil for healing ulcers and relieving pain respectively in severe Buerger's disease. Very-low quality evidence suggests there is no difference in pain scores and amputation rates between folic acid and placebo, in people with Buerger's disease and hyperhomocysteinaemia. High quality trials assessing the effectiveness of pharmacological agents (intravenous or oral) in people with Buerger's disease are needed.
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Affiliation(s)
- Daniel G Cacione
- Department of Surgery, UNIFESP - Escola Paulista de Medicina, Rua Borges Lagoa, 564 cj 124, Vila Clementino, São Paulo, Brazil, 04038000
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Abstract
Prostacyclin analogs, such as epoprostenol, treprostinil, iloprost, and beraprost, have long been used for pulmonary arterial hypertension (PAH) treatment, yet their relative efficiency remains disputed. Eligible randomized controlled trials (RCTs) involving the 4 therapies mentioned above were retrieved from PubMed, Embase, and Cochrane (up to August 1, 2015). Odds ratios (ORs) were estimated for dichotomous data (mortality, functional class (FC) amelioration, and discontinuation); standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated for continuous data (6-min walk distance [6-MWD]). Patients taking epoprostenol were anticipated to demonstrate more expedient 6-MWD than those taking placebo when network meta-analysis (NMA) was implemented (SMD = 52.19; 95% CI: 24.28-113.39), the trend of which was identical with that of pairwise meta-analysis (SMD = 69.28; 95% CI: 10.43-128.98). Nonetheless, the prominent advantages of treprostinil over placebo (SMD = 30.15; 95% CI: 19.29-40.01) in 6-MWD could not be replicated by NMA. Furthermore, direct and indirect (NMA) comparisons also differed in FC amelioration. For example, the superiority of epoprostenol over placebo as evident with the use of NMA (OR = 42.79; 95% CI: 10.63-301.98) could not be confirmed by pairwise meta-analysis. As suggested by indirect comparisons among 4 prostanoids, epoprostenol appears to result in remarkably favorable FC amelioration comparing to other regimens (all P < 0.05). Participants taking beraprost were more probable to withdraw in comparison with those administrated with iloprost (OR = 10.07; 95% CI: 1.47-160.65). Taking mortality, FC amelioration, discontinuation, and 6-MWD into account, epoprostenol could be recommended as an alternative treatment for patients with moderate/advanced PAH.
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Affiliation(s)
- Huijun Zhang
- From the Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, PR China
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Vitale V, Monami M, Mannucci E. Prostanoids in patients with peripheral arterial disease: A meta-analysis of placebo-controlled randomized clinical trials. J Diabetes Complications 2016; 30:161-6. [PMID: 26516035 DOI: 10.1016/j.jdiacomp.2015.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 08/12/2015] [Revised: 09/08/2015] [Accepted: 09/09/2015] [Indexed: 10/23/2022]
Abstract
AIMS Prostanoids are indicated in the treatment of peripheral arterial disease (PAD). Available trials suggest that these compounds could reduce the symptoms of intermittent claudication, even though the quality of studies is poor. The present meta-analysis is aimed at verifying the effects of prostanoids on amputation rate and ulcer healing in patients with lower limb PAD. MATERIALS AND METHODS The review protocol was published on http://www.crd.york.ac.uk/prospero (CRD42015020258). A comprehensive search for published and unpublished trials comparing iloprost, alprostadil, prostaglandin-E1, epoprostenol, or taprostene with placebo/no therapy on amputation rate in patients with PAD and ulcer healing rate in patients with concomitant foot ulcers. Mantel-Haenzel odds ratio (MH-OR) was calculated with random effect models for the chosen endpoints. RESULTS A total of 18 trials, enrolling 3,077 and 2,763 patients in the prostanoid and comparator groups, respectively were included in the analysis. Only 11 and 10 of those trials reported data on total and major amputations, respectively. Prostanoids were associated with a significantly lower risk of major (MH-OR [95% confidence interval] was 0.77 [0.63; 0.93], p=0.007), but not total, amputations. Healing rate (available only in 7 trials) was not significantly augmented by prostanoid treatment. CONCLUSIONS Available data are not sufficient to support an extensive use of prostanoids in patients with critical limb ischemia, as an adjunct to revascularization or as an alternative to major amputation in cases which cannot undergo revascularization.
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Affiliation(s)
- Valentina Vitale
- Diabetology, Careggi Teaching Hospital, Via delle Oblate 4, 50141 Florence, Italy
| | - Matteo Monami
- Division of Geriatric Cardiology and Medicine, Careggi Teaching Hospital.
| | - Edoardo Mannucci
- Diabetology, Careggi Teaching Hospital, Via delle Oblate 4, 50141 Florence, Italy.
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Affiliation(s)
- S Cekic
- Uludag University Faculty of Medicine Division of Pediatric Immunology and Rheumatology, Uludag University School of Medicine, Bursa, Turkey
| | - S S Kilic
- Uludag University Faculty of Medicine Division of Pediatric Immunology and Rheumatology, Uludag University School of Medicine, Bursa, Turkey
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Segreto F, Tosi D, Marangi GF, Pendolino AL, Santoro S, Gigliofiorito P, Persichetti P. Iloprost administration in acrodermatitis of Hallopeau complicated by acquired toes syndactyly: a case report and review of the literature. Eur Rev Med Pharmacol Sci 2015; 19:2945-2948. [PMID: 26367710] [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] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Acrodermatitis Continua of Hallopeau (ACH) is a variant of pustular psoriasis often very difficult to treat. Secondary syndactyly, also called "pseudosyndactyly", is rare and can be a complication of burns, dystrophic epidermolysis bullosa or trauma. If left untreated, joint complications and definitive functional impairments may occur. CASE REPORT We report a case of a 74-year-old man with acrodermatitis continua of Hallopeau involving the toes and complicated by syndactyly. ACH regression following Iloprost administration was also observed. DISCUSSION Published studies are mainly limited to case reports only, due to the rarity of the disease. Therefore, there are no clear-cut therapeutic management guidelines available for this chronic and sometimes debilitating disease. ACH is often recalcitrant to the available therapies. Topical and systemic treatments have been described in literature with no long-lasting results. CONCLUSIONS To our knowledge, this is the first report of foot syndactyly associated to ACH. In our patient, ACH symptoms regressed with Iloprost administration: this finding has never been previously described in literature. If confirmed by other clinical experiences, Iloprost could be a further therapeutic option in ACH.
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Affiliation(s)
- F Segreto
- Plastic and Reconstructive Surgery Unit, Università Campus Bio-Medico di Roma, Rome, Italy.
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Peregud-Pogorzelska M, Kornacewicz-Jach Z. [Pregnant woman with pulmonary hypertension]. Przegl Lek 2015; 72:193-195. [PMID: 26455018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pulmonary hypertension is a disease with diverse etiology. According to the New ESC guidelines, pregnancy is contraindicated for a patent with pulmonary hypertension and qualify such patent to class IV NYHA, regardless of the reason of hypertension. Pregnancy is revived for a patient with pulmonary hypertension despite of the fact that recent treatment methods including specific therapy with the endothelin receptor antagonistst (bosentan), phosphodiesterase inhibitors (sildenafil) and prostacyclin analogs (iloprost) were introduced. In the case of coincidence of pregnancy and pulmonary hypertension, patients should be managed in a center with expertise in pulmonary hypertension with all therapeutic options available.
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