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Foeldvari I, Torok KS, Antón J, Blakley M, Constantin T, Cutolo M, Denton CP, Fligelstone K, Hinrichs B, Li SC, Maillard S, Marrani E, Moinzadeh P, Orteu CH, Pain CE, Pauling JD, Pilkington C, Rosser F, Smith V, Furst DF. Best clinical practice in the treatment of juvenile systemic sclerosis: expert panel guidance - the result of the International Hamburg Consensus Meeting December 2022. Expert Rev Clin Immunol 2024; 20:387-404. [PMID: 38149621 DOI: 10.1080/1744666x.2023.2298354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1,000,000 children. Currently there is only one consensus treatment guideline concerning skin, pulmonary and vascular involvement for jSSc, the jSSc SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) initiative, which was based on data procured up to 2014. Therefore, an update of these guidelines, with a more recent literature and expert experience, and extension of the guidance to more aspects of the disease is needed. AREAS COVERED Treatment options were reviewed, and opinions were provided for most facets of jSSc including general management, some of which differs from adult systemic sclerosis, such as the use of corticosteroids, and specific organ involvement, such as skin, musculoskeletal, pulmonary, and gastroenterology. EXPERT OPINION We are suggesting the treat to target strategy to treat early to prevent cumulative disease damage in jSSc. Conclusions are derived from both expert opinion and available literature, which is mostly based on adult systemic sclerosis (aSSc), given shared pathophysiology, extrapolation of results from aSSc studies was judged reasonable.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Kathryn S Torok
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jordi Antón
- Department of Pediatric Rheumatology. Hospital Sant Joan de Déu and Universitat de Barcelona, Barcelona, Spain
| | - Michael Blakley
- Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tamás Constantin
- Unit of Pediatric Rheumatology, Tűzoltó Street Department, Pediatric Centre, Semmelweis University, Budapest, Hungary
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology-Department of Internal Medicine and Specialties, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Kim Fligelstone
- Scleroderma & Raynaud's United Kindgom (SRUK) (Research Subcommittee, Patient Research Partner), FESCA, London, UK
| | - Bernd Hinrichs
- Children's pulmonology, Asklepios Klinik Nord - Heidberg, Hamburg, Germany
| | - Suzanne C Li
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - Edoardo Marrani
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Catherine H Orteu
- UCL Institute of Immunity and Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Clare E Pain
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | - John D Pauling
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium and ERN ReCONNET
| | | | - Franziska Rosser
- University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Vanessa Smith
- University of California, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
| | - Daniel F Furst
- Division of Rheumatology Fellow, Geffen School of Medicine at the University of California in Los Angeles, Los Angeles, CA, USA
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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Milan MJDC, Dans LF, Torres-Ticzon VMF. Acute limb ischemia in an adolescent with COVID-19 and systemic scleroderma: a case report. BMC Pediatr 2022; 22:737. [PMID: 36577976 PMCID: PMC9795154 DOI: 10.1186/s12887-022-03761-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/20/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Juvenile Scleroderma is a rare autoimmune disease of the connective tissue. Its concurrence with COVID-19 can lead to limb ischemia as both disease entities are pro-inflammatory and pro-thrombotic. To date, there is no case report describing the symptomatology and course of disease in patients with juvenile Scleroderma and COVID-19. CASE PRESENTATION An adolescent with acute limb ischemia presented with a history of generalized hypo-and-hyperpigmented skin lesions and mild, non-productive cough. She tested positive for SARS-CoV-2 on nasopharyngeal swab RT-PCR. Further work-up revealed elevated anti-phospholipid antibodies, anti-nuclear antibody, and D-dimer; low Protein S activity; and evidence of peripheral arterial disease on imaging studies. She was started on peripheral vasodilators, Methotrexate, and anticoagulation. Close monitoring of the affected limbs and other organs involved was done. Control of limb ischemia was achieved after 4 months of regular Cyclophosphamide infusion. Continued multi-disciplinary care was ensured for this patient. CONCLUSION There is evolving knowledge about the interplay of COVID-19 hyperinflammatory state and rheumatologic disorders. COVID-19 is thought to exacerbate cutaneous manifestations of autoimmune disorders via antigen protein mimicry and cytokine imbalance. Moreover, COVID-19 is characterized by complex hematopathologic processes that put a patient in a hypercoagulable state. Elevated D-dimer can be seen in both COVID-19 and systemic sclerosis owing to their pro-thrombotic sequela. There is scarcity of data on the association of Protein S activity with COVID-19 and systemic sclerosis. More studies need to be carried out to ultimately arrive at a consensus on thrombosis prophylaxis for patients with Scleroderma and COVID-19.
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Affiliation(s)
- Mark Jason D. C. Milan
- grid.11159.3d0000 0000 9650 2179Department of Pediatrics, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Leonila F. Dans
- grid.11159.3d0000 0000 9650 2179Department of Pediatrics, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Philippines ,grid.11159.3d0000 0000 9650 2179Division of Pediatric Rheumatology, Department of Pediatrics, College of Medicine and Philippine, General Hospital, University of the Philippines, Manila, Philippines
| | - Vanessa Maria F. Torres-Ticzon
- grid.11159.3d0000 0000 9650 2179Department of Pediatrics, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Philippines ,grid.11159.3d0000 0000 9650 2179Division of Adolescent Medicine, Department of Pediatrics, College of Medicine and Philippine, General Hospital, University of the Philippines, Manila, Philippines
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Klein-Weigel P, Ruttloff A, König D, Nielitz J, Steindl J, Sander O, Richter JG. [Functional vascular acrosyndromes]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:591-600. [PMID: 35925129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Vascular acrosyndromes are characterized by sparse, uniform clinical manifestations and a variety of possible pathomechanisms. The present article focuses on the functional entities. Raynaud phenomenon is based on cold- or stress-induced vasospasms of acral arteries. It is defined by the color changes of the skin, in the typical case white-blue-red (tricolore). The long fingers are most commonly affected. The etiology is unknown, and the pathophysiology is poorly understood. A distinction is made between primary and a secondary Raynaud phenomenon. The most important underlying diseases include collagenosis, primarily systemic sclerosis, and malignancies; furthermore, medications and drugs may promote vasospasm. Treatment is aimed at preventing or breaking the vasospasm, but has been only partially effective in doing so. Acrocyanosis is a vasospastic dystonic acral disorder that results in permanent reddish-livid discoloration, especially of the hands and feet. Secondary forms occur in collagenosis, malignancies, and myelodysplastic syndromes. The etiology and pathophysiology are virtually unknown. Targeted pharmacological intervention is not possible. Unlike all other vascular acrosyndromes, erythromelalgia is characterized by hyperemia. The primary form is a genetic sodium channelopathy, while secondary forms include malignancies, connective tissue diseases, and myelodysplastic syndromes. The symptoms are often distressing and disabling. Therapy requires a multimodal approach that includes both nonpharmacological and pharmacological strategies. Close interdisciplinary collaboration is essential for the management of this disease.
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Affiliation(s)
- Peter Klein-Weigel
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland.
| | - Andreas Ruttloff
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Dana König
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Jessica Nielitz
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Julia Steindl
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Oliver Sander
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Jutta G Richter
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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5
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Herrick AL. Advances in the Treatment of Systemic Sclerosis. Rheumatology (Oxford) 2022. [DOI: 10.17925/rmd.2022.1.2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Although systemic sclerosis (SSc) is currently incurable, there have been recent advances in treatment. This review article begins by providing a brief background to SSc in terms of disease subtyping and autoantibodies, because both predict disease trajectory and help clinicians to select appropriate monitoring and treatment protocols. Broad principles of management are then described: ‘disease-modifying’ therapies and therapies directed at reducing disease burden and/or progression of SSc-related digital vascular disease and of internal organ involvement. Next, advances in the management of digital vasculopathy, pulmonary arterial hypertension (PAH), interstitial lung disease (ILD) and early diffuse cutaneous SSc are discussed in turn, for example: (a) increased use of phosphodiesterase inhibitors and endothelin receptor antagonists for digital vasculopathy; (b) early recognition and treatment of PAH, including with combination therapies; (c) increased use of mycophenolate mofetil and of nintedanib in ILD; and (d) immunosuppression now as standard practice in early diffuse cutaneous SSc, and autologous haematopoietic stem cell transplantation for highly selected patients with progressive diffuse disease. Finally, future challenges are discussed, including ensuring that all patients with SSc are monitored and treated according to best practice guidelines, and whenever possible giving patients the opportunity to participate in clinical trials.
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Klein-Weigel P, Sander O, Reinhold S, Nielitz J, Steindl J, G. Richter J. Raynaud's Phenomenon: A Vascular Acrosyndrome That Requires Long-Term Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0023. [PMID: 33632387 PMCID: PMC8287761 DOI: 10.3238/arztebl.m2021.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Some 5-10% of the German population are affected by Raynaud's phenomenon (RP). In around 10-20% of cases RP arises from an underlying disease, most commonly a connective tissue disease. This review encompasses the diagnosis and differential diagnosis of RP and examines the efficacy of the currently available pharmaceutical and non-pharmaceutical treatment options. METHODS We conducted a selective literature search in PubMed using the search terms "Raynaud's phenomenon", "Raynaud's syndrome," "vasospasm," "vascular acrosyndrome," and "systemic sclerosis," together with a search of the Cochrane Database of Systematic Reviews up to April 2020. RESULTS Raynaud's phenomenon mainly affects the fingers or toes and is typically triggered by cold or emotional stressors. The most important diagnostic steps are demonstration of a tendency towards digital vasospasm, exclusion of occlusions in the afferent arteries and acral vessels, nail-fold capillaroscopy, and determination of autoantibody status. Tumor screening should be arranged in the presence of B symptoms or first manifestation of RP in old age. The onset of RP in childhood is a rare occurrence and points to a secondary origin. The principal options for treatment are protection against cold and administration of calcium antagonists, which reduces the occurrence of RP by around 20-40 %. The treatment of RP in patients with systemic sclerosis is described in the recommendations of the European League Against Rheumatism (EULAR). CONCLUSION At onset or after years of latency, patients with Raynaud phenomenon may have an underlying disease (most commonly a connective tissue disease). Long-term specialist care is necessary for asymptomatic patients with risk factors and for those with clinically manifest symptoms of an underlying condition alike.
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Affiliation(s)
- Peter Klein-Weigel
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Oliver Sander
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
| | - Simone Reinhold
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jessica Nielitz
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Julia Steindl
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jutta G. Richter
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
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Amissah-Arthur MB, Wu LP. Management of severe Raynaud's Phenomenon secondary to autoimmune vasculopathy in a young woman. Ghana Med J 2021; 55:96-100. [PMID: 38322394 PMCID: PMC10665273 DOI: 10.4314/gmj.v55i1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Raynaud's phenomenon as a cause of acute limb ischaemia in the warmer climates of Sub-Saharan Africa region is uncommon because it is usually thought of as a disease common in cold weather. The prevalence of connective tissue diseases among Black Africans is increasing, and these conditions are associated with secondary Raynaud's phenomenon and ischaemic digital lesions. We present the case of a 36-year old female with dermatomyositis/systemic sclerosis overlap and secondary Raynaud's phenomenon who presented with acute limb ischemia (wet gangrene of all digits) in a Tertiary Hospital in Ghana. Young patients presenting with acute limb ischaemia should also be screened for an underlying connective tissue disease. In patients with connective tissue disease, the onset of digital vasculopathy can be rapid and progressive, hence treatment must be prompt and comprehensive to enable better clinical outcomes. Funding None declared.
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Affiliation(s)
| | - Lily P Wu
- School of Medicine and Dentistry, University of Ghana Medical School, Accra, Ghana
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Juche A, Siegert E, Mueller-Ladner U, Riemekasten G, Günther C, Kötter I, Henes J, Blank N, Voll RE, Ehrchen J, Schmalzing M, Susok L, Schmeiser T, Sunderkoetter C, Distler J, Worm M, Kreuter A, Horváth ON, Schön MP, Korsten P, Zeidler G, Pfeiffer C, Krieg T, Hunzelmann N, Moinzadeh P. [Reality of inpatient vasoactive treatment with prostacyclin derivatives in patients with acral circulation disorders due to systemic sclerosis in Germany]. Z Rheumatol 2020; 79:1057-1066. [PMID: 32040755 PMCID: PMC7708340 DOI: 10.1007/s00393-019-00743-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hintergrund Das Raynaud-Phänomen und die damit häufig einhergehenden digitalen Ulzerationen stellen für Patienten mit systemischer Sklerose (Sklerodermie [SSc]) ein frühes und sehr belastendes Symptom mit bedeutenden Einschränkungen der Arbeitsfähigkeit und Lebensqualität dar. Der Einsatz vasoaktiver Medikamente (insbesondere intravenöser Prostazyklinderivate) soll helfen, das Risiko hypoxischer Gewebeschäden bis hin zum Verlust der Finger zu reduzieren. Methoden Um Aufschluss über die aktuelle Versorgung von Patienten mit Prostazyklinderivaten im klinischen Alltag in Deutschland zu erhalten, führten wir eine Umfrage unter den im Deutschen Netzwerk für systemische Sklerodermie (DNSS) zusammengeschlossenen Kliniken durch. Zusätzlich erfolgte eine separate Patientenbefragung über die Sklerodermie Selbsthilfe e. V., die sich nur auf die Symptome „Raynaud-Phänomen“ und „Digitale Ulzera“ und den Einsatz intravenöser Prostazyklinderivate bezog. Ergebnisse Von den befragten 433 Patienten gaben 56 % an, dass sie bereits aufgrund ihrer Erkrankung und Symptome mit Prostazyklinderivaten behandelt wurden. Insgesamt 61 % erhielten die Therapie aufgrund starker Raynaud-Symptomatik und 39 % aufgrund digitaler Ulzerationen. Die meisten Befragten erfuhren durch die Therapie nicht nur eine Verbesserung des Raynaud-Phänomens und der digitalen Ulzera, sondern auch eine wesentliche Verbesserung von Einschränkungen im Alltag. Sie gaben zudem an, wesentlich weniger fremde Hilfe in Anspruch genommen sowie wesentlich weniger Fehlzeiten bei der Arbeit gehabt zu haben. Schlussfolgerung Die Patienten empfanden durchweg einen positiven Effekt der Therapie mit Prostazyklinderivaten auf das Raynaud-Phänomen, ihre digitalen Ulzerationen, Schmerzen und Alltagseinschränkung und fühlten sich durch die stationäre Therapie gut und sicher betreut. Diese positiven Effekte in der Patientenwahrnehmung sind eine eindrückliche Stütze und bestätigen nachdrücklich die auf europäischer und internationaler Ebene erarbeiteten Therapieempfehlungen. Zusatzmaterial online Die Online-Version dieses Beitrags (10.1007/s00393-019-00743-9) enthält die 2 Fragebögen, die für die Befragung verwendet wurden. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“. ![]()
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Affiliation(s)
- A Juche
- Klinik für Rheumatologie, Immanuel Krankenhaus Berlin-Buch, Berlin, Deutschland
| | - E Siegert
- Klinik für Rheumatologie u. klinischer Immunologie, Charité Berlin, Berlin, Deutschland
| | - U Mueller-Ladner
- Rheumatologie und klinische Immunologie, Kerckhoff-Klinik, Bad Nauheim, Deutschland
| | - G Riemekasten
- Klinik für Rheumatologie und Immunologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - C Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - I Kötter
- Klinik für Rheumatologie, klinische Immunologie u. Nephrologie, Asklepios Kliniken Hamburg, Hamburg, Deutschland
| | - J Henes
- Zentrum für interdisziplinäre Rheumatologie, Immunologie und Autoimmunerkrankungen INDIRA und Medizinische Klinik II, Universitätsklinik Tübingen, Tübingen, Deutschland
| | - N Blank
- Medizinische Klinik f. Hämatologie, Onkologie u. Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - R E Voll
- Klinik für Rheumatologie u. Klinische Immunologie, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
| | - J Ehrchen
- Klinik für Hautkrankheiten, allg. Dermatologie u. Venerologie, Universitätsklinikum Münster, Münster, Deutschland
| | - M Schmalzing
- Rheumatologie/Klinische Immunologie, Medizinische Klinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - L Susok
- Klinik für Dermatologie, Allergologie u. Venerologie der Ruhr-Universität Bochum, Krankenhaus St. Josef-Hospital Bochum, Bochum, Deutschland
| | - T Schmeiser
- Klinik für Rheumatologie, Immunologie u. Osteologie, St. Josef Wuppertal, Wuppertal, Deutschland
| | - C Sunderkoetter
- Universitätsklinik u. Poliklinik für Dermatologie u. Venerologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - J Distler
- Medizinische Klinik für Rheumatologie u. Immunologie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - M Worm
- Klinik für Dermatologie, Venerologie u. Allergologie, Charité Berlin, Berlin, Deutschland
| | - A Kreuter
- Klinik für Dermatologie, Venerologie und Allergologie, HELIOS St. Elisabeth Klinik Oberhausen, Universität Witten/Herdecke, Oberhausen, Deutschland
| | - O N Horváth
- Klinik für Dermatologie u. Allergologie, Ludwig-Maximilians Universität München, München, Deutschland
| | - M P Schön
- Klinik für Dermatologie, Venerologie u. Allergologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Niedersächsisches Institut für Berufsdermatologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - P Korsten
- Klinik für Nephrologie u. Rheumatologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - G Zeidler
- Klinik für internistische Rheumatologie, Orthopädie u. Rheumachirurgie, Johanniter-Krankenhaus im Fläming, Treuenbrietzen, Deutschland
| | - C Pfeiffer
- Klinik für Dermatologie u. Allergologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - T Krieg
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland
| | - N Hunzelmann
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland
| | - P Moinzadeh
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland.
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Albuquerque JVD, Andriolo BNG, Vasconcellos MRA, Civile VT, Lyddiatt A, Trevisani VFM. Interventions for morphea. Cochrane Database Syst Rev 2019; 7:CD005027. [PMID: 31309547 PMCID: PMC6630193 DOI: 10.1002/14651858.cd005027.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Morphea (morphoea) is an immune-mediated disease in which excess synthesis and deposition of collagen in the skin and underlying connective tissues results in hardened cutaneous areas. Morphea has different clinical features according to the subtype and stage of evolution of the disease. There is currently no consensus on optimal interventions for morphea. OBJECTIVES To assess the effects of treatments for people with any form of morphea. SEARCH METHODS We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, and five trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials. SELECTION CRITERIA Randomised controlled trials of topical, intralesional, or systemic treatments (isolated or combined) in anyone who has been clinically diagnosed by a medical practitioner with any form of morphea. Eligible controls were placebo, no intervention, any other treatment, or different doses or duration of a treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcomes were global improvement of disease activity or damage assessed by a medical practitioner or by participants, and adverse effects. Secondary outcomes were improvement of disease activity and improvement of disease damage. We used GRADE to assess the quality of the evidence for each outcome. MAIN RESULTS We included 14 trials, with a total of 429 randomised participants, aged between 3 and 76 years. There were juvenile and adult participants; over half were female, and the majority had circumscribed morphea, followed by linear scleroderma. The settings of the studies (where described) included a dermatologic centre, a national laboratory centre, paediatric rheumatology and dermatology centres, and a university hospital or medical centre.The studies evaluated heterogenous therapies for different types of morphea, covering a wide range of comparisons. We were unable to conduct any meta-analyses. Seven studies investigated topical medications, two evaluated intralesional medications, and five investigated systemic medications. The study duration ranged from seven weeks to 15 months from baseline.We present here results for our primary outcomes for our four key comparisons. All of these results are based on low-quality evidence.The included studies were at high risk of performance, detection, attrition, and reporting bias.Global improvement of disease activity or damage after treatment may be higher with oral methotrexate (15 mg/m², maximum 20 mg, once a week, for 12 months or until disease flare) plus oral prednisone (1 mg/kg a day, maximum of 50 mg, in a single morning dose, for three months, and one month with gradually decreased dose until discontinuation) than with placebo plus oral prednisone in children and adolescents with active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed) (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.20 to 4.45; number needed to treat for an additional beneficial outcome (NNTB) 3; 1 randomised controlled trial (RCT); 70 participants, all juvenile). This outcome was measured 12 months from the start of treatment or until flare of the disease. Data were not available separately for each morphea type. There may be little or no difference in the number of participants experiencing at least one adverse event with oral methotrexate (26/46) or placebo (11/24) (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT; 70 participants assessed during the 12-month follow-up). Adverse events related to methotrexate included alopecia, nausea, headache, fatigue and hepatotoxicity, whilst adverse events related to prednisone (given in both groups) included weight gain (more than 5% of body weight) and striae rubrae.One three-armed RCT compared the following treatments: medium-dose (50 J/cm²) UVA-1; low-dose (20 J/cm²) UVA-1; and narrowband UVB phototherapy. There may be little or no difference between treatments in global improvement of disease activity or damage, as assessed through the modified skin score (where high values represent a worse outcome): medium-dose UVA-1 phototherapy versus low-dose UVA-1 group: MD 1.60, 95% CI -1.70 to 4.90 (44 participants); narrowband UVB phototherapy versus medium-dose UVA-1 group: MD -1.70, 95% CI -5.27 to 1.87 (35 participants); and narrowband UVB versus low-dose UVA-1 group: MD -0.10, 95% CI -2.49 to 2.29 (45 participants). This RCT included children and adults with active morphea (circumscribed morphea, linear scleroderma (with trunk/limb variant and head variant), generalised morphea, or mixed morphea), who received phototherapy five times a week, for eight weeks. Outcomes were measured at eight weeks from the start of treatment.Safety data, measured throughout treatment, from the same RCT (62 participants) showed that treatment with UVA-1 phototherapy may cause mild tanning compared to narrowband UVB: narrowband UVB versus medium-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.42; 35 participants; narrowband UVB versus low-dose UVA-1: RR 0.03, 95% CI 0.00 to 0.41; 45 participants. However, there may be no difference in the number of participants reporting mild tanning when comparing medium and low dose UVA-1 phototherapy (RR 1.00, 95% CI 0.91 to 1.10; 44 participants). Transient erythema was reported in three participants with narrowband UVB and no participants in the low- or medium-dose UVA-1 groups. AUTHORS' CONCLUSIONS Compared to placebo plus oral prednisone, oral methotrexate plus oral prednisone may improve disease activity or damage in juvenile active morphea (linear scleroderma, generalised morphea or mixed morphea: linear and circumscribed), but there may be a slightly increased chance of experiencing at least one adverse event.When medium-dose UVA-1 (50 J/cm²), low-dose UVA-1 (20 J/cm²), and narrowband UVB were compared against each other in treating children and adults with active morphea (circumscribed morphea, linear scleroderma, generalised morphea and mixed morphea), there may be little or no difference between these treatments on global improvement of disease activity or damage. UVA-1 phototherapy may cause more mild tanning than narrowband UVB, but there may be no difference between medium- and low-dose UVA-1 phototherapy. These results are based on low-quality evidence.Limitations of data and analyses include risk of bias and imprecision (small number of participants or events and wide confidence intervals). We encourage multicentre RCTs to increase sample size and evaluate, with validated tools, different treatment responses according to the subtypes of morphea and age groups.
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Affiliation(s)
- Julia V de Albuquerque
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Monica RA Vasconcellos
- Universidade Federal de São PauloDepartment of DermatologyPedro de Toledo St. 508São PauloBrazil04039‐001
| | - Vinicius T Civile
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Anne Lyddiatt
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Virginia FM Trevisani
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
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10
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Herrick AL. Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:89-101. [PMID: 35382391 PMCID: PMC8922643 DOI: 10.1177/2397198319826467] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/27/2018] [Indexed: 09/05/2023]
Abstract
Raynaud's phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud's phenomenon is very common, affecting approximately 3%-5% of the general population. Although much rarer, systemic sclerosis-related Raynaud's phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud's phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis-related Raynaud's phenomenon (which is the most researched form of Raynaud's phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from 'isolated' to systemic sclerosis-related Raynaud's phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both 'uncomplicated' and 'complicated' Raynaud's phenomena (i.e. Raynaud's phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5-10 years are highlighted.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
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11
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Management of Raynaud’s phenomenon in systemic sclerosis—a practical approach. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:102-110. [DOI: 10.1177/2397198318823951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
Abstract
Raynaud’s phenomenon is nearly universal in systemic sclerosis. Vasculopathy is part of systemic sclerosis. Raynaud’s phenomenon can cause of complications and impairment, especially when tissue ischemia and digital ulcers develop. There are many treatment options for Raynaud’s phenomenon in systemic sclerosis often with sparse data and few robust studies comparing the different treatment options. Recommendations from guidelines usually include calcium channel blockers as first-line pharmacological treatment. In the clinical setting, multiple variables such as financial factors, geography where access to medications varies, and patient factors, baseline hypotension, can influence the treatment for Raynaud’s phenomenon and digital ulcers. Prostacyclins and PDE-5 inhibitors are reserved for more severe Raynaud’s phenomenon or healing of digital ulcers. Prevention of digital ulcers may also include endothelin receptor blocker (bosentan) in some countries. Other treatments had less consensus. Algorithms developed by systemic sclerosis experts might be helpful in deciding which treatment to choose for each setting, using a step-wise strategy, which intends to complement guidelines. This review focuses on a practical approach to the treatment of Raynaud’s phenomenon and digital ulcers in systemic sclerosis, based on algorithms designed by systemic sclerosis experts using consensus, and we review the evidence that supports treatment from initial to second and third-line options.
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Hinze AM, Wigley FM. Pharmacotherapy Options in the Management of Raynaud's Phenomenon. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018; 4:235-254. [PMID: 31538045 DOI: 10.1007/s40674-018-0102-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose of review Multiple classes of medications have been studied for the treatment of Raynaud's phenomenon (RP) with or without digital ischemia. The goal of this review is to discuss the outcomes of recent studies and to report on our approach to the management of RP in light of the available evidence. Recent findings Comparing treatments for RP remains a challenge as efficacy endpoint vary widely among trials. While calcium channel blockers are used first-line in the pharmacologic management of RP, phosphodiesterase 5 inhibitors have also been shown to be beneficial in reducing symptoms. In the setting of digital ischemia, administration of intravenous prostanoids is the standard of care. Bosentan has shown benefit in the prevention of future ulcers in patients with scleroderma. Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients. Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common. Summary Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP. Based on the available evidence, we start with CCBs and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist in cases of recurrent digital ulcers. A surgical sympathectomy may be used in refractory cases of digital ischemia. A digital block may also be a less invasive, but temporary, intervention allowing for titration of medical therapy.
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Affiliation(s)
- Alicia M Hinze
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
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Mitropoulos A, Gumber A, Crank H, Akil M, Klonizakis M. The effects of upper and lower limb exercise on the microvascular reactivity in limited cutaneous systemic sclerosis patients. Arthritis Res Ther 2018; 20:112. [PMID: 29871697 PMCID: PMC5989435 DOI: 10.1186/s13075-018-1605-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/24/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Aerobic exercise in general and high-intensity interval training (HIIT) specifically is known to improve vascular function in a range of clinical conditions. HIIT in particular has demonstrated improvements in clinical outcomes, in conditions that have a strong macroangiopathic component. Nevertheless, the effect of HIIT on microcirculation in systemic sclerosis (SSc) patients is yet to be investigated. Therefore, the purpose of the study was to compare the effects of two HIIT protocols (cycle and arm cranking) on the microcirculation of the digital area in SSc patients. METHODS Thirty-four limited cutaneous SSc patients (65.3 ± 11.6 years old) were randomly allocated in three groups (cycling, arm cranking and control group). The exercise groups underwent a 12- week exercise program twice per week. All patients performed the baseline and post-exercise intervention measurements where physical fitness, functional ability, transcutaneous oxygen tension (ΔTcpO2), body composition and quality of life were assessed. Endothelial-dependent as well as -independent vasodilation were assessed in the middle and index fingers using LDF and incremental doses of acetylcholine (ACh) and sodium nitroprusside (SNP). Cutaneous flux data were expressed as cutaneous vascular conductance (CVC). RESULTS Peak oxygen uptake increased in both exercise groups (p < 0.01, d = 1.36). ΔTcpO2 demonstrated an increase in the arm-cranking group only, with a large effect, but not found statistically significant,(p = 0.59, d = 0.93). Endothelial-dependent vasodilation improvement was greater in the arm-cranking (p < 0.05, d = 1.07) in comparison to other groups. Both exercise groups improved life satisfaction (p < 0.001) as well as reduced discomfort and pain due to Raynaud's phenomenon (p < 0.05). Arm cranking seems to be the preferred mode of exercise for study participants as compared to cycling (p < 0.05). No changes were observed in the body composition or the functional ability in both exercise groups. CONCLUSIONS Our results suggest that arm cranking has the potential to improve the microvascular endothelial function in SSc patients. Also notably, our recommended training dose (e.g., a 12-week HIIT program, twice per week), appeared to be sufficient and tolerable for this population. Future research should focus on exploring the feasibility of a combined exercise such as aerobic and resistance training by assessing individual's experience and the quality of life in SSc patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT number): NCT03058887 , February 23, 2017.
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Affiliation(s)
- A. Mitropoulos
- Centre for Sport and Exercise Science, Collegiate Campus, Sheffield Hallam University, Collegiate Crescent, Sheffield, S10 2BP UK
| | - A. Gumber
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - H. Crank
- Centre for Sport and Exercise Science, Collegiate Campus, Sheffield Hallam University, Collegiate Crescent, Sheffield, S10 2BP UK
| | - M. Akil
- Rheumatology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - M. Klonizakis
- Centre for Sport and Exercise Science, Collegiate Campus, Sheffield Hallam University, Collegiate Crescent, Sheffield, S10 2BP UK
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Denton CP, Hachulla É, Riemekasten G, Schwarting A, Frenoux JM, Frey A, Le Brun FO, Herrick AL. Efficacy and Safety of Selexipag in Adults With Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Randomized, Placebo-Controlled, Phase II Study. Arthritis Rheumatol 2017; 69:2370-2379. [PMID: 29193819 PMCID: PMC6099416 DOI: 10.1002/art.40242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 08/22/2017] [Indexed: 01/03/2023]
Abstract
Objective To determine the effect of selexipag, an oral, selective IP prostacyclin receptor agonist, on the frequency of attacks of Raynaud's phenomenon (RP) in patients with systemic sclerosis (SSc). Methods Patients with SSc‐related RP were randomized 1:1 to placebo (n = 38) or selexipag (n = 36) in individualized doses (maximum of 1,600 μg twice daily) during a 3‐week titration period. The primary end point was the weekly average number of RP attacks during the study maintenance period, analyzed using a Bayesian approach with a negative binomial model adjusted for baseline number of RP attacks. Other outcome measures included Raynaud's Condition Score (RCS), RP attack duration, and treatment‐emergent adverse events (AEs). Results Baseline characteristics were comparable between treatment groups. For 83.3% of patients, the individualized maintenance dosage of selexipag was ≤800 μg twice daily. No significant difference was observed between placebo and selexipag in weekly average number of electronic diary (eDiary)–recorded RP attacks during the maintenance period (14.2 attacks during the maintenance period and 21.5 attacks during the baseline week in the placebo group [n = 32] versus 18.0 attacks during the maintenance period and 22.4 attacks during the baseline week in the selexipag group [n = 27]; adjusted mean treatment difference of 3.4 in favor of placebo). No significant treatment effect was observed on RCS or RP attack duration. In the double‐blind period, 86.8% of placebo‐treated patients and 100% of selexipag‐treated patients reported ≥1 AE; 55.3% and 91.7%, respectively, reported ≥1 prostacyclin‐associated AE. Conclusion Treatment with selexipag did not reduce the number of RP attacks compared with placebo. The safety profile of selexipag was similar to that previously reported. This study provides important information about the feasibility of eDiary reporting of RP attacks in clinical trials.
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Affiliation(s)
| | - Éric Hachulla
- National Referral Centre for Rare Systemic Auto-immune Diseases, Department of Internal Medicine, Hôpital Huriez, University of Lille, Lille, France
| | | | - Andreas Schwarting
- Johannes Gutenberg University, Mainz, and ACURA Rheumatology Centre RLP, Bad Kreuznach, Germany
| | | | - Aline Frey
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust and NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Herrick AL. Evidence-based management of Raynaud's phenomenon. Ther Adv Musculoskelet Dis 2017; 9:317-329. [PMID: 29201156 PMCID: PMC5700788 DOI: 10.1177/1759720x17740074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
Raynaud's phenomenon (RP) is relevant to the rheumatologist because it may signify an underlying connective tissue disease and also because it can be very challenging to treat, especially when it has progressed to digital ulceration or critical ischaemia. This review article discusses diagnosis (does this patient have an underlying connective tissue disease?), including the role for nailfold capillaroscopy, and treatment. Management of 'uncomplicated' RP is first described and then treatment of RP complicated by progression to digital ulceration or critical ischaemia, highlighting recent advances (including phosphodiesterase type 5 inhibition, and endothelin 1 receptor antagonism) and the evidence base underpinning these. Possible future therapies are briefly discussed.
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Affiliation(s)
- Ariane L. Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK, M13 9PT and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK
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Fardoun MM, Nassif J, Issa K, Baydoun E, Eid AH. Raynaud's Phenomenon: A Brief Review of the Underlying Mechanisms. Front Pharmacol 2016; 7:438. [PMID: 27899893 PMCID: PMC5110514 DOI: 10.3389/fphar.2016.00438] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/03/2016] [Indexed: 11/28/2022] Open
Abstract
Raynaud’s phenomenon (RP) is characterized by exaggerated cold-induced vasoconstriction. This augmented vasoconstriction occurs by virtue of a reflex response to cooling via the sympathetic nervous system as well as by local activation of α2C adrenoceptors (α2C-AR). In a cold-initiated, mitochondrion-mediated mechanism involving reactive oxygen species and the Rho/ROCK pathway, cytoskeletal rearrangement in vascular smooth muscle cells orchestrates the translocation of α2C-AR to the cell membrane, where this receptor readily interacts with its ligand. Different parameters are involved in this spatial and functional rescue of α2C-AR. Of notable relevance is the female hormone, 17β-estradiol, or estrogen. This is consistent with the high prevalence of RP in premenopausal women compared to age-matched males. In addition to dissecting the role of these various players, the contribution of pollution as well as genetic background to the onset and prevalence of RP are also discussed. Different therapeutic approaches employed as treatment modalities for this disease are also highlighted and analyzed. The lack of an appropriate animal model for RP mandates that more efforts be undertaken in order to better understand and eventually treat this disease. Although several lines of treatment are utilized, it is important to note that precaution is often effective in reducing severity or frequency of RP attacks.
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Affiliation(s)
- Manal M Fardoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Joseph Nassif
- Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Khodr Issa
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Elias Baydoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Ali H Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
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Temprano KK. A Review of Raynaud's Disease. MISSOURI MEDICINE 2016; 113:123-6. [PMID: 27311222 PMCID: PMC6139949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Raynaud's phenomenon is a relatively common but often unrecognized clinical syndrome causing characteristic color changes in the digits as a result of vasospasm. This may occur after exposure to a cold environment, emotional stress, or from other physical or medication exposures. Differentiating between primary and secondary Raynaud's is important as secondary Raynaud's can be complicated by digital ischemia and gangrene whereas primary Raynaud's is generally a benign condition. Referral to a rheumatologist is recommended to help evaluate for an underlying rheumatologic condition and to guide future therapy.
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Lo AH, Chan YC, Law Y, Cheng SW. Successful treatment of jellyfish sting-induced severe digital ischemia with intravenous iloprost infusion. J Vasc Surg Cases 2016; 2:31-33. [PMID: 31724607 PMCID: PMC6849917 DOI: 10.1016/j.jvsc.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/02/2016] [Indexed: 02/05/2023] Open
Abstract
Jellyfish sting-induced vasospasm and vasculitis is a rare complication that could lead to severe digital ischemia and gangrene. We report a 39-year-old woman with severe pain in her right middle, ring, and little fingers after being stung by a jellyfish. Therapy was initiated with a course of intravenous iloprost infusion and subcutaneous low-molecular-weight heparin, with successful revascularization. Our case illustrates that although emergency transfer to a vascular center is ideal, even in a delayed setting, patients can still benefit from specialist vascular care with a combination of medication and iloprost treatment, with acceptable functional outcome.
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Affiliation(s)
- Arthur H Lo
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
| | - Yuk Law
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
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García de la Peña Lefebvre P, Nishishinya MB, Pereda CA, Loza E, Sifuentes Giraldo WA, Román Ivorra JA, Carreira P, Rúa-Figueroa I, Pego-Reigosa JM, Muñoz-Fernández S. Efficacy of Raynaud's phenomenon and digital ulcer pharmacological treatment in systemic sclerosis patients: a systematic literature review. Rheumatol Int 2015; 35:1447-59. [PMID: 25824427 DOI: 10.1007/s00296-015-3241-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 03/02/2015] [Indexed: 11/29/2022]
Abstract
To evaluate the efficacy of current treatments for the Raynaud phenomenon (RP) in patients with systemic sclerosis (SSc), a systematic literature search was performed using Medline, EMBASE, and Cochrane Central Register of Controlled Trials (from 1961 to October 2011). We included meta-analyses, systematic reviews, clinical trials, and high-quality cohort studies published in English or Spanish. Patient populations had to include adults diagnosed with limited cutaneous or diffuse SSc who had associated RP and/or digital ulcers under pharmacological treatment. Efficacy of treatments was evaluated based on: number of RP episodes, RP severity, episode-free time, ulcer improvement/healing, and appearance of new ulcers. We used the Jadad scale of methodological quality to evaluate the quality of randomized clinical trials, and the 2009 Oxford Centre for Evidence-Based Medicine classification for other studies. Of a total of 1617 studies identified, only 27 fulfilled inclusion criteria. Drugs received the following grade recommendations: Grade A for nifedipine, nicardipine, quinapril, IV iloprost, bosentan, tadalafil, and MQx-503; Grade B for beraprost, cicaprost, DMSO, cyclofenil, and atorvastatin; and Grade C for misoprostol, prazosin, OPC-2826, enalapril, sildenafil, antioxidant, and stanazolol. Calcium channel blockers, prostanoids, tadalafil, and bosentan received the highest recommendation level for their effectiveness. However, most systematic reviews reviewed just a handful of studies with small sample sizes and short follow-ups. Our review shows that the existing evidence on the efficacy of RP treatment in SSc patients is inconclusive which calls for further research, especially in the form of prospective studies of high quality with long-term follow-ups.
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Affiliation(s)
- Paloma García de la Peña Lefebvre
- Servicio de Reumatología, Hospitales Universitarios Grupo Madrid (Madrid, Montepríncipe, Sanchinarro y Torrelodones), c/Oña nº10, 28050, Madrid, Spain,
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Ravelli FN, Andriolo BNG, Vasconcellos MRA, Lyddiatt A, Fernandes Moça Trevisani V. Interventions for morphea. Hippokratia 2014. [DOI: 10.1002/14651858.cd005027.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Flávia Naranjo Ravelli
- Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Rua Borges Lagoa, 564 cj 63 Vl. Clementino São Paulo São Paulo Brazil 04038-000 São Paulo
| | - Brenda NG Andriolo
- Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Rua Borges Lagoa, 564 cj 63 Vl. Clementino São Paulo São Paulo Brazil 04038-000 São Paulo
| | - Monica RA Vasconcellos
- Universidade Federal de São Paulo; Department of Dermatology; Pedro de Toledo St. 508 São Paulo Brazil 04039-001
| | - Anne Lyddiatt
- The University of Nottingham; c/o Cochrane Skin Group; A103, King's Meadow Campus Lenton Lane Nottingham UK NG7 2NR
| | - Virginia Fernandes Moça Trevisani
- Universidade Federal de São Paulo; Rheumatology/Internal Medicine and Therapeutics; Rua Marie Satzke 119 São Paulo São Paulo Brazil 04664-150
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Abstract
This review focuses on new findings and developments relevant to the clinician caring for patients with primary and secondary [especially systemic sclerosis (SSc)-related] Raynaud phenomenon (RP). In the last 18 months, several clinical trials and observational studies of RP and of SSc-related digital ulceration have been published, reflecting increased awareness of disease burden and increased interest by pharmaceutical companies: new insights into pathophysiology are driving new approaches to treatment. Key developments are the increased use of phosphodiesterase type V inhibitors in severe RP, and of bosentan (an endothelin-1 receptor antagonist) for prevention of recurrent SSc-related digital ulcers. Other treatments being researched include topical glyceryl trinitrate (applied locally to the digits), botulinum toxin (for severe digital ischemia/ulceration), and several other drugs including oral prostanoids. Increased availability and interest in nailfold capillaroscopy, by facilitating early diagnosis of SSc, should pave the way for studies of early intervention and vascular protection.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, University of Manchester, Salford M6 8HD, UK.
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Shah AA, Schiopu E, Hummers LK, Wade M, Phillips K, Anderson C, Wise R, Boin F, Seibold JR, Wigley F, Rollins KD. Open label study of escalating doses of oral treprostinil diethanolamine in patients with systemic sclerosis and digital ischemia: pharmacokinetics and correlation with digital perfusion. Arthritis Res Ther 2013; 15:R54. [PMID: 23597147 PMCID: PMC5011881 DOI: 10.1186/ar4216] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 04/18/2013] [Indexed: 11/12/2022] Open
Abstract
Introduction Treprostinil diethanolamine is an innovative salt form of the prostacyclin analogue, treprostinil sodium, developed as an oral sustained release (SR) osmotic tablet. The availability of a formulation permitting convenient systemic delivery might have applicability to scleroderma vascular complications. We evaluated pharmacokinetics and perfusion in scleroderma patients with digital ischemia following escalating twice-daily doses of treprostinil diethanolamine SR. Methods Scleroderma patients with digital ulcers were enrolled in this dual-center, open-label, phase I pharmacokinetic study. Drug concentrations and perfusion, quantified by laser Doppler imaging, were measured over 12 hours at the 2 mg and 4 mg (or maximally tolerated) doses. Pharmacokinetic parameters were determined from individual plasma concentration versus time profiles using non-compartmental analysis methods. Digital perfusion and skin temperature were modeled as a function of log-transformed drug concentration and other covariates by performing repeated measures analyses using random effects models. Results Nineteen scleroderma patients (84% female, 53% limited scleroderma) received treprostinil diethanolamine SR with dose titration up to 4 mg twice daily as tolerated. Peak concentrations (mean maximum plasma concentration (Cmax) = 1,176 and 2,107 pg/mL) occurred approximately 3.6 hours after dose administration, and overall exposure (under the plasma concentration-time curve from time 0 to 12 hours post dose (AUC0-12) = 7,187 and 12,992 hr*pg/mL) was linear between the 2 mg and 4 mg doses. Perfusion and digital skin temperature were positively associated with log-transformed plasma concentration at the 4 mg dose (P = 0.015 and P = 0.013, respectively). The most frequent adverse events were similar to those seen with prostacyclin analogues. Conclusions Oral treprostinil diethanolamine was effectively absorbed in patients with scleroderma. Drug administration was temporally associated with improved cutaneous perfusion and temperature. Treprostinil diethanolamine may provide a new therapeutic option for Raynaud's phenomenon and the peripheral vascular disease of scleroderma. Trial Registration ClinicalTrials.gov NCT00848939. Electronic supplementary material The online version of this article (doi:10.1186/ar4216) contains supplementary material, which is available to authorized users.
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Abstract
The management of patients with systemic sclerosis (SSc) can be challenging because disease-associated damage is often difficult to reverse and curative therapies are not yet available. Early identification and appropriate monitoring of patients with SSc is, therefore, critical so that active disease can be controlled and tissue damage prevented or delayed. However, early diagnosis of SSc is often difficult because the early clinical stages of the disease can be very similar to that of other autoimmune conditions. Screening for major organ manifestations of SSc, particularly interstitial lung disease, pulmonary hypertension, renal involvement and cardiac disease is a priority because involvement of these organs is associated with shorter life expectancies and early intervention might prevent disease progression. The prevention and management of digital ischaemia is also important as appropriate therapy often prevents substantial morbidity and functional loss. Treating gastrointestinal dysmotility can usually be managed using proton pump inhibitors and promotility agents, although in severe cases total parenteral nutrition is required. Calcinosis in patients with SSc is another common challenge that requires appropriate disease management and pain control. Each of these topics, which are relevant to both physicians and patients with SSc, are reviewed in further detail herein.
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Topal AA, Dhurat RS. Scleroderma therapy: clinical overview of current trends and future perspective. Rheumatol Int 2012; 33:1-18. [PMID: 23011088 DOI: 10.1007/s00296-012-2486-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 07/07/2012] [Indexed: 12/20/2022]
Abstract
Systemic sclerosis is a chronic autoimmune condition with a complex pathogenesis and a high rate of mortality and morbidity. Internal organ involvement requires interdisciplinary approach in individual patient management. New discoveries in the pathogenesis of scleroderma herald a drastic change in the traditional outlook to therapy and have led to the development of the target-based approach in management. The challenge at present is to translate these advances in molecular mechanisms into well-designed clinical trials that will recognize potential disease-modifying therapies. This article is an evidence-based review of prevailing treatment options and future therapeutic targets in systemic sclerosis.
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Affiliation(s)
- Afsha A Topal
- T.N.M.C & BYL Nair Hospital, OPD 16, OPD building, Mumbai Central, Mumbai 400 008, India.
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25
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Abstract
The past 10 years have seen the publication of results from several multicentre clinical trials in primary and systemic sclerosis (SSc)-related Raynaud phenomenon. The publication of these studies has occurred as a result of new insights into the pathogenesis of Raynaud phenomenon, which are directing new treatment approaches, and increased international collaboration between clinicians and scientists. Although the pathogenesis of Raynaud phenomenon is complex, abnormalities of the blood vessel wall, of neural control mechanisms and of intravascular (circulating) factors are known to interact and contribute. Key players relevant in drug development include nitric oxide, endothelin-1, alpha adrenergic receptor activation, abnormal signal transduction in vascular smooth muscle, oxidative stress and platelet activation. The main advances in diagnosis have been a clearer understanding of autoantibodies and of abnormal nailfold capillary patterns as independent predictors of SSc, and widespread use and increased availability of capillaroscopy. The ultimate aim is to translate the advances made in the pathophysiology and early diagnosis into development of treatments to prevent and reverse digital vascular dysfunction and injury. This Review provides an update of the pathogenesis, diagnosis and treatment of Raynaud phenomenon. Current and future treatment approaches are discussed, and some key unanswered questions are highlighted.
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Pattanaik D, Brown M, Postlethwaite AE. Vascular involvement in systemic sclerosis (scleroderma). J Inflamm Res 2011; 4:105-25. [PMID: 22096374 PMCID: PMC3218751 DOI: 10.2147/jir.s18145] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Systemic sclerosis (SSc) is an acquired multiorgan connective tissue disease with variable mortality and morbidity dictated by clinical subset type. The etiology of the basic disease and pathogenesis of the systemic autoimmunity, fibrosis, and fibroproliferative vasculopathy are unknown and debated. In this review, the spectrum of vascular abnormalities and the options currently available to treat the vascular manifestations of SSc are discussed. Also discussed is how the hallmark pathologies (ie, how autoimmunity, vasculopathy, and fibrosis of the disease) might be effected and interconnected with modulatory input from lysophospholipids, sphingosine 1-phosphate, and lysophosphatidic acid.
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Affiliation(s)
- Debendra Pattanaik
- Division of Connective Tissue Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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27
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Abstract
Digital ischemic loss is a cause of significant morbidity in patients with systemic sclerosis (SSc). Microvascular disease with intimal proliferation and luminal narrowing of small digital arteries, as well as macrovascular disease with narrowing or occlusion of larger digital arteries, contribute to the perfusion defects involved in digital ischemic loss. Immediate clinical evaluation and treatment are mandatory at the onset of critical digital ischemia to prevent digital loss. Hospitalization for medical therapies including intravenous prostacyclin therapy should be considered for all SSc patients who present with critical digital ischemia. Surgical interventions are typically reserved for patients who fail medical therapies and for those with late stage, necrotic tissue. This paper summarizes the current knowledge regarding the risk factors, pathogenesis, evaluation, and treatment of digital ischemic loss in SSc.
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28
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Levien TL. Advances in the treatment of Raynaud's phenomenon. Vasc Health Risk Manag 2010; 6:167-77. [PMID: 20448801 PMCID: PMC2860448 DOI: 10.2147/vhrm.s4551] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Indexed: 11/23/2022] Open
Abstract
Raynaud's phenomenon is a common condition characterized by vasospasm of the digital arteries and resulting cyanosis and redness. It often does not require pharmacologic management, but in some cases symptoms are severe and pharmacologic management is necessary. Calcium channel blockers are often used first-line, but in some patients are ineffective. Patients with severe symptoms or intolerance to available therapies have prompted exploration of alternative therapies, including endothelin antagonists, phosphodiesterase-5 inhibitors, antioxidants, newer vasodilators, statins, and botulinum toxin. These newer therapies provide the focus for this review.
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Affiliation(s)
- Terri L Levien
- College of Pharmacy, Washington State University Spokane, WA, USA.
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30
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Abstract
The term Raynaud's phenomenon describes an abnormal vasospastic response to cold or emotional stress. It is a common condition with a prevalence of 3-5% of the population. Clinically, Raynaud's phenomenon manifests as sharply demarcated colour changes of the skin of the digits that is often accompanied by paraesthesia. Raynaud's phenomenon can be subdivided into primary, or idiopathic, and secondary forms, in the latter of which associated diseases or causes can be identified. The pathogenesis of the disease is incompletely understood. Pathologic changes have been observed primarily in vascular smooth muscle cells, endothelial cells and perineuronal microvasculature. Current therapeutic strategies include supportive treatments, topical therapeutic approaches and systemic medication. Drug therapies with proven efficacy include calcium channel blockers, prostacyclin analogues, fluoxetine, losartan and sildenafil.
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32
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Abstract
The therapy of systemic sclerosis (SSc) remains a challenge for dermatology, rheumatology, internal medicine, and other disciplines. Organ involvement, above all kidney and lungs, is a key therapeutic issue. The current developments in organ-specific therapy are the main topic of the article. Finally, possibilities of disease-modifying drugs and value of HSCT are discussed.
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Affiliation(s)
- M Meurer
- Dermatologie am Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Volpe A, Biasi D, Caramaschi P, Bambara LM, Carletto A, Degan M, Minuz P. Iloprost infusion does not reduce oxidative stress in systemic sclerosis. Rheumatol Int 2007; 28:335-7. [PMID: 17704920 DOI: 10.1007/s00296-007-0443-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Accepted: 07/30/2007] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis is a connective tissue disease in which oxidative stress represents an important player among the complex pathogenetic mechanisms of the disease. Iloprost, an analogue of natural prostacyclin, is used in systemic sclerosis for the treatment of severe Raynaud's phenomenon and ischemic ulcers. There is a clear evidence that iloprost attenuates oxidative damage induced by ischemia-reperfusion phenomena. The aim of this study is to evaluate the effect of iloprost on oxidative status in ten patients with systemic sclerosis by measuring urinary levels of 8-isoprostaglandin-F(2alpha), a member of F(2)-isoprostanes. We found that systemic sclerosis patients cyclically treated with iloprost showed increased urinary level of 8-isoprostaglandin-F(2alpha )in comparison with healthy subjects; urinary 8-isoprostaglandin-F(2alpha) did not diminish soon after the iloprost infusion as well as 3, 15 and 30 days after the drug administration. Unlike experimental studies, in vivo the strong vasodilator effect of iloprost infusion did not reduce oxidative status.
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Affiliation(s)
- Alessandro Volpe
- Department of Clinical and Experimental Medicine, University of Verona, P.le LA Scuro 10, 37134, Verona, Italy.
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Distler M, Distler J, Ciurea A, Kyburz D, Müller-Ladner U, Reich K, Distler O. [Evidence-based therapy of Raynaud's syndrome]. Z Rheumatol 2007; 65:285-9. [PMID: 16804699 DOI: 10.1007/s00393-006-0068-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Raynaud's syndrome has a prevalence of 3-5% in the general population. Despite its high frequency, the majority of available therapies have not been validated in randomized controlled trials. Effective therapies with a high level of evidence include the calcium channel blocker nifedipine. As analyzed by meta-analyses, nifedipine showed improvement of the peripheral circulation, as well as reduction of both the intensity and frequency of attacks in patients with primary and secondary Raynaud's syndrome as compared to placebo. Similar results in a metaanalysis were obtained for intravenous infusions of iloprost in patients with secondary Raynaud's phenomenon associated with systemic sclerosis. In addition, intravenous infusions of iloprost improved healing of fingertip ulcers in patients with systemic sclerosis. Therapies with significant effects in single randomized controlled trials include angiotensin II-receptor type 1 antagonists (losartan), the calcium channel blockers felodipine und amlodipine, serotonin-reuptake-inhibitors (fluoxetine) und phosphodiesterase-V-inhibitors (sildenafil, vardenafil). However, the results for these promising substances have to be confirmed in long-term trials with larger patient numbers.
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Affiliation(s)
- M Distler
- Abt. Dermatologie und Venerologie, Georg-August-Universität Göttingen
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35
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Abstract
While primary Raynaud phenomenon (RP) only rarely leads to complications, secondary RP when associated with systemic sclerosis (SSc) frequently results in necrosis, ulcers or even gangrene. Therefore timely therapeutic intervention is required. Management of RP includes physical therapy, avoidance of triggers, and a variety of medications, depending on the disease severity. On the basis of published studies and of our own experience we suggest: a) for primary and uncomplicated secondary RP, calcium channel blockers in adequate doses; b) for SSc-associated secondary RP with hypertension, cardial or renal involvement, drugs which interfere with angiotensin; c) in case of concomitant depression, exploitation of the vasodilatory effects of serotonin reuptake inhibitors, d) in presence of ulcers or marked trophic alterations, intravenous administration of iloprost, e) for recalcitrant cases and endangered digits, sildenafil, f) for prevention of severe relapses, the endothelin-receptor antagonist bosentan. The drugs mentioned in c-f are not approved for RP and used off-label. In patients with secondary SSc-associated RP, timely therapy can reduce the percentage of complications such as ulcers or amputations. In addition, timely treatment of RP possibly retards ensuing fibrotic processes.
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Affiliation(s)
- C Sunderkötter
- Klinik und Poliklinik für Dermatologie, Universitätsklinik Münster, Von-Esmarch-Strasse 58, 48129, Münster, Deutschland.
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Ghofrani HA, Osterloh IH, Grimminger F. Sildenafil: from angina to erectile dysfunction to pulmonary hypertension and beyond. Nat Rev Drug Discov 2006; 5:689-702. [PMID: 16883306 PMCID: PMC7097805 DOI: 10.1038/nrd2030] [Citation(s) in RCA: 376] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In less than 20 years, the first selective type 5 phosphodiesterase inhibitor, sildenafil, has evolved from a potential anti-angina drug to an on-demand oral treatment for erectile dysfunction (Viagra), and more recently to a new orally active treatment for pulmonary hypertension (Revatio). Here we describe the key milestones in the development of sildenafil for these diverse medical conditions, discuss the advances in science and clinical medicine that have accompanied this journey and consider possible future indications for this versatile drug.
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Affiliation(s)
- Hossein A Ghofrani
- Medical Clinic II/V, Department of Internal Medicine, University Hospital Giessen and Marburg, GmbH, Klinikstrasse 36, 35392 Giessen, Germany.
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Riemekasten G. [Recommendations of the German Society of Rheumatology on therapy of Raynaud syndrome and acral ulcerations]. Z Rheumatol 2005; 64:90-2. [PMID: 15793673 DOI: 10.1007/s00393-005-0692-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Riemekasten
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité, Schumannstrasse 20/21, 10117 Berlin, Germany.
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Paramothayan NS, Lasserson TJ, Wells AU, Walters EH. Prostacyclin for pulmonary hypertension in adults. Cochrane Database Syst Rev 2005; 2005:CD002994. [PMID: 15846646 PMCID: PMC7004255 DOI: 10.1002/14651858.cd002994.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Primary pulmonary hypertension (PPH) is progressive, resulting in right ventricular failure. Pulmonary hypertension can be idiopathic or associated with other conditions. Prostacyclin is a potent vasodilator and inhibitor of platelet aggregation, and can be given orally, subcutaneously, intravenously or inhaled via a nebuliser. OBJECTIVES To determine the efficacy of prostacyclin or one of its analogues in idiopathic primary pulmonary hypertension. SEARCH STRATEGY Electronic searches were carried out with pre-specified terms. Searches were current as of July 2004. SELECTION CRITERIA Two reviewers selected randomised controlled trials (RCTs) involving adults with pulmonary hypertension for inclusion. DATA COLLECTION AND ANALYSIS Study quality was assessed and data extracted independently by two reviewers. Outcomes were analysed as continuous and dichotomous outcomes. We sub-grouped data where possible by aetiology of PH (PPH, PH secondary to connective tissue disorder or mixed populations). MAIN RESULTS Nine RCTs of mixed duration (3 days-52 weeks), recruiting 1175 participants were included (NYHA functional classes II-IV). Intravenous prostacyclin versus usual care (four studies): There were significant improvements in exercise capacity of around 90 metres, cardiopulmonary haemodynamics and NYHA functional class over 3 days-12 weeks. Effects were consistent in primary and secondary pulmonary hypertension. Oral prostacyclin versus placebo (two studies): Short-term data (3-6 months) indicated that there was a significant improvement in exercise capacity, but data from one study of 52 weeks reported no significant difference at 12 months. No significant differences were observed for any other outcome. Subcutaneous treprostinil versus placebo (two studies, 8-12 weeks):One large study reported a significant median improvement in exercise capacity of around 16 metres. Cardiopulmonary haemodynamics and symptom scores favoured treprostinil. Infusion site pain and withdrawals due to adverse events were more frequent with treprostinil. Inhaled prostacyclin versus placebo (one study, 12 weeks):There was a significant increase in exercise capacity of approximately 36 metres. Treatment led to better symptom scores and functional class status than with placebo. Subgroup analyses reported by individual studies showed a better exercise capacity in participants with PPH, than those participants with PH secondary to other diseases. Side effects and adverse events were common in the studies. AUTHORS' CONCLUSIONS There is evidence that intravenous prostacyclin in addition to conventional therapy at tolerable doses optimised by titration, can confer some short-term benefits (up to 12 weeks of treatment) in exercise capacity, NYHA functional class and cardiopulmonary haemodynamics. There is also some evidence that patients with more severe disease based upon NYHA functional class showed a greater response to treatment.
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Affiliation(s)
- N S Paramothayan
- Respiratory Medicine, St Helier Hospital NHS Trust, Wrythe Lane, Carshalton, Surrey, UK.
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