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Kortelainen S, Käyrä M, Rissanen T, Paltta J, Taimen K, Pirilä L, Huhtakangas J. Causes and predictors of death among Finnish patients with systemic sclerosis. Scand J Rheumatol 2024; 53:269-275. [PMID: 38742838 DOI: 10.1080/03009742.2024.2335781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/25/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE The aim of this study was to assess causes and predictors of death among Finnish patients with systemic sclerosis (SSc). METHOD Medical records of patients registered with the ICD-10 code M34 from 1996 to 2018 in two university hospitals were reviewed retrospectively. Clinical data were collected until the end of 2020. Death certificates were obtained from Statistics Finland up to August 2021. Using death certificates and patient records, the cause of death for each patient was determined. The mean age at death, median time from SSc diagnosis, and factors predicting death were analysed. RESULTS Among 313 SSc patients, 91 deaths occurred between April 2000 and September 2020. Overall 5 and 10 year survival rates were 88.4% and 80.2%, respectively. SSc was the most common primary cause of death (n = 35) and interstitial lung disease (ILD) was the most common SSc-related cause of death (n = 13). Moreover, 52% of the patients with diffuse SSc and 33% of those with limited cutaneous SSc died as a result of SSc itself. Patients who died because of SSc were significantly younger [mean ± sd age 65.6 ± 12.7 years, 95% confidence interval (CI) 61.2-70.1] than those who died from other causes (74.2 ± 9.6 years, 95% CI 71.5-76.9) (p = 0.0006). ILD, pulmonary arterial hypertension, gastrointestinal involvement, male gender, and older age at disease onset predicted death. CONCLUSION The disease itself was the major cause of death among Finnish SSc patients, in both diffuse and limited forms of SSc.
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Affiliation(s)
- S Kortelainen
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland
- Department of Medicine, University of Turku, Turku, Finland
| | - M Käyrä
- Division of Rheumatology, Center of Internal Medicine and Respiratory Medicine, Oulu University Hospital, Oulu, Finland
| | - T Rissanen
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - J Paltta
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland
- Department of Medicine, University of Turku, Turku, Finland
| | - K Taimen
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland
- Department of Medicine, University of Turku, Turku, Finland
| | - L Pirilä
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland
- Department of Medicine, University of Turku, Turku, Finland
| | - J Huhtakangas
- Division of Rheumatology, Center of Internal Medicine and Respiratory Medicine, Oulu University Hospital, Oulu, Finland
- Cancer Research and Translational Medicine Research Unit, Medical Research Centre Oulu, Oulu, Finland
- Division of Rheumatology, Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland
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Lee YH, Song GG. Standardized mortality ratios in systemic sclerosis: a meta-analysis assessing overall and sex- and disease subtype-specific differences. Z Rheumatol 2024; 83:175-182. [PMID: 37597012 DOI: 10.1007/s00393-023-01401-x] [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] [Accepted: 07/07/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE This study aims to evaluate the overall and sex- and illness subtype-specific standardized mortality ratios (SMRs) in patients with systemic sclerosis (SSc). METHODS We searched and examined studies that compared the overall and sex- and illness subtype-specific SMRs in patients with SSc to those in the general population using MEDLINE, EMBASE, and Cochrane databases (until May 2023). We then conducted a meta-analysis of the overall and sex- and illness subtype-specific SMRs in patients with SSc. RESULTS Overall, 29 studies including 30,673 patients with SSc and 5582 deaths met the inclusion criteria. Patients with SSc had a higher overall SMR than that in the general population (SMR: 2.742, 95% confidence interval [CI]: 2.224-3.38091, p < 0.001). The SMR significantly increased in populations from Europe, North America, Asia, and Oceania according to regional stratification. A sex-specific meta-analysis revealed a substantial increase in the SMR in both men and women (SMR: 3.598, 95% CI: 3.097-4.180, p < 0.001; SMR: 2.833, 95% CI: 2.4384-3.292, p < 0.001, respectively) and the mortality rate was higher in men compared to women. A substantial increase in the SMR in diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc (lcSSc) was observed in a disease subtype-specific meta-analysis. In addition, the SMR in the dcSSc group was higher than that in the lcSSc group (SMR: 4.726, 95% CI: 3.795-5.885, p < 0.001; SMR: 1.987, 95% CI: 1.586-2.489, p < 0.001, respectively). CONCLUSION Our findings demonstrated that the mortality rate in patients with SSc was 2.74-times greater than that in the general population. The mortality rate was higher in men compared to women. Additionally, compared to patients with lcSSc, those with dcSSc showed much higher fatality rates.
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Affiliation(s)
- Young Ho Lee
- Department of Rheumatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea (Republic of).
| | - Gwan Gyu Song
- Department of Rheumatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea (Republic of)
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3
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Bento da Silva A, Lourenço MH, Cunha-Branco J, Gonçalves MJ. Particularly severe form of refractory gastrointestinal involvement in systemic sclerosis. BMJ Case Rep 2023; 16:e254537. [PMID: 37015763 PMCID: PMC10083804 DOI: 10.1136/bcr-2022-254537] [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] [Indexed: 04/06/2023] Open
Abstract
A woman with systemic sclerosis presents with a severe and rapidly progressive form of gastrointestinal involvement, mainly marked by recurrent refractory episodes of pseudo-obstruction, culminating in severe malnutrition and dependence of parenteral nutrition. The impact on her quality of life was extremely significant. As a last resort, she started intravenous immunoglobulin with progressive improvement of her symptoms, allowing for the reinstitution of oral diet and removal of parenteral nutrition. After more than 1 year, she maintains clinical stability. Systemic sclerosis has a heterogeneous phenotype, but gastrointestinal involvement is one of the most frequent. Severe manifestations are rare, but can lead to severe malnutrition and are associated with high morbidity and mortality rates. Their management is challenging, as the available treatments are still very limited. A better understanding of its pathophysiology, which seems to be unique, is essential to provide more effective treatments and improving quality of life.
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Affiliation(s)
- Ana Bento da Silva
- Rheumatology, Centro Hospitalar de Lisboa Ocidental - Hospital de Egas Moniz, Lisbon, Portugal
- Rheumatology, Comprehensive Health Research Center, NOVA Medical School, Lisbon, Portugal
| | - Maria Helena Lourenço
- Rheumatology, Centro Hospitalar de Lisboa Ocidental - Hospital de Egas Moniz, Lisbon, Portugal
- Rheumatology, Comprehensive Health Research Center, NOVA Medical School, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Jaime Cunha-Branco
- Rheumatology, Centro Hospitalar de Lisboa Ocidental - Hospital de Egas Moniz, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Maria João Gonçalves
- Rheumatology, Centro Hospitalar de Lisboa Ocidental - Hospital de Egas Moniz, Lisbon, Portugal
- Rheumatology, Comprehensive Health Research Center, NOVA Medical School, Lisbon, Portugal
- Escola Superior de Tecnologia da Saúde de Lisboa, Lisbon, Portugal
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Li JX. Secular Trends in Systemic Sclerosis Mortality in the United States from 1981 to 2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15088. [PMID: 36429809 PMCID: PMC9690027 DOI: 10.3390/ijerph192215088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Systemic sclerosis (SSc) has the highest mortality rate among autoimmune disorders. Individuals with SSc frequently die from complications or infections related to SSc. Nonetheless, the sex-age-period interaction of SSc is complex and remains unclear. The study aims to analyze the secular trend of SSc mortality based on data regarding underlying cause of death (UCD) and multiple causes of death (MCD) and clarify the sex-age interaction with time. METHODS The multiple-cause mortality statistics provided by the National Center for Health Statistics were used to identify all deaths in the United States from 1981 to 2020 in which SSc was indicated anywhere on the death certificates. The age-standardized mortality rate (ASMR) was determined for both sexes, as well as the variations in these rates. Joinpoint regression analysis was utilized to determine the annual percentage change (APC) of ASMR. RESULTS A total of 44,672 and 66,259 individuals who died between 1981 and 2020 were identified based on the UCD and MCD data, respectively. According to the UCD data, SSc-related AMSR (SSc-ASMR) of the male and female decedents, respectively, declined from 5.01 and 1.94 in 1981-1990 to 4.77 and 1.32 in 2011-2020, respectively (mortality rate ratio 0.95, 95% confidence interval 0.92-0.98). From 1986 to 1999, the APC of SSc-ASMR in female decedents decreased except for those aged 45-64 years (APC 2.1%, p = 0.002). For MCD analysis, in trend 1, only APC of SSc-ASMR in male decedents aged 45-64 years decreased. The SSc-ASMR of both male and female decedents fell on trend 2 arm. In 2011-2020, the ratio of UCD to MCD increased across all age groups for both sexes compared to 1981-1990. Overall, compared to the male decedents, the SSc-ASMR in female decedents increased significantly before 1999, peaked in 1999, followed by continuous decrease until 2020 according to UCD and MCD statistics. CONCLUSIONS Over the past four decades, the SSc deaths based on the MCD data were 1.48 times more than the UCD data, and the proportion of UCD over MCD increased over time. The SSc-ASMRs in all the sex-age groups significantly decreased over the past two decades. Notably, the mortality rate ratio of women to men with SSc increased in the past four decades.
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Affiliation(s)
- Jing-Xing Li
- Department of General Medicine, China Medical University Hospital, No. 2, Yude Rd., North District, Taichung 404327, Taiwan; ; Tel.: +886-905-770-531
- School of Medicine, China Medical University, Taichung 404327, Taiwan
- Graduate Institute of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University, Taipei 100225, Taiwan
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Cacciapaglia F, Airò P, Fornaro M, Trerotoli P, De Lorenzis E, Corrado A, Lazzaroni MG, Natalello G, Montini F, Altomare A, Urso L, Verardi L, Bosello SL, Cantatore FP, Iannone F. Survival and Prognostic factors from a multicentre large cohort of unselected Italian Systemic Sclerosis patients. Rheumatology (Oxford) 2022; 62:1552-1558. [PMID: 36074979 DOI: 10.1093/rheumatology/keac512] [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: 04/20/2022] [Revised: 08/03/2022] [Accepted: 08/23/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Survival and death prognostic factors of systemic sclerosis (SSc) patients varied during the last decades. We aimed to update the 5- and 10-year survival rates and identify prognostic factors in a multicentre cohort of Italian SSc patients diagnosed after 2009. METHODS Patients who received a diagnosis of SSc after January 1st, 2009, and were longitudinally followed up in 4 Italian Rheumatologic Centres were retrospectively assessed up to December 31st, 2020. Overall survival of SSc patients was described using the Kaplan-Meier method. Predictors of mortality at 10-year follow-up were assessed by the Cox-regression model. A comparison of our cohort with the Italian general population was performed by determining the standardized mortality ratio (SMR). RESULTS A total of 912 patients (91.6% females, 20% dcSSc) were included. Overall survival rates at 5 and 10 years were 94.4%, and 89.4% respectively. The SMR was 0.96 (95% CI 0.81-1.13), like that expected in the Italian general population. Pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) associated with pulmonary hypertension (PH) significantly reduced survival (p< 0.0001). Main death predictors were male gender (HR = 2.76), diffuse cutaneous involvement (HR = 3.14), older age at diagnosis (HR = 1.08), PAH (HR = 3.21), ILD-associated PH (HR = 4.11), comorbidities (HR = 3.53), and glucocorticoid treatment (HR = 2.02). CONCLUSIONS In the last decade, SSc patients have reached similar mortality of that expected in the Italian general population. Male gender, diffuse cutaneous involvement, comorbidities, and PAH with or without ILD represent the main poor prognostic factors.
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Affiliation(s)
- Fabio Cacciapaglia
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Paolo Airò
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University, Brescia, Italy
| | - Marco Fornaro
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Paolo Trerotoli
- Medical Statistics, Department of Biomedical and Human Oncologic Science, University of Bari, Bari, Italy
| | - Enrico De Lorenzis
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Ph.D Program in Biomelocular Medicine, Cicle XXXV, University of Verona, Verona, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University, Brescia, Italy
| | - Gerlando Natalello
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Fabio Montini
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Alberto Altomare
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Livio Urso
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Lucrezia Verardi
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Silvia Laura Bosello
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Francesco Paolo Cantatore
- Ph.D Program in Biomelocular Medicine, Cicle XXXV, University of Verona, Verona, Italy
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
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A Narrative Review of Pathogenetic and Histopathologic Aspects, Epidemiology, Classification Systems, and Disease Outcome Measures in Systemic Sclerosis. Clin Rev Allergy Immunol 2022; 64:358-377. [PMID: 35254622 PMCID: PMC10167186 DOI: 10.1007/s12016-022-08929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/03/2022]
Abstract
Systemic sclerosis (SSc) is a rare systemic autoimmune disease, characterized by the presence of three main actors: vasculopathy, immune activation, and fibrosis. This pathologic process is then translated in a clinical picture with great variability among different patients in terms of type of organ involvement, disease severity and prognosis. This heterogeneity is a main feature of SSc, which, in addition to the presence of early phases of the disease characterized by mild symptoms, can explain the high difficulty in establishing classification criteria, and in defining patients' subsets and disease outcomes. The definition of disease outcomes is particularly relevant in the setting of clinical trials, where the aim is to provide reliable endpoints, able to measure the magnitude of the efficacy of a certain drug or intervention. For this reason, in the last years, increasing efforts have been done to design measures of disease activity, damage, severity, and response to treatment, often in the context of composite indexes. When considering disease outcomes, the experience of the patient represents a relevant and complementary aspect. The tools able to capture this experience, the patient-reported outcomes, have been increasingly used in the last years in clinical practice and in clinical trials, both as primary and secondary endpoints. This comprehensive narrative review on SSc will therefore cover pathogenetic and histopathologic aspects, epidemiology, classification systems, and disease outcome measures, in order to focus on issues that are relevant for clinical research and design of clinical trials.
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7
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Moore DF, Steen VD. Overall mortality. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:3-10. [PMID: 35382244 PMCID: PMC8922633 DOI: 10.1177/2397198320924873] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/14/2020] [Indexed: 11/30/2023]
Abstract
Systemic sclerosis is a highly morbid, complex autoimmune disease that is variable both in its phenotype and the attendant mortality driven by such manifestations. This review article synthesizes mortality data from the best available meta-analyses, subgroup analyses of single cohorts, and subjective comparisons of individual cohort studies, which in aggregate suggest that mortality in systemic sclerosis has been gradually improving over the past several decades. This review also summarizes the literature describing various risk factors for mortality in systemic sclerosis.
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Affiliation(s)
- Duncan F Moore
- Division of Rheumatology, Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Virginia D Steen
- Division of Rheumatology, Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
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Abstract
PURPOSE OF REVIEW Systemic sclerosis (scleroderma, SSc) is a rare multisystem autoimmune disease characterized by autoantibodies, vasculopathy, and fibrosis of the skin and internal organs. This review aims to provide an overview and summary of the recent epidemiological studies in systemic sclerosis. RECENT FINDINGS Global trends of scleroderma demonstrate greater prevalence of SSc in European, North, and South American patients compared with East Asian patients. However, the greatest prevalence (47 in 100 000), was found among the indigenous peoples in Canada. Phenotypical differences exist depending on the age of presentation with greater internal organ involvement and disease acceleration present in older patients. Sex differences include greater severity of disease expression, relative prevalence of diffuse cutaneous SSc, and organ involvement in males versus females. New studies conflict with previous data reporting greater proportion of pulmonary arterial hypertension in females. Furthermore, the effect of low median household income is demonstrated as a factor increasing risk of death in SSc patients. SUMMARY Understanding the epidemiological factors in SSc enables patient care through patient classification, prognostication, and monitoring. Future research may emphasize enrichment of SSc patients in randomized trials who are more likely to progress or be treatment responsive, focused screening, and personalized patient care through the creation and validation of new SSc criteria and subsets.
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Abdouh I, Porter S, Fedele S, Ni Riordain R. Validity and reliability of the Mouth Handicap of Systemic Sclerosis questionnaire in a UK population. J Oral Pathol Med 2020; 49:986-993. [PMID: 32531075 DOI: 10.1111/jop.13060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND The objective of this study was to explore the psychometric properties of the Mouth Handicap in Systemic Sclerosis (MHISS) specifically exploring aspects of validity and reliability of MHISS in UK SSc patients. METHODS A total of 150 questionnaires were distributed in this study at the Oral Medicine Department of UCLHT Eastman Dental Hospital, the Outpatient Rheumatology Clinic of the Royal Free Hospital and Scleroderma Family Day. Participants were asked to complete three questionnaires (SF-36, OHIP-14 and MHISS) along with a pro forma of demographic and disease-specific questions. Both convergent validity and internal consistency reliability were examined. The convergent validity was assessed by Spearman's correlation coefficient, and internal consistency reliability was assessed by Cronbach's alpha. RESULTS Of the 150 questionnaires distributed to participants, 68 respondents were included. With regard to construct validity, a low to moderate degree of convergent validity was found between MHISS total score and all SF-36 subscales. However, the total MHISS score was highly correlated to all OHIP subscales. CONCLUSION MHISS questionnaire is a self-administered patient-reported outcome measure that assesses the mouth disability in SSc patients. However, improving the global and oral health of SSc patients is important as there is no cure for the disease; thus, instruments that record the impact of the condition and indicate the effect of treatment on the lives of patients are of paramount importance. Current results demonstrate good preliminary psychometric properties (validity and reliability) in a UK population with further exploration of psychometric properties with an emphasis on interpretability required.
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Affiliation(s)
- Ismail Abdouh
- Oral Medicine, UCL Eastman Dental Institute, London, UK.,Oral Medicine, College of Dentistry, Taibah University, Al Madinah Al Munawarah, Saudi Arabia
| | | | - Stefano Fedele
- Oral Medicine, UCL Eastman Dental Institute, London, UK.,Oral Theme UCLH/UCL NIHR, Biomedical Research Centre, London, UK
| | - Richeal Ni Riordain
- Oral Medicine, UCL Eastman Dental Institute, London, UK.,UCL Eastman and University College Cork, London, UK
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Panopoulos S, Chatzidionysiou Κ, Tektonidou MG, Bournia VK, Drosos AA, Liossis SNC, Dimitroulas T, Sakkas L, Boumpas D, Voulgari PV, Daoussis D, Thomas K, Georgiopoulos G, Vosvotekas G, Garyfallos Α, Sidiropoulos P, Bertsias G, Vassilopoulos D, Sfikakis PP. Treatment modalities and drug survival in a systemic sclerosis real-life patient cohort. Arthritis Res Ther 2020; 22:56. [PMID: 32293545 PMCID: PMC7092571 DOI: 10.1186/s13075-020-2140-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/05/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND European data indicate that systemic sclerosis (SSc)-related death rates are increasing, thus raising concerns about SSc's optimal management. Herein, we describe current treatment modalities and drug survival in a real-life SSc cohort. METHODS Details on immunosuppressive/antiproliferative (methotrexate, mycophenolate, cyclophosphamide, azathioprine, rituximab, tocilizumab) and vasoactive agent [(endothelin receptor antagonists (ERAs), sildenafil, iloprost, and calcium channel blockers (CCB)] administration during the disease course (11.8 ± 8.4 years, mean + SD) of 497 consecutive patients examined between 2016 and 2018 were retrospectively recorded. Drug survival was assessed by Kaplan-Meier analysis. RESULTS Methotrexate was the most frequently administered immunosuppressive/antiproliferative agent (53% of patients), followed by cyclophosphamide (26%), mycophenolate (12%), and azathioprine (11%). Regarding vasoactive agents, CCB had been ever administered in 68%, ERAs in 38%, iloprost in 7%, and sildenafil in 7% of patients; 23% of patients with pulmonary fibrosis had never received immunosuppressive/antiproliferative agents, 33% of those with digital ulcers had never received ERAs, iloprost, or sildenafil, whereas 19% of all patients had never received either immunosuppressive/antiproliferative or other than CCB vasoactive agents. Survival rates of methotrexate, cyclophosphamide, and mycophenolate differed significantly, being 84/75%, 59/43%, and 74/63% at 12/24 months, respectively, with inefficacy being the most frequent discontinuation cause. Conversely, CCB, ERAs, and sildenafil had high and comparable retention rates of 97/91%, 88/86%, and 80/80%, respectively. CONCLUSIONS Existing therapeutic limitations indicate that more evidence-based treatment is warranted for successful management of SSc. Vasculopathy seems to be managed more rigorously, but the low retention rates of immunosuppressive/antiproliferative drugs suggest that effective and targeted disease-modifying agents are warranted.
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Affiliation(s)
- S Panopoulos
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece.
| | - Κ Chatzidionysiou
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - M G Tektonidou
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - V K Bournia
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
| | - A A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Medical School, University of Patras, Patras, Greece
| | - T Dimitroulas
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - L Sakkas
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - D Boumpas
- Joint Rheumatology Program, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - P V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - D Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, Medical School, University of Patras, Patras, Greece
| | - K Thomas
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - G Georgiopoulos
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - G Vosvotekas
- 1st Department of Medicine, Aristotle University of Thessaloniki, School of Medicine, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Α Garyfallos
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P Sidiropoulos
- Department of Clinical Rheumatology, Clinical Immunology and Allergy, Faculty of Medicine-University of Crete, Heraklion, Greece
| | - G Bertsias
- Department of Clinical Rheumatology, Clinical Immunology and Allergy, Faculty of Medicine-University of Crete, Heraklion, Greece
| | - D Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology -Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - P P Sfikakis
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Agiou Thoma str., 115 27, Athens, Greece
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11
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Baker Frost D, Wolf B, Peoples C, Fike J, Silver K, Laffoon M, Medsger TA, Feghali-Bostwick C. Estradiol levels are elevated in older men with diffuse cutaneous SSc and are associated with decreased survival. Arthritis Res Ther 2019; 21:85. [PMID: 30940202 PMCID: PMC6444502 DOI: 10.1186/s13075-019-1870-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/18/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a female-predominant disease, characterized by excessive extracellular matrix deposition (ECM) with dermal and internal organ fibrosis. Considering the sex-based disparity in disease incidence, estradiol (E2), an estrogen form with pro-fibrotic effects, may play a role in SSc. We reported that post-menopausal women with diffuse cutaneous (dc)SSc have higher serum E2 levels compared to similar aged, healthy controls. Since males with SSc tend to have more severe disease, we examined serum E2 in dcSSc males in relation to disease characteristics and survival. METHODS We measured serum E2 in 83 dcSSc men > 50 years old from the University of Pittsburgh Scleroderma Center and similar aged healthy controls. Using statistical modeling, we examined the associations between serum E2, internal organ involvement, autoantibody profiles, and survival. RESULTS Male dcSSc patients had significantly higher serum E2 levels compared to healthy males and similar aged dcSSc post-menopausal women. Male dcSSc patients with high serum E2 had significantly more heart involvement, a trend for higher skin thickness progression rate, and worse survival. Using Cox regression modeling, increased serum E2 levels in anti-Scl-70 antibody-positive dcSSc males were associated with an increased risk of death. CONCLUSIONS dcSSc males > 50 years old have higher levels of serum E2 compared to healthy controls and dcSSc post-menopausal women. Elevated serum E2 levels in dcSSc males are associated with heart involvement, trend to progression of dermal fibrosis, and, if anti-Scl-70 antibody positive, worse survival. Our study expands on previous work implicating E2 in dermal fibrosis in SSc and associates E2 levels with internal organ involvement and survival. These data suggest a role for estrogen imbalance in dcSSc.
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Affiliation(s)
- DeAnna Baker Frost
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Bethany Wolf
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.,College of Medicine, Department of Public Health Sciences, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Christine Peoples
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Jessica Fike
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Katherine Silver
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Maureen Laffoon
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Thomas A Medsger
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology and Immunology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
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