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Kim I, Goulding M, Tian F, Karami S, Pham T, Cheng C, Biehl A, Muñoz M. Benzonatate Exposure Trends and Adverse Events. Pediatrics 2022; 150:189946. [PMID: 36377394 PMCID: PMC9732921 DOI: 10.1542/peds.2022-057779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adverse events (AE), including death, occur in children with benzonatate use. This study aims to understand recent trends in benzonatate exposure and clinical consequences in pediatric patients. METHODS This retrospective analysis of data from IQVIA pharmacy drug dispensing, National Poison Data System, National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project, FDA Adverse Event Reporting System, and the medical literature evaluated exposure trends and medication-related AEs with benzonatate. Trends for comparator narcotic and nonnarcotic antitussive medications were analyzed where possible for context. RESULTS During the study period, pediatric benzonatate prescription utilization increased but remained low compared with pediatric utilization of dextromethorphan-containing prescription antitussive medications. Among the 4689 pediatric benzonatate exposure cases reported to US poison control centers from 2010 to 2018, 3727 cases (80%) were for single-substance exposures. Of these, 3590 cases (77%) were unintentional exposures and most involved children 0 to 5 years old (2718 cases, 83%). Cases involving intentional benzonatate exposure increased among children 10 to 16 years old with a more pronounced increase for multiple-substance exposures. Most benzonatate cases involving misuse or abuse were for children 10 to 16 years old (59 cases, 61%). The proportion of cases with serious adverse effects was low. There were few cases annually of serious AEs with benzonatate in children. CONCLUSIONS There were rising patterns of unintentional ingestion of benzonatate in children 0 to 5 years old and intentional benzonatate ingestion in children 10 to 16 years old. Rational prescribing and improved provider and caregiver awareness of benzonatate toxic effects may reduce risks associated with benzonatate exposure.
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Biehl A, Harinstein L, Brinker A, Glaser R, Muñoz M, Avigan M. A case series analysis of serious exacerbations of viral hepatitis and non-viral hepatic injuries in tocilizumab-treated patients. Liver Int 2021; 41:515-528. [PMID: 33320444 DOI: 10.1111/liv.14766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Reports of moderate to severe liver injury associated with tocilizumab, an interleukin-6 (IL-6) receptor antagonist, have been reported in the post-marketing setting. This case series aims to characterize cases of tocilizumab-associated clinically significant hepatic injury. METHODS We analysed cases of severe acute liver injury associated with tocilizumab reported in the FDA Adverse Event Reporting System and the medical literature. RESULTS We identified 12 cases in which tocilizumab was a suspected primary cause of liver injury and eight cases in which serious sequelae of underlying or coincident viral hepatitis were temporally associated with its use. Using the Drug-Induced Liver Injury Network (DILIN) severity scale, five of 12 cases were Grade 5 (two liver transplants, three deaths), one was Grade 4 (liver failure) and six were Grade 3 (serious events with elevated bilirubin). Two cases reported liver atrophy with low hepatocellular expression of Ki-67, a marker of cellular proliferation. Among the eight cases of tocilizumab-associated viral hepatitis exacerbation, three were scored as DILIN severity Grade 5 (one liver transplant, two deaths), one was Grade 4 (liver failure), and four were Grade 3. The reported viral hepatitis events were hepatitis B virus (HBV) reactivation (n = 3), hepatitis C virus (HCV) flare (n = 1), cytomegalovirus (CMV)-induced liver failure (n = 1), Epstein-Barr virus hepatitis (n = 1), acute hepatitis E (HEV, n = 1) and HEV-induced macrophage activation syndrome (n = 1). CONCLUSION Tocilizumab may be a primary cause of severe liver injury, as well as exacerbate underlying viral hepatitis. The disruption by tocilizumab of IL-6-mediated immune protection and hepatocyte regeneration may aggravate clinical outcomes in some cases.
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Affiliation(s)
- Ann Biehl
- Office of Pharmacovigilance and Epidemiology, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Lisa Harinstein
- Office of Pharmacovigilance and Epidemiology, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Allen Brinker
- Office of Pharmacovigilance and Epidemiology, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Rachel Glaser
- Division of Rheumatology and Transplant Medicine, Office of New Drugs, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Monica Muñoz
- Office of Pharmacovigilance and Epidemiology, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Mark Avigan
- Office of Pharmacovigilance and Epidemiology, US FDA Center for Drug Evaluation and Research, Silver Spring, MD, USA
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3
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Fike A, Kent R, Biehl A, Ward MM. Panniculitis following baricitinib initiation for treatment of rheumatoid arthritis. Joint Bone Spine 2020; 87:509-510. [PMID: 32461123 DOI: 10.1016/j.jbspin.2020.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/08/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Alice Fike
- Intramural Research Program, National Institutes of Arthritis, Musculoskeletal and Skin Diseases (NIAMS), 10 Center Drive Rm 10N318 Bethesda, Maryland 20892, United States.
| | - Rhett Kent
- Forefront Dermatology, 8505 Arlington Blvd. Suite 210, Fairfax VA 22031, United States
| | - Ann Biehl
- Clinical Trials and Outcomes Branch, Intramural Research Program, National Institutes of Arthritis, Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health, 10 Center Drive Bethesda, Maryland 20892, United States
| | - Michael M Ward
- Clinical Trials and Outcomes Branch, Intramural Research Program, National Institutes of Arthritis, Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health, 10 Center Drive Bethesda, Maryland 20892, United States
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4
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2019; 71:1599-1613. [PMID: 31436036 DOI: 10.1002/art.41042] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | | | | | | | - David Yu
- University of California, Los Angeles
| | | | - Nigil Haroon
- University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Meika A Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora
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5
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res (Hoboken) 2019; 71:1285-1299. [PMID: 31436026 DOI: 10.1002/acr.24025] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | | | | | | | - David Yu
- University of California, Los Angeles
| | | | - Nigil Haroon
- University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Meika A Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora
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Hasni S, Gupta S, Davis M, Poncio E, Temesgen-Oyelakin Y, Joyal E, Fike A, Manna Z, Auh S, Shi Y, Chan D, Carlucci P, Biehl A, Dema B, Charles N, Balow JE, Waldman M, Siegel RM, Kaplan MJ, Rivera J. Safety and Tolerability of Omalizumab: A Randomized Clinical Trial of Humanized Anti-IgE Monoclonal Antibody in Systemic Lupus Erythematosus. Arthritis Rheumatol 2019; 71:1135-1140. [PMID: 30597768 DOI: 10.1002/art.40828] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/27/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Autoreactive IgE antibodies have been implicated in the pathogenesis of systemic lupus erythematosus (SLE). We hypothesize that omalizumab, a monoclonal antibody binding IgE, may improve SLE activity by reducing type I interferon (IFN) production by hampering plasmacytoid dendritic cells and basophil activation. This study was undertaken to assess the safety, tolerability, and clinical efficacy of omalizumab in mild to moderate SLE. METHODS Sixteen subjects with SLE and a Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score of ≥4 and elevated autoreactive IgE antibody levels were randomized to receive omalizumab or placebo (2:1) for 16 weeks, followed by 16 weeks of open-label treatment and a 4-week washout period. The SLEDAI-2K score, British Isles Lupus Assessment Group index (BILAG 2004) score, and physician's global assessment of disease activity were recorded at each visit. The type I IFN-induced gene signature was determined using quantitative polymerase chain reaction. RESULTS Omalizumab was well tolerated with no allergic reactions, and mostly mild adverse events comparable to those experienced with placebo treatment. SLEDAI-2K scores improved in the omalizumab group compared to the placebo group at week 16 (P = 0.038), as well as during the open-label phase in subjects initially receiving placebo (P = 0.02). No worsening in BILAG scores or the physician's global assessment was detected. There was a trend toward a reduction in IFN gene signature in subjects treated with omalizumab (P = 0.11), especially in subjects with a high baseline IFN signature (P = 0.052). CONCLUSION Our findings indicate that omalizumab is well tolerated in SLE and is associated with improvement in disease activity. Larger randomized clinical trials will be needed to assess the efficacy of omalizumab in patients with SLE.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland
| | | | | | | | - Ann Biehl
- Clinical Center, NIH, Bethesda, Maryland
| | | | | | - James E Balow
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland
| | - Meryl Waldman
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland
| | | | - Mariana J Kaplan
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Juan Rivera
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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7
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Gupta S, Hasni S, Davis M, Poncio E, Temesgen-Oyelakin Y, Joyal E, Fike A, Manna Z, Auh S, Shi Y, Chan D, Carlucci P, Biehl A, Dema B, Charles N, Balow J, Waldman M, Siegel R, Kaplan MJ, Illei G, Rivera J. CT-08 Safety and tolerability of omalizumab, a humanized anti-IgE monoclonal antibody in systemic lupus erythematosus ( STOP LUPUS). Clin Trials 2018. [DOI: 10.1136/lupus-2018-lsm.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Betancourt BY, Biehl A, Katz JD, Subedi A. Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheum Dis Clin North Am 2018; 44:371-391. [PMID: 30001781 DOI: 10.1016/j.rdc.2018.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Providing safe and effective pharmacotherapy to geriatric patients with rheumatologic disorders is challenging. Multidisciplinary care involving rheumatologists, primary care physicians, and other specialties can optimize benefit and reduce adverse outcomes. Oral disease-modifying antirheumatic drugs, including methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, and the small molecule inhibitors tofacitinib and apremilast have distinctive monitoring requirements and specific adverse reaction profiles. This article provides clinically relevant pearls for use of these interventions in older patients.
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Affiliation(s)
- Blas Y Betancourt
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA.
| | - Ann Biehl
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, FDA, 10001 New Hampshire Avenue, Hillandale Building, 4th Floor Silver Spring, MD 20993, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
| | - Ananta Subedi
- National Institutes of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health Clinical Center, Bethesda, MD 20814, Maryland, USA
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Banerjee S, Biehl A, Gadina M, Hasni S, Schwartz DM. Erratum to: JAK-STAT Signaling as a Target for Inflammatory and Autoimmune Diseases: Current and Future Prospects. Drugs 2017; 77:1261. [PMID: 28608167 PMCID: PMC7608299 DOI: 10.1007/s40265-017-0772-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shubhasree Banerjee
- Rheumatology Fellowship and Training Branch, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA.
| | - Ann Biehl
- Clinical Center, National Institutes of Health, Bethesda, USA
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
| | - Sarfaraz Hasni
- Lupus Clinical Research Program, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
| | - Daniella M Schwartz
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
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Abstract
The Janus kinase/signal transduction and activator of transcription (JAK-STAT) signaling pathway is implicated in the pathogenesis of inflammatory and autoimmune diseases including rheumatoid arthritis, psoriasis, and inflammatory bowel disease. Many cytokines involved in the pathogenesis of autoimmune and inflammatory diseases use JAKs and STATs to transduce intracellular signals. Mutations in JAK and STAT genes cause a number of immunodeficiency syndromes, and polymorphisms in these genes are associated with autoimmune diseases. The success of small-molecule JAK inhibitors (Jakinibs) in the treatment of rheumatologic disease demonstrates that intracellular signaling pathways can be targeted therapeutically to treat autoimmunity. Tofacitinib, the first rheumatologic Jakinib, is US Food and Drug Administration (FDA) approved for rheumatoid arthritis and is currently under investigation for other autoimmune diseases. Many other Jakinibs are in preclinical development or in various phases of clinical trials. This review describes the JAK-STAT pathway, outlines its role in autoimmunity, and explains the rationale/pre-clinical evidence for targeting JAK-STAT signaling. The safety and clinical efficacy of the Jakinibs are reviewed, starting with the FDA-approved Jakinib tofacitinib, and continuing on to next-generation Jakinibs. Recent and ongoing studies are emphasized, with a focus on emerging indications for JAK inhibition and novel mechanisms of JAK-STAT signaling blockade.
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Affiliation(s)
- Shubhasree Banerjee
- Rheumatology Fellowship and Training Branch, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
| | - Ann Biehl
- Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarfaraz Hasni
- Lupus Clinical Research Program, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniella M Schwartz
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, Maryland, USA
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Banerjee S, Biehl A, Gadina M, Hasni S, Schwartz DM. Erratum to: JAK-STAT Signaling as a Target for Inflammatory and Autoimmune Diseases: Current and Future Prospects. Drugs 2017; 77:939. [PMID: 28365883 PMCID: PMC7608410 DOI: 10.1007/s40265-017-0736-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Shubhasree Banerjee
- Rheumatology Fellowship and Training Branch, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA.
| | - Ann Biehl
- Clinical Center, National Institutes of Health, Bethesda, USA
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
| | - Sarfaraz Hasni
- Lupus Clinical Research Program, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
| | - Daniella M Schwartz
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis Musculoskeletal and Skin diseases, National Institutes of Health, Bethesda, USA
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12
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Banerjee S, Biehl A, Ghaderi-Yeganeh M, Manna Z, Hasni S. Low incidence of opportunistic Infections in Lupus Patients treated with Cyclophosphamide and Steroids in a Tertiary care setting. ACTA ACUST UNITED AC 2017; 5. [PMID: 29276769 DOI: 10.18103/mra.v5i3.1084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Infection is common cause of morbidity and mortality in systemic lupus erythematosus (SLE). Our objective was to determine incidence and types of infections, particularly opportunistic infections, in SLE patients receiving cyclophosphamide, and to identify contribution of variables like demographics, steroid, other immunosuppressives, white blood cell and absolute neutrophil count to infection risk. Patients and Methods We did retrospective chart review of SLE patients in our institute over last 10 years, who received minimum six cyclophosphamide infusions. Types of infection, cumulative steroid dose, and maintenance medications were recorded. Statistical analyses were done using SAS software. Results 87.1% of the 31 patients were female. Mean age was 37.9 years, 48.4% Hispanic, 25.8% African American, 6.4% Asian and 19.4% were Caucasian. No one was on pneumocystis jirovecii pneumonia (PJP) prophylaxis. There were 42 episodes of infection in 31 patients. Different infections were urinary tract infections (UTI), upper respiratory infections (URI), line sepsis, bacterial pneumonia, PJP, mucocutaneous infections and viral gastroenteritis. Infection frequency was significantly higher among Asians compared to Caucasians (p =0.0152). Infection rate was significantly higher during cyclophosphosphamide induction phase (65.9%) compared to maintenance phase (34.1%) (p value=0.0041). Infection rate was higher with higher cumulative steroid dose and in patients on quarterly cyclophosphamide infusion compared to those on oral azathioprine or mycophenolate mofetil. No association found among baseline white blood cell (WBC) or absolute neutrophil count (ANC) and infection rate. Conclusion We found higher infection rates among Asians and in patients with higher cumulative steroid dose. Single incidence of PJP noted despite absence of prophylaxis. Quarterly cyclophosphamide was associated with higher infection rates. Larger prospective studies are needed to confirm our results.
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Affiliation(s)
- Shubhasree Banerjee
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ann Biehl
- National Institutes of Health Clinical Center Department of Pharmacy, National Institutes of Health, Bethesda, Maryland
| | - Maryam Ghaderi-Yeganeh
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Zerai Manna
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sarfaraz Hasni
- National Institutes of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
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Abstract
OBJECTIVES The Institute of Medicine has established aims for improvement in patient care that emphasize safe, timely, effective, efficient, equitable, and patient-centered medicine. This goal is echoed by the Accreditation Council for Graduate Medical Education (ACGME). METHODS The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) graduate medical education program implemented a Clinical Learning Environment Review (CLER) project whose aim is to support a patient and trainee safety environment. An ongoing biannual patient and learner safety conference is able to capture close calls, safety attitudes, potential learner mistreatment, and trainee fatigue in a nonpunitive manner that supports answering the question, "What was learned and what needs to be improved?" RESULTS Group recommendations were captured at a quality improvement conference. We documented a shift in attitudes away from one where the institution is perceived to be weakest at supporting safety reporting. CONCLUSIONS This project is designed to serve as a mechanism for insuring care that is respectful and responsive to patient needs and values. It identifies keys to avoiding wasted re-sources or harmful delay while also seeking to improve care based upon scientific knowledge.
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Affiliation(s)
- James D. Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 6N-216F, Building 10, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Ann Biehl
- Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
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